Opioid Use, Perioperative Risks, and Associated Postoperative Complications in Foot and Ankle Surgery

Category: Ankle, Midfoot/Forefoot, Opioid Use Research Introduction/Purpose: Within the United States, opioid abuse has become a national crisis. Twenty-nine percent of patients prescribed opioids misuse them with nearly 12% developing addiction. One previous study has shown that patients undergoing foot/ankle surgery were left with extra narcotic pain medications following surgery, many of whom would have preferred to dispose of them. Our purpose was to evaluate factors in foot and ankle surgery that are associated with increased risk of prolonged post-operative opioid pain medication usage and identify the risk of various post-operative complications that may be associated with pre-operative opioid usage. We hypothesize that pre-operative opioid use will place patients at an increased risk of post-operative usage. Methods: The MarketScan commercial claims and encounters database, including approximately 39 million patients per year, was searched to identify patients who underwent foot/ankle surgery based on CPT code from 2005-2014. Preoperative comorbidities including DSM-V mental health disorders, chronic pain, chronic regional pain syndrome (CRPS), obesity, tobacco use, medications and diabetes were queried and documented. Patients who utilized opioids at least one month up to 3 months prior to surgery were identified. This timeframe was chosen to exclude patients who had been prescribed post-operative narcotic medications up to 1 months pre-operatively. We utilized odds ratios (OR), 95% Confidence Intervals (CI), and regression analysis to determine factors that are associated with prolonged post-operative opioid use at 3 time intervals. Results: 112,893 patients underwent foot/ankle surgery. 11,523 (10.2%) patients utilized opioids 1-3months pre-operatively. Of those, 5,732 (5.0%) utilized opioids post-operatively at 6 weeks, 4,364 (3.8%) at 3 months, 3,475 (3.08%) at 6 months and 2,579 (2.2%) at 1 year. Pre-operative opioid use was associated with increased post-operative use (6-12weeks: OR 7.24, 95% CI 6.92- 7.58; 3-6months: OR 11.03, 95% CI 10.45-11.63; 6-12months: OR 14.1, 95% CI 13.3-15.1; >12months: OR 14.74, 95% CI 13.68-15.88). Tobacco use, chronic pain, DSM-V diagnosis and non-opioid analgesia yielded increased risk of post-operative opioid usage. Diagnosis of CRPS, obesity or diabetes did not have an increased risk. Pre-operative opioid use was associated with an increased risk of readmission, DVT, pulmonary embolism, I&D of surgical site, myocardial infarction, UTI and post-operative bleeding (Table 1). Conclusion: Our study found a number of factors that are associated with prolonged post-operative opioid usage which included pre-operative opioid use 1-3months before surgery, tobacco use, chronic pain, DSM-V diagnoses and pre-operative use of certain non-opioid medications. We also found patients with pre-operative opioid exposure to be at an increased risk of a number of significant post-operative complications, including an increased risk of readmission at 30 and 90 days. This data provides orthopaedic surgeons a number of variables to consider when determining post-operative analgesia strategies, and provides health systems, providers and payers information on complications associated with pre-operative opioid utilization.

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Risk Factors For Prolonged Opioid Use After Spine Surgery

Global Spine Journal ◽

10.1177/21925682211003854 ◽

2021 ◽

pp. 219256822110038

Author(s):

Christopher Kowalski ◽

Ryan Ridenour ◽

Sarah McNutt ◽

Djibril Ba ◽

Guodong Liu ◽

...

