CEimpact Podcast

New Pain Guidelines from the American Dental Association

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Join us this episode as we discuss new recommendations from the American Dental Association on acute pain management.
 
The GameChanger
Dosing acetaminophen and ibuprofen where they peak at the same time due to their synergistic properties, resulting in treatment being often more effective than hydrocodone-apap and oxycodone-apap for pain relief.
 
Guest
Karen Baker, M.S.Pharm., R.Ph
Associate Professor
Colleges of Dentistry and Pharmacy, University of Iowa


Reference
https://www.ada.org/about/press-releases/new-guideline-details-acute-pain-management-strategies-for-adolescent-adult-dental-patients

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CPE Information
 
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Discuss new guideline details on acute pain management for dental patients.
2. Identify how appropriate prescribing for acute dental pain can improve treatment and outcomes.

0.05 CEU/0.5 Hr
UAN: 0107-0000-24-157-H01-P
Initial release date: 04/22/2024
Expiration date: X/042/2025
Additional CPE details can be found here.

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Speaker 1:

Hey, CE Plan members from CE Impact. This is Game Changers. I am so excited about our guest today because she was one of my very favorite instructors and preceptors when I was at the University of Iowa College of Pharmacy, and we were just talking before we hit record that that was 30 years ago. So I don't know whether that's a good thing or a bad thing. I guess we both still are here and doing our thing, so that's great, but I have to admit I'm feeling a little bit intimidated today. I will call that out because she's also one of the smartest people I know and you will all find that out very quickly and she has been in this practice for a really long time and has a lot to share with us today. So it will be worth it, because this is going to be a lot of fun, if nothing else. So let me introduce you to Dr Karen Baker.

Speaker 2:

Thanks, jen. Yes, indeed, 30 years ago, and I've been here since 1981. So that seems hard to believe because it's been. It's gone real fast. I could. I just want to tell you a little bit about my practice here at the College of.

Speaker 2:

Dentistry University of Iowa and we're the only college of dentistry that has an in-house pharmacy full service retail pharmacy compounding lab associated with it, as well as two full-time clinical pharmacists. So this is a very well-developed clerkship site for P1s and P4s. We've had pharmacy students here since 1972. And I'm so proud of the fact that when my dental students graduate they say well, one of the first things I need to do is find my pharmacist. I'm going to find my pharmacist in my town or in my city, and so I love that. They have that established relationship. So we teach extensively. My partner here is Dr Amy Dunleavy, who's been here two years now and she's a graduate of the University of Iowa and then did a community residency with Osterhouses, so she's an Iowa product and we managed to get her back here. So and she also is very adept at compounding and I think is going to be teaching some compounding classes at the College of Pharmacy. So we're joint appointed with the College of Pharmacy. We're 80-20 and we have been that way for many, many years here with our two positions. So Amy is new and brings all that energy that the new graduate brings.

Speaker 2:

So anyway, what we do here is we do clinical consultations. We manage a full-time retail pharmacy with a compounding lab and Dr Dunleavy does a lot of compounding. We mail compounders to all the states we're licensed in, including Iowa, to manage mucosal diseases and head and neck pain. So we can finish up with that in terms of you know, towards the end we'll talk about what the community pharmacist or clinical pharmacist needs to look for when it comes to head and neck, because that's something that the patient can present to you easily and modestly in a community setting. So I think you need to be aware of what you need to look for and what are the warning signs of emergent care needs in those patients.

Speaker 2:

So we do a lot of teaching. We teach basic pharmacology for dental students as well as applied clinical pharmacology to dental students and then teach the grad students as well. So we're a very well-developed, as I said, clerkship site, training site. We have, you know, p4s here right now and they're in our clinics. They're in oral surgery, oral medicine and also in our special geriatric, special needs clinics. So we have some really good experiences for them in those clinics as well.

