Good afternoon, everyone, and welcome to today's webinar. I am Felicia Bloom, Manager in the Practice Institute at the American Dental Association. On behalf of the ADA and our collaboration with the Providers Clinical Support System, PCSS, I am very pleased to bring you today's webinar, Opioids, Dentistry, and Addiction, the Dentist's Role in Treating Pain. Our presenters do not have any conflicts to disclose. The goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications, as well as for the prevention and treatment of substance use disorders. Here are our educational objectives for today's program. Our presenters today are Sharon Parsons, DDS, and David Kimberley, DDS, MD, FACS. Dr. Sharon Parsons owns a group practice in Columbus, Ohio, where she practices with two associates. She has been active in all levels of organized dentistry and is a past president of the Ohio Dental Association. Dr. Parsons was the recipient of the Lucy Hobbs Humanitarian Award and the Icons of Dentistry Award. Dr. David Kimberley is an oral surgeon in private practice in Akron, Ohio. He is a past president of the Ohio Dental Association, the Akron Dental Society, and the past chair of the ODA's Council on Dental Care Programs and Dental Practice and the Ethics Subcommittee. Thank you, everyone, for joining us today. It is now my true honor to turn everything over to Drs. Kimberley and Parsons. Thank you, Felicia. That was a wonderful introduction. Now I would like to introduce you to someone else. This is Sean Herman. At the time this photo was taken, he was about 18 years old. Sean was your typical guy. He was a catcher on the baseball team in high school. He was very bright. He was in the gifted program all through school. He had a very sharp wit, dry sense of humor. He was not a wilting violet you would always know when he came in the room. Was he a perfect kid? No, none of them are. He was like most kids, got in trouble, did things he shouldn't have done, but all in all was not a big troublemaker. I'm going to tell the story of Sean and his journey as we go through our presentation today. So I'm going to start with our next slide. And this is one of the main things that I want you to remember from today. In the adolescent brain, between the ages of 13 and 26, the prefrontal cortex is forming. And in this little tender age group, if exposed to an opioid, they are five times more likely to become addicted. And I want to say that again, five times more likely to become addicted. So 13 to 26, that's sports injuries in middle school, high school, college, and that's also wisdom teeth. And that's where we come in. Of all the people with addiction, 96.5% started substance use before age 21. So they fall in that age group that I was talking about. And genetics account for 40 to 70% of the risk. So let's say you're seeing a patient in your office, and they're in that age group. I'm not good enough to be able to look at one patient and say, you know, I'm pretty sure Johnny's okay. But that Mary, she's, you know, she may have a problem with all this. You don't know. And I think you probably need to look at every patient as though they could be genetically predisposed to addiction. In my case, Sean was in college, he had been accepted to Ohio State in their scholars program. It was his junior year. He was living off campus. And he just didn't seem to be quite right. He was about half a beat behind on everything he did, and he seemed to be kind of tired and things just weren't quite right. And I would ask him what was going on. And he would always have an excuse. Oh, mom, you know, I've been studying. I you know, I'm tired. I had this going on. There was always a ready excuse until it got so bad that finally, I got him to talk to me. And he told me that, and I remembered this instance, he had told me that he was going to go ride dirt bikes, and it was finals week. And you know, as a typical mother, you tell them, you know, don't do that. That's ridiculous. You're going to fall, you're going to hurt yourself. And as a typical son, he didn't listen, and he did it anyway. And he fell and he hurt himself, just like his mom said, but he didn't want me to know. So he didn't go to the emergency room. He didn't go to the doctor. He talked to his roommates, the guy next door came over and said, Hey, I've got something that's going to get you through, you'll get through your finals, you'll be just fine. And he handed him four pills. Well, it turns out that those four pills were Oxycontin. And they did get him out of pain. And they did get it in various finals. And apparently he liked them a lot. And he went back for more. And that was the start of a five year ordeal that was a nightmare. And I will talk more about that as we go on. So Oxycontin, that came on the market in 1995. And they had said that there was a less than 1% chance of addiction if you use Oxycontin. Now, as we all know, that was not true. But that's what they said. Also, they changed the way that they sold to practitioners, the way I understand it. Up until that time, most of the drug companies would have someone who was a retired pharmacist or retired physician come to the doctor's office. And they would, you know, talk about they'd be very knowledgeable, they would talk about, you know, the pluses, the minuses in how you might want to use this new drug that had come on the market. Apparently, Purdue Pharma decided that young attractive females would be the way