Abstract
Background:
The purpose of this study was to describe dentists’ training experiences relevant to pain management, addiction, and prescription opioid drug diversion and examine associations between these training experiences and dentists’ opioid prescribing practices.
Methods:
A web-based, cross-sectional survey was conducted among practicing dentist members of the National Dental Practice-Based Research Network (PBRN; N=822). The survey assessed pain management prescribing practices and training experiences related to pain management and assessment for addiction and drug diversion. Survey data were linked with National Dental PBRN Enrollment Questionnaire data regarding practitioner demographics and practice characteristics.
Results:
The majority of dentists (67%) reported prior training in pain management; however, a minority of dentists reported prior training regarding identification and assessment of drug abuse or addiction (48%) or identification of prescription drug diversion (25%). The majority of training experiences across all topics occurred through continuing dental education participation. Dental school training relevant to pain management, addiction, and identification of drug diversion was more prevalent among more-recent dental school graduates. Training experiences were associated with prescribing practices.
Conclusions:
Results suggest that across multiple levels of training, many dentists are not receiving training specific to addiction assessment and identification of drug diversion. Such training is associated with greater consistency of risk mitigation implementation in practice.
Keywords: Opioid, Opioid Education, Opioid Prescribing, Dentists
INTRODUCTION
Medical prescribers’ contribution to the initiation and maintenance of the epidemic has been well documented.1,2 Many individuals who go on to develop opioid use disorders, including those individuals who ultimately transition to heroin use, report that early exposure to opioids was through a legitimate prescription or a prescription shared from family or friends.2-4 This risk is particularly highlighted among adolescents and young adults: a combination of medical and non-medical opioid use in adolescents, as well as adolescent non-medical use in isolation, have been associated with elevated risk for substance use disorder symptoms in adulthood.4
Opioids account for nearly one-third of prescriptions issued by dentists and dentists prescribe a notable volume of immediate release opioids, accounting for an estimated 12% of annual immediate release opioid prescriptions.5-9 Prior research suggests that a majority (80%-90%) of patients report having unused medication leftover from their post-procedural dental prescription.10 Dental opioid prescribing is particularly frequent for adolescent patients, a group at increased risk for misuse.11-14 Furthermore, research suggests that dentists do not regularly implement recommended risk mitigation strategies - including screening for prescription drug abuse/misuse, querying a prescription drug monitoring program (PDMP), and providing thorough patient education regarding safe use, storage, and disposal when prescribing opioid medications for pain management.7,15,16
Increasing attention has been given to the importance of training in pain management and addiction in medical schools, medical residency programs, and continuing education initiatives.17-21 The current study presents findings from a national survey of dental practitioners with the aims of: (1) describing training experiences relevant to pain management, addiction, and drug diversion; (2) identifying the relevance of various training resources to dentists’ prescribing practices; and, (3) examining associations between training experiences and dentists’ prescribing practices.
METHODS
Participants
This study was conducted in partnership with the National Dental PBRN, a consortium of dental practices and dental organizations focused on improving the scientific basis for clinical decision-making.22 Detailed information about the network is available on its web site (https://www.nationaldentalpbrn.org). The Institutional Review Board (IRB) at the lead investigator’s institutions and IRBs associated with the Network approved this project. A total of 1,428 network members were randomly selected and invited to participate in this cross-sectional survey study. Inclusion/exclusion criteria are discussed in detail in a prior publication.16
Survey
The development and test/retest reliability of this survey are detailed in a previous publication.16 The final survey was administered online via Research Electronic Data Capture (REDCap), and consisted of 137 potential items (publicly available at http://nationaldentalpbrn.org/study-results/reducing-prescription-opioid-misuse-dental-provider-intervention-development-survey.htm). Survey data were paired with practitioner and practice characteristics from the network’s Enrollment Questionnaire items. Enrollment Questionnaire items had documented test/re-test reliability and were adapted from previous work in a practice-based study of dental care (publicly available at http://nationaldentalpbrn.org/study-results/).
