Points of Impact: Romesh Nalliah, D.D.S., M.H.C.M.

Why is it important for dentists to be engaged in addressing the opioid epidemic?

For one, dentists are often involved in healthy young people’s first experience with opioids, since they write prescriptions for pain after wisdom teeth removal. Because of this, dentists are the number one prescriber of opioids in the 10- to 19-year age group. Among these pre-teens, teens, and young adults, dentists prescribe more than double the amount of opioids than the next most frequent prescribers, who are pediatricians and emergency room doctors. The risk with this age group is that they are primarily naive opioid users, meaning they are being exposed to opioids for the first time, and our research shows that opioid-naive individuals are more likely to become persistent users. That can lead to addiction and other harmful, even lethal, consequences. We also know that opioid prescriptions for adults following dental care procedures have been increasing over the last 20 years.

What kind of guidelines exist for opioid prescribing in dentistry?

To date, there has been limited guidance for clinical decision-making related to opioids, which results in enormous variability in approaches to pain relief. In one study, the number of tablets prescribed by dentists for a single procedure varied from 10 to 40. Research has also shown that more than half of opioids that dentists prescribe go unused, which of course presents a major source of potential diversion for those medications to fall into the wrong hands. Even antibiotic prescribing, which is decreasing across almost every other health profession, is increasing in dentistry. We need to completely revamp our methods of medication prescribing in dental medicine.

Why do prescribing practices differ so much between dentists?

Besides the lack of guidelines, part of the issue is that 60 percent of dental providers are in solo practice, and are rarely co-located with a medical office of any kind. Around 85 percent of dental practices are owned by one person, as opposed to a board or a leadership structure like a hospital would have. In those environments, communication and sharing best practices between other dentists is challenging. The U.S. healthcare system itself is very fragmented; even the rules and regulations to acquire licensure in dentistry are highly variable from state to state, and so standardizing practices can be difficult.

What are some solutions for improving practices?

Through the Michigan Opioid Prescribing and Engagement Network (Michigan OPEN), we’re working on reducing opioid prescribing by dentists throughout the state of Michigan. We’ve been working to prepare dentists for the new opioid prescribing legislation that rolled out on June 1 this year. The law requires dentists to educate patients on safe storage and disposal of opioids, and also requires them to check the Michigan Automated Prescribing System (MAPS) for their patients’ other prescriptions before issuing an opioid prescription that exceeds a three-day supply.

Along with the Michigan Department of Licensing and Regulatory Affairs (LARA) and the U-M Injury Prevention Center, Michigan OPEN co-developed guidelines for safe opioid prescribing in dentistry. The recommendations help providers prepare for appointments, suggest alternative acute pain therapies, and provide post-procedural guidelines to treat acute pain (there are acute pain recommendations for emergency and surgical departments as well). We’ve also developed patient education resources that are freely available to dental providers across Michigan, who can customize these materials with their institution or practice’s logo free of charge. The dental prescribing guidelines are quite detailed. They even address how you can frame the philosophy of your practice so that when patients come they already understand your mindset towards opioids. We want to continue to shift patients’ thinking away from ‘You know, my dentist cares about me so she or he is giving me opioids for this weekend,’ and more toward, ‘My dentist cares about me, so she or he wants to think about my well-being, my whole self, and me as a person and my life, and be much more thoughtful about prescribing and use as many other mechanisms as possible for pain control before having to move to an opioid.’ These guidelines are an important first step, but we need to continue to expand evidence regarding effective pain control in dental medicine, particularly with effective alternatives to opioids, to inform strong prescribing guidelines. Both dental school education and continuing dental education, as well as professional organizations, have a role to train and retrain our profession for a new conservative approach to prescribing. I’d even go so far as to say that alternative prescribing techniques should be mandated in continuing dental education requirements to maintain licensure.

How can shared electronic health records improve practices?

Real-time communication through electronic health records can help dentists overcome their isolation from the rest of the health system, and lets dentists better communicate with each other and with primary care providers. Partnering with primary care can be very, very difficult, but it’s critical. Dentistry and primary care cannot afford to practice in isolation. More and more research demonstrates that oral health affects systemic disease outcomes, and vice versa. Open electronic health records, like the data offered through the MAPS system, provide an opportunity to better standardize care and facilitate information sharing between providers, particularly when it comes to opioids. Looking at other states that have implemented mandates for healthcare providers to consult prescription drug monitoring databases before prescribing opioids: in New York, opioid prescribing went down 75 percent, in Florida, it went down 50 percent, and, in Tennessee, it went down 36 percent. So we know this kind of legislation works and it’s terrific that Michigan has moved that through the legislative pathways and now implemented it.

What has your research has shown about the use of emergency services for dental issues?

Our team’s research has shown that there's about 1.4 million people every year who go to the emergency room with a dental problem in America. And the reasons they go to the emergency room instead of a dentist vary: they didn't have dental insurance, they didn't have access to a dentist, or they neglected their dental problem so much that a dental visit was not enough and they needed additional medical interventions. Medicare has essentially no dental coverage; it will only cover services when a dental issue is secondary to a major medical condition, for example, if a patient is having radiation therapy because of cancer and they need dentures, then it's covered. So those people are more likely to go to the emergency room because they have no coverage. Medicaid adult insurance is also very limited. It varies from state to state and, so those people also have essentially no coverage, and then, of course, there are the uninsured. So those three groups tend to be, unfortunately, frequent users of the emergency room for dental issues -- or I should say, more frequent than certainly people with private insurance. In some of our forthcoming research, we wondered how many of those people had used pain medication to neglect and postpone dental care, and how many of them may have used opioids, and how many may have developed opioid addictions. We’re finding that whites were about twice as likely as blacks and Hispanics to have a dental emergency and a concurrent opioid abuse problem. We’re also finding that Medicare, Medicaid, and uninsured individuals were 4-5 times more likely than private insured people to have a dental emergency and a concurrent opioid abuse problem.

How does precision health intersect with issues of opioid overuse?

In terms of medication, precision health is all about getting the right drug to the right person at the right time. And opioid prescribing is about making sure not to give an opioid to the wrong person at the wrong time. Historically, we would just write an opioid prescription for everyone following a dental procedure. Now, we think much more holistically about different approaches to pain control and customizing those approaches to the individual. Within the U-M School of Dentistry, I’m chairing a task force that's developing and implementing precision health and learning health systems into dentistry. My interest and my background in research has been in large secondary data sets, and so working with big data to identify opportunities for systems improvement and new approaches to precision medicine is a lot of fun for me. In dentistry we can be really, really slow to adopt change. I think dentists tend to be conservative people and we tend to be suspicious people. And that makes us good at our work, because I think that we are very detail-oriented and thoughtful about care delivery. But sometimes to move forward rapidly, it's challenging, especially when the profession is so siloed. The idea of rapid iterative change embodied by learning health systems represents a major philosophy shift, and a tremendous opportunity to integrate new and effective ideas much more rapidly than we’ve been able to through traditional quality improvement projects.

Dr. Nalliah’s other health services research includes work in process evaluation across hospitals, healthcare, and education; on vulnerable populations, and unnecessary hospitalizations.