Pain, Pills and New Perceptions
The beauty of dentistry and medicine, in general, is the ever-present evolution and growth of evidence-based practices guided by novel understanding. The advancement of knowledge allows our “practice” of the healing arts, to be refined continuously to better serve our patients and customize treatment modalities for maximized efficacy in rendering patient care. The following are recent advances in the understanding of how the medical community has a better under-standing of areas impacting dentistry.
Let us first talk about pain, our nemesis in the field of oral health, and how we man-age it in our patients is poorly understood. We can appreciate this vital sign in dealing with nociception that fluctuates through-out the day. Our internal clock, known as the circadian rhythm, dictates our bodily functions down to the cellular level. In a recent study from July, a group of twelve men was evaluated on two aspects concerning pain perception. It was discovered that pain sensitivity peaked at around 3 a.m. to 4 a.m. and minimized reaching its lowest point, highest pain threshold, 12 hours later. The second aspect was observing the effects of sleep deprivation on pain. sensitivity. The data in the study demonstrated that 80% of pain sensitivity could be explained by the circadian drive and 20 percent is attributed to sleep deprivation. These factors work in modulating the perception of pain in males so further work needs to be done with larger sample sizes and gender/age distributions.
Interestingly, the work helps to open a door to give credence to why our patients cannot sleep from a toothache that feels “worse at night” compounded by a series of sleepless nights. When considering eco-nomic stresses, pandemic pressures, and uncertainty for the future our patients may experience disrupted sleep. This study supports a comprehensive patient-centered perspective on how the brain us-es its rhythmic functions to modify pain and will help us improve as oral health providers.
Now for a better understanding of pills and their pharmacodynamics, here is a unique study. We have all mentioned at some point to our patients to take a medication on a specific schedule or with a dietary re-striction such as with food or n.p.o. (non-per-os) albeit, we may have never considered what body position to recommend for oral administration. A new study out of Johns Hopkins University has looked at just that, oral administration, dissolution, and how they are impacted by body positioning. The human stomach is an asymmetric organ by design, and this may prove to be advantageous to practitioners in recommending pharmacologic/positional therapies.
In considering four different body positions the research team looked at four models for pill administration: (standing/sitting), lying flat on the back, lying on the right side, and finally lying on the left side. What came about was a remarkable difference in pill breakdown (dissolving) based on body positioning. Patients on their left side experienced more than 90 minutes to break down the pill. Patients taking their pill standing up/sitting down as well as patients lying on their back took 25 minutes on average to have pills dissolve.
The most surprising finding was patients taking pills while positioned on their left flank had a pill breakdown of 10 minutes. This broad range of physiologic/digestive activity should be a monumental wake-up call to providers when using the p.o. (per os) route.
The variance should make us reflect on patients that may be bedridden or handicapped or incapacitated. This may allow us to consider not only taking medication but indicate to our patients the recommended body positioning for rapid vs. gradual uptake merited by the clinical circumstances including sedation, pain management, and emergent antibiotic therapies.
Finally, a new perception of NSAIDs (non-steroidal anti-inflammatory drugs) has come out of the European Society of Cardiology (E.S.C.) Congress of 2022. The several types of NSAIDs such as aspirin, ibuprofen, and naproxen to name a few have helped many manage toothaches and other physical maladies of craniofacial nature. The general acceptance of NSAIDs as part of the analgesia armamentarium has allowed for their broad use, however, a new observational study out of Denmark has looked at a group of 331,189 patients from 1998 to 2021 and evidenced a troubling trend. The group analyzed type 2 diabetics where the average age was 62 and 56% were men. The short-term use of NSAIDs in poorly controlled type 2 diabetics was associated with an increased risk for a first-time hospitalization for heart failure potentially driven by the fluid imbalances from their pharmacology. This new finding will help drive further understanding as to whether these medications are safe in this at-risk sub-group.
In these recent findings of “pain, pills, and perceptions” we have to at a minimum re-consider “best practices.” The three afore-mentioned areas help us to appreciate the nuances of evolving evidenced based medicine and oral health practices that can be modified to better serve our community. As one of my dental school instructors remind-ed my class with regards to the practice of healthcare, “I hope the day you graduate, is not your day of utmost knowledge. Strive to debunk, trust yet verify, and always have the humility to be better tomorrow than you are today.”
SOURCES:
Daguet I, Raverot V, Bouhassira D, Gronfier C. Circadian rhythmicity of pain sensitivity in humans. Brain, 2022 (in press). https://academic.oup.com/brain/advance-article-abstract/doi/10.1093/brain/awac147/6637506
Lee JH, Kuhar S, Seo JH, Pasricha PJ, Mittal R. Computational modeling of drug dissolution in the human stomach: Effects of posture and gastroparesis on drug bioavailability, Physics of Fluids, August 09, 2022. https://hub.jhu.edu/2022/08/16/the-best-posture-to-take-a-pill/
Holt A, et al. non-steroidal anti-inflammatory drugs linked with heart failure patients with diabetes. European Society of Cardiology, August 23, 2022. https://www.escardio.org/The-ESC/Press-Office/Press-releases/Non-steroidal-anti-inflammatory-drugs-linked-with-heart-failure-in-patients-with-diabetes