Speaker 1:

Yeah, yeah, it is so cool and I can attest to that. I mean, just how much you learn about the other practices and you know you don't I mean they, you know you don't really make that connection. I think at a typical, you know, college of pharmacy where you don't maybe don't have that connection to the college of dentistry. And so so much of you know the med list and what you're seeing, you know on the dental side. I mean, I know, even when you go to the dentist and you're they're like what are your meds? And you know you think, well, why does this relate? And it does. So it's, it's really cool that you're educating dentists to access their pharmacist, because it's so important, because they're not keeping up on that probably. I mean, they have enough to keep up on, they do.

Speaker 2:

I mean that's exactly the thing. It's like a medicine specialty as well. I mean they have to keep up with the technology and the techniques and so that's very intensive. It's very technologically intensive in dentistry these days. So just to keep up with that is hard enough. But then to deal with the medical side of on cannabis but we won't get into that. Maybe I need to just chill out, I probably need to just mellow out a little bit, but you know, the whole cannabis legalization thing has really impacted dentistry in ways that we we really couldn't imagine.

Speaker 2:

Just simple things like getting informed consent. If somebody comes in high, I mean, how do you get, how do you get valid informed consent to do an irreversible procedure, and medicine deals with this all the time as well. So we deal with all the things that you would expect to deal with in a pharmacy setting, a medical setting. But we also face. The challenge that you just mentioned, jen, was that when we say now we need a complete and accurate list of everything that you take for medicines, and many times the patient will say there's nothing I'm on that you need to know about. I've heard that thousands of times from patients because they think the mouth is separate from the rest of their body, and that certainly isn't the case.

Speaker 1:

So that's a challenge for us here. Yeah, yeah and such. I mean just an interesting perspective. You're dialed into it, but most people aren't so I'm really excited to talk about this today, and maybe we'll have to have you back to talk about cannabis.

Speaker 2:

Because that is something I had not even thought about. Oh my goodness, yeah, it's an issue.

Speaker 1:

Yeah, I bet I mean just in, like the pain management in the office, right, if you're having a procedure or something. Yeah, that hadn't even occurred to me, so we'll have to do that. Well, today we are going to talk about kind of a timely topic, although I think this is, you know, an age old topic. But there was just a publication in the Journal of the American Dental Association and I'll say, if we say ADA, it's not the American Diabetes Association, there's also another ADA. So we say in pharmacy we have a million acronyms, but I think all of healthcare and the world has too many acronyms, it's hard to keep track. But when we were initially talking about this, we said ADA and somebody on our team was like wait, what, why is? Why are they talking about pain?

Speaker 1:

The American Diabetes Association, it's like American Dental Association, but they just released some evidence-based practice, clinical practice guidelines for the management of acute pain, and I think that's something you know. I mean, and we can talk about this with the opioid epidemic and you know you hear a lot of people say it starts with a simple wisdom teeth. You know somebody got their wisdom teeth out or prescribed hydrocodone or oxycodone, and you know. Then we know what happens from there to some people if you're opioid naive, so talk to us a little bit about, maybe, how this came about, what the history of pain management in dental practice has been and where we are now like. What are the practice guidelines that everybody should be adhering to and that we see in pharmacy guidelines that everybody should be adhering?

Speaker 2:

to and that we see in pharmacy. Yeah, it's certainly dentistry is associated with having to manage pain. I mean, when you think about the specialty areas that manage pain emergency department dentistry I mean and some of that pain can be very, very acute and very intense. So the history is, I think that, going back to looking at the opioid epidemic, dentistry was implicated by many folks. Attorneys general, national senators, national politicians would come on and say you know, it just takes one prescription for wisdom teeth. And of course, here's the problem. The crux of the issue is that you're doing large numbers of osseous or bone removal procedures in adolescents. So it's the adolescent who is the at-risk group.

