AMERICAN SOCIETY OF ORAL AND MAXILLOFACIAL SURGEONS (AAOMS)

• AAOMS is a professional organization that represents oral and maxillofacial surgeons in the US.
• AAOMS members are bound to adhere to national standards through continuing education.
• The organization offers its members continuing education (CE) in several formats, such as live webinars, CE on demand, and OMS knowledge update (OMSKU). Live webinars provide a platform for members to learn from professionals of other associations, ask questions to expert speakers, and interact in the discussion at hand. CE on demand offers online courses and access to webinars and programs at the members' convenience. Lastly, OMSKU is an innovative way to achieve continuing education. It provides members with online interactive tutorials written by professionals of the OMS field and other experts in various fields.
• The organization also holds annual meetings and scientific sessions and exhibitions for its members.

NATIONAL INSTITUTE OF HEALTH (NIH)

•  NIH encourages practitioners to collaborate with other agencies to share resources and education about the latest and most up-to-date scientific findings to reduce the dental community's reliance on opioid as a pain reliever, which can potentially lead to opioid abuse and addiction.

THE JOURNAL OF ORAL and MAXILLOFACIAL SURGEONS

• The Journal of Oral and Maxillofacial Surgeons offers OMS articles of research of the latest innovations in therapeutic drugs and devices.

AMERICAN COLLEGE OF MAXILLOFACIAL SURGEONS (ACOMS)

• The American College of Maxillofacial Surgeons (ACOMS) is dedicated to providing educational activities to their members through their Learning Center.
•  ACOMS Learning Center provides content from ACOMS events, such as conferences, CE on demand, and live educational events.

RESEARCH STRATEGY

KEY FINDINGS:

Oral surgeons are typically the early adopters of new technology

• According to Technavio, the growing adoption of 3D printing technology by dental professionals like dental surgeons has a positive impact on the market — this contributes to its growth significantly over the forecast period.
•  New product launches is another aspect that is boosting the market growth — the North American region like the United States has led the market in 2018 with more research and development investments in healthcare technology to improve its existing products and developing innovative products.
• According to NYU College of Dentistry reports, the technology which is the application of scientific knowledge for practical purposes is and always has been a core component of dentistry.
• Louis Rafetto, President-elect of the American Association of Maxillofacial Surgeon says Oral Surgeries remain same but the way and the method to do it has changed — the healthcare technology used to treat and operate on the face, mouth, and jaw is constantly evolving and changing.
•  Oral surgeons have some different needs in IT services and support but they would always need reliable and updated equipment with appropriate HIPAA compliance and patient-friendly software for oral surgery.
•  Olulu reports that digital technology has become more prevalent in oral surgery — this is because the acceptance of new technology between senior and junior surgeons has continued to grow.
• Out of all generations such as Millennial, Boomer, and Gen-X surgeons; millennial oral surgeons believe in the value of innovation; they are more likely to adopt new techniques and technology in their surgical procedures.
•  Millennial oral surgeons are protective of their leisure time — they strongly believe in using their technology to reduce their overall workload.

Correlation between the rate of technology adoption and the likelihood that they'll use new products in their medical practice:

• The Healthcare authorities’ like healthcare organizations and hospitals incorporate themselves into the process of digitization — the team members whether they are digital native or immigrant are treated as valuable assets and have been trained regularly so that new products can be used in their medical practice.
• To remain competitive in the healthcare industry, digitally native millennial and digitally immigrant senior oral surgeons have collaborated to adopt technology in their medical practice with the creative ways to engage with patients, staff, and referring dentists.
• The surgeons and their team members have pursued innovative and digital solutions to foster practice growth and to expand their market share in implant dentistry.
• The digital technology is a key feature that has positively influenced the adoption of digital technology in the broader community of interest — more dental schools are training students with the introduction and familiarity of advanced technology. Thus, the traditional barriers within dental schools are rapidly eroding.
• The familiarity of prosthodontist faculty with digital technology is a key feature and has become an important part of the curriculum.
• This has positively influenced the adoption of digital technology in the broader community of interest.
• Most dental surgeons in the United States specifically in Miami region are equipped with new technology like digital X-rays that helps dentists to repair cavities without drilling and allows zooming-in on a live image and can assess the situation better.

