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A guide to the management of amalgam in the dentistry environment

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A guide to the management of amalgam in the dentistry environment


Unused dental surgery prescriptions may help fuel opioid epidemic

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the United States is in the midst of a prescription opioid epidemic. Evidence suggests people who abuse prescription opioids often use leftover pills that were prescribed for friends or family members. Now, new research finds over half of opioids prescribed to patients who have dental surgery - such as wisdom tooth removal - are not used.

A report on the study, by researchers at the University of Pennsylvania (Penn) in Philadelphia, is published in the journal Drug and Alcohol Dependence.

The authors suggest if there were more drug disposal kiosks in pharmacies, and if dentists reduced the amount of opioid pills they prescribe following surgery by just a little, it could reduce the mountain of unused pills - and therefore the amount of misuse - significantly.

They estimate - if we translate their findings to the whole U.S. population - that potentially over 1 million opioid pills prescribed to patients following removal of wisdom teeth are unused.

Opioids to relieve pain are often prescribed following surgery or injury, or for health conditions such as cancer.

In recent years in the U.S., there has been a dramatic increase in prescribing opioids for chronic, non-cancer pain, such asback pain or osteoarthritis, even though they carry serious risks and there is no evidence about their long-term effects.

Anyone who takes prescription opioids can become addicted to them. Once addicted, it can be hard to stop. Taking too many prescription opioids can stop a person's breathing, leading to death.

According to the Centers for Disease Control and Prevention (CDC) in 2014, nearly 2 million Americans either abused or were dependent on prescription opioid painkillers. The CDC now refer to the situation as an epidemic.

Since 1999, the number of overdose deaths in the U.S. involving opioids has nearly quadrupled, and we now know, say the CDC, that a driving factor is increase in overdoses from prescription opioid painkillers.

Seventy-nine patients had over 1,000 opioid pills left over

For their investigation, the team looked at prescription opioid use in 79 patients who were prescribed the painkillers following dental impaction surgery.

They were also interested in how specific information about a drug-disposal program in pharmacies might affect the willingness of patients to properly dispose of any unused pills.

The results showed that just 24 hours after surgery, patients were reporting an average pain level of 5 out of 10 while on painkillers. By day 2, just over half (51 percent) were reporting levels of 0-3 out of 10, and by day 5, nearly 80 percent were reporting low levels of pain.

Nearly all the patients (94 percent) were given a prescription for an opioid painkiller. In addition, 82 percent were also given a prescription-strength nonsteroidal anti-inflammatory drug (NSAID), and 78 percent received a prescription antibiotic.

The vast majority of patients (93 percent) did not have post-surgery complications. On average, after 3 weeks, these patients had only used 13 out of the 28 opioid pills prescribed, leaving a total of over 1,000 unused pills. Only five of the patients used all their prescribed opioids.

Co-author Elliot V. Hersh, a professor in the departments of oral & maxillofacial surgery and pharmacology at Penn's School of Dental Medicine, says:

"Results of our study show within 5 days of surgery, most patients are experiencing relatively little pain, and yet, most still had well over half of their opioid prescription left."

Drug disposal centers can make a difference

The team also found that giving patients specific information about a pharmacy-based drug disposal program, in addition to general information, led to a 22 percent increase in patients who either used the facility or planned to use it as a way to dispose of leftover opioid pills.

This was compared with patients who were only given the general information, comprising a hotline to ring and a sheet describing controlled substances and the risks of keeping opioid pills.

The team suggests putting more drug disposal centers in grocery stores, retail pharmacies, and other places patients visit regularly could substantially increase proper disposal of unused prescription opioids.

Another suggestion the team makes is that by just moderately reducing the quantity they prescribe following surgery, dentists and oral surgeons could also potentially reduce surplus opioid pills.


Stem cell manipulation shows promise for cartilage renewal and joint repair

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for people with a type of jaw joint disorder that results from loss of cartilage, the only treatments available address symptoms but do not repair the damaged tissue. Now, a new study of mice suggests stem cells already present in the jaw joint could be manipulated to repair it.

The study, led by Columbia University Medical Center in New York, NY, is published in the journal Nature Communications. The authors describe how manipulating stem cells in the temporomandibular joint (TMJ) of mice with TMJ degeneration led the cells to repair cartilage in the joint.

The researchers also found that transplanting just a single TMJ stem cell into a mouse spontaneously generated cartilage and bone and even began to form a bone marrow niche.

Lead and corresponding author Mildred C. Embree, assistant professor of dental medicine at Columbia, says:

"This is very exciting for the field because patients who have problems with their jaws and TMJs are very limited in terms of clinical treatments available."

Stem cells - immature cells that have the potential to mature into virtually any type of tissue cell - hold great promise for regenerative medicine, where faulty, damaged, or injured tissue is repaired by encouraging new cells to grow.

Alternative to stem cell transplanting

One way to regenerate tissue is to transplant stem cells into the affected area. However, as the authors explain in their paper, this approach can be risky - for instance, the donor cells could be rejected by the recipient's immune system, introduce pathogens, or even give rise to tumors.

An alternative approach that could avoid these risks is the possibility that stem cells already present in the affected area could be induced to make new cells repair the damaged tissue.

Cartilage is a type of tissue that cushions bones and lines the joints to enable smooth movement without damage.

Within the TMJ, the cartilage is of a type called fibrocartilage. This type is also found in the knee meniscus and the discs between the vertebrae of the spine.

Once it is damaged - for instance through injury or disease - fibrocartilage does not regrow or heal, with the result that people suffer permanent disability.

In the United States alone, there are up to 10 million people - mostly women - with TMJ disorders. Children with juvenile idiopathic arthritis can also have stunted jaw growth that cannot be treated with existing drugs. The researchers suggest their findings could lead to new treatments that help these groups.

Suppressing Wnt signals

In their study, Prof. Embree and colleagues - including Jeremy Mao, the Edwin S. Robinson Professor of Dentistry (in Orthopedic Surgery) at Columbia - show for the first time that the "fibrous superficial zone" in the TMJ of mice harbors fibrocartilage stem cells (FCSCs).

They also discovered that a single FCSC transplanted into a live mouse is capable of not only generating cartilage and bone, but also of organizing the microenvironment to support the process - rather like specialized niches in bone marrow.

Moreover, the researchers showed that they could manipulate FCSCs to differentiate into the required cell types by suppressing a type of cell signal called Wnt. They found that overactive Wnt signals disrupt the stability of fibrocartilage and promote degeneration by depleting FCSCs.

The findings could also open up routes to new treatments for repairing fibrocartilage in joints other than the TMJ, including the knees and vertebral discs, as Prof. Embree explains:

"Those types of cartilage have different cellular constituents, so we would have to really investigate the molecular underpinnings regarding how these cells are regulated."

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