Speaker 2:

We all know that substance use disorder is a pediatric disease. Most patients with a substance use disorder I believe it's 90% had their first usage as an adolescent, and an adolescent is 12 to 17. So it's always very dangerous to expose an adolescent to a psychoactive substance I don't care if it's THC for cannabis, or whether it's an opioid without those inhibitory pathways that form in the prefrontal cortex. And how long do we figure that that takes? Probably age 25, although some would say millennials, maybe age 35. And I say that because I have two millennial children and they would be appalled if they knew I was saying things like that. But they won't watch my podcast, so that's fine. They don't even listen to my voicemail messages.

Speaker 1:

So if you think, about Do they even have a voicemail set up? No, no, if they see there's a voicemail, they just delete and then call. Yeah, they're like wait. I didn't even know how to access my voicemail.

Speaker 2:

That's just not a thing anymore. Yeah, so you know. Remember that when you're treating someone who's 16, the risks of exposing them to opioids are much higher. And we, of course, in this country do take out third molars prophylactically, because we know that the retention of third molars can lead to pathology. So if you're wondering, why do we even do that, there are a lot of things that happen when you retain third molars, certainly with certain types of anatomy that lead to periodontitis, periodontal disease. You know your bone dissolves back there in the alveolar bone. So there are reasons to take out wisdom teeth. Crowding is one of them as well. This country, we have to have straight teeth, so straight white teeth, by the way.

Speaker 1:

Very white Very white.

Speaker 2:

They have to be almost shockingly white. So remember that we take out their molars. Now other countries the UK, which is what England, scotland, wales, northern Ireland Since 2011,. The NICE guidelines, the guidelines for National Health Service, say you don't prophylactically routinely take out third molars. So you cannot compare apples to oranges when you compare US dentistry to dentistry in the UK, because they're not doing widespread osseous surgery in adolescents over there and we are so again. So dentistry is many times implicated as the first exposure of an opioid naive adolescent to opioids. So that carries a heavy weight in terms of risks and I think that's where we've been the spotlight.

Speaker 2:

I think in some circles the contribution of dental opioids to the opioid crisis has been overblown because our prescription numbers are counted, as you know.

Speaker 2:

Look, dentists prescribe 10% of the immediate release opioid prescriptions in the United States, although that's down now substantially since 2015, probably by 60%. Remember, and pharmacists know this the prescriptions that you get for opioids from dentists might be 12 tablets. They used to be more, they used to be maybe 20 or 25. Yet the prescription that you get from a pain management clinic might be 120 or 90 or 240. So remember, you know you have to count actual MMEs versus or number of tablets and tablet strength versus just number of prescriptions. So in that sense, I think dental contributions to the opioid crisis have been a bit amplified over what they truly have been. So I do take issue a bit with that. But having said that, having said that dentistry's got the message, certainly, since 2015, reductions in numbers of prescriptions and actual numbers of tablets per prescription have been dramatic in dental prescribers. So, believe me, dentists, including oral and maxillofacial surgeons, have gotten they've gotten the message on this.

Speaker 1:

Yeah, so what does it look like now? I mean, what is the typical prescribing pattern for wisdom teeth removal or other you know procedure?

Speaker 2:

Well, that's really good that you differentiate, because remember who's doing wisdom teeth removal or other you know procedure. Well, that's really good that you differentiate, because remember who's doing wisdom teeth removal primarily oral and maxillofacial surgeons. These are people who are dentists, who usually undergo anywhere from four to six additional years of training to become oral and maxillofacial surgeons, and they do much more than wisdom teeth removal. They do many other kinds of complex oral and maxillofacial surgeries as well. So that specialty does the difficult surgery. So they're the one that's going to do the wisdom teeth where they're angled backwards and you're going to have to take out bone to get those teeth out. So they're going to do the difficult surgery.