to go, who really didn't have a lot of knowledge. So this kind of changed the way that drugs were promoted. And I'm going to turn this over to Dr. Kimberly, because he has more information on this. Thanks, Sharon. My portion of this presentation deals with my experience prescribing narcotic pain medication. And the numbers that I'm going to show are startling, to say the least. But I want everyone to understand that that's the way we were trained. To Sharon's point, specifically, I've been in private practice for about 20 years and was in education for a few years before that. And in the 90s, we were told that narcotic pain medication, specifically OxyContin, in the extended release was not habit forming, and that no one should be in pain. And also to Sharon's point, the drug reps that would come in were buying you textbooks and buying you lunches, and they had beautiful suits and watches and the females were extremely willing to entertain you as far as bringing you lunch and dinners and after work parties and that type of stuff. But very little was done explaining the details of the pharmacokinetics or the pharmacology of the drugs. With one exception, we did have a PharmD that was the director of our pharmacy program that came and spoke at Grand Rounds and general surgery and made a very compelling case that OxyContin was a safe medication and that really no one should have to suffer after surgery. Specifically, I remember this because it happened to me. I had a one month rotation in second year general surgeon in the breast service, and we were doing needle low-care breast biopsies that day. And this particular individual's family had come through, and in the post-operative area, I mentioned to him, I was at that Grand Rounds, I discussed, you know, wanted to follow your guidelines, and I prescribed Percocet for what was essentially a relatively minor soft tissue biopsy and a substantial number, 20. And I was berated because I obviously didn't understand that OxyContin was the drug to give and she needed quite a few OxyContin. And I remember thinking to myself, that just doesn't seem logical, but you are the director of the pharmacy program and you are a PharmD, so I complied. Fast forward, I realize now that was a huge mistake, and these numbers I think will be shocking. So is drug addiction a disease or a moral failing? When I first started looking into this, I found that most of my colleagues that were trained as I was, felt that drug addiction, specifically opioid addiction, was not the fault of the practitioners, and it was certainly a moral failing or a decision, a conscious decision made by the patients. You prescribe the medication, should they choose to take it in a way that is not prescribed, that's their problem. We didn't understand that drug addiction is actually a disease that is very similar to diabetes. And I'll kind of draw the analogies here. So we know that no one would say that somebody with type 2 diabetes today, we wouldn't say, hey, you know, you just choose to eat too many cheeseburgers. That's a contributing factor, but we also know that there's a genetic predisposition to type 2 diabetes, as there is in addiction. We know that there's a specific organ or organ systems in type 2 diabetes, as there is in addiction. So we know that with diabetes, there's too much glucose, not enough insulin. And we see that in addiction, there's also a neurotransmitter, there's too much dopamine. The results in diabetes of too much glucose, not enough insulin, is tissue receptor downregulation. Well, lo and behold, we now know that in addiction, it's the same thing, receptor downregulation in the midbrain. With diabetes, the effect is glycemic instability. With addiction, it's depression, craving, and all the signs that go along with addiction. So how did I get involved in this? Sharon and I had a meeting. And after the meeting, she wasn't doing so great. I thought maybe I'd talk to her a little bit after the meeting. So we stopped, and we're having an adult beverage and just talking about life. And she told me she was really having a rough time with Sean, which is completely understandable. And I said to her, I'm so sorry, as a friend would say, I'm so sorry, Sharon. What can I do? And I really expected her to say, thank you for asking, you know, I'll be fine. But instead, as Sharon, only Sharon would do, she looked at me with those glassy blue eyes and said, you know, you need to stop prescribing narcotics. You need to look at the way you prescribe narcotics. So rather than just saying, okay, I will and walking away the way I do so many other things, I could see the pain in her eyes. And I thought, well, let me just take a look at what I've done and what my prescribing habits are. And what I found was shocking. So in 2015, I pulled all of my prescriptions and the procedures that I did. And I found that I wrote 2,268 narcotic prescriptions. And of those 2,268 narcotic prescriptions, little less than 500 were non-oxycodone or hydrocodone prescriptions. So those might've been Tylenol with codeines or some Ultrams or something of that nature. My default prescription for Wisdom Teeth at that time was 685 cases, was the five milligram Percocets dispensing 30 with one to two tabs every four hours for pain. And that was pretty common. That was pretty common. And the asterisk after the 30 is we used to prescribe Vicodin and they would get 20 tabs of Vicodin with a refill. But then the pharmacy