That first paper on the collective experience of more than 1,800 trial patients found that the combination of ibuprofen and acetaminophen provided better pain relief than hydrocodone with acetaminophen for the first two days after surgery and greater satisfaction over the post-operative period. The new subgroup analysis, published in JAMA Network Open, demonstrated that the results held for both male and female patients.

“We wanted to determine whether the pain medication’s effects were consistent in males and females separately,” said Janine Fredericks Younger, an associate professor at Rutgers School of Dental Medicine and lead author of the analysis. “And what we found is that in both subgroups (males and females), the non-opioid was superior for that first day and night, and then no worse than the opioid for the rest of the post-op period.”

The trial that produced both papers, funded by an $11 million grant from the National Institutes of Health, compared patients who received 400 milligrams of ibuprofen (Advil, Motrin) combined with 500 milligrams of acetaminophen (Tylenol) against those who got 5 milligrams of hydrocodone with acetaminophen.

The gender-specific analysis was particularly important because women consistently report higher pain levels after surgery, raising questions about whether pain medications work differently for each sex.

“There’s obviously different biological mechanisms, different hormones involved,” said Cecile Feldman, dean of Rutgers School of Dental Medicine and senior author of both studies. “But results confirm that the analgesic effect for both groups is the same.”

The researchers deliberately enrolled equal numbers of men and women from the start, allowing them to conduct robust subgroup analyses. Patients across five universities tracked their pain twice daily for nine days using electronic diaries, rating not just pain but also sleep quality, ability to perform daily activities and overall satisfaction.

On every measure, the over-the-counter combination matched or beat the opioid. Patients taking the non-opioid medications reported better sleep quality and less interference with daily activities. Those who received opioids were twice as likely to call back requesting additional pain medication.

“The results actually came in even stronger than we thought they would,” Feldman said. “We expected to find the non-opioid to be non-inferior, so that at least it was no worse than opioids. We were surprised to see that it was actually superior.”

Dental procedures are a common entry point for opioid exposure. Dentists wrote more than 8.9 million opioid prescriptions in 2022, ranking among the nation’s leading prescribers of the drugs.

“There are studies out there to show that when young people get introduced to opioids, as many have via wisdom tooth extraction, there’s an increased likelihood that they’ll eventually use them again, and then it can lead to addiction,” said Fredericks Younger, noting that opioid overdoses kill more than 80,000 Americans annually.

The research focused on the extraction of impacted wisdom teeth, which requires cutting into gums and sometimes removing bone, making it one of the most painful dental procedures. The Food and Drug Administration uses this as a standard model for testing pain medications because it reliably produces moderate to severe pain for about 48 hours.

Feldman said the results, showing the superiority of the over-the-counter medication to opioids, likely apply to other dental procedures but cannot be automatically generalized to surgeries in other parts of the body. She would like to see similar studies conducted for a range of procedures, particularly those for orthopedic injuries, which frequently result in opioid prescriptions for high school and college athletes.

Despite mounting evidence, many dentists continue writing “just in case” opioid prescriptions for patients who are told to start with over-the-counter medications. The next phase of research will examine why these prescribing patterns persist.

“How can we now, with the evidence and the knowledge that we have, eliminate these prescriptions from being written?” Fredericks Younger said.

The findings align with American Dental Association recommendations to avoid opioids as first-line pain treatment. Feldman said the study’s results leave little room for doubt.

“We feel pretty confident in saying that opioids should not be prescribed routinely for dental procedures,” she said. “Our non-opioid combination really should be the analgesic choice.”

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And these problems were linked to children’s oral care routine, more commonly experienced among those who skipped dental hygiene recommendations or followed them less often, according to the University of Michigan Health C.S. Mott Children’s Hospital National Poll on Children’s Health.

“Maintaining oral health from a young age, including regular brushing and flossing, helps prevent tooth decay, gum disease and other issues that make it difficult for children to eat and speak clearly,” said Mott Poll Co-Director Sarah Clark, M.P.H.

“Over a third of parents in our poll reported their child does not regularly brush twice a day – the most basic level of oral hygiene.”

The nationally representative report is based on 1,801 responses from parents with at least one child aged 4-17 polled in August 2024.

Oral hygiene practices often neglected

Sixty-four percent of parents say their child brushes their teeth twice a day and roughly 60% say brushing lasts for at least two minutes.

But fewer parents say their child consistently follows other oral health recommendations. For example, only a third of parents report their child regularly brushes the tongue, and less than a quarter floss regularly, which helps remove hard-to-reach food remnants between the teeth.

Both the tongue and the crevices between teeth are areas that harbor bacteria that cause tooth decay, gum disease or bad breath, Clark notes.

