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Children’s Use of Non-Dental Services for Oral Pain Costing The NHS £2.3m a year

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The study of more than half of all of the pharmacies in London and nearly 7,000 parents finds that most pharmacy visits for children’s pain medications in London are to treat oral pain.

Lead researcher Dr Vanessa Muirhead from Queen Mary’s Institute of Dentistry said: “The fact that only 30 per cent of children with oral pain had seen a dentist before going to a pharmacy highlights a concerning underuse of dental services.

“Children with oral pain need to see a dentist for a definitive diagnosis and to treat any tooth decay. Not treating a decayed tooth can result in more pain, abscesses and possible damage to children’s permanent teeth.

“These children had not only failed to see a dentist before their pharmacy visit; they had seen GPs and a range of other health professionals outside dentistry. This inappropriate and overuse of multiple health services including A&E is costing the NHS a substantial amount of money at a time when reducing waste is a government priority.”

Nearly one in ten children had signs of a dental emergency
Previous research has found that the main cause of planned hospital admissions for children aged 5-9 years is to have their decayed teeth extracted under general anaesthesia. Meanwhile, a quarter of five-year-olds in England still have tooth decay in their baby teeth and approximately one in five 12-year-olds have tooth decay in their adult teeth.

Only 58 per cent of children in England and 49 per cent of children in London had visited a dentist in 2016, even though dental care is free in the UK for under 18s and national guidelines recommend dental visits at least every year for children.

  • In this latest study, published in BMJ Open and jointly funded by Healthy London Partnership and NHS England London Region, 951 pharmacies collected information from 6,915 parents seeking pain medications for their children in November 2016 – January 2017, and found that:Nearly two-thirds (65 per cent) of parents seeking pain medications for their children were doing so to relieve their children’s oral pain.
  • Only 30 per cent of children with oral pain had seen a dentist before the pharmacy visit while 28 per cent had seen between one and four different health professionals (including GPs, health visitors, school nurses and A&E departments – GPs being the most common).
  • Nearly one in ten children had signs and symptoms indicating a dental emergency and community pharmacy staff signposted them to emergency services.
  • The cost to the NHS of children contacting health professionals outside dentistry over the period was £36,573 (an annual cost of £373,288). Replicating these findings across all pharmacies in England could mean that the NHS spends an estimated £2.3 million annually when children with oral pain inappropriately use multiple health services.
  • 41 per cent of the children had toothache; 20 per cent had pain from a newly erupting tooth and 15 per cent had a painful mouth ulcer.
  • Saturdays and Sundays were the peak days for parents to visit pharmacies for pain medication for children’s oral pain. This could partly explain why some parents had not seen a dentist due to limited urgent dental care services over the weekend.

GPs, pharmacists and dentists need to talk to each other
Dr Muirhead added:

“We need to develop integrated systems and referral processes where GPs, community pharmacists and dentists talk to each other to make sure that children with toothache see a dentist as soon as possible for treatment. We also need better training for community pharmacy staff giving parents advice and look at how dentists manage children who have toothache.”

The researchers also highlight the need to work towards preventing tooth decay from occurring in the first place. This includes rolling out Scotland’s Childsmile programme more widely, where fluoride toothpaste is distributed to all pre-school children, all nurseries have supervised toothbrushing every day and early years’ settings have healthy low sugar meals and snacks.

The study limitations include the extrapolation of cost estimations which contained several assumptions. The researchers also possibly underestimated the number of children with oral pain in London because only community pharmacies were used as a means of identifying children and parents.

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Ibuprofen, Acetaminophen More Effective Than Opioids In Treating Dental Pain

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Opioids are not among the most effective — or longest lasting — options available for relief from acute dental pain, a new examination of the results from more than 460 published studies has found.

Ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) alone or in combination with acetaminophen are better at easing dental pain, according to new research conducted with the School of Dental Medicine at Case Western Reserve University.

The study examining relief of acute pain in dentistry — recently featured on the cover of The Journal of the American Dental Association — evaluated the safety and efficacy of dozens of pain-relief options.

“What we know is that prescribing narcotics should be a last resort,” said Anita Aminoshariae, an associate professor in the dental school’s Department of Endodontics and one of the study’s authors.