board came along and said, well, you can't write refills for Vicodin. So our thought process at the office was, well, then we'll just give 30 Percocets. That makes sense. That way they'll have a few extra in case they need them, in case 20 is not enough. So that's the law of unintended consequences. So for a straight tooth extraction, you got 20 Percocet. You got 30 for a WSYS, you got 20 for a straight tooth extraction. So you might think to yourself, so what? That's, you know, okay. 20 or 30 at a time. Well, I wrote for 20,550 Percocet or Vicodin tabs for kids age 15 to 24 years old. That's when they get their WSYS out. That's the golden years for WSYS. So I soaked all those kids with narcotics and didn't think anything of it. So 21,700 Vicodin tabs for other adults and implants and biopsies and that kind of stuff. So that's a total of 42,000 class two narcotic tabs for me in one year. That's horrendous. So let's extrapolate. Okay. So if there are 300 oral surgeons in Ohio, according to Amos, and let's say 200 are in practice, some guys are in academics, some guys are retired. If they prescribed as I did, and that's, I know that sounds crazy today. We would never do that today, but that's 8,450,000 class two narcotic tabs just for oral surgeons. In the state of Ohio. So let's look at the big picture here. There are 7,000 dentists. Let's take out the oral surgeons, the pediatric guys, they're not, and gals, they're not going to use that. Orthodontists, they don't write prescriptions. So if they did 10% of my level, just 10% of what I prescribed, it would be 25,350,000 class two tabs. That is huge. Those are tabs that are out there floating around in the community. And most people don't use all of those. So those are the ones that are in your parents' medicine cabinet, or there's some place where kids can get ahold of them, 25 million tabs. So after that, we did a deep dive and started thinking about, is it possible to make our postoperative medication routine better? What is the goal? So we obviously want to decrease nociception, which is the noxious stimulus of pain. So we started using long-acting local anesthetic, specifically Marcane. I don't use Expiril, which is a lyophilized papivacaine that's expensive. And as long as you're using the Marcane, that seems to be okay. But some of my colleagues are now using the Expiril. We decrease inflammation with non-steroidal anti-inflammatories to the maximum effect. And we use acetaminophen to its fullest potential. So we now know that decreasing inflammation and using a non-narcotic pain reliever like Tylenol is extremely effective. Now we also want to decrease the pain perception, the suffering component of surgery. So what I have found is if you educate the patient and the family as to what to expect, it's going to be uncomfortable for you. We're going to give you some medication that will decrease the pain, but it's okay to have some discomfort. That's your body's way of saying, don't do that. That's completely normal. And we also use narcotic as a rescue medication only in very rare cases. So, 2017, the default prescription for whizzies, everybody gets, for me, 20 tablets of ibuprofen, 600 milligrams, and they're to take one of those four times a day until gone. I also give them some penicillin, and I want them to take one of those four times a day with the ibuprofen until gone. So, that's a five-day course of antibiotic and anti-inflammatory. I don't make it every six hours for two reasons. One, I don't want the patients to think they're taking it for pain. I want them to take it as a scheduled medication along with their antibiotic. That way, they have the idea that it's important to take it. Don't take it as you need it. You need this, just take it. And we do it four times a day instead of the 800 milligrams, three times a day because that act of taking something is, in my opinion, gives the patient the feeling that, oh, I can take something now. It gives them the ability to treat any discomfort they're having on a more frequent basis. And then we use some Tylenol, over-the-counter acetaminophen, extra strength, one every four hours as they need it for pain. If we have complicated cases or if the patient requests it, the maximum we're going to give is six tablets of Percocet, the five, 325s. And they can add that to that extra strength Tylenol if they have to. But I always tell them, I would prefer that you take another extra strength Tylenol before you try the Percocet. But if you have to, you can use that Percocet. So for tooth extractions and soft tissue surgery, it's over-the-counter nonsteroidals and acetaminophen. If the patient requests a narcotic, we'll give them some Ultram, the 50 milligram Ultrams. Or we'll give them Vicodin. But they get no refills. And if they have a problem, they need to come back in and see us. So what I found, I don't get any requests for refills. Patients don't call you and say, hey, I need more. That used to happen nightly. You'd get phone calls. Then those of us that are surgeons, periodontists, endodontists, oral surgeons, even dentists that do surgery, fewer calls for pain and insomnia, especially insomnia. The calls I used to get with narcotics, hey, I can't sleep. Well, I can't sleep either. You called me at three o'clock in the morning. I mean, I can't sleep now either. We don't get that call anymore. I never get calls for nausea. Patients and their parents are thrilled that we have the conversation