Survey Recruitment Methodology
Study recruitment took place between August 29, 2016 and December 5, 2016. Dentists received an invitation email explaining the study and inviting them to participate using a unique electronic link to the questionnaire and were sent up to 5 reminders via email and phone. Dentists who had not completed the survey within a 10-week timeframe were considered non-respondents. Dentists were offered a $50 remuneration code for their participation.
Statistical Analysis
The following variables were examined for their association with the extent of training experiences: (1) decade in which dentist graduated from dental school; (2) specialist training (yes/no); (3) any advanced general dentistry training (yes/no); (4) frequency of prescribing opioids; (5) frequency of recommending NSAIDS or acetaminophen in combination with prescribing opioids; (6) frequency of recommending NSAIDS; (5) frequency of recommending acetaminophen; (7) frequency of PDMP use; (8) consistency of educating patients regarding risks associated with opioids; and, (9) self-rated knowledge regarding the risks of addiction, misuse, and diversion associated with prescription opioids. In order to be asked questions regarding PDMP use, dentists had to indicate holding a current DEA license to prescribe controlled substances.
For these analyses, prior training experiences were assessed by asking, “Have you received training in (pain management, addiction, drug diversion),” with answer responses of “yes (1)” and “no (2).” Extent of Prior Training was assessed with the subsequent question “How much instruction did you receive.” Answer options were presented in a Likert scale and included: none (0), less than 2 hours (1), half-day instruction/seminar (2), full-day instruction/seminar (3), multi-day instruction/seminar (4), and semester/quarter of instruction or more (5). Dentists were asked to rate “how valuable each of the following resources has been in giving you information about controlled substance prescribing” on a scale that included: very valuable (1), somewhat valuable (2), not valuable (3), and do not use this source for information about controlled prescribing (4).
Prescribing was assessed by asking dentists, “In the past 6 months, when patients have needed medication for pain management, for how many patients have you: recommended NSAIDs, recommended acetaminophen, prescribed an opioid only, or prescribed an opioid and recommended OTC medication.” Answer options ranged from none (1) to all patients (7). Prescription Drug Monitoring Program (PDMP) Use variable summed items regarding frequency of checking the PDMP prior to any opioid prescription, prior to prescribing to high-risk patients, prior to prescribing to new patients, and prior to prescribing refills. Lower scores (range: 4 to 28; Mean=13.8; Median=14) on this item represented more-frequent use of the PDMP. Patient Education variable summed items for frequency of educating patients regarding risks, side effects, secure storage, disposal, and non-medical use risks associated with opioid medication. Lower scores (range: 5 to 35; Mean=21.7; Median=23) on this item represented more-consistent provision of patient education. Finally, dentists were also asked “How would you rate your level of knowledge regarding the risks of addiction, misuse, and diversion (intentional and unintentional) associated with prescription opioids?” Answer options included: very knowledgeable (1), somewhat knowledgeable (2), and not very knowledgeable (3).
All data were consolidated in an SPSS database for analysis. Frequency distributions and descriptive statistics were figured for all outcome variables of interest. Associations of practitioner- and practice-level characteristics, as well as self-reported opioid prescribing practices, with extent of training related to pain management, addiction, and drug diversion were examined with Pearson bivariate correlation or one-way ANOVA analyses, as appropriate.
RESULTS
Survey Participation
Of the 1,428 dentists invited to participate, a total of 822 (58% of invited) dentists completed the survey. Among dentists not completing the survey, the majority did not ever access the survey (508 of 606). A minority accessed but did not complete (49 of 606), had provided an inactive email address on their enrollment questionnaire (33 of 606), explicitly refused participation (10 of 606), or no longer met eligibility criteria at the time of survey deployment (6 of 606). Descriptive information about participating dentists (N=822) and their respective practice characteristics are presented in Table 1. Additional information comparing survey completers to non-completers are reported in more detail elsewhere.16
Table 1.