Speaker 2:

And what kind of surgery hurts the most? Mandible? So remember, your maxilla is fixed, it doesn't move. But mandibular surgery hurts more, and so they're going to do those what we call distoangular mandibular impaction surgeries. Those are the, those are the very difficult surgeries and that's what your OMS, your OMS facial surgeon, is going to do. And they need to have the option of rescue opioids in patients, because these are these can be for one to three days really painful surgeries. Now, typical dental procedures. Let me tell you what a general dentist do they say take some Tylenol, take some ibuprofen or naproxen sodium, or take them together if they anticipate moderate pain, which is what we do now. Incredibly effective, In fact, kind of unbelievably effective.

Speaker 1:

Yeah, I would agree with that. It's so funny that you say that because we, a couple of years ago actually Jake Galdo on our team, we were talking about that and he was citing some articles and I, you know, I tell people that now, like that's my go-to is one ibuprofen and one Tylenol and, it's amazing, with that synergistic effect I mean that that treats every headache.

Speaker 2:

It does, and you have plenty of headaches, I know that.

Speaker 2:

We won't talk about the reasons but, I won't, I don't, we don't want to get into that, but remember that's that's a key thing for pharmacists to make sure they emphasize, but remember that's a key thing for pharmacists to make sure they emphasize. So in dentistry. So you asked, what do general dentists do versus OMS? And believe me, oral maxillofacial surgeons lay the foundation with non-opioid pain relief and then they only will add in limited numbers of tablets of opioids as rescue what we call rescue analgesia, of opioids as rescue, what we call rescue analgesia. So again, in dentistry, it is always non-steroidals first, because they are the most effective for inflammatory pain.

Speaker 2:

And what are we dealing with in dentistry? Inflammatory pain, not neuropathic pain, generally inflammatory pain. So we need to use anti-inflammatories and we need to use them on a scheduled, regular basis. So we don't want patients to wait until pain return to medicate again. So if they've had a procedure, we want to make sure that we schedule the non-opioid medication for one to three days, and so that is typically our range, and then after that it's as needed. So that's what a typical general dentist will do. Most general, many general dentists don't even, don't even apply for DEA numbers anymore because they do not prescribe controlled substances.

Speaker 1:

Yeah, and, and how, what? How great to just avoid the whole situation.

Speaker 2:

Exactly and I. That's really quite common. Now, of course they have to remember that they then can't prescribe benzodiazepines for minimal sedation for the anxious patient. So sometimes there's a catch-22 there. Well, no, I need to maintain my DEA number because I need to prescribe a benzodiazepine just prior to a dental procedure. But anyway, that's what a general dentist does. First line, if you can tolerate and don't have any contraindications, is a non-steroidal, and then if that's not adequate after the first hour and you still have the throbby pain, then you add in the acetaminophen and if that works, then that is your combo and you take them concomitantly and that's very important for the pharmacist to emphasize you want them to peak at the same time because they are synergistic, which is a relatively new finding.

Speaker 1:

When I say new which is so basic, I mean when I heard that it was like duh.

Speaker 2:

Well, you know, it's so funny because for years and years we'd say, oh yeah, take Tylenol, take acetaminophen. But we really didn't understand the true mechanism of acetaminophen because we always said, oh, it's centrally acting, it's COX-3 inhibitory in the central nervous system. But now we know that it inhibits the step after the non-steroidal. It inhibits that step in the formation of inflammatory mediators from arachidonic acid. So I know everybody has the arachidonic acid cascade. Maybe artwork that has it. I do, certainly.

Speaker 1:

And so there it is.

Speaker 2:

So we've got ibuprofen that works at the step just prior to where the peroxidase inhibition is, and that's acetaminophen. So acetaminophen works centrally and peripherally, and that's the part we didn't know until about what 2011. And then, in 2013, the definitive studies by Hirsch and Moore came out that showed that the number needed to treat for pain relief was lower, with 400 milligrams of ibuprofen plus a thousand of acetaminophen. And notice what I just said I said a thousand. So 400 plus a thousand is better than hydrocodone plus acetaminophen or oxycodone plus acetaminophen, which, if you told the average person on the street, they would say I don't believe you. Yeah, I don't believe you. So it is really. We've known this since about 2013.