about narcotics and that we have a significant post-operative conversation about what to expect. Knowledge is key. Knowledge is king. Gives them the feeling that they know what to expect. Turn that back over to you, Sharon. Thanks. So in just a minute, I'm going to go over some different drugs and things that you can look for in your office to pick up on some signs that your patient may be taking something that you don't know about. So I talked about Sean and I talked about him admitting what had happened to him. At that point in time, he went into rehab. And back in the early 2010, 2011, rehab was basically 10 days to two weeks. It was a one and done. You did some things on your own. You had outpatient things. But it wasn't the resident long-term rehab, which is the most effective they've found. So he did his two weeks in rehab. He was doing really well. But one thing he learned while he was in rehab was that OxyContin is basically synthetic heroin. So when he relapsed, which the majority of people that go through rehab do, he wound up taking heroin because it's pennies on the dollar. They call it the addiction waltz. Most people that have an addiction and are trying to get better and trying to go through rehab or recover, go through the 12-step program. And the first three steps are the most difficult. So they're constantly repeating those steps. One, two, three, one, two, three, like a waltz. So he would get better. He would get worse. This went on for a year or two. He was living with me. And it finally got to the point that I had to kick him out of my house. I had to do the tough love thing. Dave talked about the comparing diabetes and addiction. And some of the symptoms of addiction are behavioral because it is a disease of the brain. They will lie like a champion. They will do anything to get what they need. So after I'd been stolen from quite a few times, I had to have him leave my home. At that point in time, he went down to Georgia. He had a friend down there. What I didn't know was that that friend also was a drug addict. While he was in Georgia, same thing, better, worse, better, worse. And when I thought he had hit rock bottom, he went into a program down there, which at the time I credited for saving his life. It was, you know, kind of a dramatic program and it was a tough and he made it through that. And for a while he was doing great, but then he slipped and it was back to using and things got pretty bad. His father brought him home and he was living with his father. And, and while someone was there and watching him, you know, full time and kind of keeping their thumb on him and making him do the right thing, he really could do well for long periods of time, but not left on his own. But at that point in time, he went back to school. He got his degree. He was doing very well. He was attending narcotic anonymous meetings. And ironically, he went on a narcotics anonymous trip, a whitewater raft. And on that trip the raft turned over, he fell out. He got his foot wedged under a rock and, you know, jerk to get it out and tore tendons in his ankle. He had to have surgery on that ankle. And even though Sean told the surgeon that he had a history of addiction and asked not to be given any narcotics, they gave them to him anyway. So things started all over again. He ended up getting a girlfriend and I thought, Oh, this is great. Maybe this means he's going to turn his life around. But she ended up becoming addicted as well. Things looked like they were really pretty bad. And he started to turn a corner. He went through withdrawal. He was doing very well. He decided, you know, this relationship I have with this girl is kind of toxic. We use drugs together and I really need to get away from this. I agreed to let him move back in with me. Which was a, you know, I had to really ponder that. So he was supposed to be in my house fully on a Monday and this was Sunday night. And I thought, I thought, well, Sean, why don't you just spend the night here with me tonight? And, you know, we'll watch a movie together. We'll do something. And he said, no, mom, I want to go back for one last night with her. I just, I feel like I really need to do this. Well, Monday morning at about four in the morning, I got a knock on my door. And it was the police. And they were there to inform me that my son had died of a drug overdose. And if you are in my position, anyone who deals with someone who suffers from addiction, you know, in the back of your mind that that's always a possibility. But it's the day that you, you just don't ever want to come. And my mother at the time was living. And I didn't want to wake her up four in the morning with that news. So I waited until about six. I called her. And she lives about 45 minutes away. And she hurried up, got herself together. And she came over to be with me. Well, about two hours after she got there, she collapsed in my kitchen and died. They think from a massive heart attack caused by stress. Those four pills that were given to Sean led to such tragedy for my family. I hear from, from dentists all the time. I've done this. I prescribed this way, my whole career, and I've never gotten anyone addicted. Well, I'm here to tell you, you're never going to know. That was Sean's first taste of something. Yes. He sought more on his own, but that's what your patients will do. They will not come back to you and ask you for more. They're too smart for that. They will go someplace