Keyword(s):

Mental Health ◽

Chronic Pain ◽

Spine Surgery ◽

Pain Syndrome ◽

Lumbar Spine Surgery ◽

Opioid Use ◽

Chronic Regional Pain Syndrome ◽

Increased Risk ◽

Operative Complications ◽

Post Operative Complications

Study Design: Retrospective review. Objective: Our purpose was to evaluate factors associated with increased risk of prolonged post-operative opioid pain medication usage following spine surgery, as well as identify the risk of various post-operative complications that may be associated with pre-operative opioid usage. Methods: The MarketScan commercial claims and encounters database includes approximately 39 million patients per year. Patients undergoing cervical and lumbar spine surgery between the years 2005-2014 were identified using CPT codes. Pre-operative comorbidities including DSM-V mental health disorders, chronic pain, chronic regional pain syndrome (CRPS), obesity, tobacco use, medications, and diabetes were queried and documented. Patients who utilized opioids from 1-3 months prior to surgery were identified. This timeframe was chosen to exclude patients who had been prescribed pre- and post-operative narcotic medications up to 1 month prior to surgery. We utilized odds ratios (OR), 95% Confidence Intervals (CI), and regression analysis to determine factors that are associated with prolonged post-operative opioid use at 3 time intervals. Results: 553,509 patients who underwent spine surgery during the 10-year period were identified. 34.9% of patients utilized opioids 1-3 months pre-operatively. 25% patients were still utilizing opioids at 6 weeks, 17.3% at 3 months, 12.7% at 6 months, and 9.0% at 1 year after surgery. Pre-operative opioid exposure was associated with increased likelihood of post-operative use at 6-12 weeks (OR 5.45, 95% CI 5.37-5.53), 3-6 months (OR 6.48, 95% CI 6.37-6.59), 6-12 months (OR 6.97, 95% CI 6.84-7.11), and >12 months (OR 7.12, 95% CI 6.96-7.29). Mental health diagnosis, tobacco usage, diagnosis of chronic pain or CRPS, and non-narcotic neuromodulatory medications yielded increased likelihood of prolonged post-op opioid usage. Conclusions: Pre-operative narcotic use and several patient comorbidities diagnoses are associated with prolonged post-operative opioid usage following spine surgery. Chronic opioid use, diagnosis of chronic pain, or use of non-narcotic neuromodulatory medications have the highest risk of prolonged post-operative opioid consumption. Patients using opiates pre-operatively did have an increased 30 and 90-day readmission risk, in addition to a number of serious post-operative complications. This data provides spine surgeons a number of variables to consider when determining post-operative analgesia strategies, and provides health systems, providers, and payers with information on complications associated with pre-operative opioid utilization.

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Opioid Use, Perioperative Risks, and Associated Postoperative Complications in Foot and Ankle Surgery

Foot & Ankle Specialist ◽

10.1177/1938640020977988 ◽

2020 ◽

pp. 193864002097798

Author(s):

Ryan Ridenour ◽

Christopher Kowalski ◽

Djibril Ba ◽

Guodong Liu ◽

Jesse Bible ◽

...

Keyword(s):

Mental Health ◽

Chronic Pain ◽

Postoperative Complications ◽

Tobacco Use ◽

Published Data ◽

Foot And Ankle ◽

Opioid Use ◽

Factors Associated ◽

National Crisis ◽

Ankle Surgery

Introduction Opioid abuse has become a national crisis. Published data demonstrate that patients undergoing foot and ankle surgery are left with excess narcotic medications postoperatively. The purpose of our study was to evaluate factors associated with prolonged postoperative opioid use following foot and ankle surgery and identify associations between preoperative opioid use and postoperative complications. Methods MarketScan commercial claims and encounters database was searched to identify foot and ankle patients. Preoperative comorbidities were queried and documented. Patients utilizing opioids 1 to 3 months prior to surgery were identified. Adjusted odds ratios and 95% CIs were calculated using multivariable logistic regression to determine associations between opioid use (preoperatively and postoperatively), readmission, and complications. Results A total of 112 893 patients were included in the study. Preoperative use had a statistically significant association with postoperative use out to 1 year. Tobacco use, chronic pain, mental health diagnosis, and nonopioid medications had a statistically significant association with postoperative use. Preoperative opioid use had a statistically significant association with readmission and postoperative complications. Conclusion Our study found a number of factors associated with prolonged postoperative opioid use (preoperative use, tobacco use, chronic pain, mental health disorders, and certain nonopioid medications). We identified an association between preoperative opioid use and postoperative complications and readmission. Levels of Evidence Prognostic Level IV Evidence

