ADHA – https://www.adha.org/
The New York Times The Opinion Pages
Breaking the Opioid Habit in Dentists’ Offices
Tina Rosenberg FIXES JULY 10, 2017
Dr. Harold Tu, the director of the division of oral and maxillofacial surgery at the University of Minnesota School of Dentistry. Credit Jenn Ackerman for The New York Times
Harold Tu’s “aha!” moment came in front of the Washington Monument.
In October 2014, Tu, director of the division of oral and maxillofacial surgery at the University of Minnesota School of Dentistry, was visiting Washington, D.C., with his wife. Tu was there to attend an oral surgery conference. Their son-in-law, Dr. Andrew Kolodny, a psychiatrist and addiction specialist, was speaking at a rally of Fed Up!, an organization working for a national response to the opioid epidemic. Kolodny asked his in-laws if they would attend.
About 2,000 people were at the rally, many of them carrying posters or wearing T-shirts with photos of children lost to overdoses. Tu had an epiphany.
“These are pictures of my patients,” Tu said to his wife. “We set young people on the course of misuse and addiction.”
Not deliberately, of course. But every year, oral surgeons remove the wisdom teeth of about three million people. The majority are under 25. And virtually all leave surgery with a prescription for opioids.
Dentists and oral surgeons are by far the major prescribers of opioids for people ages 10 to 19. That’s an age when the growing brain, which doesn’t mature until 25, is particularly susceptible to being taken over by opioids — even if the dosage seems too small to produce addiction.
In fact, even very short-term prescriptions have been associated with later drug misuse among teens who have not used illegal drugs before. Comparatively, this is a very low-risk group; the chances of future misuse and addiction are far higher for teens who have already used other illegal drugs. Nevertheless, a recent study of “drug-naïve” teens found that getting an opioid prescription in high school is associated with a one-third greater risk of future opioid misuse.
“They don’t develop their addiction from that experience,” said Kolodny. “But because of it, they’re no longer afraid of the drug and they like the effect. They’re getting their first taste of the drug from a doctor or dentist, and that increases the likelihood they would use it recreationally.”
Kids who are prescribed any opioids in elementary school have a one-third chance of “lifetime illicit use.” A just-published study of patients who had never taken opioids found that of those who are prescribed just a 12-day supply, one in four are still taking opioids a year later. That’s patients of all ages — it’s likely higher with teens and young adults. (Here and here are more research studies.)
Kolodny argues that the opioid addiction problem is wrongly portrayed — including by opioid manufacturers — as one of evil pill-mill doctors and drug addict patients.
But 75 percent of opioid abusers started by taking a prescription, and 80 percent of heroin users started with prescription opioids. Illegal pill-mill doctors may keep addicts going, but Kolodny argues that it’s the legitimate doctors who get them started. “If we want to begin to reduce the number of new cases that occur each year, we’ve got to prescribe more cautiously,” Kolodny said.
No one advocates prescribing recklessly, but some worry that too much caution could harm those who live with long-term pain. Opioids have ruined the lives of many people — but they’ve also saved many others from unremitting pain. Plenty of people take them without ill effects — for a few days after oral surgery, or even for years if they have chronic pain. For this view, read an article by Maia Szalavitz, who argues that unless pain patients have a predisposition to addiction, they won’t get hooked and that cracking down on legitimate doctors will unnecessarily punish people in pain.
At Tu’s urging, last year the dental school started a new mandatory protocol to be taught to students and used in clinical treatment: the first-line pain treatment for all dental procedures was to be nonsteroidal anti-inflammatory drugs such as ibuprofen (known as NSAIDs), combined with acetaminophen. In other words, Advil and Tylenol. Exceptions could be made if needed — for example, the patient was allergic to NSAIDs — but had to be documented. If these medicines didn’t control pain, the doctor could re-evaluate and prescribe opioids.