Speaker 1:

Yeah, yeah, it is really powerful. And we always used to say, like you know, do opposite, and that doesn't. You know, it doesn't make any sense. Now that we understand that, must stagger those medicines.

Speaker 2:

Now, where does that come from? That comes from not wanting to treat with too much non-steroidal in a very young child, especially for teething pain or fever. So that's where it comes from. It's sort of a legacy, sort of a holdover. But I think what we need to explain is look, we need to have maximized peak synergistic pain relief because we are trying to do this without opioids. This is what we're dealing with inflammatory bone pain in adolescent and we want to make sure that we maximize non-opioid analgesia. And the way we do that is by giving the drugs concomitantly. The good news is their adverse effects are not additive. That's good and it's short term.

Speaker 1:

Well, and I think that brings up a good point. I thought one of the interesting statements in the article was that 37% of emergency room visits that are linked to a dental symptom received an opioid, whereas other pain it was 14% received an opioid. So I don't know if that's just an element of not understanding, but I think that message that you just said is so important for that group as well. For emergency room, like if there's dental pain, you know, do you do the same thing? Do you do that 1,400 and get them triaged into the place where?

Speaker 2:

they need to be. Yes, and you know that that gets to to the real crux of the issue, which is what? What's going on with dental pain and where does that patient need to be seen? That patient needs to have definitive dental treatment. We call it the three D's. The three D's are diagnosis, definitive dental treatment. What's the third D Drugs? But that's the third D Drugs, but that's the third D. So the first D is diagnosis. The second D is definitive dental treatment the root canal, the drainage and debridement, the extraction.

Speaker 2:

So pulpal dental pain is intense. So I do understand if a patient presents in an emergency department in endodontic crisis, meaning they have pulpal dental pain, it is intense and that patient will present with very intense symptoms of pain. So I understand the reflex, which is well, this patient needs opioids, but, yeah, this patient needs the foundational non-opioids. But what they really need is definitive dental treatment and that presents a problem in terms of access of care access to care. What if you're going to have to wait five days to see the endodontist for a multi-rooted root canal, five days with this pain? So again, it is problematic and it's an access to care issue, as well as not understanding who's able to render definitive dental treatment and it typically is not an emergency department or a quick care clinic.

Speaker 1:

Yeah, right, right. So let's talk about that a little bit, because I think you know, if you are in a community pharmacy, you might be the first one to see, you know that patient if they're not headed straight to the ER, which a lot of people do. But so so let's. I mean, I think access to care you mentioned is an issue, and if you're not in an urban setting, you know there is that. I mean, how far do you have to travel to even see a specialist who can help you with the diagnosis, let alone getting in to have the procedure? So what, what does that look like? What are you seeing? I mean, I know you're lucky, you're fortunate that you're at a you know a facility where you can handle all of that. But but I know you also have outreach clinics in small rural areas as well.

Speaker 1:

So what does that issue look like?

Speaker 2:

Well, I, think that in in a lot of rural areas I mean, you got to understand that when you graduate from dental school, you are trained here at Iowa. You have done root canals, you have done extractions, so you have done incision and drainage. In some cases it depends on what you see, but you have done these procedures so you should be able to render some of this care. Now, when it gets complex, what you want to do is refer to a specialist, and that would be an endodontist, for example, or an oral and maxillofacial surgeon, and that might present. The challenge right there is can they get you in Now?

Speaker 2:

I will say that for an emergent case, most, for example, oral and maxillofacial surgeons will make themselves available as an endodontists as well will make themselves available to somebody who's got, you know, high, a high intensity symptom presentation. So I will say that that that does happen. So you go to your general dentist and if they they deem it necessary to send you to the specialist, they will make the call to the specialist and typically they have good relationships certainly in Iowa we do. I mean, the general dentists are the referral base to the specialist, so they'll make the referral and then grade the urgency of it so that you can figure that out.