Descriptive results regarding dentists and their respective practices (N=822)
| Variable | Frequency | Percent of Total Sample |
|---|---|---|
| Practitioner Sex | ||
| Male | 582 | 70.8% |
| Female | 231 | 28.1% |
| Practitioner Ethnicity | ||
| Hispanic | 42 | 5.2% |
| Non-Hispanic | 771 | 93.8% |
| Practitioner Race | ||
| White or Caucasian | 660 | 80.3% |
| Black or African American | 39 | 4.7% |
| American Indian or Alaskan Native | 3 | 0.4% |
| Asian | 80 | 9.7% |
| Native Hawaiian or Pacific Islander | 2 | 0.2% |
| Other | 29 | 3.5% |
| Practitioner Type | ||
| General Practitioner | 635 | 77.3% |
| AEGD | 67 | 8.2% |
| GPR | 155 | 18.9% |
| FAGD | 84 | 10.2% |
| MAGD | 31 | 3.8% |
| Other Advanced Training | 127 | 15.5% |
| Any Advanced General Training+ | 343 | 41.7% |
| Specialist | 187 | 22.7% |
| Practice Type | ||
| Private Practice | 647 | 78.7% |
| Managed Care Organization | 64 | 7.8% |
| Public Health/Community/Government | 46 | 5.6% |
| Academic Setting | 58 | 7.1% |
| Specialty Training | ||
| Endodontist | 59 | 7.2% |
| Periodontist | 74 | 9.0% |
| Prosthodontist | 28 | 3.4% |
| Oral and Maxillofacial Surgeon | 27 | 3.3% |
| Practitioner Network Region | ||
| Western | 132 | 16.1% |
| Midwest | 96 | 11.7% |
| Southwest | 177 | 21.5% |
| South Central | 134 | 16.3% |
| South Atlantic | 134 | 16.3% |
| Northeast | 149 | 18.1% |
| Practice Location a | ||
| Inner City of Urban Area | 119 | 14.5% |
| Urban (not inner city) | 229 | 27.9% |
| Suburban | 357 | 43.4% |
| Rural | 112 | 13.6% |
| Year of Dental School Graduation | ||
| Before 1980 | 145 | 17.6% |
| 1980-1989 | 267 | 32.5% |
| 1990-1999 | 179 | 21.8% |
| 2000-2009 | 165 | 20.1% |
| 2010 or Later | 64 | 7.8% |
AEGD: Advanced Education in General Dentistry; GPR: General Practice Residency; FAGD: Fellowship in the American Academy of General Dentistry; MAGD: Master in the Academy of General Dentistry.
Dentists could endorse having completed multiple advanced general dentistry trainings, therefore the sum of dentists endorsing AEGD, GPR, FAGD, MAGD, and other advanced training (464) is not reflective of the total number of general dentists reporting any advanced training in general dentistry (343).
When assessed for correlation with training experiences, practice location was dichotomized into “Rural” and “Non-Rural” practice location.
Variables that do not sum to 100% reflect missing data.
Training Experiences
The majority of dentists (n=549, 67%) reported prior training in pain management; however, a minority of dentists reported prior training regarding identification and assessment of drug abuse or addiction (n=393, 48%) or identification of prescription drug diversion (n=206, 25%). Results regarding the frequency and timing of these training experiences are presented in Table 2. Resources providing information about controlled substance prescribing are presented in order of their value to dentists in Table 3.
Table 2.
Dentists’ (N=822) self-reported training experiences regarding pain management (pain), identifying and assessing for drug abuse or addiction (addiction), and identification of prescription drug diversion (diversion).