else, but you may be their first taste of something. So I really want you to think about that before you prescribe to this age group. And when you're in your office, there are certain things that you might pick up from a patient in your chair, especially an adolescent. So I'm going to go through, and I may go through kind of quickly about all these signs and symptoms of drug use. Opioids. Slurred speech. Poor memory. Their coordination is off. Like I said, Sean was always about half a beat behind and their pupils don't always look the same. Some days they would look like they were dilated. Sometimes they'd look like they were constricted. Constipation. That's a really big one. That's, that's a dead giveaway for opioids. Sleep patterns are off. He could never sleep at night. He was up half the night. They can be hostile. They can be angry. They can be angry and sometimes they can be extremely aggressive. They will hallucinate at times. Withdrawal from social activities. Sean was so embarrassed by his addiction and he had just, he really didn't really want to be with his friends because he was so embarrassed about his, his own condition. Also their behaviors of manipulation and lying and stealing make their friends not want to be with them. Also tooth grinding. And this is where we come in on almost all of these drugs, extreme tooth grinding, and sometimes high decay rates can be a factor. Heroin. Basically the same as an opioid. Like I said, Oxycontin is synthetic heroin. You may notice needle marks, their arms, especially, but sometimes when they get really sneaky, they can, you know, do it in between their toes or any place else. Cocaine. This will be extremely dilated pupils. They're excited. They're talkative. They're confident. They'll even be euphoric at times. Their sleep patterns can be very abnormal. A decreased appetite, increased heart rate, which is very important for us, you know, runny nose, nose bleeds, sniffing all the time. They may have burned fingers. They can have mouth sores. They can really have worn their teeth down in a short period of time. That's something I've noticed on some patients. Buckles of their teeth can have a high decay rate. So, you know, this is something to look out for. Meth. They'll go long periods of time without sleeping. They have a, they'll have an extreme weight loss, gaunt appearance. They'll be anxious. They'll be confused at times. Pupils are dilated. They'll get really sweaty. They'll have increased blood pressure. Another thing that's important for us. They'll have skin sores, a lot of skin sores. Sometimes on their face, they'll pick at their face. It causes their blood vessels to shrivel over time. They'll have a dry mouth. Also tooth grinding, high, high carries rate. You know, hence the term meth mouth. Meth salts. And you're not going to see these this often, but they're sitting stream stimulant. And these people can be extremely violent and have unnatural strength, increased blood pressure, heart rate, and body temperature used over time. You can have chest pain, kidney pain, muscle tension, nausea, confusion, paranoia. They get very, very agitated. So, you know, you really don't want to be around anybody who's going through this. Club drugs. These are stimulants that will look like candies. A lot of times they'll have irregular sleeping patterns. And just like a lot of the others, dry mouth, grinding over time. If this is used with any regularity, you can actually have brain damage from this. Marijuana. This is more and more common with medical marijuana or legalized recreational marijuana, but they'll have bloodshot eyes. They'll be very lethargic, sometimes talkative. You have an increased appetite, memory problems, dry mouth. So you do have an increased chance of throat cancer because if they are smoking the marijuana, just like with smoking a cigarette, an increased chance of period disease. So sometimes it will cause vomiting, which can cause enamel erosion. Alcohol. Dialyzed blood vessels. You know, you smell that they've been drinking. They might get bigger buildup plaque and tooth decay. Adderall, which is really big with, you know, anywhere from preteen to through college and beyond. So headache, restless, fatigue, nausea, they'll have a dry mouth. They might sound hoarse with long-term abuse. They can get numbness in their limbs, dizziness, hives, chest pains, and seizures even. So why am I telling you all this? A lot of patients, especially adolescents might see the dentist a lot more than they see a physician. They'd see us twice a year for cleanings. Patients are always going to say they don't do anything. Parents are often in denial. So I'm going to, I'm going to tell you a story. And in my office, I had a long-term patient who lived out of town. And she asked me if I would see her daughter. Daughter was a young lady who had been seeing someone in their hometown. And she said, she just has some trouble with this front tooth. Would you take a look? And, you know, I took a look and I started to treat her and it became evident that everything I was doing, she would break. And the mother had told me that, you know, she had had an issue with, with a drug. And I believe it was a crack cocaine, but that she had, you know, gone through rehab. She's fine now. She just wanted me to know that history. Well, everything I made, she broke. I mean, broke right off. Even she broke the tooth to the point that it had to be extracted and I'm