Implications of use of opioid-containing analgesics for palliation of acute dental pain.

BACKGROUND: Initial palliation of acute dental pain with an opioid-containing pain reliever (OPR) is inappropriate but more likely to occur among the under- and uninsured who are unable to access the customary resources for dental care. OBJECTIVE: To assess the implications of palliation with an OPR, the authors determined the prevalence of several health attributes and socioeconomic status (SES) of patients taking prescription or over-the-counter (OTC) palliative medications before they presented to an academically affiliated dental clinic for definitive treatment of acute dental pain. METHODS: Prior palliation with any OPR/antibiotic combination was compared with a self-reported mood disorder, use of a psychotherapeutic or street drug, low SES (on Medicaid or self-payer), or high SES (having commercial dental insurance). RESULTS: Palliative medications were being taken by 34 percent of 851 patients including 20 percent who were taking an OPR. Use of any palliative prescription medication was significantly associated with low SES (odds ratio: 1.25; 95%; confidence interval: 1.35-2.88; p = 0.004). By comparison, high SES patients were significantly more likely to have used OTC analgesics or no medication (p < 0.001). Significantly more low SES patients self-reported mood disorders and street drug use (p = 0.048 and p = 0.019), respectively. Patients taking OPRs included those with self-reported mood disorders or use of a psychotherapeutic or street drug. CONCLUSIONS: Palliation of acute dental pain with OPRs cannot resolve the underlying dental condition and contributes to drug misuse and adverse interactions. Preferable palliation should utilize combinations of non-OPR analgesics. These have fewer risks and may provide an incentive to seek definitive dental treatment.

Relevance of smoking interventions for dental clinic patients with smoking-related disease.

OBJECTIVES: Despite a decline in cigarette smoking in the United States, high rates persist among the socioeconomically underserved who consequently are at risk for smoking-related disease (SRD). Since academically affiliated dental clinics are more likely to encounter underserved patients, smoking interventions could address both the oral and systemic risks of continued smoking. To determine the relevance of providing smoking counseling in the context of SRD, this study examined the prevalence of smoking and its associations with socioeconomic status (SES), SRD and its sequela, and medication use. METHODS: Socioeconomic and smoking status was determined from 1,797 electronic health records of a sample of patients at a Pennsylvania dental clinic in 2010. Low SES included patients who were covered by a Medicaid program (MA) or "self-payers." High SES encompassed those with an employment-based commercial dental insurance (COM). Self-reported smoking rates were compared with patients' SES, SRDs or sequela, and medications being used for the management of their SRDs. RESULTS: Overall, 41.7 percent of these patients were smoking. Smoking was related to SES with the highest rate (52.7 percent) among MA patients compared with 31.5 percent in patients with COM. In addition, 37 percent of patients with SRD or sequela and 33 percent who were taking medications for their management were smoking. CONCLUSIONS: Academically affiliated dental clinics are more likely to encounter underserved patients who smoke and have SRD. For greater patient impact and receptivity, it is essential that tobacco cessation interventions emphasize the risks of smoking on systemic as well as oral health.

Medical conditions and medication use in a U.S. dental school clinic population.

OBJECTIVES: The aim of the study was to characterize coexisting medical conditions and medication use in patients treated at a US dental school in 2010 and to assess their implications on providing dental care. STUDY DESIGN: Data on the types and prevalence of self-reported medical conditions and the use of medications were extracted from the electronic health records of 1797 adult patients and compared against their socioeconomic status (SES). RESULTS: Within this sample, 8.7% were classified as American Society of Anesthesiologists (ASA) physical status (PS) 1. The remainder were designated PS 2 to PS 4 for smoking, having one or more medical conditions that ranged from myasthenia gravis (<1%) to hypertension (24%), or both. Medications for hypertension were the most frequently reported (23%), followed by more than 40 other classes of drugs. CONCLUSIONS: Dental practitioners must be prepared to treat larger numbers of older patients, whose life expectancies continue to increase as advances in pharmacotherapeutics and biomedical technologies improve the control of their chronic medical conditions.

Self-report of latex allergy by patients visiting a dental clinic.