| Pain | Addiction | Diversion | |
|---|---|---|---|
| How much training | |||
| None | 273 (33%) | 429 (52%) | 616 (75%) |
| < 2 Hours | 70 (8.5%) | 98 (11.9%) | 68 (8.3%) |
| Half-Day | 116 (14.1%) | 102 (12.4%) | 52 (6.3%) |
| Full-Day | 105 (12.8%) | 71 (8.6%) | 37 (4.5%) |
| Multi-Day | 93 (11.3%) | 58 (7.1%) | 21 (2.6%) |
| ≥ Semester/Quarter | 149 (18.1%) | 54 (6.6%) | 22 (2.7%) |
| When was training * | |||
| Dental School | 265 (32.2%) | 136 (16.5%) | 53 (6.4%) |
| Residency | 176 (21.4%) | 85 (10.3%) | 27 (3.3%) |
| Specialty Training | 105 (12.8%) | 56 (6.8%) | 25 (3.0%) |
| CDE** | 423 (51.5%) | 324 (39.4%) | 183 (22.3%) |
Dentists could endorse receiving training during any of the timeframes listed; categories are not mutually exclusive.
CDE = Continuing Dental Education. Training frequencies do not sum to 100% due to some individuals selecting “other” as a response.
Table 3.
Dentists’ impressions regarding the value of information about controlled substance prescribing provided by practice resources.
| Very | Somewhat | Not | Do Not Use | |
|---|---|---|---|---|
| Work Experience | 610 (74%) | 201 (25%) | 7 (1%) | 4 (<1%) |
| CDE* | 456 (56%) | 332 (40%) | 11 (1%) | 23 (3%) |
| Colleagues | 297 (36%) | 433 (53%) | 54 (7%) | 38 (4%) |
| Journal Articles | 255 (31%) | 482 (59%) | 50 (6%) | 35 (4%) |
| Internet | 154 (19%) | 483 (59%) | 102 (12%) | 83 (10%) |
| Reference Books | 158 (19%) | 425 (52%) | 114 (14%) | 125 (15%) |
| Drug Manufacturers | 95 (12%) | 370 (45%) | 223 (27%) | 134 (16%) |
| Internship/Residency/Fellowship | 255 (31%) | 185 (23%) | 44 (5%) | 338 (41%) |
CDE = Continuing Dental Education
We examined extent of training as a function of the decade in which dentists reported graduating from dental school (Figures 1-4 in Appendices). The percent of dentists receiving any training in pain management (χ2 [1, N=820]=0.13, p=.72) and identification of drug diversion (χ2 [1, N=820]=0.08, p=.78) did not statistically differ as a function of graduating prior to (versus in or after) 2010; however, those graduating in or after 2010 (63%) were significantly more likely to report participating in any training related to addictions (χ2 [1, N=820]=6.0, p=.01) than those graduating prior to 2010 (47%). The percent of dentists who reported receiving training related to pain management, addiction assessment, or identification of prescription drug diversion as a part of the dental school curricula steadily increased from 1980 (and prior) to 2010 (and later).
Figure 1. Pain Management Training.
Percent of dentists graduating within an indicated decade who endorsed various levels of training regarding pain management strategies.
Figure 4. Dental School Training Experiences.
Decade of dental school graduation and percent of dentists reporting receipt of training regarding pain management, addiction assessment, and diversion identification as part of their dental school curricula.
Associations Between Training Experiences and Practice Characteristics and Behaviors
A greater extent of training in pain management strategies was significantly associated with specialist training [F(1,804)=24.7, p<.001], higher frequency of recommending NSAIDs in combination with opioid prescribing (r=0.113, p<.01), higher frequency of recommending NSAID/acetaminophen use in isolation (r=0.08, p<.05), higher consistency of educating patients regarding their opioid prescription and its risks (r=−0.18, p<.01), and higher self-rated knowledge regarding risks associated with abuse and diversion (r=0.19, p<.01).
A greater extent of training regarding the identification/assessment for drug abuse and addiction was significantly associated with more-consistent provision of patient education (r=−0.24, p<.01), and higher self-rated knowledge regarding risks associated with abuse and diversion (r=−0.31, p<.01).
A greater extent of training regarding identification of prescription drug diversion was significantly associated with higher frequency of PDMP use (r=−0.11, p<.05), higher consistency of educating patients regarding their opioid prescription and its risks including diversion (r=−0.25, p<.01), and higher self-rated knowledge regarding risks associated with abuse and diversion (r=−0.24, P,.01). Negative correlations are due to coding for the PDMP use variable, such that lower scores reflect more consistent/higher frequency PDMP use.