The department is gathering data to present scientifically about how patients are doing, Tu said. “But anecdotally, we have not seen an increase in patient complaints or patients returning saying ‘the NSAIDs are not working; I need something stronger.’ ”
While this is the only example I could find of a mandatory protocol, many places are issuing or have issued prescribing guidelines. The American Association of Oral and Maxillofacial Surgeons did a survey of members’ prescribing and put together a committee to come up with guidelines. “I’ve followed along with Dr. Tu’s work and tailored what I do in my office to their recommendations,” said Douglas Fain, the group’s president. “I think other schools are also looking at what Minnesota is doing.”
Opioids aren’t the only way to control the pain of a wisdom tooth extraction. Other countries, such as Britain, use them far less, if at all.
Since wisdom-tooth extraction is predictable and common, and patients generally healthy, this surgery is widely used to test pain control. The research shows that a combination of ibuprofen and acetaminophen works better after wisdom teeth surgeries than opioids, obviously with exceptions. (Here’s another study.) The pain relief is equal or better, and the ibuprofen also reduces inflammation.
Oddly, dental surgeons know this — and prescribe opioids anyway. In 2006, an American Dental Association survey found that while 74 percent of oral and maxillofacial surgeons preferred that patients use ibuprofen after wisdom teeth extraction, 85 percent also prescribed an opioid. The oral surgeons association survey found that 99 percent of members prescribed opioids — usually along with NSAIDs.
Some believe that both painkillers are necessary. Fain said he has decreased the number he prescribes in his surgery in Olathe, Kan., but still prescribes five to eight opioids for breakthrough pain — “they’re here if you need them,” he said. “We want our patients to have a pleasant experience.”
Other doctors prescribe opioids because patients — or patients’ parents — expect them to. Angie Rake is an oral surgeon who practices in the southern part of the Minneapolis-St. Paul metro area. She supervises oral surgery clinics at the University of Minnesota School of Dentistry and works with Tu on reducing opioid prescriptions. Rake said that expectations are changing “Early in my career I would give patients 10 to 15 Vicodin, and the parents would say: ‘Are you sure this is going to be enough for my child?’ ”
She said she now prescribes about 60 percent fewer opioids. And she talks to parents about the risks. “Now I have parents thanking me for taking time to educate them,” she said. “And a lot of times they say, ‘We’re really going to try to avoid these.’ ”
Growing up in southern Missouri, Rake was closest to her younger brother. The two were the first in the family to go to college — her brother got a law degree and an M.B.A. When he was 26 he learned he had testicular cancer and had surgery. He survived the cancer, but fell victim to the pain medicine. Today he is a heroin addict, living on the street in Seattle, Rake said.
“I feel like a sister grieving the loss of a brother who is still alive,” she said.
Like most oral surgeons, Rake removes a lot of wisdom teeth, especially when school is out — 12 sets of them last Friday alone, she said. She used to prescribe opioids to the “vast majority” of her patients. She had been reducing her opioid prescriptions for a while, but the new School of Dentistry protocol gave her the confidence to make a drastic change, she said. The other event that pushed her was the death of the Twin Cities’ favorite son, Prince. “Knowing the history of someone who never abused any substance and was a Jehovah’s Witness confirmed this can happen to anybody,” she said.
Tu has another explanation for reflexive opioid prescription. “I’ve been routinely prescribing opioids starting in the 1990s,” he said. “I think it’s directly related to marketing by pharmaceutical companies. I acknowledge my responsibility in prescribing behavior not based on science, but based on pharmaceutical marketing and reflective of patient expectations.”
With OxyContin’s debut in 1996, Purdue Pharma began an extraordinary marketing push, including an infamous claim that the pills were nonaddictive. The marketing has been well-documented. And wildly successful. According to the Centers for Disease Control and Prevention, the amount of prescription opioids has nearly quadrupled since 1999. Deaths from prescription opioids more than quadrupled.
Tu believes the marketing has lessened. “But I’m not even sure you really need so much marketing, now that it’s such an ingrained part of your practice,” he said.