Speaker 1:

Yeah, so before we started recording, we were talking a little bit about. You know, some things that people, that pharmacists, may see that you wouldn't necessarily think as a dental issue when you're talking about pain. So can you talk a little bit about that too? Because I you know, you mentioned a couple of things and I was like, oh yes, I mean we need to be able to triage that. And again to recommend the pain management in the meantime?

Speaker 2:

Yes, so I think it's very, very true that the community pharmacist, the accessible healthcare provider, is going to see something oral, facial, because it can be presented in a public setting, versus some things that we won't go into, that you really can't. So you can see what's going on with somebody's face and neck and mouth, because they will show you and what are you worried. So what does the pharmacist really have to dial in on and say this is an urgency, this is an urgency. Anything periocular, anything that involves periocular redness or swelling or inflammation, needs to be seen that day, because there's a threatened central nervous system communication with this infection, which is very dangerous. Another thing you might not realize is anything submandibular, so under the chin here, because there is a direct communication with fascial planes that could lead to a space infection, what's called a submandibular space infection, which can cut off your airway. So again, if you see a swelling here now, it might just be a salivary gland infection, which is usually staph, but it also might be a submandibular space infection due to migration of bacteria from an infected site or a previous surgery. So what do you need to be really alarmed about?

Speaker 2:

Three things periocular, submandibular and rapidly progressive cellulitis. So a rapidly progressive cellulitis means it's diffuse, it's indurated, it's hard as a board and it is spreading. So those are the things that we call urgencies that need to be seen that day. Of course, if it's 7 PM now, what are you going to do? But hopefully it's a little earlier in the day.

Speaker 2:

I woke up and my eye was swollen. That's a typical scenario. So that's where you, as the, as the triage person say, you need to see at minimum your general dentist or a general dentist today, and probably preferably an oral and maxillofacial surgeon. An oral surgeon is who you need to see today to treat that definitively and to either get them referred. Many oral and maxillofacial surgeons, if not almost all, have hospital privileges, hospital admittance privileges, and they will get you admitted for a head and neck infection if you need to be on IVs. Sometimes these rapidly progressive infections will not be amenable to oral antibiotics and you know so it's becoming more complex and that's kind of another topic, but we really are, especially in in the face of reported penicillin allergy. We're very limited in the antibiotics that are going to work for these kinds of infections which is a whole nother topic, that's another I noticed that you said reported penicillin allergy, so we won't that's another topic.

Speaker 1:

Yes, yeah, that's a whole nother topic we could talk about. Well, and what are the? I mean, what's the prevalence of that Cause? The way you talk about it, I'm like, oh my goodness. And then I'm thinking I know people that have had that and I don't feel like the first thing you think about is something related to your mouth. I mean, because those are presenting in other places.

Speaker 2:

Yes, do we call those odontogenic infections. What does that mean? Tooth source. So you've got a couple of different sources in the mouth. You've got periodontal source, which is the supportive structures of the tooth. That's a periodontal related infection.

Speaker 2:

But the tooth source infections are sometimes due to people who don't have adequate dental care. Sometimes due to people who don't have adequate dental care who have what we call deep cavities, deep caries that penetrate into the pulp chamber and then lead to a periapical pathology that then can just blow up and spread. So you know a lot of what leads to these serious complications. Number one would be lack of dental care and lack of home care. Right, that's one. Number two, it could be a post-procedural complication. So that's what you ask is now have you had a procedure, a dental procedure, or is this just something that arose without you seeing a dentist? And then, how often do you see a dentist? These are the questions to get the feel for is this patient what we call a dental attender, meaning do they go to the dentist or do they only go when their face enlarges, which we have? Those folks as well, yeah, so those are your risk group.