DISCUSSION
This national survey study presents findings regarding the opioid prescribing practices of active dentists and training experience relevant to acute pain management, assessment of addiction, and identification of prescription drug diversion within their practice. This work is particularly timely given the broad national impact of opioid abuse and overdose and the identification of dentists as leading licit sources of immediate release opioids, particularly among adolescents and young adults.8,11,23,24
The low training prevalence in identification of diversion is consistent with findings from a smaller, statewide of survey of dentists that found that 28% reported prior training experiences and - also similar to the current findings - those training experiences were associated with differences in practice behaviors.7 Whereas the increase in training among more-recent graduates appears to be at least partially driven by the notable integration upsurge of these topics into dental school training curricula, it is worth note that even among dentists graduating in or after 2010, few received training pertinent to addiction (less than 50%) and diversion (less than 20%). That 75% of dentists had no training related to identification of diversion is particularly concerning given data indicating that the majority of individuals who misuse prescription opioids often get them from family and/or friends.2-4 Importantly, the current study found that training experiences were associated with self-reported prescribing practices. All training experiences were associated with increased provider report of knowledge of risks of addiction, misuse, and diversion (intentional and unintentional) associated with prescription opioids. These findings support recent efforts by the American Dental Association promoting mandatory training their recent policy statement on opioids.25
This study has limitations that should be noted. Recruitment for this study was supported by the National Dental PBRN infrastructure and resulted in a 59% response rate among eligible invited dentists. Previous analyses from the network have demonstrated that network practitioners, although diverse, have much in common with the profession at large (e.g., representation of race, gender, ethnicity, number of offices, percentage of patients with insurance coverage, number of operatories, patient visits per week).26,27 Findings from several network studies document that network dentists report patterns of diagnosis and treatment that are similar to patterns of non-network dentists.28-34 However, dentists who enroll in the Network may still be different from non-enrollees in ways that we’ve not measured. All data were cross-sectional, self-reported, and retrospective in nature, subjecting them to potential bias. No objective prescribing data were collected; however, dentists’ self-report of prescribing practices in the current study generally correspond with objective reports of dental opioid prescribing.8 Systemic factors that were not assessed by the current survey could have influenced the findings of this study.
Overall findings suggest that many dentists do not receive training specific to addiction assessment and identification of drug diversion, despite such training being associated with greater consistency of risk mitigation implementation in practice.
Figure 2. . Addiction Training.
Percent of dentists graduating within an indicated decade who endorsed various levels of training regarding identification, and assessment of drug abuse or addiction.
Figure 3. Diversion Training.
Percent of dentists graduating within an indicated decade who endorsed various levels of training regarding identification of prescription drug diversion.
Acknowledgments
An Internet site devoted to details about the nation’s network is located at http://NationalDentalPBRN.org. We are very grateful to the network’s Regional Coordinators who followed-up with network practitioners to improve the response rate (Midwest Region: Tracy Shea, RDH, BSDH; Western Region: Stephanie Hodge, MA; Northeast Region: Christine O’Brien, RDH; South Atlantic Region: Hanna Knopf, BA, Deborah McEdward, RDH, BS, CCRP; South Central Region: Claudia Carcelén, MPH, Shermetria Massingale, MPH, CHES, Ellen Sowell, BA; Southwest Region: Stephanie Reyes, BA, Meredith Buchberg, MPH, Colleen Dolan, MPH).
Role of Funding Sources
This research was supported by the National Institute on Drug Abuse grant K23-DA036566 and the National Institute of Dental and Craniofacial Research grant U19-DE-22516. NIDA/NIDCR had no role in the study design, collection, analysis, or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.