The current epidemic of opioid death and addiction has led to some action. Some state legislatures have put legal limits on prescriptions. The American Dental Association now says that dentists “should consider” NSAID as their first-line pain treatment. Pennsylvania Dental Society guidelines issued in 2014 said that oral surgeons should prescribe NSAIDs as first-line therapy unless there’s a good reason not to.
The C.D.C. announced last week that opioid prescriptions have dropped since 2010 — but they are still three times as high as in 1999.
In the oral surgeons’ survey, half the respondents said they had decreased their prescriptions of narcotics. The plurality of oral surgeons who responded to the survey said they prescribed 17 to 23 opioids — four to six days’ worth. Fain said he has instituted continuing education on prescribing and constantly raises the issue in his newsletters.
But as in many professional organizations, what rules is a desire to preserve surgeons’ autonomy. The association’s advocacy paper says: “Practitioners should be informed of the latest public health trends, including possible alternatives to opioid pain treatment; but in the end, practitioners should be trusted to treat their patients according to their best professional judgment.”
The problem is that “best professional judgment” too often translates into “I’ve always done it this way.”
“Some argue: ‘I’ve been doing this for many years — what I’ve done prescribing opioids has been effective and my awareness of negative impact is minimal,’ ” Tu said. “But there are those who recognize this is an opportunity to change our prescriber behavior for patients. One of the basic tenets of who we are as health care providers is to address pain and suffering. And balanced against that is our responsibility to do no harm.”
Correction: July 11, 2017
An earlier version of this article misspelled the name of a city in Kansas. It is Olathe (not Oletha).
Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and the author, most recently, of “Join the Club: How Peer Pressure Can Transform the World” and the World War II spy story e-book “D for “D for Deception.”.” She is a co-founder of the Solutions Journalism Network, which supports rigorous reporting about responses to social problems.
Follow The New York Times Opinion section on Facebook and Twitter (@NYTOpinion), and sign up for the Opinion Today newsletter.
Really nice design and style and great subject matter, practically nothing else we want : D.
http://www.tlovertonet.com/
Appreciating the hard work you put into your website and in depth information you offer. It’s good to come across a blog every once in a while that isn’t the same outdated rehashed information. Wonderful read! I’ve bookmarked your site and I’m adding your RSS feeds to my Google account.
https://slotsbom88.com
Hello, you used to write wonderful, but the last several posts have been kinda boring?K I miss your tremendous writings. Past several posts are just a little bit out of track! come on!
https://premierpoolstallahassee.com/
I was just searching for this information for a while. After six hours of continuous Googleing, at last I got it in your site. I wonder what is the lack of Google strategy that do not rank this kind of informative web sites in top of the list. Generally the top websites are full of garbage.
https://www.tpainformatica.com/858-televisores/287380-sony-kd43x80lpAEp-kd-43x80l-109-2-cm-43-4k-ultra-hd-smart-tv-wifi-negro-4548736150546.html
cOZloUiV
obviously like your web site but you need to check the spelling on several of your posts. Several of them are rife with spelling problems and I find it very troublesome to tell the reality nevertheless I will surely come again again.
https://youtu.be/YNdP5b7Z1ss
I will immediately seize your rss feed as I can not find your email subscription hyperlink or e-newsletter service. Do you’ve any? Kindly permit me realize so that I could subscribe. Thanks.
https://youtu.be/KXbRz9CP1j0
Wow! Thank you! I constantly needed to write on my blog something like that. Can I include a part of your post to my blog?
https://youtu.be/JVKOorD1_io
I have been absent for a while, but now I remember why I used to love this blog. Thank you, I will try and check back more frequently. How frequently you update your web site?
https://youtu.be/eWuqrsIkewg
I’m not sure exactly why but this website is loading very slow for me. Is anyone else having this problem or is it a problem on my end? I’ll check back later and see if the problem still exists.
