Dental pain management in primary care

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Welcome to the Australian Prescriber Podcast. My name is Ashlea Broomfield, your host for this episode, and today I'm talking with Professor Peter Parashos who's the Chair of endodontics at the Melbourne Dental School. Welcome Peter.

Thank you Ashlea. It's a pleasure to be with you.

Peter. Today we're talking about dental pain and as a GP it's one of those things that I really struggle with about where the pain is coming from, what do I need to do to treat it and how can I treat it? So we're going to be covering some of those subjects today and I'm so excited that you've written an article for Australian Prescriber covering all the different ways that dental pain may present and different ways of treating it. Firstly, can we start with this idea of pulpitis and what are the different parts of pulpitis?

Essentially any pulpitis refers to what's happening within the dental pulp of the tooth. And the dental pulp as we know is an enervated connective tissue, it's not, as unfortunately some of the lay impressions are, that it's a nerve, but it's not specifically a nerve only. It's a combination of a variety of different tissues to form a little organ in itself. So that organ, when it is damaged either by dental decay, caries or by trauma, can then become infected and that infection is quite variable as to its extent. If it's an early acute infection, then sometimes that pulpitis is reversible. So the pulp's immune system will essentially repair the damage that's been done, but then there are other times when the necrosis within the pulp, then the necrotic tissue the inflammatory response becomes so aggressive that it overwhelms the immune system. And the pulp eventually becomes necrotic and that allows the bacteria that are causing the problem in the beginning to then completely invade the pulp and that's where endodontics comes in.

In your article, you talk about that difference between the reversible and irreversible pulpitis, what are the clinical differences between the two?

Well, clinically reversible is recognised most of the time as being a pain usually to some sort of thermal stimulus and usually cold, where the patient will say that, "I've had something cold to eat or drink and it hurts momentarily and then eventually it disappears." So that's sort of the early stages of reversible pulpitis and then it's kind of like a continuum. Eventually, it will progress to the stage where that stimulus that causes the pain may cause a quite an intense response. So rather than that short, sharp, almost stabbing sort of pain as a result of the cold stimulus, it can then progress to a lingering throbbing sort of pain. And at the end point of that is when the patient needs to take painkillers, they are woken up when they're asleep. So basically it becomes a spontaneous pain rather than one that's stimulated usually by a thermal stimulus.

And how is the treatment different for the different stages?

With reversible pulpitis, we now have gone into an era where we try and kind of save the pulp, if you like. We try and retain that pulp because it still has its immune system and it has an amazing reparative ability, particularly in younger patients, but it doesn't stop having that reparative ability at any age really. So if we can retain that pulp, we allow the tooth to essentially function as a normal tooth. And we have vital pulp therapies these days where we can actually... It's kind of like a surgical procedure with our dental drills and using specific techniques where we keep microorganisms out and particularly with using rubber dam, isolating the tooth, so that once we amputate that necrotic part of the pulp, we'll leave behind the healthy part of the pulp.

Now we're very lucky in that the way that the pulp becomes necrotic is sort of like a wave of necrosis, starting from the top part of the tooth, the crown part of the tooth where the decay starts and then it gradually progresses towards the root tip or apically. So if we catch it early enough, we can actually repair that damage, but if we don't or if a patient doesn't seek treatment at that particular stage, then unfortunately it gets to the point where the whole pulp becomes necrotic, becomes infected and that's when we have to undertake orthograde endodontic treatment, which basically means just removing the infected pulpal tissue and disinfecting the root canal space.

And if a GP or a pharmacist is seeing somebody that sounds like they're in that early reversible stage, what kind of primary treatment can they recommend whilst they're awaiting the dentist?

Essentially it depends on what's stimulating the pain. If it's simply a cold drink or something like that, then the simplest thing to do is just ask the patient to try and avoid those sorts of stimuli until they can get to see their dentist. If it's got to do with perhaps chewing on the side of where the pain is sort of originating from, then the patient can avoid eating on the tooth until they get to the dentist. It's very rare that you'd need any sort of analgesia because it's a short sharp sort of stimulus and most certainly we don't need antibiotics at that stage.

When you're getting along the spectrum where somebody is having more prolonged pain, what are the recommended analgesia options?

Currently, we sort of subscribe to the current recommendations in the Therapeutic Guidelines and it depends on the degree of pain. The guidelines are now divided into mild to moderate acute pain versus severe pain, so from mild to moderate, and this is what we tend to recommend is a combination of ibuprofen and paracetamol. And there are a number of proprietary products that come with the ibuprofen and the paracetamol already combined. The problem with some of those is that the combinations vary in the amount of ibuprofen that they have. So from a strictly pharmacological point of view, you may not necessarily be getting the full therapeutic dosage of the ibuprofen, but I don't think it's going to clinically, I don't think it's going to matter all that much. But from a purist point of view, we'd be recommending a couple of tablets of ibuprofen, usually of 200 mg each, as well as paracetamol of 1000 mg and be taking that usually four to six hourly.

With more severe pain we try and avoid any sort of opioids these days and unfortunately we occasionally see opioids being prescribed when the patient then follows up and comes to us, particularly in an emergency situation. And they're just so doped out if you like that it's very hard to then treat patients who are that severely affected. So I think if we rely on just that combination of the ibuprofen and the paracetamol, that's usually adequate enough to get to see a dentist and it's not that difficult getting into see, particularly if a patient has a regular dentist who they can go and see. There are people who specialise in root canal treatment or endodontics, who would see the patient very soon. So it's rare that we would make a patient wait if they're in such a dire straits.

What's the role of using local anaesthetics either injected by a doctor around the dental tissue or a nerve block or local anaesthetic gels?