Speaker 1:

Yeah Well, and you talk about access to care. I mean we have a community health worker for us, that we train technicians in pharmacy settings to be community health workers, and that's one of the questions that we ask, because I don't think people I mean people feel it's interesting the concepts that that people relate to dental care. I mean it is healthcare. It is important to have that preventive, but people view it as preventive. Instead, you know they're waiting for something to happen and then because it's also expensive, and so I think that's the other thing that you know a lot of people.

Speaker 1:

they don't have insurance, they don't have the means to see a provider on a regular basis. So that is one of the concepts that we teach in community health worker asking those questions.

Speaker 2:

So yes, yeah, and you know it is one of the tenants of diabetes management, in other words, is one of them is ensuring regular dental care. I mean, that's right on the list. I think it's number seven on the list of things that you do when you newly diagnose a patient as type two diabetic, for example. So it is it is important component and it's inter interrelated. But yeah, I think your risk, you know your risk group, is those who either don't have access, don't have the economic means, don't have dental insurance, and just say you know, I'm only going to go if I have a crisis. Yeah, yeah, and that's, that's really dangerous. It's quite dangerous to do, yeah, yeah absolutely Well.

Speaker 1:

I have one more question, and this is a little bit selfish, because I have accessed your clinic on number of occasions for canker sores, and so that's another thing that I think pharmacists see, and compounded products are big in that space too. So while I have you, can we talk a little bit about that as well, and what we should be recommending as pharmacists and what truly works, because I think there's a lot out there that doesn't work.

Speaker 2:

Yes, and I do. Actually, next week I'm giving a lecture to the would it be the P2s on intraoral therapeutic agents for common mucosal diseases that's what it's called. So that's one of my lectures to the P2 students and we talk about this and most P2 students are surprised I that canker sores are not infectious. There's not an infectious etiology. So what is a canker sore? It is an exaggerated autoimmune response to minor trauma. So you've got two processes there. You're predisposed genetically, and health care workers seem to have a higher prevalence of canker sores and you might say that's because they're so stressed. Well, it's also. There's a genetic predisposition as well. So if it's always been, your family's always had canker sores, you're likely to be a canker sore sufferer. And boy do they hurt. By the way, they really hurt. I get them. So, especially if they're on your tongue oh my goodness, because your tongue moves all the time. So it's just torture, yeah. So what is a canker sore? It's an exaggerated autoimmune response to minor trauma.

Speaker 2:

So what can you do? Number one limit the trauma. And that's the part that most clinicians miss. They say well, let's treat it. Well. Let's first look at underlying predisposing factors we call them baseline initiatives to try to prevent and reduce severity and also occurrence, and that would mean limit traumatic procedures, foods and chemicals in the oral cavity. So that's where the pharmacist can come in and say, okay, what are you using for and I know this is time consuming and maybe you know if you're too busy you can't really get into this but you have to say you need to limit chemicals in the oral cavity in your toothpaste, mouthwash, whatever you use in the oral cavity. So you need to limit the trauma and you know what that means. No whiteners, oh that's a problem.

Speaker 2:

And that's a problem for people that go oh no, I have to use my high detergent, high whitener, high stain preventive. Well, all of that breaks down your proteinaceous pellicle, which is that smooth layer that protects your mucosa, and so what you need to say is look, you need a low chemical toothpaste. Where do you look for low chemical toothpaste? Look to your feet in the drugstore. If you're in the drugstore and you look down at your feet, the old school toothpastes are down there, the cheap ones they're like. Well, with inflation let me $2.29.

Speaker 2:

They used to be $1.79. So they're $2.29. Those are the and the pediatric ones, pediatric toothpaste, those are the low chemicals. So what are you looking at at eye level? Five shades whiter in two days, guaranteed to glow in the dark like David Schwimmer and friends, you know I mean. So that's what you're looking at at eye level. But you got to do the old school ones, the low chemicals. And of course, your dentist, or basically your hygienist, is going to know this and they're going to say, yeah, you need to stop using all these high whitener, high chemical, high detergent toothpaste because that's going to make you have canker sores. You know the other thing popcorn people like popping.