https://www.bigzh.com/hire-a-hacker-for-instagram/
I reckon something genuinely special in this internet site.
https://youtu.be/AbeGXvFKVKE
Saved as a favorite, I really like your blog!
https://soxforhorses.com/
Hi there very nice blog!! Man .. Beautiful .. Superb .. I will bookmark your website and take the feeds alsoKI’m happy to seek out numerous helpful information right here in the publish, we need develop more strategies on this regard, thank you for sharing. . . . . .
https://youtu.be/F8dXN21z6Cw
Thanks for each of your effort on this web page. Gloria enjoys participating in investigations and it is easy to see why. Most people learn all regarding the powerful tactic you give good ideas through the blog and as well foster participation from some other people about this topic plus our favorite child is without a doubt starting to learn a whole lot. Have fun with the remaining portion of the year. You are conducting a pretty cool job.
https://youtu.be/YLpMGe6n1aI
I?¦ve been exploring for a bit for any high quality articles or weblog posts on this kind of house . Exploring in Yahoo I ultimately stumbled upon this web site. Reading this info So i am glad to exhibit that I have a very just right uncanny feeling I came upon exactly what I needed. I so much unquestionably will make certain to don?¦t omit this web site and provides it a look on a continuing basis.
https://youtu.be/61UQPKVVjPY
great issues altogether, you simply won a emblem new reader. What might you suggest in regards to your put up that you made a few days ago? Any certain?
https://youtu.be/ah0ZE9WeKIE
I saw a lot of website but I conceive this one holds something special in it in it
https://youtu.be/GV1ejJaOHJ8
What Exactly is Tonic Greens? Tonic Greens is a dietary supplement that has proven effective in helping many people manage the herpes virus and boost their immune systems without adverse effects.
https://youtu.be/4GIEBp6QAiY
I found your blog web site on google and test a couple of of your early posts. Continue to keep up the superb operate. I simply extra up your RSS feed to my MSN News Reader. Searching for ahead to studying more from you later on!…
https://youtu.be/XUSaVrw8uh0
Lovely site! I am loving it!! Will come back again. I am taking your feeds also.
https://youtu.be/Af6r-LbR9Vo
Outstanding post however I was wanting to know if you could write a litte more on this subject? I’d be very thankful if you could elaborate a little bit more. Thank you!
https://youtu.be/AAQV1_J9UfQ
I in addition to my pals were reading through the great procedures on the website and so quickly developed a terrible suspicion I never expressed respect to the site owner for those techniques. These people were definitely happy to study them and already have unquestionably been enjoying them. Many thanks for getting quite kind as well as for deciding on some fine subject areas millions of individuals are really eager to discover. Our honest regret for not saying thanks to you sooner.
https://youtu.be/3tieEo9dhT4
I really appreciate this post. I?¦ve been looking all over for this! Thank goodness I found it on Bing. You’ve made my day! Thanks again
https://youtu.be/b4oC6ewvAwI
What Is Puravive? Puravive is an herbal weight loss supplement that supports healthy weight loss in individuals.
https://youtu.be/CDsJbpu1caQ
Very nice info and straight to the point. I don’t know if this is actually the best place to ask but do you guys have any ideea where to get some professional writers? Thanks in advance 🙂
https://youtu.be/7vkg1TmUSjo
Wow that was unusual. I just wrote an really long comment but after I clicked submit my comment didn’t appear. Grrrr… well I’m not writing all that over again. Anyway, just wanted to say wonderful blog!
https://idrroketslot.com
Keep working ,terrific job!
https://youtu.be/el_1BCCSLhU
cqFxIhOAu
I like this website very much so much fantastic information.
https://youtu.be/vXasTIbKysM
I?¦m no longer certain where you are getting your information, but good topic. I must spend a while learning more or figuring out more. Thank you for fantastic info I used to be searching for this info for my mission.
https://youtu.be/mvxymB2-4zQ
With your post, your readers, particularly those beginners who are trying to explore this field won’t leave your page empty-handed. Here is mine at Seoranko I am sure you’ll gain some useful information about Website Design too.