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Postoperative Opioid Prescribing Practice in Foot and Ankle Surgery

Journal of the American Podiatric Medical Association ◽

10.7547/20-223 ◽

2021 ◽

Author(s):

Brandon M Brooks ◽

Bradley M Brooks ◽

Brady M Brooks ◽

Adam E Fleischer ◽

Robert G Smith ◽

...

Keyword(s):

United States ◽

Online Survey ◽

The United States ◽

Practice Variation ◽

Foot And Ankle ◽

Linear Regression Models ◽

Time Of Surgery ◽

Opioid Prescribing ◽

Ankle Surgery ◽

Prescribing Practice

Background: Clinicians, governmental agencies, patients, and pharmaceutical companies all contribute to the United States' opioid epidemic. These same stakeholders can make meaningful contributions to resolve the epidemic by identifying ineffective habits and encouraging change. The purpose of this study was to determine if postoperative opioid prescribing practice variation exists in foot and ankle surgery. We also aimed to identify if demographic characteristics of podiatric foot and ankle surgeons were associated with their postoperative opioid prescribing practices. Methods: We administered an open, voluntary, anonymous, online questionnaire distributed on the internet via Qualtrics, an online survey platform. The questionnaire consisted of six foot and ankle surgery scenarios followed by a demographics section. We invited Podiatric foot and ankle surgeons practicing in the United States to complete the questionnaire via email from the American Podiatric Medical Association's membership list. Respondents selected the postoperative opioid(s) that they would prescribe at the time of surgery, as well as the dose, frequency, and number of "pills" (dosage units). We developed multiple linear regression models to identify associations between prescriber characteristics and two measures of opioid quantity: dosage units and MME. Results: Eight hundred and sixty podiatric foot and ankle surgeons completed the survey. The median number of dosage units never exceeded 30 regardless of the foot and ankle surgery. Years in practice correlated with reduction in opioid dosage units prescribed at the time of surgery. Conclusions: Postoperative opioid prescribing practice variation exists in foot and ankle surgery. In comparison to the orthopedic community, podiatric foot and ankle surgeons prescribe approximately 25% fewer opioids at the time of surgery than orthopedic foot and ankle surgeons. Further research is warranted to determine if additional education is needed for young surgeons.

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Postoperative Tourniquet Pain in Patients Undergoing Foot and Ankle Surgery

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00423 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0042

Author(s):

Ashish Shah ◽

Eva Lehtonen ◽

Samuel Huntley ◽

Harshadkumar Patel ◽

John Johnson ◽

...

Keyword(s):