Speaker 2:

You know our sad yeah, those little holes, those little those they call us micro cuts.

Speaker 2:

That makes sense so if you stop popping from popcorn for a month you can have a big reduction in cankers. So trauma limit trauma. So let's do that first for a month and see how, what our baseline is. Then how do you treat? If you still have lesions, especially if you have the big ones that take a long time to heal, there might be something else going on. They're like Bechet's. There are other disease states. There's minor apathy, major apathy and herpetiform recurrent apathy. So there's three categories. So let's say you still get canker sores, then you want to cut off the autoimmune response. So no, that doesn't mean you.

Speaker 2:

You put tetracycline, you open a minocycline or a doxycycline capsule. That's, that's antimicrobial. But what's going to help is corticosteroids. Now how do you get a corticosteroid in the mouth? It's pretty tough. Dexamethasone oral solution is available, but it's not very potent on a milligram basis which sounds odd to say about dexamethasone so probably a compounded triamcinolone 0.1 or 0.2%. That's actually called Iowa rinse. We've used it here to manage patients with non-microbial mucositis since about 1976. So it's called Iowa rinse across the United States. So that's what you have to use and you have to, you know, work through making sure the patient doesn't swallow it and all that. So topical corticosteroids to cut off the autoimmune response. Step one get rid of the chemicals and the traumatic foods. So step one is that and then step two is if we still have symptomatic canker sore formation now we need to cut off that autoimmune response and order some Iowa rinse Iowa rinse. Pharmacy will go, oh yeah, that's corticosteroid. Yes, it is.

Speaker 1:

Yes, we know exactly what that is. Well, vanity has a cost, right? You can't have white teeth and not have canker sores. So you got to decide.

Speaker 2:

Yeah, it's a problem Getting those white teeth is you pay a heavy price. You know beauty does hurt, so yes, it does it does comes at a price.

Speaker 1:

It comes at a price. Well, thank you so much. This was so interesting, um, I think it's just. You know some, a few topics that we don't talk about very often. I know it's your world and you live it, um, but I really appreciate you coming on and talking about this. I think we identified a couple other things, so we'll have to have you back.

Speaker 2:

Okay, thanks, jen, it was great seeing you.

Speaker 1:

Yeah, it was so fun. So thank you so much, and that is it for this week, unless you have anything else you want to wrap up with.

Speaker 2:

Well, you know just the final word on the guidelines. You know the pain guidelines. What we have, we had March of 2016 CDC guidelines for opioids, but that was just chronic pain. And then the November 2022 CDC guidelines updated the chronic pain and then added acute pain, in which dentists were finally included there. But I will tell you that the November 2022 guidelines we'd been doing everything in those guidelines for at least five or six years, if not longer, so they just sort of they just sort of codified what dentistry has been doing.

Speaker 2:

And then we have the September 2023 guidelines for pediatric pain management. So you can find those on the ADA website and this is all published in JADA, the general American dental association. And then we have the February, which you alluded to in the beginning of the podcast, the February 2024 guidelines, which is in JADA, and you can easily just go to the American Dental Association clinical guidelines, and they're there and essentially they all say the same thing First line is not opioids. First line is not opioids. We know that, we hear, we've been teaching that for many, many years to our dental students. But again, and then we talked about the synergism, and so that's what I leave you with is the synergism of concomitant acetaminophen ibuprofen or acetaminophen naproxen sodium.

Speaker 1:

Yeah, yeah, that's the game changer, whether it's new or not, that is the game changer, right there.

Speaker 1:

Yes, thank you, and we will have all of those references in our show notes. So if you can just click on those show notes, you'll be able to access all those articles. So thank you for referencing that, giving us a little bibliography so well, that is it for this week. If you're a CE plan member, be sure to claim your CE credit for this episode by logging into CEimpactcom. And, as always, have a great week, keep learning. Thank you, karen, and we'll talk to you all next week. You