Each day, more than 115 Americans die as a result of an opioid overdose, according to the National Institutes of Health.

“No patient should go home in pain,” Aminoshariae said.

“That means that opioids are sometimes the best option, but certainly should not be the first option.”

Aminoshariae said the goal of the systematic review was to summarize data — using five in- depth studies — of the effectiveness of oral-pain medications.

“The best available data suggests that the use of nonsteroidal medications, with or without acetaminophen, offers the most favorable balance between benefits and harms, optimizing efficacy while minimizing acute adverse events,” she said.

She cited the national opioid epidemic as one of many reasons why health-care providers should take note of the findings.

The research found that, for adults, a combination of 400 milligrams of ibuprofen and 1,000 milligrams of acetaminophen was superior to any opioid-containing medications studied.

“Our aim was to create a compendium detailing both the benefits and harms of these medications as a resource for dentists to use in their clinical decision-making,” Aminoshariae added.

The study also found that opioids or drug combinations that included opioids accounted for the most adverse side effects — including drowsiness, respiratory depression, nausea/vomiting and constipation — in both children and adults.

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Gum Disease May Be A Key Initiator Of Rheumatoid Arthritis Related Autoimmunity

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The results of a study presented at the Annual European Congress of Rheumatology (EULAR 2018) demonstrates increased levels of gum disease, and disease-causing bacteria, in individuals at risk of rheumatoid arthritis (RA).

“It has been shown that RA-associated antibodies, such as anti-citrullinated protein antibodies, are present well before any evidence of joint disease. This suggests they originate from a site outside of the joints,” said Dr Kulveer Mankia of Leeds Institute of Rheumatic and Muscoskeletal Medicine and the Leeds Biomedical Research Centre (study author).

“Our study is the first to describe clinical periodontal disease and the relative abundance of periodontal bacteria in these at-risk individuals. Our results support the hypothesis that local inflammation at mucosal surfaces, such as the gums in this case, may provide the primary trigger for the systemic autoimmunity seen in RA.”

Rheumatoid arthritis is a chronic inflammatory disease that affects a person’s joints, causing pain and disability. It can also affect internal organs. Rheumatoid arthritis is more common in older people, but there is also a high prevalence in young adults, adolescents and even children, and it affects women more frequently than men.

The prevalence of gum disease is increased in patients with RA and could be a key initiator of RA-related autoimmunity. This is because autoimmunity in RA is characterised by an antibody response to citrullinated proteins and the oral bacterium Porphyromonas gingivalis (Pg) is the only human pathogen known to express an enzyme that can generate citrullinated proteins.

“We welcome these data in presenting concepts that may enhance clinical understanding of the key initiators of rheumatoid arthritis,” said Professor Robert Landewé, Chairperson of the Scientific Programme Committee, EULAR.

“This is an essential step towards the ultimate goal of disease prevention.”

In results from the study, dentists diagnosed clinical gum disease in significantly more at-risk individuals than in healthy controls (73% vs. 38%, p=0.02). In addition, the percentage of sites with clinical attachment level (CAL) ?2mm, pocket depth (PD) ?4mm, bleeding on probing (BOP), periodontal disease (PDD), and active periodontal disease (PDD+BOP), were all significantly greater in the at-risk individuals compared to controls (p<0.05). In non-smokers, PDD and active PDD were more prevalent in at-risk individuals compared to controls.

DNA was isolated from the subgingival plaque, next to the gums, of each participant and used to measure the levels of three types of bacteria, Pg, Aggregatibacter actinomycetemcomitans (Aa) and Filifactor Alocis. Results showed that there was increased abundance of both Pg and Aa in at-risk individuals. However, in at-risk individuals, only Pg was significantly increased at healthy dental sites and was associated with the overall extent of gum disease (p<0.001).

The study included 48 at-risk individuals (positive test for anti-citrullinated protein antibodies, musculoskeletal symptoms but no clinical synovitis), 26 patients with RA and 32 healthy controls. The three groups were balanced for age, gender and smoking. At-risk individuals underwent ultrasound assessment to assess for subclinical synovitis; only two (4%) were found to have ultrasound synovitis. Dentists examined six sites per tooth in each participant and a clinical consensus was agreed in each by three dentists.