Blood Pressure ◽

Postoperative Pain ◽

Length Of Stay ◽

Systolic Blood Pressure ◽

Foot And Ankle ◽

Opioid Use ◽

Tourniquet Time ◽

Pain Scores ◽

Regional Nerve Block ◽

Ankle Surgery

Category: Other Introduction/Purpose: The tourniquet is commonly used in orthopedic surgeries on the upper and lower extremities to reduce blood loss, improve visualization, and expedite the surgical procedure. However, tourniquets have been associated with multiple local and systemic complications, including postoperative pain. Guidelines vary regarding ideal tourniquet pressure and duration, while the practice of fixed, high tourniquet pressures remains common. The relationship between tourniquet pressure, duration, and postoperative pain has been studied in various orthopaedic procedures, but these relationships remain unknown in foot and ankle surgery. The purpose of this study was to assess for correlation between excessive tourniquet pressure and duration and the increased incidence of tourniquet pain in foot and ankle surgery patients. Methods: Retrospective chart review was performed for 132 adult patients who underwent foot and ankle surgery with concomitant use of intraoperative tourniquet at a single institution between August and December of 2015. Patients with history of daily opioid use of 30 or more morphine oral equivalents for greater than 30 days, patients who underwent foot and ankle surgery without regional nerve block, patients deemed to have failed regional nerve block, and patients who underwent foot and ankle surgery without tourniquet use were excluded. Patient’s baseline systolic blood pressure, tourniquet pressure and duration, tourniquet deflation time, tourniquet reinflation pressure and duration, intraoperative blood pressure and heart rate changes, intra-operative opioid consumption, PACU pain scores, PACU opioid consumption, and PACU length of stay were collected. Statistical correlation between tourniquet pressure and duration and postoperative pain scores, pain location, narcotic use, and length of stay in PACU was assessed using linear regression in SPSS. Results: Average age of patients was 47.6 years (Range: 16 - 79). Tourniquet pressure was 280 mmHg in 90.6% of patients (Range: 250-300 mmHg). Only 3.8% percent of patients had tourniquet pressures 100-150 mmHg above systolic blood pressure. Mean tourniquet time was 106.2 ± 40.1 min. Tourniquet time showed significant positive correlation with morphine equivalents used in the perioperative period (N = 121; r = 0.406; p < 0.001). Long tourniquet times (= 90 minutes) were associated with greater intraoperative opioid use than short tourniquet times (= 90 minutes) (19 mg ± 22 mg vs. 5 mg ± 11.6 mg; p <0.001). Tourniquet duration and PACU length of stay had a positive association (R2 = 0.4). Conclusion: The majority of cases of foot and ankle surgery at our institution did not adhere to current tourniquet use guidelines, which recommend tourniquet pressure between 100 and 150 mmHg above patient’s systolic blood pressure. Prolonged tourniquet times at high pressures not based on limb occlusion pressure, as observed in our study, lead to increased pain and opioid use and prolonged time in PACU. Basing tourniquet pressures on limb occlusion pressures could likely improve the safety margin of tourniquets, however randomized studies need to be completed to confirm this.

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Subsequent Injury is Common after Foot and Ankle Surgery in Patients Receiving Workers’ Compensation

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00171 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0017

Author(s):

Gabrielle Bui ◽

Phinit Phisitkul ◽

Natalie Glass ◽

Chris Cychosz ◽

Sean Boarini

Keyword(s):

Retrospective Chart Review ◽

Anatomical Location ◽

Workers Compensation ◽

Foot And Ankle ◽

Chi Square ◽

Legal Representation ◽

Increased Risk ◽

Ankle Surgery ◽

Poor Outcomes ◽

Subsequent Injury

Category: Ankle Introduction/Purpose: Workers’ compensation (WC) has been associated with poor outcomes following a variety of injuries and surgeries. Previous studies have investigated surgical outcomes via satisfaction surveys, but rates of subsequent injury following surgery have not been specifically studied. The purpose of this study was to investigate the rates, locations and risk factors for subsequent injuries in WC patients and non-WC patients who underwent the same surgeries. Methods: With IRB approval, we identified the records of patients with a foot or ankle surgery performed by a single surgeon from 2009-2015. We included only surgeries with one of the most common current procedural terminology (CPT) codes from the WC population. A retrospective chart review was performed on all WC and non-WC patients with at least one of these CPT codes. A subsequent injury was defined as a new injury at a different anatomical location that occurred from 2 months to 2 years after the index surgery. Chi-square and two-tailed t-tests were used to compare WC and non-WC patient populations, and to determine factors associated with subsequent injuries. Results: Overall, the WC population had higher rates of subsequent injury than the non-WC population 23.21% versus 7.27%, p=.0011. Within the WC patient population, patients with subsequent injuries were older than patients without subsequent injuries 48.78±7.30 versus 41.58±12.40, p=.0137. In a blinded review of the charts and Iowa Courts Online, legal representation was found to be more common in WC patients with subsequent injuries than WC patients without subsequent injuries (76.92% versus 37.21%, p=.0240). In the non-WC population, there were more males in the group without subsequent injuries than in the group with subsequent injuries 42.48% versus 8.33%, p=.0287. There were no significant differences in locations of subsequent injury. Hip, knee and contralateral foot and ankle were common areas of subsequent injury in both groups. Conclusion: Overall, WC patients had higher rates of subsequent injury than non-WC patients. Within the WC group, legal representation further raised the risk of subsequent injury. Gender may mediate variable reporting of subsequent injuries in non-WC populations. While the reason for this increased risk of subsequent injury is not known, the differences are enough that they should be considered when counseling WC patients considering these surgeries. Additionally, if further study supported these findings, knowledge of the areas at risk for subsequent injury might lead to preventative strategies that could decrease the risk of subsequent injury.