watching her in the chair and she's restless and she can't sit still. And, you know, she seemed to be all over the place. And as a mom, I would want to know. So I called, I called her mother and I said, look, I know you told me that your daughter was clean, but I don't know that she is. I just have a feeling that she may be using again. And she got very angry with me and she hung up on me. And I thought, well, there I go. I've lost a patient. And a couple of weeks went by and the front desk came and told me that this patient had called and she wanted me to call her. So I called her back and she said, you know, you told me what I didn't want to hear about my daughter. I wanted to think that my daughter was getting better and I didn't want to hear you say that. It made me really angry, but I thought about what you said and I started to watch her and you were right. She was, she was using again and we got her into rehab. She told me, she said, I, I think there's a good chance that you saved her life. So sometimes you make that judgment, that value decision. Do you risk losing a patient or do you risk really losing the patient as in losing their life? You may be saving a life. And as this becomes more and more common and this last year, there were more overdose deaths than ever before in 2020. I don't know what the daily rate is right now. I know a year or so ago, every day, 192 people died of an overdose. And to put that into perspective, that's basically the amount of people you can fit on a 727. So every single day, there's a plane going down with no survivors. You know, when we had a problem with Boeing, the planes, two of them went down and everyone was up in arms. They wanted to ground the fleet and we were all worried. Well, we've got 363 more guaranteed to go down. I think we all need to be a little more worried about this. It's not just our families, our friends, our friends' children, it's our patients, it's the children of our patients. It affects every one of us and we're all in this together. You have anything you wanna add? No, I think that last bullet point there is key though. Make sure you know what resources are available in your area. We, in our practice, stress very hard. We see a lot of young people and we are, now that you know what to look for, you'll be shocked at how many people you'll have a high suspicion. And it is a very tricky, tricky conversation to have because parents do not wanna hear it. But those of us that have been trained and have been exposed to what addiction does and what the patterns of addiction are, when you see it, you know it. And it's very, very rare that you're incorrect. But the thought, your line, do you wanna lose a patient or do you wanna lose a patient is spot on because I'd rather be a little bit more aggressive. You'll know it when you see it. So familiarize with the resources, please. So I'm gonna turn it over for questions. Yeah, sure. This is Julie. I will go ahead and read them as we may be having a technical issue. Can I go back? There was many questions in the chat actually about the last patient that Dr. Parsons was just mentioning. And there was some concern about HIPAA issues. Can you talk a little bit about that? I think that the attendees were having a lively conversation. Absolutely. Anytime the patient is a minor, you always can speak with the parent about the condition of the minor child. If the patient is not a minor, then it is a HIPAA violation. And that I would never wanna tell someone that you should violate HIPAA. That's a judgment call. And that's something that you'll have to decide for yourself but I certainly could never tell you, I think you should break HIPAA. So in our office, we see primarily young people and every now and then we'll have a patient that you'll see in the pre-op that's under 18. And then when they come in for surgery, they're over 18. And that's a tricky conversation. If there's a question, I'm pretty good about talking to the patient and letting them know, hey, are we in front of my assistants? Is there an adult or somebody that I can share information with? I shouldn't say trick, but convincing them that, hey, we need to share some information about your treatment options and that type of stuff. And it may not be a bad, especially if that other person is gonna be financially responsible. And you've gotta get permission from somebody that's 18. You cannot violate HIPAA. You cannot do it. As badly as I've wanted to at times, there have been times where I've tried to communicate as best, the best way possible that you need to be on the lookout for potential issues. But if the patient does not want you to share information, you just can't do it. You just can't do it. It's an ethical conundrum. And this is Felicia Bloom. Can you all hear me? Yes. Oh, okay. Thank you. I'm so sorry. Not sure what happened, but first I wanna thank you, Dr. Parsons and Dr. Kimberley. And I'm quoting one of our attendees who said you are both so brave and generous for sharing your stories. So thank you. We have so many great questions. I wanted to know one audience member asked, is Xperil approved for dental blocks now? It was my understanding it was approved for dental infiltrations only. Exactly. It is not approved for blocks and please do not use it as a block. So we do use it. We use it for infiltrative around the lower wisdom teeth. We get good results with just Marcane and the postoperative prescription regimen that I