Statistical Data on adopting new technology:

• According to a survey conducted by American College of Prosthodontists, dental educators are encouraging using more advanced technologies with the introduction of 92% use of 3-D radiography, 69% use of intraoral scanners in contrast to 56%, and 32% of private practice prosthodontists.
• At the clinical level, the three most widely adopted new technologies are digital radiography — 91%, cone-beam CT — 85%, CAD/CAM indirect restorations — 58%, and virtual surgical guides and implant placement — 30%.
• Approximately 50% of post-graduate oral programs included aspects of digital denture technology in their program curriculum — however, most educators plan to include digital denture fabrication in their curriculum by 2020.
• As per the survey conducted by the American College of Prosthodontists, 65% of prosthodontists utilize advanced digital dentistry in their practice and approximately 50% of American College of Prosthodontists members have adopted this.
• Thus, we conclude that oral surgeons are quick learners in adopting New technologies in the US.

Research Strategy

HELPFUL FINDINGS

•  Patients' discharge after oral surgery varies per individual and based on the complexity of the surgery.
• Various oral surgeries are associated with different pain intensity and other medical complications.
• According to WHO, pain intensity can be categorized as mild, moderate, and severe.
• After oral surgery, patients are placed under medical observation to ensure their stability before discharge.
• The major determinant of patient discharge after oral surgery is patient stability and to ensure that their vital signs are within the normal range.
• A report revealed that patients are discharged after oral surgery before the effect of the anesthesia elapsed.
• Also, patients are advised to report to the hospital immediately if any medical complications showed up such as severe bleeding.
• After patients have gone through the recovery phase, patients are discharged with pain relieve prescription to manage the post-oral surgery pain after the anesthesia effect has elapsed.
• A report revealed that the majority of patients present with mild to moderate pain after oral surgery, while others present with moderate to severe pain following oral surgery.
•  Opioid medications are generally prescribed for patients with moderate to severe pain, following oral surgery.
•  Non-opioid medications are generally prescribed for patients with mild to moderate pain, following oral surgery.
• Some examples of opioid medications include hydromorphone, codeine, tramadol, among others.
• Also, some examples of non-opioid analgesics include acetaminophen, gabapentin, ibuprofen, naproxen, among others.
• A report revealed that there is a high prescription of opioid analgesics in various surgical specialties, including oral surgery for the management of post-operative pain.
• In conclusion, as a result of the advancement in medicine, the anticipated pain intensity of patients after oral surgery does not influence patients' prolong admission in the hospital due to the availability of various analgesics that can be used by patients at home to mitigate the severity of pain, as directed by the doctor.

RESEARCH STRATEGY

• According to the Journal of Pain Research article, The Challenges of Pain Control and The Role of The Ambulatory Pain Specialist in The Outpatient Surgery Setting, it is important to consider lowering costs without sacrificing the patient's safety.

•  Multi modal techniques can be used to reduce the development of chronic pain.

• Transition of pain from acute to chronic causes medical and economic burdens.
• It is important to fully control acute pain with multi-modal approaches to preemptively prevent chronic pain.

• Some physicians may not include effective analgesics on their formularities because their costs are high, high co-payments and need for authorization.
• A recent survey of a large physician practice, shows that many physicians are unaware of cost drivers or do not think they need to participate in issues concerning cost in their healthcare institutions.

• A study by the NBCI on the influence of the insurance status on surgical treatment of acute spinal fractures shows that patients with insurance were more likely to undergo surgery than the uninsured.

