Pi DENTAL CENTER BLOG

The Opiate Crisis and How It Relates To Dentistry

Posted by Chris Raines on Feb 28, 2017 4:46:08 PM

Pennsylvania Guidelines for Dentists Regarding OpioidsDentists are among the leading prescribers of opioid prescriptions. The opiate crisis, which takes lives, destroys families and increases crime, has significantly increased in recent years. New regulations and programs address this issue.

A February 2017 panel discussion that included the Montgomery County Department of Drug and Alcohol, the Sheriff’s office, County Commissioner, Dr. Valerie Arkoosh, a Salvation Army representative, and survivors and advocates, was held to address the 138% increase in Montgomery County drug overdoses in 2016.

Research suggests that abuse of prescribed opioids can open the door to heroin use. Nearly half of young people who inject heroin surveyed in three recent studies reported abusing prescription opioids before they started heroin. Some individuals reported switching to heroin because it is less expensive and easier to obtain than prescription opioids. *

More people are dying from heroin overdose than in the past and authorities say that this is due to Fentanyl, which drug dealers often use to cut heroin. It is 80 to 100 times stronger than morphine.

Chief Deputy Michael Beaty, Montgomery County Sheriff’s Office, reported 237 drug related deaths in 2016 (213 were accidental and 98 involved Fentanyl). He asserted that drug use increases other crimes, such as theft.

Cocaine, methamphetamine, oxycodone and the prescription anti-anxiety medications alprazolam (Xanax) and clonazepam (Klonopin) contribute to overdose deaths.

Drug abuse is not only an urban problem. It occurs all locations, including suburban and, surprisingly, rural areas. A 2015 report from the Center for Rural Pennsylvania showed that overdose deaths from heroin, which sells for as little as $5 per bag on the streets, as well as prescription painkillers and other opioids have increased by 470% compared to the previous 20 years. More Pennsylvanians ages 20 to 44 are dying annually from overdoses than from motor vehicle accidents.

“Because of the uptick in cases, the treatment system is being severely taxed. Treatment centers, like Eagleville Hospital, need more beds.” said Kay McGowan, Montgomery County Deputy Administrator of Drug and Alcohol.

McGowan addressed the issue of relapse by recovering addicts. “So many people relapse when they are prescribed meds by a doctor.” Physicians and dentists must conduct careful screening  to determine if the patient is in recovery. Alternatives, such as Nsaids, should be prescribed.

Benny Mosakowski lived in a tranquil suburban community where he attended Plymouth Whitemarsh High School and played football in the 1980’s.  Prescription opioid medications had been prescribed for a football injury.  Benny states that he became instantly hooked on the prescribed pills. He found that the pills were readily available to him but eventually switched to heroin. Benny never thought that heroin addiction could happen but his life quickly spiraled out of control.  Mr. Mosakowski related, “I needed heroin as much as I needed air. I never learned to be an adult or developed coping skills. At 35, I’d had two marriages and 2 children and was sticking a needle in my arm every day.” It took Benny 10 years to stay clean. Thanks to Eagleville Hospital, as of 2012, he has not had another drug. “This is a disease and not a deficiency. I have seen more people die in the past 1 ½ years than in the previous 15. When you reach a state of willingness, if the help is there, you can quit. The problem starts in the medicine cabinet, but then heroin costs less than pills.” Today, Mr. Mosakowski is a survivor and advocate helping others.

The Journal of the American Medical Association reveals that dentists routinely prescribe opioid analgesics. The first sign of this unexpected source of opioid prescriptions was discovered in 2011. At that time a survey of members from the American Dental Association Survey Center was taken and the findings were surprising. The data shows the following:

  • 85% of dental surgeons said they almost always prescribed an opioid
  • 64% of surgeons said that their opioid prescription of choice was hydrocodone with acetaminophen
  • The average number of hydrocodone with acetaminophen was 20 tablets
  • In 96% of the cases, the only medical instructions provided for taking the pills was "as needed for pain”**

Gary Tuggle, who oversees the DEA’s Philadelphia Division, states, “It is imperative that law enforcement, healthcare and treatment professionals, elected officials, and community groups work together to address the factors impacting availability, use and abuse of these drugs.”