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Cellular Messengers Communicate With Bacteria In The Mouth

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A new UCLA-led study provides clear evidence that cellular messengers in saliva may be able to regulate the growth of oral bacteria responsible for diseases, such as periodontitis and meningitis.

The study’s findings, which suggest that a body’s cellular messengers play an important role in managing the amount of good and bad bacteria in the mouth, are published online and will appear in the May issue of the Journal for Dental Research.

Study authors Dr. David Wong, professor of oral biology and associate dean for research at the UCLA School of Dentistry, and Dr. Wenyuan Shi, chief executive officer and chief science officer at the Forsyth Institute, an oral health research institute in Cambridge, Massachusetts, asked the question of whether our RNA — the cellular messengers — can communicate with harmful bacteria in the mouth.

RNA acts as a messenger that transports DNA’s instructions to other parts of the cell. Small regulatory noncoding RNAs, known as sRNAs, regulate our genes. A new class of sRNAs has also been discovered called tsRNA, which is transfer RNA-derived small RNA. tsRNA is found in human body fluids, including blood, tears and saliva.

The research team began by analyzing salivary sRNAs and found many of them belong to tsRNA with their sequences matching the partial transfer RNA sequences of several Gram-negative oral bacteria — bacteria that have a highly toxic outer layer that can cause periodontal disease. These salivary tsRNAs could potentially affect bacterial tRNA, a type of RNA molecule that helps decode a messenger RNA sequence into a protein and is required for bacterial growth. The Gram-negative bacterium used in the study to test this hypothesis was Fusobacterium nucleatum (F. nucleatum), the bacteria responsible for periodontitis.

The team showed that host cells respond to the presence of F. nucleatum by releasing specific tsRNA with sequence matching to tRNA of F. nucleatum. Furthermore, these released tsRNAs can inhibit the growth of F. nucleatum, but they have no effect on the growth of Gram-positive oral bacteria, such as Streptococcus mitis, a bacterium that responds to antibiotics.

“This study establishes that there is a clear channel of communication between RNA messengers and bacteria in our mouth,” said Wong, who holds the Felix and Mildred Yip Endowed Chair in Dentistry.

“Furthermore, we have shown that these messengers may play an important role in mediating interactions between bacteria and their host.”

Another significant study finding was the majority of tRNA bacteria sequences that show high sequence similarity with salivary tsRNAs came from antibiotic-resistant Gram-negative bacteria. This observation could lead to a better understanding of the mechanisms behind the growth of oral bacteria, resistance to antibiotics, and in-turn oral diseases, Wong said.

“Our findings could lead to new therapies to treat diseases caused by harmful bacteria,” said Shi, a former professor of oral biology at the UCLA School of Dentistry.

“As a convener for oral health and biotech experts, Forsyth is thrilled about collaborating with UCLA on this exciting research.”

For example, one of the hallmarks of periodontitis is a shift from mostly Gram-positive bacteria to mostly Gram-negative bacteria. With a better understanding of how Gram-negative bacteria grow, perhaps there is potential to reverse the growth or even kill Gram-negative bacteria.

“Our finding could potentially open a new door for prevention and treatment of periodontal diseases” said Dr. Xuesong He, a researcher at the Forsyth Institute and the co-first author on this study.

Additional co-authors of the research include Batbileg Bor and Lujia Cen, both from the Forsyth Institute; Feng Li, Kikuye Koyano, Xinshu “Grace” Xiao and Feng Li from Hunan University of Chinese Medicine. Feng Li also conducts research at the UCLA School of Dentistry.

This research was supported by grants from the National Institute of Dental and Craniofacial Research and from the National Institutes of Health.

Wong is co-founder of RNAmeTRIX Inc., a molecular diagnostic company. He holds equity in RNAmeTRIX and serves as a company director and scientific advisor. The University of California also holds equity in RNAmeTRIX. Intellectual property that David Wong invented and which was patented by the University of California has been licensed to RNAmeTRIX. Wong also is a consultant to GlaxoSmithKline, PeriRx, Wrigley and Colgate-Palmolive. Shi is the founding scientist of C3J Therapeutics, Inc., which has licensed technologies from UC Regents that could be indirectly related to this research project.

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