REFERENCES
- 1.Maxwell JC. The prescription drug epidemic in the United States: a perfect storm. Drug Alcohol Rev. May 2011;30(3):264–270. [DOI] [PubMed] [Google Scholar]
- 2.Butler MM, Ancona RM, Beauchamp GA, et al. Emergency Department Prescription Opioids as an Initial Exposure Preceding Addiction. Ann Emerg Med. August 2016;68(2):202–208. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Canfield MC, Keller CE, Frydrych LM, Ashrafioun L, Purdy CH, Blondell RD. Prescription opioid use among patients seeking treatment for opioid dependence. J Addict Med. June 2010;4(2):108–113. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.McCabe SE, Veliz P, Schulenberg JE. Adolescent context of exposure to prescription opioids and substance use disorder symptoms at age 35: a national longitudinal study. Pain. October 2016;157(10):2173–2178. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Gupta N, Vujicic M, Blatz A. Opioid prescribing practices from 2010 through 2015 among dentists in the United States: What do claims data tell us? Journal of the American Dental Association (1939). April 2018;149(4):237–245.e236. [DOI] [PubMed] [Google Scholar]
- 6.Moore PA, Nahouraii HS, Zovko JG, Wisniewski SR. Dental therapeutic practice patterns in the U.S. II. Analgesics, corticosteroids, and antibiotics. Gen Dent. May-Jun 2006;54(3):201–207; quiz 208, 221-202. [PubMed] [Google Scholar]
- 7.McCauley JL, Leite RS, Melvin CL, Fillingim RB, Brady KT. Dental opioid prescribing practices and risk mitigation strategy implementation: Identification of potential targets for provider-level intervention. Subst Abus. 2016;37(1):9–14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.McCauley JL, Hyer JM, Ramakrishnan VR, et al. Dental opioid prescribing and multiple opioid prescriptions among dental patients: Administrative data from the South Carolina prescription drug monitoring program. Journal of the American Dental Association (1939). July 2016;147(7):537–544. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Levy B, Paulozzi L, Mack KA, Jones CM. Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012. Am J Prev Med. September 2015;49(3):409–413. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Maughan BC, Hersh EV, Shofer FS, et al. Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial. Drug Alcohol Depend. November 1 2016;168:328–334. [DOI] [PubMed] [Google Scholar]
- 11.Dautremont EA, Ebramzadeh E, Beck JJ, Bowen RE, Sangiorgio SN. Opioid Prescription and Usage in Adolescents Undergoing Orthopaedic Surgery in the United States: A Systematic Review. JBJS Rev. August 2017;5(8):e5. [DOI] [PubMed] [Google Scholar]
- 12.Denisco RC, Kenna GA, O'Neil MG, et al. Prevention of prescription opioid abuse: the role of the dentist. Journal of the American Dental Association (1939). July 2011;142(7):800–810. [DOI] [PubMed] [Google Scholar]
- 13.Gupta N, Vujicic M, Blatz A. Multiple opioid prescriptions among privately insured dental patients in the United States: Evidence from claims data. Journal of the American Dental Association (1939). April 12 2018. [DOI] [PubMed] [Google Scholar]
- 14.Mutlu I, Abubaker AO, Laskin DM. Narcotic prescribing habits and other methods of pain control by oral and maxillofacial surgeons after impacted third molar removal. J Oral Maxillofac Surg. September 2013;71(9):1500–1503. [DOI] [PubMed] [Google Scholar]
- 15.Herman C The Minnesota Prescription Monitoring Program. Northwest Dent. Mar-Apr 2011;90(2):33–35. [PubMed] [Google Scholar]
- 16.McCauley JL, Leite RS, Gordan VV, et al. Opioid prescribing and risk mitigation implementation in the management of acute pain: Results from The National Dental Practice-Based Research Network. Journal of the American Dental Association (1939). May 2018;149(5):353–362. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Alexandridis AA, McCort A, Ringwalt CL, et al. A statewide evaluation of seven strategies to reduce opioid overdose in North Carolina. Inj Prev. February 2018;24(1):48–54. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Barth KS, Guille C, McCauley J, Brady KT. Targeting practitioners: A review of guidelines, training, and policy in pain management. Drug Alcohol Depend. April 1 2017;173 Suppl 1:S22–S30. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Haegerich TM, Paulozzi LJ, Manns BJ, Jones CM. What we know, and don't know, about the impact of state policy and systems-level interventions on prescription drug overdose. Drug Alcohol Depend. December 1 2014;145:34–47. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Kear C, McKeithen T, Robertson S. ER/LA opioid REMS and accredited education: Survey results provide insight into clinical roles, educational needs, and learner preferences. Subst Abus. Apr-Jun 2017;38(2):145–149. [DOI] [PubMed] [Google Scholar]