BACKGROUND: The prevalence of latex allergy among dental patients is not known, although it has been increasing in the population since 1982, when the use of gloves was expanded to prevent the transmission of infectious diseases. METHODS: A retrospective cross-sectional study was undertaken of 1,798 electronic health records (EHRs) of new clinic patients who registered at the University of Pittsburgh School of Dental Medicine (SDM) dental clinic between January and June 2010. Data extracted from the EHRs included age, gender, and a history of a previous latex reaction, asthma, or allergy to penicillin. RESULTS: A previous reaction to latex was reported by 59 patients (3.3%). Women were almost three times more likely to report this (4.7% versus 1.6%, P = 0.0005). Histories of asthma or penicillin allergy in women were significantly associated with latex allergy (P = 0.0005 and P = 0.0001, respectively). CONCLUSIONS: The reported rate of a previous reaction to latex in this patient sample was higher than that of the general population. This may, in part, be related to repeated exposures to latex-containing gloves. CLINICAL IMPLICATIONS: Practitioners are increasingly likely to encounter patients who have had a reaction to latex. Non-latex products must be available for these patients, who are more likely to be women and individuals with asthma or an allergy to penicillin.

The therapeutic applications of and risks associated with acetaminophen use: a review and update.

BACKGROUND: In response to the April 2010 U.S. Food and Drug Administration's (FDA's) revision of warning labeling for over-the-counter (OTC) acetaminophen, or N-acetyl-p-aminophenol (APAP), products, the authors reviewed APAP's potential for liver toxicity. TYPES OF STUDIES REVIEWED: The authors reviewed the literature in which investigators examined data related to the epidemiology of APAP-related liver toxicity, studies in which the investigators evaluated the risk factors for its occurrence and case reports. They included articles that were used by the FDA as the basis for establishing the new labeling requirements. RESULTS: Findings from the literature in which investigators have examined the relationship between APAP and liver toxicity indicate several key risk factors. Foremost are the extensive use of one or more APAP-containing compounds (particularly combinations with opioid agents) and the small margin of safety between the therapeutic and toxic doses. Both of these factors lead to unintentional or intentional drug overdose. Concurrent use of alcohol may contribute to hepatotoxicity, but it may be related to behavior rather than biochemical mechanisms involved in liver damage. CONCLUSIONS: The widespread use of APAP has contributed to a substantial increase in the number of cases of acute liver toxicity in the United States. Since APAP is a component of many prescription and OTC medications, unintentional overdose can occur. CLINICAL IMPLICATIONS: APAP has numerous applications in dentistry, but if it is used conjointly for other conditions, the risk of the patient's experiencing an overdose increases. In the context of recent FDA concerns about the increased incidence of APAP-related liver toxicity, the authors provide recommendations for safe prescribing practices for APAP. Practitioners should caution patients to follow recommended dosage instructions and avoid taking multiple APAP-containing products.

Sialadenosis in patients with advanced liver disease.

Sialadenosis (sialosis) has been associated most often with alcoholic liver disease and alcoholic cirrhosis, but a number of nutritional deficiencies, diabetes, and bulimia have also been reported to result in sialadenosis. The aim of this study was to determine the prevalence of sialadenosis in patients with advanced liver disease. Patients in the study group consisted of 300 candidates for liver transplantation. Types of liver disease in subjects with clinical evidence of sialadenosis were compared with diagnoses in cases who had no manifestations of sialadenosis. The data were analyzed for significant association. Sialadenosis was found in 28 of the 300 subjects (9.3%). Among these 28 cases, 11 (39.3%) had alcoholic cirrhosis. The remaining 17 (60.7%) had eight other types of liver disease. There was no significant association between sialadenosis and alcoholic cirrhosis (P = 0.389). These findings suggest that both alcoholic and non-alcoholic cirrhosis may lead to the development of sialadenosis. Advanced liver disease is accompanied by multiple nutritional deficiencies which may be exacerbated by alcohol. Similar metabolic abnormalities may occur in patients with diabetes or bulimia. Malnutrition has been associated with autonomic neuropathy, the pathogenic mechanism that has been proposed for sialadenosis.

The patient with asthma: implications for dental practice.