OVERVIEW

• In the United States, one of the most common surgeries in the mouth is tooth extraction or the removal of the wisdom teeth. Among all tooth removals, 95% is represented by tooth extraction.
• On average, about 3 million people was treated by oral surgeons for tooth extraction, mostly under 25 years old.
• Historically, opioid-based medicines are given by oral surgeons to their patients as the first-line treatment of pain. This has become the standard method of prescription since the 1970s.
• Patients who get their first exposure to opioid due to dental surgery are young adults aged 15 to 24.
• A recent study published by the American Dental Association (ADA) in their journal JADA, indicated that the use of Ibuprofen together with nonsteroidal anti-inflammatory drugs (NSAIDs) is better than using opioids because of the dangerous effects in patient's health of prolonged use of opioid.

ORAL SURGEONS' ROLE IN THE PATIENT'S PAIN MANAGEMENT

• After an oral surgery, the next concern of the oral surgeon is to provide the most effective pain relief. But the prescription takes place right after the surgery while the patient is still numb after the anesthesia treatment. And therefore, the level of pain is not gauged fully.
• To treat the pain, 22% of oral surgeons still prescribe more than 20 opioid tablets, and more than 30 tablets was prescribed by 11%.
• Some oral surgeons declare that their issuance of opioid prescription has become a tradition because it has been considered effective and their "awareness of its negative impact is minimal".
• Based on a survey by an oral surgeons' association, 99% of their members still prescribe opioids, but they are now usually prescribing it along with NSAIDs.

• According to the National Institutes of Health, about 115 Americans die each day due to opioid overdose.
• In a survey to more than 1 million opioid patients undergoing surgery, the long duration of taking opioid is considered to be the strongest predictor of misuse and risk for individuals aged 15-24.
• Every day that a patient remain dependent to opioid pills, it increases the chances of addiction.

PATIENT'S ROLE IN PAIN MANAGEMENT (IN ORAL SURGEON'S POINT OF VIEW)

• In a minor oral surgery, techniques to eliminate pain have progressed, but the application of the local anesthesia itself is very painful, giving the perception to most patients that dental treatment is invasive and painful.
• Aside from pain management, anxiety control plays a big role on how patients react to the whole process of surgery.
• Among patients, about 20% either do not take pain relievers or requires a more intense relief of their pain after an oral surgery.
•  Angi Rake, an oral surgeon who supervises oral surgery clinics and works on reducing the prescription of opioids among other surgeons, stated that in some cases, the patients themselves (or their parents) "expect" that the oral surgeon will prescribe opioid to eliminate the pain and sometimes asks why they have prescribed less than usual.

ORAL SURGEONS' CONFIDENCE LEVEL ON HOW PAIN WORKS AND ITS TREATMENT

• The current scare of opioid addiction and possible death has led some legislature and state to put legal limits when it comes to prescription.
• The ADA now suggests oral surgeons and dentists to consider NSAIDs prescription as their first-line treatment for pain.
• Among the oral surgeons surveyed, 50% of the respondents said they have decreased the prescription of opioid to their patients.
• The new discovery released by ADA on better pain management after oral surgery enables oral surgeons and dentists to address the patient's level of pain in A safer way.

USEFUL FINDINGS

VARIANCE IN POST-SURGERY SATISFACTION LEVELS AMONG ORAL SURGERY PATIENTS

• The combination of acetaminophen and ibuprofen is often offered as an alternative to opioid-based pain medications following oral surgery to address the patient’s pain level in new, safer ways.
• Also, for some patients, opioid-based pain relievers may be the only option.
• However, almost 20% of patients have the need for intense pain relief, and some cannot take pain relievers.
• Also, lifestyle habits, such as smoking or alcohol consumption may delay the pain-relief time for some patients.
• It was found that two-thirds of 14 to 17-year-olds receive opioid prescriptions from dentists following the third molar extraction.
• Since opioids are often used out of dentists’ fear of an unsatisfied patient, this two-thirds of 14 to 17-year-olds who went through third molar extraction can be seen as patients running the risk of not being satisfied through medications other than opioid.