- 21.Zisblatt L, Hayes SM, Lazure P, Hardesty I, White JL, Alford DP. Safe and competent opioid prescribing education: Increasing dissemination with a train-the-trainer program. Subst Abus. Apr-Jun 2017;38(2):168–176. [DOI] [PubMed] [Google Scholar]
- 22.Gilbert GH, Williams OD, Korelitz JJ, et al. Purpose, structure, and function of the United States National Dental Practice-Based Research Network. J Dent. November 2013;41(11):1051–1059. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Han B, Compton WM, Blanco C, Crane E, Lee J, Jones CM. Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health. Ann Intern Med. September 5 2017;167(5):293–301. [DOI] [PubMed] [Google Scholar]
- 24.Hedegaard H, Warner M, Minino AM. Drug Overdose Deaths in the United States, 1999-2016. NCHS Data Brief. December 2017(294): 1–8. [PubMed] [Google Scholar]
- 25.American Dental Association. American Dental Association Announces New Policy to Combat Opioid Epidemic. March 26,2018. Accessed April 11, 2018 at: https://www.ada.org/en/press-room/news-releases/2018-archives/march/american-dental-association-announces-new-policy-to-combat-opioid-epidemic
- 26.Makhija SK, Gilbert GH, Rindal DB, et al. Practices participating in a dental PBRN have substantial and advantageous diversity even though as a group they have much in common with dentists at large. BMC Oral Health. October 15 2009;9:26. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Makhija SK, Gilbert GH, Rindal DB, et al. Dentists in practice-based research networks have much in common with dentists at large: evidence from the Dental Practice-Based Research Network. Gen Dent. May-Jun 2009;57(3):270–275. [PMC free article] [PubMed] [Google Scholar]
- 28.Gilbert GH, Riley JL, Eleazer PD, Benjamin PL, Funkhouser E, National Dental PCG. Discordance between presumed standard of care and actual clinical practice: the example of rubber dam use during root canal treatment in the National Dental Practice-Based Research Network. BMJ Open. December 9 2015;5(12):e009779. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Gordan VV, Garvan CW, Heft MW, et al. Restorative treatment thresholds for interproximal primary caries based on radiographic images: findings from the Dental Practice-Based Research Network. Gen Dent. Nov-Dec 2009;57(6):654–663; quiz 664-656, 595, 680. [PMC free article] [PubMed] [Google Scholar]
- 30.Gordan VV, Garvan CW, Richman JS, et al. How dentists diagnose and treat defective restorations: evidence from the dental practice-based research network. Oper Dent. Nov-Dec 2009;34(6):664–673. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Heaven TJ, Gordan VV, Litaker MS, et al. Concordance between responses to questionnaire scenarios and actual treatment to repair or replace dental restorations in the National Dental PBRN. J Dent. November 2015;43(11):1379–1384. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Norton WE, Funkhouser E, Makhija SK, et al. Concordance between clinical practice and published evidence: findings from The National Dental Practice-Based Research Network. Journal of the American Dental Association (1939). January 2014;145(1):22–31. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Rindal DB, Gordan VV, Fellows JL, et al. Differences between reported and actual restored caries lesion depths: results from The Dental PBRN. J Dent. March 2012;40(3):248–254. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.American Dental Association Survey Center: (2012). The 2010 Survey of Dental Practice. Chicago: American Dental Association. [Google Scholar]