A history of asthma is reported commonly by adult dental patients and may be more prevalent in children. An acute episode of asthma in the dental office may be precipitated by extrinsic factors such as inhaled allergens, as well as intrinsic factors such as fear or anxiety. An asthma episode should be considered a medical emergency and must be treated promptly by inhalation of a bronchodilating agent. A history of asthma in the dental patient should alert the dentist to implement strategies that may prevent an acute attack and to be prepared to manage this potentially life-threatening medical emergency appropriately. The chronic use of bronchodilating inhalers and/or glucocorticoids for the management of asthma can increase the likelihood of oral candidiasis, particularly in patients who have additional risk factors such as smoking, denture use, or the use of xerostomic medications.

Medication-induced hyposalivation: etiology, diagnosis, and treatment.

Polypharmacy in the nation's growing geriatric population will require increasingly complex pharmacologic management of multiple disease states. This brief review describes normal salivary function, potential causes of salivary dysfunction, oral health concerns associated with hyposalivation, diagnostic tests, and options for patient care. Medications can reduce salivary flow, creating the condition known as xerostomia. A major complication of xerostomia is the promotion of dental caries. Asking several standardized questions regarding symptoms may help confirm salivary gland hypofunction. The general approach to patients with hyposalivation and xerostomia is directed at palliative treatment for the relief of symptoms and prevention of oral complications.

Burning mouth syndrome and peripheral neuropathy in patients with type 1 diabetes mellitus.

OBJECTIVE: Burning mouth syndrome (BMS) has been attributed secondarily to diabetes, poor glycemic control, and diabetic neuropathy. The prevalence and predictor factors of BMS were compared in type 1 diabetes mellitus (T1DM) and nondiabetic subjects. STUDY DESIGN: An assessment of 371 adult T1DM subjects and 261 control subjects participating in a cross-sectional epidemiological study of oral health complications of diabetes was performed. Subjects were participants of the Pittsburgh Epidemiology of Diabetes Complications study. Prevalence of BMS was determined by response to the following questions: "Do you now or in the last month had any persistent uncomfortable sensations in your mouth or tongue? If yes, would you describe the feeling as tingling, burning, sore, numb, or other?" RESULTS: Burning mouth syndrome symptoms were reported by 28 T1DM and control subjects (4.6%). Eleven had oral pathologies that might explain the BMS, including atrophy of the tongue papillae, fissured tongue, denture stomatitis, and candidiasis. The prevalence of BMS within the two groups with no pathologies was similar; 12/371 (3.2%) vs. 5/233 (2.1%). Multivariate analyses of the 12 T1DM subjects with BMS found significant associations for female gender (P=.042) and a diagnosis of diabetic peripheral neuropathy (P=.024). CONCLUSIONS: In this T1DM population, BMS or related discomforts occurred slightly more frequently than in the control group. Symptomatic T1DM subjects were more likely to be female who had also developed peripheral neuropathy. These findings and other similarities between BMS and diabetic peripheral neuropathy suggest that a neuropathic process may be an underlying source of BMS in some patients who have no apparent oral abnormality.

Dental health status of liver transplant candidates.

A prerequisite dental evaluation is usually recommended for potential organ transplant candidates. This is based on the premise that untreated dental disease may pose a risk for infection and sepsis, although there is no evidence that this has occurred in organ transplant candidates or recipients. The purpose of this study was to assess the prevalence of dental disease and oral health behaviors in a sample of liver transplant candidates (LTCs). Oral examinations were conducted on 300 LTCs for the presence of gingivitis, dental plaque, dental caries, periodontal disease, edentulism, and xerostomia. The prevalence of these conditions was compared with oral health data from national health surveys and examined for possible associations with most recent dental visit, smoking, and type of liver disease. Significant risk factors for plaque-related gingivitis included intervals of more than 1 yr since the last dental visit (P = 0.004), smoking (P = 0.03), and diuretic therapy (P = 0.005). Dental caries and periodontal disease were also significantly associated with intervals of more than 1 yr since the last dental visit (P = 0.004). LTCs with viral hepatitis or alcoholic cirrhosis had the highest smoking rate (78.8%). Higher rates of edentulism occurred among older LTCs who were less likely to have had a recent dental evaluation (mean 88 months). In conclusion, intervals of more than 1 yr since the last dental visit, smoking, and diuretic therapy appear to be the most significant determinants of dental disease and the need for a pretransplantation dental screening evaluation in LTCs. Edentulous patients should have periodic examinations for oral cancer.

A survey of dental care protocols among US organ transplant centers.