MORE PATIENTS CHOOSE OPIOID FOR ACUTE PAIN MANAGEMENT

• An opioid is often prescribed when the pain is acute. 
• In terms of patients choosing filling out their prescriptions for an opioid for pain management after the surgical procedure relating to wisdom teeth removal, it was found that 56,686 wisdom tooth patients filled their opioid prescriptions between 2009 and 2015.
• While, a far less number, i.e., 14,256 wisdom tooth patients didn’t fill an opioid prescription.
• Therefore, it can be inferred that people going through acute pain after wisdom teeth removal is four times higher (56,686 Vs. 14,256) than the ones not going through it.
• As per a report published in NCBI PubMed, pain following oral surgery was highly prevalent in the United States, which made active management of post-surgical pain, a primary concern for clinicians.

SATISFACTION PERCENTAGE AMONG PATIENTS WHO HAVE UNDERGONE OVERALL DENTAL CARE

• In terms of Dental Care as a whole, almost one-fourth of patients treated were dissatisfied with a certain aspect of their dental care experience.
• It was also found that in the realm of overall dental care treatment satisfaction of patients who received invasive treatment did not differ much from those who received non-invasive treatment.

Research Strategy

Reports from Associations of Surgeons

Academic and Medical Databases

Providers of Surgeries i.e, hospitals

Medical news sources

KEY INSIGHTS

• A third molar extraction is the dental procedure that requires the most pain management.
• There are 3.5 million third molar extractions in the US annually.
• The pain medications most commonly prescribed following a third molar extraction are hydrocodone, oxycodone, Vicodin®, or a combination of APAP and hydrocodone.
• Two of 384 (64%) respondents in a survey of 600 oral and maxillofacial surgeons reported that they did not prescribe a narcotic after the removal of an impacted third molar.
• "The most frequently prescribed narcotic was hydrocodone 5 mg, followed by oxycodone and codeine. Most the practitioners prescribed 20 tablets, however, 22% prescribed more, with 40 practitioners prescribing more than 30 tablets."
• Opioid pain medications are usually prescribed for 3-10 days following dental surgeries.
• There are no references or research on the effectiveness of hydrocodone as a pain medication.
• To treat pain following the extraction of wisdom teeth, oral surgeons usually prescribe 325 mg of acetaminophen taken with 200 mg of Ibuprofen.
• Patients typically receive opioid pain medication following dental surgery. However, by talking to their surgeon, they may reach a mutual decision to try non-opioid pain management.
• Because doctors do not know how much pain a patient will experience, they will often provide a prescription for an opioid analgesic sufficient to manage the worst (most painful) recovery.
• After a surgical procedure, patients expect their oral surgeon to manage any pain experienced during their recovery, causing their oral surgeon to feel obligated to prescribe opioids.
• Some patients feel dissatisfied with a non-opioid option and may consider a prescription of non-opioid pain management as uncaring or unsympathetic.
• "Effective pain management is, after all, the Holy Grail for achieving patient satisfaction."
• Prescribing non-opioid pain managements can have significant consequences such as poor ratings on social media from upset patients who feel neglected.
• The American Association of Oral and Maxillofacial Surgeons (AAOMS) published a white paper with recommendations on their postoperative pain management methods.
• According to a Nielsen Harris Poll, 7 out of 10 US respondents opt for a non-opioid medication to treat post-surgical pain from third molar (wisdom tooth) extraction if given the choice.

RESEARCH STRATEGY

Patient’s Pain Perception Before Surgery

• As per the American Society of Anesthesiologists (ASA), 75% of patients have some concerns on anesthesia before oral surgery and 37% are fearful and have an anxiety of general anesthesia in oral surgery.
• As per the Oral & Maxillofacial Surgery of Utah, many patients experience potential pain anxiety before oral surgery.

Prevention Techniques

• Oral surgeons suggest patients discuss their fear of pain with their respective surgeons and ask for anesthesia options where surgeons alter the mode of ingesting anesthesia such as laughing gas, oral sedation, and IV sedation to give the patient a pain-free surgical experience.
• Oral surgeons suggest patients focus on breathing and listening to music during the surgery. They also suggest patients talk to the oral surgery team before the surgery to relieve their pain anxiety concerning oral surgery.