In between brushing, rinsing the mouth with water after consuming sugary foods or beverages can help to prevent the sugar from adhering to the teeth; however, only 15% of parents report their child regularly uses this strategy.

Overall, just one in five parents say their child does at least four of the top six recommended oral health tasks on all or most days — with less consistency reported among boys than girls. Children who followed fewer practices and did them less frequently had more oral health challenges.

“Regular oral health prevents plaque buildup and keeps gums healthy by preventing inflammation, bleeding, and infection,” Clark said. “Teaching kids the importance of a comprehensive oral hygiene routine sets the foundation for lifelong oral health.”

Over a third of parents polled have also noticed that their child has bad breath, which was more common among children who only followed one or less oral hygiene practices all or most days.

Most parents attribute their child’s bad breath to “morning breath” or lack of brushing or flossing while less than a quarter cited smelly food, mouth breathing or dental problems.

“Neglecting oral health habits is not only harmful for overall health but can increase the risk of discolored teeth and bad breath, which can be embarrassing for children and cause low self-esteem,” Clark said.

To improve oral hygiene, she adds, parents need to find ways to ensure that all family members have enough time in the morning and evening while also making sure children are brushing and flossing correctly.

Dental visits essential for catching problems early

Most parents polled say their child’s most recent dentist visit was within the past year, but 7% said it was one to two years ago and 4% said it’s been more than two years. Parents reporting their child follows 0-1 oral hygiene recommendations all or most days are also more likely to say their child has not had a dental visit in over a year

The American Dental Association recommends a dental visit every six months to discover early signs of decay, monitor the growth of teeth, and educate children and families on oral hygiene, Clark says.

“Each child’s oral health needs are unique. Dentists can provide tailored recommendations; for example, some children will benefit from sealants or fluoride varnish to protect the teeth from sources of decay,” she said.

“Early detection allows for timely intervention, often reducing the need for more invasive treatments later.”

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The Interactive Talk presentation, “An Online Platform to Promote Customized Self Oral Healthcare,” will take place on Thursday, June 22, 2023, at 2:10 p.m. Colombia Time (UTC-05:00) during the “Health Promotion and Education” session.

The study by Chloe Meng Jiang of the University of Hong Kong, SAR, China developed an online platform to facilitate patient oral health self-care with guidance from dental professionals, which was soft launched in Hong Kong in March 2020 for pilot testing. The comprehensive online platform integrates online shopping for oral health products with the delivery of up-to-date oral health information and education.

Dentists and dental hygienists can register on the platform for free, while patients can register to use the service through an invitation link sent by the clinic. The platform supplies customized oral health products that are recommended by the dentist/hygienist based on the patient’s oral health condition, and proactive online oral health information and education.

The platform has been on a trial run for more than 20 months. As of November 2022, seven dental clinics and ten dentist/hygienists had registered at the platform. A total of 495 patients had registered and joined as active users. A total of 631 pieces of customized dental care instruction had been distributed to the registered patients by dentists/hygienists through the platform. Patients had logged in 835 times, and more than half of them re-visited the platform. A total of 348 purchases were recorded. The mean amount of transaction per purchase was HKD 441 (around USD 57). The most popular items purchased were toothpaste, dental floss, mouth rinse, and manual toothbrushes.

Based on the preliminary data, the online platform is a promising tool to promote customized oral health self-care among dental patients. It helps to nature positive dental behavior among dental patients by connecting them with dental professionals.

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The authors, who are affiliated with the Ribeirão Preto Dental School (FORP-USP) and School of Pharmaceutical Sciences (FCFRP-USP), investigated the effects of celecoxib and indomethacin, non-steroidal anti-inflammatory drugs (NSAIDs) classified by the World Health Organization (WHO) as the first step on the analgesic ladder, alongside paracetamol.

In recent years, dentists at FORP-USP’s Dental Enamel Clinic, who research and deal with the problem on a daily basis, have observed a sharp rise in the number of children seeking treatment for pain, white or yellow tooth spots, and dental sensitivity and fragility. In some cases, simple chewing can fracture the children’s teeth. All these are classical symptoms of DEDs of the type known as enamel hypomineralization, whose causes are poorly understood.

As a result of this disorder, dental decay in the form of carious lesions appears sooner and more frequently in these patients, whose restorations are less adhesive and tend to fail more. Studies have shown they may have to replace restorations ten times more often over a lifetime than people with healthy teeth.