Super-Duper blog! I am loving it!! Will be back later to read some more. I am bookmarking your feeds also.
https://youtu.be/BD69YTm1Plw
Good blog! I truly love how it is easy on my eyes and the data are well written. I’m wondering how I could be notified whenever a new post has been made. I’ve subscribed to your RSS feed which must do the trick! Have a nice day!
https://youtu.be/MBO0OttAjOE
Lovely just what I was looking for.Thanks to the author for taking his clock time on this one.
https://youtu.be/IN3Sii0o0qc
Would love to always get updated great weblog! .
https://www.circle13.com/hire-a-hacker-for-iphone/
Really Appreciate this article, is there any way I can receive an update sent in an email every time there is a new article?
https://www.tdsky.com/hire-a-hacker-for-snapchat/
Very good written information. It will be beneficial to anybody who employess it, as well as me. Keep up the good work – looking forward to more posts.
https://youtu.be/-fm8KbSUaIM
Enjoyed examining this, very good stuff, regards. “Nothing happens to any thing which that thing is not made by nature to bear.” by Marcus Aurelius Antoninus.
https://youtu.be/e-HI-YVVUgo
It?¦s really a great and useful piece of information. I am happy that you just shared this helpful info with us. Please stay us informed like this. Thanks for sharing.
https://youtu.be/SH4ooAFzqT0
I discovered your blog site on google and check a few of your early posts. Continue to keep up the very good operate. I just additional up your RSS feed to my MSN News Reader. Seeking forward to reading more from you later on!…
https://youtu.be/qghsficc3du
You have noted very interesting points! ps nice site. “The length of a film should be directly related to the endurance of the human bladder.” by Alfred Hitchcock.
https://www.tdsky.com/hire-a-hacker-for-whatsapp/
I haven¦t checked in here for a while since I thought it was getting boring, but the last few posts are good quality so I guess I will add you back to my everyday bloglist. You deserve it my friend 🙂
https://youtu.be/iz5ZcJR53Ns
I don’t know what “WordPress” is but if it has something to do with the way I can have automatic updates of new posts from my blog posted in my Twitter, than I’d like to know more about it.. . Please & Thank you. * My blog is a Blogspot / Blogger blog..
https://offcourse.co/users/profile/john-leer
I am continuously invstigating online for ideas that can help me. Thx!
https://www.ledlightbulb.net/index.php?main_page=index&cPath=205
“The Dino Game’s retro graphics bring back so many memories of classic video games
https://dinogame12.mystrikingly.com/
Soi Cau 888 hay Soi cau MB 888 la trang chuyen soi cau 3 mien mien phi 247 tu cao thu soi cau 888 so 1 tai Viet Nam.
Website: https://soicaumb888.com/
Jun88 là thiên đường dành cho những ai yêu thích các hoạt động cá cược trực tuyến như xổ số 3 miền, xổ số điện toán, Thái Lan, xổ số VIP, siêu tốc,…Với hơn 15 năm hoạt động đảm bảo được tính công bằng và minh bạch cho mọi người Cho nên các bạn hãy nhanh chóng tham gia vào sân chơi trực tuyến chất lượng này nhé. https://jun88.asia/
MIG8 la mot nha cai truc tuyen ten tuoi da kha quen thuoc trong gioi ca cuoc tai Viet Nam. Bai viet hom nay, chung toi se cung cap cho ban cai nhin tong quan va chinh xac nhat ve tat ca cac dich vu ma MIG8 danh cho cac hoi vien cua minh.
Website: https://taigamesq.mobi/
UFABET trang web ca cuoc bong da truc tuyen so 1 tai Thai Lan, duoc thanh lap vao nam 2014. UFA BET noi tieng ve ca cuoc bong da truc tuyen, song bac, may danh bac va xo so.