Influences on Oral Surgeon's Treatments During Surgery

• Oral surgeons often modify the treatment plan to calm down patients with pain anxiety.
• Oral surgeons allow patients to choose the type of sedation during surgery. Some patients want to be unconsciousness during the surgery and for such patients, surgeons use IV sedation.
• For patients who are moderately worried about pain during oral surgery, a local anesthetic is given as an oral pill which numbs the oral cavity but enables the patient to remain conscious.

Patient’s Pain Perceptions After Surgery

• According to oral surgery associates, "many patients feel that they do not need the stronger medication for pain relief." Side effects patients experience from the medication include nausea, drowsiness, and vomiting.

Prevention Techniques

• For the first level of pain management, oral surgeons suggest patients take drugs such as ibuprofen and Acetaminophen for recovery.
• Oral surgeons suggest discontinuing the medication if the patient gets the hives or a rash and also suggest immediate consultation.

RESEARCH STRATEGY

ROLE OF A CAREGIVER

•  Opioid Drug Abuse/Intake: Opioid prescription is a very common practice by oral surgeons and other dental healthcare providers to curtail the pain patients feel after severe dental procedures or surgeries. Unmonitored dosage of opioid can be fatal, especially in adolescent and minor patients. Hence, parents/caretakers play an important role to ensure the safe and competent opioid intake during pain management for the patients and follow the directed guidelines of opioid safety principles for patients and caregivers by American Academy of Pain Medicine to curtail drug abuse.
•  Consent Form: In multiple states of the United States such as Pennsylvania, Ohio, and others, the minor patients' caregiver/parents are required to provide their consent by signing a form for prescribing opioid prescriptions to the patients in non-emergency circumstances for medical treatment and pain management including dentistry.
•  Patient Care: Through studies, it was found that the role of a caregiver/parents whose children were prescribed opioids after inpatient surgery need to ensure proper disposal of the leftover medication to avoid any risk of drug abuse due to diverted pills.

ORAL SURGEONS

Conversation with a Caregiver

• Since opioid prescription is a common practice by dentists for pain management in the treatment of oral pain, the caregiver/parent of adolescent/minor patients (1-21 years) share the past medical history and are required to share their consent by signing a form to acknowledge the risk associated with opioid intake.
• For proper patient care after inpatient surgery, the dentist/surgeon shares proper guidelines to the caregiver/parent of the patient, especially, in the case of minor patients on the opioid intake and proper disposal of leftover pills.
• Patients with Alzheimer’s disease (AD) are heavily dependent on caregivers with low oral health literacy and at times are at greatest risk, so caregivers need to be included in all patient education efforts and pain management treatment.

Surgeons Decisions Around Pain Management/Prevention

•  Wisdom tooth extraction is often the first-time patients are exposed to opioids. According to a survey report by the American Society of Anesthesiologists, parents/caregivers of minor patients have conflicting thoughts about using opioids to treat their child’s pain.
• The survey report states that "more than half of parents said they are concerned their child may be at risk for opioid addiction" although they believe that opioids are more effective at managing their child’s pain after surgery.
• It is possible that the patients pain treatment course could be altered, influencing the oral surgeon after the pre-surgery discussion with the parent/caregiver on the general thoughts on pain management and pain medications, and details on patient’s pain tolerance, personal history of substance use disorder (SUD) or SUD within the family, and any particular concerns about pain medications/opioids

Trying New Products

• The national survey by American Society of Anesthesiologists highlights that 59% of parents whose children were prescribed opioids asked their doctor about pain management alternatives. 88% of parents recognized non-opioid over-the-counter medications such as acetaminophen to be effective in treating pain.
• The survey also revealed that only a few parents are aware of the range of options available under the non-opioid pain treatment, pain therapy, and other alternative medications for children.

RESEARCH STRATEGY