use. But I have used it. I do use it in rare cases for individuals that have hypergia from opioid use in the past. And we know that they're not going to get any opioid use, but you have to use it as an infiltration. You cannot use it for a block. That's a great question. Okay, great. We have so many questions. Thank you, audience. If parents are not interested, I know the conversation about HIPAA is so important. If parents are not interested in their child's addiction or possible addiction, what could the provider do to mitigate the situation? Well, I know for me what it is. Okay, go ahead. You do not get narcotics. If I have a strong suspicion, you do not get narcotics. I may not be able to save this patient. I'm not going to further the problem. I get very agitated about that. I won't make the problem worse. And I really have no problem telling people, no, you're not going to get any narcotics. We don't prescribe narcotics for this. If that's a problem, then you need... And you know right away, because some patients will say, what am I going to get postoperatively? And I always, that is a huge red flag for me. I'll say, well, you're going to get ibuprofen, and well, the ibuprofen doesn't work for me. Well, there are other non-steroidal anti-inflammatories and acetaminophen. We'll use Tylenol and we'll give you a long-acting. And those are individuals that I would use Expirolon on. And I said, well, we'll give you a long-acting local anesthetic, but I just won't prescribe. What do you do? Well, I'm kind of a wimp. I don't really do oral surgery and I don't do much endo. So I'm really not in a position that I ever, I don't even, I haven't prescribed a narcotic in years. I have talked to the patient themselves about what I suspected, especially if the parent was very uninterested. I'm in a unique position of what I've gone through. Sometimes I will approach a patient about something. Now, I may lose the patient. I may make that patient mad. I may make the parent mad, but I have approached them about it. The other thing that's wonderful is the ORS database, the ability to go in and see what other prescriptions a patient has been given. The tricky part about that is, as Sharon had said, you may have given them a prescription. And once they know that that medication is what they want, they'll find other ways to get it. So even if the ORS database doesn't show that they've had multiple prescriptions, it's pretty rare that you're wrong when all the red flags are going up. But I strongly encourage everyone to check their state's ORS database. Right, and it won't necessarily be called, I don't know if it's called ORS in other states. No, yeah, the Narcotic Database, yes, thank you. Right, thank you both so much. And I'm cobbling together a few questions that came in from different attendees. There were questions about how to help if you know a patient is potentially a substance use, has a substance use disorder. How do you talk to them? What type of language do you use? And we do have an attendee who bravely let us know that she's the parent of a son who's locked in a battle with meth and cocaine and what more can she do? So I think any thoughts on her situation or how to really take care of a patient where you know perhaps this patient is using? Well, I mean, personally, I will kind of just sit them up in the chair. I just generally do it one-on-one. I may ask my assistant to leave and just say, maybe I'm wrong, but some of the behaviors that I'm seeing lead me to think maybe you're using this or maybe you're doing that. And I could be wrong and I could be off base, but I'm very concerned about you, not only for your wellbeing, but for what I'm gonna be doing, the procedure I'm gonna be doing on you today. And I usually then give them some resources. If I'm wrong and if I've offended you, I'm very sorry, but I wanna give you these resources where you can reach out and get help. That's what I do. I don't, how about you? No, I think the first thing that is vital is that you're not judgmental, that you don't put them on the spot, you don't back them into a corner. And it's tricky because when you have a one-on-one conversation with a door closed, you wanna respect privacy, but you also don't wanna open yourself up to any liability. It's a tricky situation and I never accuse. I always just say, hey, this is what we're going to do. And because of the position I'm in and because of the speaking that I do across the country, I have these resources available for all of my patients. And I give them information on different resources available in the community that by the way, I got from Dr. Parsons. So it's wonderful to have that literature available and then in a very non-threatening, non-confrontational way, just say, hey, we do not prescribe narcotics for this and just to let you know. And sometimes patients, when they walk out, you can tell you're not gonna see them back, but it's rare that anybody that's not drug seeking is offended by that because you almost have to look to be offended by the way you present it. I hope that helped. Yeah, thank you. That's terrific. What are some options if a child is allergic to NSAIDs and Tylenol isn't working? I'll tell you. So I use Benadryl. I use Benadryl and I tell the patients, it also, it depends on what we're doing. So if it's significant surgery, we'll use long acting local anesthetics. We'll use Tylenol. We'll use Benadryl or some other longer acting antihistamines