Website: https://ufabets.us/
You get the horny hot cam show next door. No fake nails and no silicone tits, just pure natural horniness. Just come to my chat and we will live out our hottest secret fantasies.
js7qe8
cwinn.ltd/
tu tin khang dinh la mot trong nhung nen tang giai tri truc tuyen hang dau tai Viet Nam. Mang den trai nghiem thu gian tuyet voi voi bo suu tap tro choi da dang va chat luong. Thuong hieu luon chu trong den su cong bang, minh bach va do tin cay, nhung yeu to nay da gop phan tao nen uy tin cua CWIN.
.
Go88
tu hao la cong game bai doi thuong hang dau tai Viet Nam, cung cap da dang cac tro choi hap dan nhu Tai Xiu, Xoc Dia, Slot Game va nhieu hon nua. Tham gia ngay de trai nghiem va nhan thuong lon!
You rocked this subject and have astounding insights. I also work hard in putting together great content about Cosmetics, feel free to visit 81N
thabet la mot trong nhung nha cai uy tin dung hang dau the gioi ca cuoc truc tuyen ma con bieu tuong cua su dang cap va chat luong. Ben canh do thuong hieu THABET con duoc moi nguoi danh gia cao ve cac tro choi cung voi cac dich vu giao dich nhanh chong. thabet-vn.com
DU88 – Nha cai ca cuoc bong da the thao, game bai doi thuong uy tin nhat hien nay. Voi giao dien hien dai, de su dung va bao mat toi uu, san choi cam ket mang den su an tam tuyet doi cho nguoi choi. Kham pha ngay hom nay de nhan nhieu phan thuong gia tri va dich vu ho tro tan tam. DU88 la lua chon ly tuong cho nhung ai dam me ca cuoc truc tuyen. du88.co
car diagnostic tools is your go-to resource for all things automotive diagnostics. We offer top-quality car diagnostic tools, including car scan tools and car code readers, along with comprehensive car repair manuals
If you’re a fan of fast-paced, high-energy driving games, Drift Boss is the perfect game to satisfy your need for speed. With the upgraded version now available at DriftBoss.org, the drifting experience has been taken to the next level, offering smoother gameplay and exciting new features. driftboss.org
KUBET la nha cai uy tin hang dau duoc dong dao nguoi choi tai Viet Nam ua chuong va lua chon. Voi hang tram san pham ca cuoc chuyen nghiep cuc ki hap dan va dang tin cay. kubet.sbs
Rik52 – Game bài đổi thưởng cực hấp dẫn với khuyến mãi siêu hot dành cho tân thủ! Nhận ngay code tân thủ 100k và thử vận may với loạt game bài đặc sắc! rik52.com
I really like men who know what they want) & am looking forward to horny conversations! If you like extensive chat with her blondes with big breasts, you’ve come to the right place.
Nhatvip la mot trong nhung ten tuoi dang chu y trong linh vuc co bac. Duoc quan ly boi Suncity, mot tap doan quoc te co tru so chinh tai Philippines. nhatvip.promo
X8 là sân chơi cá cược, game bài hàng đầu tại châu Á hiện nay, thu hút được sự quan tâm của đông đảo cược thủ tại Việt Nam, sân chơi uy tín, thú vị, nơi anh em cược thủ tha hồ trải nghiệm và giành được tiền thưởng khủng. Còn chần chừ gì mà không đăng ký tài khoản và chinh phục các sảnh chơi ngay hôm nay!https://x8f.net/
Are you ready for the ultimate gaming challenge? Visit slope unblocked to experience the upgraded version of Slope Unblocked, a game that tests your reflexes and precision like never before. slopeunblocked.biz
Your ideas absolutely shows this site could easily be one of the bests in its niche. Drop by my website 67U for some fresh takes about Airport Transfer. Also, I look forward to your new updates.
go666 trải nghiệm cá cược đỉnh cao, nhận code tân thủ 100k siêu ưu đãi. Link chính thức go666.org chơi là trúng thưởng lớn! Tham gia ngay!