A coincidence aroused the researchers’ curiosity most of all: the patients’ ages. The first years of life, when DEDs form, are a period in which sickness is frequent, often with high fever. “These diseases are typically treated with NSAIDs, which inhibit the activity of cyclooxygenase [COX, a key inflammatory enzyme] and reduce production of prostaglandin [which also promotes inflammation],” said Francisco de Paula-Silva, a professor in FORP-USP’s Pediatric Department and last author of the article. “However, COX and prostaglandin are known to be physiological for dental enamel, and we therefore wondered whether these drugs interfered in the normal formation of this structure.”

The study was supported by FAPESP via three projects (10/17611-4, 14/07125-6 and 21/09272-0).

The researchers used rats to study the problem, as these animals have incisors that grow continuously, which facilitates analysis. The rats were treated with celecoxib and indomethacin for 28 days, after which practically no differences were visible to the naked eye in their teeth. However, when the researchers began extracting, they found that the teeth fractured more easily.

Analysis based on imaging and chemical composition suggested that dental mineralization had been affected. The teeth contained below-normal levels of calcium and phosphate, which are important to dental enamel formation, and mineral density was low.

When the researchers looked for the reasons for this, they found alterations in proteins required for mineralization and cellular differentiation, showing that the drugs had indeed affected the composition of the dental enamel.

Next steps

“Right now, the study at least offers us a clue to the identity of a new player that may be involved in the development of DEDs. Hitherto we’ve been totally in the dark,” said Paula-Silva. “We only achieved these important findings thanks to the efforts of FORP-USP’s Dental Enamel Clinic and collaboration with Lúcia Helena Faccioli, a professor at FCFRP-USP. She made a crucial contribution to our understanding of the role played by lipidic mediators related to inflammatory diseases that affect teeth.”

The group plan to conduct a clinical study with the aim of confirming the results of the research in the animal model. “We’re going to analyze the medical history of the children with DEDs and their use of these drugs, and we’ll set up a clinical study that will correlate the two datasets to see if the same thing happens to humans. If so, we can make recommendations on which drugs shouldn’t be used for which patients. We can also help work out an appropriate treatment protocol in future,” said Paula-Silva, comparing this situation with that of tetracycline, an antibiotic not recommended for children because it causes tooth discoloration.

Another important point to be addressed is indiscriminate use of over-the-counter drugs, a problem that appears to have worsened as pediatric care has become more common, although concrete information on this is not yet available.

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This unprecedented access would aid all types of dental professionals, including general dentists, oral surgeons, periodontists, prosthodontists, endodontists, hygienists and others. A new multi-study project from the Regenstrief Institute and Indiana University School of Dentistry has determined that information from patients’ medical records is generally not available to oral health practitioners in either an easy-to-use or timely manner.

The dental informatics researchers confirmed that requested medical information typically is faxed from a medical facility to the dental office. Faxes, sometimes unreadable when received, often are scanned into the patient’s dental record. The researchers found that, typically, the faxed information arrived in 7 to 10 days, although in the study, 30 percent took even longer.

“Oral health practitioners may need to confirm a list of medical considerations; for example, that there is no contraindication to a patient sitting in a chair for a lengthy procedure or whether a patient is taking any medication that could put them at risk for excessive bleeding during a tooth extraction or other procedure,” said senior author and study leader Thankam P. Thyvalikakath, DMD, MDS, PhD, director of the Regenstrief and IU School of Dentistry Dental Informatics program. “In this day and age of electronic data transmissions in banking, shopping and other commercial fields, should health professionals still be relying on inefficient, paper-based methods for sharing patient information?”

Demand for advanced dental care is increasing due to people living longer with chronic diseases like HIV and the growing number of older adults with natural teeth. For these patients, information from their medical file may be especially critical to appropriate dental treatment.

The researcher-clinicians found that the medical information most frequently requested by a dental office to finalize treatment decisions and procedure timing were patient diabetes status and history of blood sugar levels. Knowing this information helps oral health professionals rule out any contraindication to undergo dental treatments, determine outcomes of a surgical procedure or assess options for implant placement and calculate risk for gum disease. For example, if blood sugar numbers are high, there is a greater probability that an implant may fail.

“Retrospective Study of the Reasons and Time Involved for Dental Providers’ Medical Consults” is published in the peer-reviewed journal Frontiers in Digital Health. Authors, in addition to Dr. Thyvalikakath, who is the senior and the corresponding author, are Shuning Li, PhD, IU School of Dentistry; Karmen S. Williams, MBA, DrPH, Regenstrief Institute and IU Richard M. Fairbanks School of Public Health, IU School of Dentistry and City University of New York; Jayanth Kuman Medam, BDS, M.S., IU School of Dentistry and ELLKAY LLC; Jay S. Patel, BDS, MS, PhD, IU School of Dentistry and Temple University and Theresa Gonzalez, DDS, IU School of Dentistry.

The study was funded by IU School of Dentistry and the National Library of Medicine.

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