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0259 Shiftworkers are at Increased Risk of Developing Chronic Pain and Opioid Use Disorders: A Study of 116,000 UK Biobank Participants Over a Decade

SLEEP ◽

10.1093/sleep/zsaa056.257 ◽

2020 ◽

Vol 43 (Supplement_1) ◽

pp. A98-A99

Author(s):

L Gao ◽

P Li ◽

L Cui ◽

Y Luo ◽

C Vetter ◽

...

Keyword(s):

Chronic Pain ◽

Bone Fractures ◽

Inflammatory Diseases ◽

Opioid Use Disorder ◽

Uk Biobank ◽

Opioid Use ◽

Logistic Regression Models ◽

Diagnostic Coding ◽

Increased Risk ◽

Opioid Use Disorders

Abstract Introduction In the current epidemic of opioid-related deaths, and widespread use of opioids to treat chronic pain, there is a pressing need to understand the underlying risk factors that contribute to such devastating conditions. Shiftwork has been associated with adverse health outcomes. We tested whether shiftwork during middle age is linked to the development of chronic pain and opioid misuse. Methods We studied 116,474 participants in active employment between 2006–2010 (mean age 57±8; range 37–71) from the UK Biobank, who have been followed for up to 10 years until 2017. We included participants who were free from all forms of self-reported pain, and were not taking opioid medications at baseline. Chronic pain and opioid use disorder diagnoses were determined using hospitalization records and diagnostic coding from ICD-10. Multivariate logistic regression models were performed to examine the associations of shiftwork status (yes/no) and nightshift frequency (none/occasional/permanent) and with incident chronic pain and/or opioid use disorder during follow-up. Models were adjusted for demographics, education, Townsend deprivation index, major confounders (BMI, diabetes, bone fractures/injuries, operations, peripheral vascular disease, joint/inflammatory diseases, cancer, standing/manual labor at work) and covariates (smoking, alcohol, high cholesterol, depression/anxiety, and cardiovascular diseases). Results In total, 190 (1.6/1,000) developed chronic pain or opioid use disorders. Shiftworkers (n=17,673) saw a 1.5-fold increased risk (OR 1.56, 95% CI: 1.08–2.24, p=0.01) relative to day workers. Within shiftworkers, those who reported occasional nightshift work (n=3,966) were most vulnerable (OR 1.57, 95% CI: 1.06–2.34, p=0.02). Results remained similar after adjusting for baseline sleep duration, chronotype and insomnia. Conclusion Shiftwork, and in particular rotating nightshift work is associated with increased risk for developing chronic pain and opioid use disorders. Replication is required to confirm the findings and to examine underlying mechanisms. Support This work was supported by NIH grants T32GM007592, RF1AG064312, and RF1AG059867.

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Incidence of Venous Thromboembolism in Orthopaedic Foot and Ankle Surgeries

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00108 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0010

Author(s):

Ashish Shah ◽

Samuel Huntley ◽

Harshadkumar Patel ◽

Eildar Abyar ◽

Eva Lehtonen ◽

...