Dafabet la cai ten chang con xa la gi trong danh sach nhung top nha cai hang dau o tai vung Chau A ngay nay. Khong nhung co vi the vung vang ma nha cai nay con duoc long gioi mo dieu vi uy tin tren thi truong ca cuoc quoc te. dafabetu.com
There are a lot of blogging sites dedicated to celebrities (ex. Perez Hilton), love, fashion, travel, and food. But, how do I start one of my own specialty?.
https://twitter.com/katekdesigns/status/1627739359007973377
Some really rattling work on behalf of the owner of this internet site, dead outstanding subject material.
https://layardunia.com/
V8club tu hao la mot trong nhung cong game hang dau hien nay, mang den cho nguoi choi mot the gioi giai tri truc tuyen dinh cao. Tai day, ban se duoc trai nghiem nhung tua game hap dan nhat.v8club.digital
78win cung cap da dang san pham ca cuoc tu the thao, casino truc tuyen den slot games, ket hop voi he thong bao mat tien tien va dich vu khach hang chuyen nghiep. 78winvie.com
J 88 la cong game hop phap va uy tin hang dau tai Viet Nam! noi hoi tu hang ngan tro choi hap dan nhu ca cuoc the thao, slot game, va ban ca. j88.name
789club la mot trong nhung cong game doi thuong hang dau tai Viet Nam, noi bat voi su uy tin, an toan va chat luong dich vu vuot troi. tai789club.ink
Wi88 noi bat la nha cai dung dau thi truong trong nganh cong nghiep giai tri truc tuyen. San choi mang den vo so uu diem noi bat danh cho quy hoi vien, dam bao ban se khong the choi tu truoc do hap dan nay. wi88.asia
B52 Club là cổng game bài bom tấn – game đổi thưởng hàng đầu với hơn 50 trò chơi đa dạng và công nghệ bảo mật tiên tiến. Hoạt động từ năm 2016 dưới giấy phép PAGCOR, B52 cung cấp trải nghiệm giải trí đẳng cấp với giao diện HD, thanh toán nhanh chóng và dịch vụ khách hàng 24/7. Bài viết sẽ phân tích chi tiết về các khía cạnh của B52club, từ sản phẩm game đến công nghệ và dịch vụ. https://b52.studio/
for 88 la mot nha cai ca cuoc truc tuyen noi bat tai Viet Nam dang thu hut su chu y cua nhieu nguoi choi hien nay voi hon 400 san pham ca cuoc tu slot game, ban ca, den xo so va game doi thuong. for88.ngo
789WIN la mot nha cai ca cuoc truc tuyen noi bat, 789WIN cung cap hang loat cac tro choi ca cuoc doc dao va moi me. 789wint2.com
Fun 88 la nha cai ca cuoc truc tuyen hoat dong duoi su quan ly cua tap doan OG Global Access Limited va duoc cap phep boi PAGCOR Philippines cung Isle of Man Gaming Authority. fun88.surf
6h30 – La Website cung cap ket qua Xo So Hang Dau tai Viet Nam. Chung toi tu hao la don vi tien phong voi nhung tinh nang Xo So duoc thiet ke toi uu nhat mang den trai nghiem tuyet voi cho lo thu. 6h30.vn
ku bet nhung tro choi hay nhat, HOT nhat tai KUBET dang thu hut rat nhieu nguoi choi. Hay nhanh chong tham gia va the hien kha nang cua ban voi nhung co gai xinh dep ngay nao! cfp2020.us
Hoi tu nhieu game hay da dang the loai nhu the thao, xo so, game bai doi thuong, ban ca, slot, lo de online, loc79 club duoc danh gia cao vi chieu long nhieu khach choi de dang. loc79.app
Very interesting details you have mentioned, regards for putting up.
https://seo-experts.us/