Untreated dental disease represents a potential risk for infection in transplant patients, but the vast transplantation literature has few references to this complication. There is also little information with regard to dental care protocols for patients before and after organ transplantation. To obtain more definitive documentation about the policies that deal with dental care and experience with dental infections, we conducted a survey of US transplant centers. The instrument consisted of eight questions that addressed pre-transplant dental evaluation procedures, incidence of pre- and post-transplant dental infections, and recommendations for antibiotic prophylaxis with dental treatment after transplantation. Questionnaires were sent to 768 medical and/or surgical directors at all US transplant centers. Responses were received from 294 recipients (38%). Among the respondents, 80% routinely requested a pre-transplant dental evaluation, but 49% of these were only for specific organs. The occurrence of a dental infection prior to transplantation that resulted in a postponement or cancellation was reported by 38% of the respondents. Post-transplantation sepsis from a suspected dental source was acknowledged in 27% of the surveys. Prophylaxis with antibiotics prior to dental care was recommended by 83%; 77% indicated that it be used for all dental procedures, whether invasive or not. Most respondents (96%) recommended the 1997 American Heart Association endocarditis prevention regimen. A survey of organ transplant centers has provided some information with regard to pre-transplantation dental screening, dental infections, and the use of prophylactic antibiotics. Additional studies are needed in order to accrue more definitive data that will assist with the development of standardized and appropriate pre- and post-transplant dental care protocols.

Dental management of the (solid) organ transplant patient.

The need to provide dental care for organ transplant candidates and recipients will increase in conjunction with the continued expansion of the use of organ transplantation. For the transplant candidate, dental care usually requires application of practice standards that fall within the scope of management of the severely medically compromised patient. There are, however, few guidelines and no clinical trials or outcomes assessments that address appropriate care for transplant recipients. Furthermore, despite the high rate of infectious complications among patients who have received organ transplants, there is little evidence that dental disease contributes to this risk. This article reviews the current status of dental care practices that have been recommended and presents a rationale that can be applied as the basis for guidelines and recommendations for the treatment of the organ transplant patient.

Xerostomia: etiology, recognition and treatment.

BACKGROUND: Clinicians may encounter symptoms of xerostomia, commonly called "dry mouth," among patients who take medications, have certain connective tissue or immunological disorders or have been treated with radiation therapy. When xerostomia is the result of a reduction in salivary flow, significant oral complications can occur. TYPES OF STUDIES REVIEWED: The authors conducted an Index Medicus--generated review of clinical and scientific reports of xerostomia in the dental and medical literature during the past 20 years. The literature pertaining to xerostomia represented the disciplines of oral medicine, pathology, pharmacology, epidemiology, gerodontology, dental oncology, immunology and rheumatology. Additional topics included the physiology of salivary function and the management of xerostomia and its complications. RESULTS: Xerostomia often develops when the amount of saliva that bathes the oral mucous membranes is reduced. However, symptoms may occur without a measurable reduction in salivary gland output. The most frequently reported cause of xerostomia is the use of xerostomic medications. A number of commonly prescribed drugs with a variety of pharmacological activities have been found to produce xerostomia as a side effect. Additionally, xerostomia often is associated with Sjögren's syndrome, a condition that involves dry mouth and dry eyes and that may be accompanied by rheumatoid arthritis or a related connective tissue disease. Xerostomia also is a frequent complication of radiation therapy. CONCLUSIONS AND CLINICAL IMPLICATIONS: Xerostomia is an uncomfortable condition and a common oral complaint for which patients may seek relief from dental practitioners. Complications of xerostomia include dental caries, candidiasis or difficulty with the use of dentures. The clinician needs to identify the possible cause(s) and provide the patient with appropriate treatment. Remedies for xerostomia usually are palliative but may offer some protection from the condition's more significant complications.

Oral manifestations of drug therapy.

The oral cavity may be the target organ for a number of diverse abnormalities that develop from side effects of medications. Because of the widespread and increasing use of prescription, over-the-counter, and herbal remedies, it is becoming increasingly likely that the dentist will encounter soft tissue or dental pathologies that represent a complication of a therapeutic agent. The more common abnormalities that may occur include gingival hyperplasia, tooth discoloration, candidiasis, chemical injuries, and altered taste perception. The dental practitioner is often the primary health care provider who can recognize, diagnose, treat, and/or prevent these conditions.