Keyword(s):

Venous Thromboembolism ◽

Elective Surgery ◽

Meta Analysis ◽

Categorical Variables ◽

Continuous Variables ◽

Foot And Ankle ◽

Improvement Program ◽

Female Sex ◽

Increased Risk ◽

Ankle Surgery

Category: Other Introduction/Purpose: Venous thromboembolism (VTE) is a rare but potentially lethal complication following orthopaedic foot and ankle surgery. Surgeons continue to debate the types of patients and procedures in which it is appropriate to use chemical thromboprophylaxis. A recent meta-analysis concluded that patients at high risk for VTE after foot and ankle surgery should receive prophylaxis, but there remains a paucity of data to elucidate which demographic or comorbidity variables are most strongly associated with development of VTE. The incidence of VTE after orthopaedic foot and ankle surgery stratified by specific procedure has yet to be examined. The purpose of this study is to report the incidence of and identify risk factors for VTE in a large sample of patients receiving orthopaedic foot and ankle surgery. Methods: In this study, we retrospectively analyzed prospectively-collected data from the National Surgical Quality Improvement Program (NSQIP) 2006 to 2015 data files. The incidence of VTE was calculated for 30 specific orthopaedic foot and ankle surgeries and for four broad types of foot and ankle surgery. A total of 23,212 patients were identified and grouped by current procedures terminology (CPT) codes. Demographic, comorbidity, and complication variables were analyzed to determine associations with development of VTE. Pearson’s chi-squared test was used to compare categorical variables and Student t test was used to compare continuous variables. P-values of p<0.05 were considered statistically significant. Multivariable modelling was not possible due to the very low number of VTE cases relative to non-VTE cases. Results: The mean age at the time of surgery was 52.7±17.8 years. VTE events were documented 142 times in our sample, yielding an overall sample VTE incidence of 0.6%. The types of procedures with the highest frequency of VTE were ankle fractures (105/15,302 cases, 0.7%), foot pathologies (28/5,466, 0.6%), and arthroscopy (2/398, 0.5%). Female sex, increasing age, obesity level, inpatient status, and non-elective surgery were all significantly associated with VTE events. Postoperative pneumonia was significantly associated with VTE development. Patients who developed a VTE stayed at the hospital after surgery significantly longer than patients without VTE (6.2 vs. 3.1 days). Patients who developed VTE also had significantly higher estimated probability of morbidity (8.0% vs. 6.0%) and mortality (2.0% vs. 1.0%) when compared to patients without VTE. Conclusion: The present study confirms that VTE events after foot and ankle procedures are rare. The data presented suggest that female sex, increasing age, higher BMI, inpatient status, and non-elective procedures are associated with increased risk for VTE after orthopaedic foot and ankle surgery. Prospective, randomized, controlled trials are necessary to definitively determine the efficacy of chemoprophylaxis and to develop evidence-based clinical practice guidelines to minimize VTE after foot and ankle procedures.

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Anticoagulation Regimens and Interventional Pain Procedures

10.1093/med/9780190271787.003.0039 ◽

2018 ◽

Author(s):

Christine Oryhan ◽

Kevin Vorenkamp ◽

Daniel Warren

Keyword(s):

Chronic Pain ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Patient Characteristics ◽

The United States ◽

Bleeding Complications ◽

Risk Of Bleeding ◽

Increased Risk ◽

Spinal Epidural ◽

The Ideal

With the aging population and new anticoagulant medications, such as direct oral anticoagulants, being marketed in the United States, it is very important for pain physicians to be aware of the anticoagulants available and how they affect the safety of interventional pain procedures. In addition to anticoagulant and antiplatelet medications, other medications commonly used in the chronic pain population may put patients at increased risk of bleeding complications. Certain patient characteristics, particularly in the chronic pain population, may also increase a patient’s risk of bleeding. The chapter reviews common and emerging anticoagulant and antiplatelet medications and the ideal holding time before or after interventional pain procedures, particularly in the spine. The chapter also discusses the diagnosis, treatment, and outcomes of spinal epidural hematomas.