“There are many alternatives to opiates that are quite effective,” adds Valerie Arkoosh MD, Montgomery County Commissioner. “If a physician will not consider giving a non-narcotic medication, get a second opinion.” She emphasized, “Patients can just say no to opiates. Parents should always consider non-opiates.” Arkoosh also briefly discussed the new database that doctors and dentists must check before writing opioid prescriptions.

Many people believe that if pain relievers are prescribed by a doctor or dentist, then they are safe.  However, if these medications are taken in larger amounts, more often than prescribed, or for unintended reasons, they can cause severe adverse effects including addiction, overdose, and death. Prescribed medications should never be taken by someone other than the one for whom they were prescribed. Opioid medications should never be combined with alcohol or other drugs.

In light of the current opiate epidemic, dentists must ask themselves how they can effectively help to reduce the problem.  They must learn how to identify patients who have an addiction problem.

Pennsylvania Programs at PA.Gov

What should a dentist do if they suspect that one of their patients has an addiction problem?

New Pennsylvania Department of Health Prescription Drug Monitoring Program (PA PDMP) requirements took effect in January 2017.  Dentists must check the PA PDMP database each time they prescribe an opioid medication.

Governor Wolf said, “By reducing the pattern of over-prescribing painkillers that have such a high risk for abuse, we are fighting back against opioid abuse and heroin use before those habits even begin.”

Providers have a responsibility to diagnose and treat pain using informed clinical judgement that minimizes serious adverse effects. Consideration for the patient’s past and current history of opioid use and abuse must be included when determining which pain medications should be prescribed. The patient’s substance use history should be documented.

Ask open-ended questions to learn about the patient’s drug use. It is as difficult as it is essential. Broaching the subject feels awkward and intrusive.

Unless contraindicated, non-steroidal anti-inflammatory medications (NSAIDS) should be considered. In many cases, NSAIDs have proven to be more effective in treating dental pain than opioids. Pain therapy can be initiated immediately prior to the surgical procedure and continued on a scheduled basis following completion of the procedure.

Patients reporting unexpectedly prolonged pain, particularly those who do not show evidence of ongoing pathology, should not be prescribed opioids. They can instead be referred to a chronic pain specialist.

Relevant information should be provided so patients are well informed about the various options available for pain management. Good physician/patient communication is essential.***

Patients whose behavior indicates the presence of a substance use disorder, should be encouraged to seek evaluation for treatment through their primary medical care provider.

Pennsylvania Medication Take-Back Program ContainerPatients should be instructed in safe disposal of unused medications, to ensure that these meds will not be misused. Through the Pennsylvania Prescription Drug Take-Back Program, Med Return Collection Boxes are available for safe disposal of unused medications, including opioids. This program has placed 492 boxes across Pennsylvania. The total amount of drugs taken back and destroyed in 2015 was 56,252 pounds. https://apps.ddap.pa.gov/GetHelpNow/PillDrop.aspx

Prosthodontist, Dr. Glenn Wolfinger states, “The staff of Pi Dental Center and I have been very aware of the issues regarding opioid use and have been very careful throughout the years in how these medications were prescribed. Non-steroidal anti-inflammatory pain medications have worked well for Pi Dental Center patients.”

In light of the severity of the opioid crisis, it is obligatory that dentists and physicians follow the new Pennsylvania guidelines to identify at-risk patients and to ensure patients are prescribed safe medications.

Contact Pi Dental Center for information about dental treatment and surgical procedures and pain medications.

Ask A Dental Question Or Schedule An Appointment

 


Learn More about the opiate crisis and how it relates to dentistry:

Pennsylvania Department Of Health Prescription Drug Monitoring Program
http://www.health.pa.gov/Your-Department-of-Health/Offices%20and%20Bureaus/PaPrescriptionDrugMonitoringProgram/Pages/PDMP-Portal.aspx#.WLCb-m8rKM8

Link to Portal
https://pennsylvania.pmpaware.net/login

Mapping Pennsylvania’s Worsening Heroin Crisis
http://www.pennlive.com/news/2016/03/pennsylvanias_heroin_crisis_is.html

DEA: Drug overdose deaths up sharply in Pennsylvania By Michael Goldberg
http://www.thereporteronline.com/article/RO/20160715/NEWS/160719879

* National Institute on Drug Abuse
https://www.drugabuse.gov/publications/research-reports/heroin/how-heroin-linked-to-prescription-drug-abuse