that make folks sleepy. And then you also let the patients and their family know ice and that we're treating acute pain and that pain is a physiologic sign of injury. And as long as they're not suffering, it's gonna be okay. It's gonna be short-lived. So, and children are pretty resilient. I don't wanna say they're like dogs, but you distract them and you'd be shocked what they can tolerate. It's more the parents that, oh, my child can't handle this. I mean, yes, they can. It's gonna be fine. And these are the things that we wanna do. And if your child is truly allergic to non-steroidals, I always say to them, please see an allergist and let's make certain that that's in fact the case because we don't wanna saddle this child with a diagnosis that we're not certain of. And I've got two spectacular physicians that I work with in that field. And it's not uncommon. It's not uncommon at all. Well, thank you. And audience, we will share the slides with you because I know some of you had questions about dosing, but here's a specific one. Is the maximum daily ibuprofen dosage 3,200 milligrams? I give, okay, great. I give 800 milligrams and 500 milligrams concurrently Q6 hour and Marcane with success. Yes, it is. It is 3,200 milligrams. I go 24. I use the 600 milligram tabs because they're smaller. Those 800 milligram tabs are huge and the anti-inflammatory dose at 24 to 3,200 milligrams, I'm on the lower end of that spectrum. That way, if the patient takes more, it's okay. But I'm at 2,400 milligrams, but 3,200 milligrams is the maximum adult dose. That's a great question. Okay, great. We won't be able to get to all of them. I'm seeing if we can find one more question that perhaps our presenters can address. We did get a few questions about genetics, doctors, persons, and Kimberly, really having to do with the folks who may not have a genetic predisposition for use. How do you help those adolescents who may be taking drugs so they don't get to a point where they're addicted? And really specifically, we don't know everybody who has a genetic risk factor, certainly, but maybe how you think about your patient panel. Alicia, I am so sorry. That seems like a very important question and I'm not certain that I understand it. Did you say somebody that does not have the genetic predisposition and is still taking narcotics? Yes, let me read it specifically. Forgive me. Regarding genetics, any research on the 30 to 60% of people who are not genetically predisposed, what is the difference about adolescents and young adults who take these drugs and do not become addicted and those who do become addicted? So I don't know the specific research, but my understanding of the addiction process is there's a large percentage of individuals that are genetically predisposed, but it is not only genetic predisposition that can cause individuals to become addicted. You can, you're just more susceptible. And young children, young people, adolescents, where their prefrontal cortex has not developed to the stage where it can fight off the chemical imbalance that is caused by addiction in the midbrain. So it's, I don't, without getting into a huge long discussion about it, it's the fight between the dopamine receptors and that flood of stimulation in the midbrain that's counterbalanced by the prefrontal cortex. And when that prefrontal cortex is not completely developed, the genetic predisposition in the midbrain takes over more quickly in a certain percentage of individuals. That's why the adolescents are so susceptible, whether you're genetically predispositioned to it or not, to becoming addicted. So that is why, and we don't know who those individuals are gonna be. That is why we don't, I try very, very hard, very, very, I never do it in somebody that's under the age of 14. I just tell their parents, we're not gonna give you to codeine, we're not gonna give you anything. You're gonna take Tylenol, we're gonna give you a long-acting local anesthetic, and you just don't know who that person's gonna be. And you just try and minimize the number of narcotic tabs that you give. And you only do it if you absolutely have to have, suspect that they're gonna need breakthrough medication. I hope that answered the question. No, I think it did. Thank you so much, Dr. Kimberley and audience. I'm so sorry, that's all the time we had today. Certainly, if we did not get to your question, please feel free to email us at dentalpracticeatada.org. I wanna sincerely thank our esteemed speakers, Dr. Sharon Parsons and Dr. David Kimberley, and to all of you, our attendees for joining us today. For additional resources and support during this very challenging time, please visit the ADA at ada.org forward slash wellness, and the provider's clinical support system at pcssnow.org. Here is some information about the PCSS mentoring program. We also wanted to share information about their discussion forum. These are all the organizations, including the American Dental Association that are part of the PCSS coalition. You can find PCSS online here. It is thanks to the strength of over 163,000 ADA members that helps us successfully advocate for you and bring you essential resources like today's program. Don't miss a single development, join or renew today. This now concludes our program. Thank you so much and have a great day.

Opioids

Dentistry

Addiction

Dentist's Role

Treating Pain

Drug Use

Adolescents

Evidence-based Practices

Opioid Use Disorders