Two Topics in One Day - Evidence Based Analgesia and Opioid-Sparing Strategies for the Dental Professional & Three Serious Drug Interactions That Every Dentist Should Know About

This presentation will first review identify the potential problem in prescribing opioids for dental postsurgical pain and other painful dental conditions. The biochemical and physiological mechanisms behind post-surgical dental pain will be reviewed and a discussion of various double-blind randomized controlled trials on the efficacy of various analgesic agents following the surgical removal of impacted third molar teeth will take place.  A discussion of the “drug seeking patient” and the prescription opioid abuse problem will be highlighted.  The final portion of this discussion will focus on meta-analysis data for various analgesics in both dental pain and other post-surgical pain models. “IN OTHER WORDS WHICH ANALGESICS CONSISTENTLY LEAD THE PACK AND WHICH ARE CONSISTENTLY DOGS”.   An updated flexible analgesic schedule published in JADA will finalize the program.

This course will enable participant to:

• Describe differences in opioid prescribing habits in the USA and England in 2016.
• Discuss what can happen with even short-term exposure to opioids. 
• List various peripheral chemical mediators that contribute to post-surgical dental pain.Compare the analgesic efficacy of NSAIDs to single entity oral opioids in randomized placebo controlled double-blind oral surgery pain studies.
• Compare the short-term side effect profile of NSAIDs versus opioids.
• Discuss the potential opioid-sparing effect of combining an NSAID with acetaminophen and of employing 0.5% bupivacaine plus 1:200,000 epinephrine post-surgically.
• Discuss meta-analysis data on the numbers needed treat (NNT) to obtain one additional patient with at least 50% maximum pain relief beyond the placebo treatment. 

 Three Serious Drug Interactions That Every Dentist Should Know About

This presentation will focus on two areas.  1) Serious adverse drug interactions that may occur in the Dental Patient because of drugs the dentist prescribes or administers and 2) Serious adverse drug interactions that may occur in the Dentist himself/herself because of drugs that they are taking for various medical conditions. The three serious drug interactions that may adversely impact the dental patient that will be discussed include; 1) the ability of the antimicrobials metronidazole and fluconazole to inhibit the metabolism of warfarin by blocking cytochrome P-450 2C9 (CYP-2C9), the major metabolic pathway of warfarin, resulting in dramatic increases in patients’ international normalized ratios (INRs) and potentially fatal bleeding. 2) The ability of nonsteroidal anti-inflammatory drugs (NSAIDs) to inhibit the renal excretion of the major bipolar disorder drug lithium and lead to serious lithium toxicity. And 3)   the ability of propranolol and other nonselective beta-adrenergic blocking agents to inhibit the vasodilatory effect of epinephrine in dental local anesthetic solutions, leading to a hypertensive reactions and a concomitant reflex bradycardia. Interactions relevant to the health of the dentist themselves to be discussed includes the ability of grapefruit juice to greatly increase blood levels of statin cholesterol lowering drugs, increasing the risk of myalgias, rhabdomyolysis and acute renal failure. And some evidenced-based data on the ability of male erectile dysfunction drugs to cause a severe drop in blood pressure to patients administered sublingual nitroglycerin for an acute angina attack in the dental chair or patients on long term nitrates for control of their angina symptoms.   It is important for clinicians to understand the theoretical basis behind these often-predictable interactions, and comprehend the evidenced-based-literature that supports their existence. By doing so, they will provide the safest and best treatment for their patients and keep themselves out of trouble.

This course will enable the participant to:

• Discuss the pharmacological mechanism behind the potentially lethal metronidazole or fluconazole/warfarin interaction.
• Identify the common characteristic shared among most drugs involved in the most serious adverse drug: drug interactions
• Identify which class of anti-hypertensive drugs where the administration of high therapeutic doses of local anesthetics with epinephrine are most likely to cause a hypertensive reaction with a reflex bradycardia.
• Discuss the rationale of why ibuprofen (Advil®) and naproxen sodium (Aleve®) should be avoided in bipolar disorder patients taking lithium (Eskalith®).
• Identify a common food product that greatly increases blood levels of oral midazolam and statin cholesterol lowering drugs.
   

 Dr. Elliot Hersh is currently a Professor of Pharmacology / Oral Surgery at the University of Pennsylvania School of Dental Medicine. He received his DMD degree from RSDM, formerly UMDNJ-NJDS, in 1981 and his MS and PhD degrees from UMDNJ – Graduate School of Biomedical Sciences in 1983 and 1988 respectively.  Since arriving at the PENN in 1988 Dr Hersh has won the Dental School’s Excellence in the Teaching of Basic Science Award 20 different times and was also presented with a University Lindback Award in 1993, the highest teaching honor in the entire University.