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Knowledge, Beliefs, and Attitudes of Emergency Nurses Toward People With Chronic Pain

SAGE Open Nursing ◽

10.1177/2377960819871805 ◽

2019 ◽

Vol 5 ◽

pp. 237796081987180 ◽

Cited By ~ 1

Author(s):

Geraldine Martorella ◽

Michelle Kostic ◽

Anaïs Lacasse ◽

Glenna Schluck ◽

Laurie Abbott

Keyword(s):

Chronic Pain ◽

Survey Design ◽

The United States ◽

Considerable Proportion ◽

Clinical Environment ◽

Cross Sectional ◽

Complex Needs ◽

Negative Beliefs ◽

Increased Risk ◽

Beliefs And Attitudes

More and more people suffering from chronic pain (CP) utilize the emergency department (ED). However, their needs are not properly addressed. Stigmatization toward people with CP can partially explain this gap. Most studies in the ED have been focused on measuring nurses’ pain management knowledge in general, not negative attitudes toward CP. Hence, understanding of the determinants of the stigma related to CP is needed. The objectives of this study were to (a) describe the knowledge, beliefs, and attitudes of ED nurses toward people suffering from CP and (b) identify nurses’ characteristics associated with these perceptions. A cross-sectional web-based survey design was conducted using the KnowPain-12 questionnaire and the Chronic Pain Myth Scale. A total of 571 participants from 20 different states across the United States were recruited among whom 482 completed the entire survey. The sample included about one third of the ED nurses suffering from CP. Negative beliefs and attitudes toward people with CP were present in a considerable proportion of participants (up to 64%), even in nurses suffering from CP (up to 47.5%). Nevertheless, our results suggest that higher levels of education and suffering from CP were associated with better beliefs and attitudes toward people with CP. The ED presents an increased risk of stigmatization of people with CP as compared with the general population. Identifying determinants of the stigma associated with CP is crucial, as it will help tailoring awareness and educational campaigns. In addition, CP patients utilizing the ED often have complex needs which are difficult to address in this clinical environment. This situation can contribute to negative beliefs and attitudes. Given the scarcity of specialized care clinics for this population, health-care stakeholders should devise solutions to improve continuity of care in primary care settings and between the latter and ED.

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Analysis of Pulpal Reactions to Restorative Procedures, Materials, Pulp Capping, and Future Therapies

Critical Reviews in Oral Biology & Medicine ◽

10.1177/154411130201300607 ◽

2002 ◽

Vol 13 (6) ◽

pp. 509-520 ◽

Cited By ~ 85

Author(s):

Peter E. Murray ◽

L. Jack Windsor ◽

Thomas W. Smyth ◽

Abeer A. Hafez ◽

Charles F. Cox

Keyword(s):

Dental Health ◽

Management Strategies ◽

The United States ◽

Tissue Formation ◽

Oral Diseases ◽

Mineralized Tissue ◽

Operative Complications ◽

Caries Management ◽

Caries Lesions ◽

Post Operative Complications

Every year, despite the effectiveness of preventive dentistry and dental health care, 290 million fillings are placed each year in the United States; two-thirds of these involve the replacement of failed restorations. Improvements in the success of restorative treatments may be possible if caries management strategies, selection of restorative materials, and their proper use to avoid post-operative complications were investigated from a biological perspective. Consequently, this review will examine pulp injury and healing reactions to different restorative variables. The application of tissue engineering approaches to restorative dentistry will require the transplantation, replacement, or regeneration of cells, and/or stimulation of mineralized tissue formation. This might solve major dental problems, by remineralizing caries lesions, vaccinating against caries and oral diseases, and restoring injured or replacing lost teeth. However, until these therapies can be introduced clinically, the avoidance of post-operative complications with conventional therapies requires attention to numerous aspects of treatment highlighted in this review.

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