** http://www.soberrecovery.com/recovery/how-dentists-are-contributing-to-the-opioid-epidemic/

Info about Gary Tuggle
https://www.dea.gov/divisions/phi/phi_sac.shtml

*** Improving the management of post-operative acute pain Meissner et al.
http://www.efic.org/moxiemanager/data/files/Improving%20the%20management%20of%20post-operative%20acute%20pain.pdf

http://sanctuary.net/prescription-drugs-lead-to-illegal-drug-use/

http://www.health.pa.gov/Your-Department-of-Health/Offices%20and%20Bureaus/PaPrescriptionDrugMonitoringProgram/Pages/PDMP-Portal.aspx#.WLCb-m8rKM8

http://www.newbeginningsdrugrehab.org/guide-to-addiction-prevention-for-seniors/

https://addictionresource.com/addiction/substance-abuse-among-seniors/

http://www.health.pa.gov/Your-Department-of-Health/Offices%20and%20Bureaus/PaPrescriptionDrugMonitoringProgram/Pages/GeneralInfo.aspx#.WK84UW8rKM8

http://www.health.pa.gov/My%20Health/Diseases%20and%20Conditions/M-P/opioids/Documents/opioid_dental_prescribing_guidelines3_13_15.pdf

http://www.health.pa.gov/My%20Health/Diseases%20and%20Conditions/M-P/opioids/Pages/Prescribing-Guidelines.aspx#.WK85N28rKM8

https://www.drugabuse.gov/nidamed-medical-health-professionals/about-addiction-performance-project/addiction-performance-project/talking-to-patients-about-their-drug-use

http://ocw.tufts.edu/Content/70/lecturenotes/1260782

http://us14.campaign-archive1.com/?u=daa8d6d8dddc3e7cf2f933b1c&id=f538cf95e1&e=be06d005f4

http://www.medscape.com/viewarticle/867751

http://www.npr.org/sections/health-shots/2017/02/26/513865623/dentists-work-to-ease-patients-pain-with-fewer-opioids?sc=17&f=1001

Tags: dentist, dentistry, opiate crisis and how it relates to dentistry

What is Tilite?

Posted by Pi Dental Center on May 13, 2011 1:36:00 PM

M  letters Chris PROJECTS EmailBlasts VerticalResponse tilite2 resized 600

“A Medically Pure Ceramic Alloy With Titanium” 

Tilite is an alloy used in dental crowns, bridges and implant restorations at Pi Dental Center.  This formula is based on the same science that NASA used in the fabrication of the porcelain fused to metal heat shield for the Apollo Space Program.  Tilite absorbs heat at the same rate as the porcelain, thus eliminating the stress and strain between metal and porcelain creating an excellent porcelain bond. 

Tilite has undergone extensive testing for several years and has been proven to be completely safe and meets all FDA requirements for medical devices implanted in the body.  Tilite is the only non-gold alloy that has been approved by the FDA and for ISO certification. 

ISO certification standards relate to quality management systems and are designed to help organizations ensure they meet the needs of customers, reduce waste, increase productivity and create a more efficient, effective operation. 

Tilite has a bond strength that is unsurpassed in ceramic alloys.  A study conducted in 1984 confirmed the high compressive strength of porcelain bonded to Tilite.  It outperformed a well-known precious ceramic gold alloy! 

Tilite alloy’s thermal resistance to temperature change acts as an insulator for a patient’s tooth pulp, allowing patients to drink hot liquids or eat very cold foods with comfort. Also, the alloy is non-magnetic and will not react to other metals in the mouth or cause pain when touched by metal utensils or instruments. 

With over 125 million prostheses delivered to patients world-wide, there has not been a single documented case involving Tilite causing a problem. 

Tilite has been used in dental implant supported prostheses since 1984 with 100% success rate. 

Pi Dental Center strives to provide our patients with the best products available. Tilite has proven to meet our stringent requirements for excellence. 

Tilite is produced by Talladium, Inc., Velencia, CA 


Tags: dental implants, dental implant treatment, dentist, dentistry

Winter 2011 Insights Newsletter Highlights Dental Treatment and Planning

Posted by Thomas Balshi, DDS FACP on Mar 15, 2011 11:55:00 AM

Insights NewsletterThe Importance Of Attention To Detail

To provide consistent high quality restorations, whether for single crowns or full mouth reconstructions, attention to detail is essential from treatment planning to prosthesis delivery. We all know the critical marks of excellence. The oral examination must be thorough and include cancer screening. A written treatment plan is the ideal roadmap for sequencing the indicated treatment. The tooth is prepared allowing sufficient room for the thickness of the restoring material and with particular consideration to the health of the soft tissue response following delivery. Proper height of contour, immergence profile and correct interproximal contours are all details that impact quality care.
Before and After Photos

Once the tooth preparation is finalized, other important steps also require attention to detail. Retraction of gingival tissues is key. Consideration must be given as to whether the tissue is thick or thin and friable. When a retraction cord is used, size and the exertion of pressure placing the cord are both critical. Fibrous connections must never be compromised.

The Final Impression is a Detail of Utmost Importance.

The dental laboratory can only provide the natural looking, perfect crown we are expecting if we provide them with the most exact impression possible. Each practitioner has his or her own techniques, usually based on vast experience, for achieving the ideal impression, but what is often overlooked in this equation is the quality of the impression material being used. This is where attention to detail points to accuracy and provides for a more predictable result.
Before and After Photo

ENTER EXA’lence | this is an impression material that is clearly “new”.

Developed by GC America, EXA’lence combines vinyl and polymer to produce a totally new impression material set apart from all of the others. It is intrinsically hydrophilic without surfactants for wet-ability. It has a high tear strength that allows for easy removal from the mouth and multiple accurate pours for stone casts. In addition, its chemistry minimizes bubbles and voids, resulting in very clean and sharp impressions. The following complete implant prosthodontic rehabilitation was achieved with EXA’lence impression material.

Attention to detail is the hallmark of good dentistry and should be essential in every phase of treatment. We as dentists have autonomous control of our implant placement, our crown preparations, proper vertical dimension and articulation. What we need is to place more importance upon our choices of dental materials.

Dentists who are currently using EXA’lence report that it is both pleasant to use and consistently accurate, allowing for sulcular moisture control and very exacting subgingival and marginal detail. Lab technicians’ report that it both pours easily, allows for second pours if needed, and provides well-defined impressions. In a recent Catapult Evaluation, 81% of the evaluators said they would integrate EXA’lence into their practice. For further information on EXA’lence, please go to gcamerica.com or call 1-800-323-7063.

THE IMPORTANCE OF ATTENTION TO ORAL SCREENING

With the National Cancer Institute estimating approximately 36 thousand new cases of oral cancer for 2010 and the likelihood that close to 8 thousand will result in death, our responsibilities as dentists significantly increase. Identifying lesions early is the key to preventing fatalities. Oral cancers that present at an advanced stage have a higher death rate than breast cancer, prostate cancer, melanoma or lymphoma.

It is important that the dental profession take seriously our responsibility to identify lesions in the mouth quickly and to educate the patient thoroughly in treatment protocol. We recently presented a case study in which an older Caucasian female received maxillary and mandibular implant-supported prostheses (1992) and subsequent meticulous follow-up had no indications of any soft tissue abnormality. In 2008, the patient presented with a “rough area” on the tongue. A 5x7 mm fibroma-like elevated lesion was noted and attributed to mechanical trauma. Surface adjustments were made and the patient was advised to return for a follow-up appointment in two weeks.

This patient did not return for further evaluation but moved out of state. We requested that she immediately consult a specialist in her new location. Follow-up was then lost.

In 2010, the patient returned to Pi complaining of a sore on her tongue. She had not followed our advice and had not been seen by any dental specialist since her 2008 visit. Examination of the patient revealed an ulcerated mass on the right lateral border of the tongue, which extended onto the ventral and dorsal surfaces. The lesion was hard and irregular. A regional cancer center confirmed squamous cell carcinoma. The patient declined further care and expired a few weeks later.

Cases such as this indicate the importance of regular oral screenings for cancer and meticulous follow-up when suspicious lesions are found. It is equally essential that time be taken to carefully explain to the patient that oral cancer is curable when found early and treated accordingly. Similarly, we must also indicate the seriousness of leaving such findings untreated or approaching them holistically.

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Tags: dental implants, dental treatment, dentistry, dental treatment planning