Two ways of looking at that, Ashlea. Firstly, it's a great way of easing the patient's pain until they are able to get to us, but the other problem is that it may mask the underlying cause of the symptoms, particularly in an older patient who may have a lot of old restorative work, a lot of old fillings, extensive fillings in their teeth where it can make diagnosis difficult. If everything's anesthetised then we're unable to test individual teeth. So I guess it has to be a clinical decision that the medical practitioner makes at that time and if the patient is in such extreme discomfort, then by all means I think either an infiltration or a nerve block until the patient can get to see a dentist. Presumably they'd want to be going straight after having seen the medical colleague, and then by the time they get to the dentist then perhaps a local anesthesia may be wearing off. So we'd have to sort of play it by ear I guess once that patient’s presented to us.

And how do we help clinicians understand the difference between a pulpitis versus dental hypersensitivity?

Hypersensitivity is, yeah, that's a really good question actually. Dental hypersensitivity is very common and it can mimic the sort of pain that's related to a particular tooth that may be suffering from dental decay, dental caries or broken fillings, sometimes cracks in teeth. So it does make it a little bit difficult. I would say that the important thing to remember would be that if it's only sensitivity, then it's something that won't need any sort of analgesia until they can get to the dentist to be able to diagnose and certainly you wouldn't need any sort of nerve block or infiltration anaesthesia to deal with that.

What are some urgent considerations if someone's presenting with dental pain? What are the kinds of things we need to be really mindful of that require urgent treatment?

The greatest concern for us is when the pain is accompanied by significant swelling, intra oral swelling, particularly of the floor of the mouth where there's a risk of having airway restriction. If we have a phenomenon such as a Ludwig's angina where the whole floor of the mouth becomes inflamed and can potentially block the airway. So swelling, I think any indication that there's a spreading infection.

And in these situations would it be reasonable for medical practitioners to be prescribing antibiotics and associated with an urgent dental referral?

I think it would depend on the extent of the swelling. If the medical practitioner assesses that it's not only a spreading infection, but there are systemic signs of spread of the infection, then by all means I think it would be worthwhile and important to prescribe the antibiotics or give an antibiotic injection. And then for urgent referral to either the patient's dentist or to an endodontist, someone who can see the patient urgently, ideally on the same day.

There're some situations where patients might come and see me as a GP and say, "The dentist said I need antibiotics first before I have the dental procedure." What is all that about?

Yeah, that's a very good question. No, that doesn't apply because the best means of treating any sort of dental problem is to first diagnose it and then address the specific problem. Whether it be replacing a restoration, whether it be doing pulpotomy, whether it be undertaking endodontic treatment. Providing antibiotics is really not going to be of any benefit to either the patient or to us as clinicians, so there's no need to do that.

So we can safely say, look in this situation I wouldn't be prescribing antibiotics. And given that dentists could have the capacity to prescribe antibiotics related to any dental infections, that it would be reasonable to refer back to the original dentist if they deemed that antibiotics was necessary perioperatively.

Yeah, so I think so. And as we were saying earlier, it's very uncommon that we prescribe antibiotics these days for dental problems. It's a matter of getting in there and making the diagnosis and treating whatever disease process is occurring.

So unless we're looking at a spreading cellulitis or acute swelling with a fever, then really we don't need to be considering antibiotics at all.

Absolutely. That's entirely correct.

When should we consider something is not dental related?

Yes, that happens quite regularly where patients will present with signs and symptoms that are not as obvious as they are with pulpitis type pain. It may be throbbing sort of pain or they may report the pain to be a burning sensation or they have difficulty localising it and there's no obvious intra oral cause. We usually see that with temporomandibular disorder is a common one that presents to us, where the patient will have pain that extends over the side of the face and it may not necessarily be able to be localised by the patient.

So I guess the simplest way is to determine whether or not the patient can give you some idea of whether or not it is related to the pulp of the tooth or whether it's related to the tissues around the tooth because sometimes even periodontal diseases can present as sensitivities, as almost pulpitis type pains. And it's making that differentiation and you need to get it down into the tissues of a tooth with a periodontal probe and assess the periodontium for bleeding on probing. That sort of thing, which is ideally and probably more easily done by dentists because we have those particular instruments that are designed for that specific purpose.

And in your article you talk about the difference between that pulpitis sharp intermittent pain and then a dull kind of throbbing pain that's dental related. What would the dull throbbing pain normally be related to?

It's usually related to either extension of the disease process into the bone around the root apex, so then it starts to spread within the periapical tissues or the periradicular tissue, so the tissues around the root, but we also see sometimes periodontal disease can also present with that dull, deep sort of pain and that's when the diagnostic techniques that we have by clinical examination, radiographs, and all the various pulpal tests that we have will help us determine what the cause is for that sort of deep throbbing pain.

I love how in the article, you've got some really handy flow charts on how to consider different pathways of referral and treatment and as well as some signs and symptoms that are related to the non-dental causes of pain. It's quite handy to have as something that's a standard leaflet, perhaps in a consult room for doctors and even us pharmacists to be a bit more aware of. So I really appreciate that sort of simple flow, diagrammatic representation. Before we finish up, how can dentists help with non-dental pain?

If the non-dental pain has to do with the way the patient is occluding or in other words how their teeth come together or if they have some sort of parafunctional habit, if they're grinding their teeth and society is very stressed out these days and so lots of people grind their teeth and that can then cause these sort of symptoms. So there are ways of protecting the teeth and easing the load on the teeth by making a splint, the patient is then less likely to be exerting as much force on the teeth and so not creating as much force on the muscles, and so the muscle tiredness, it can be eased to a degree. And there are also specialists within dentistry, those who specialise in oral medicine, who we usually rely upon to be able to not only confirm that diagnosis, but then take care of those sorts concerns for the patient and manage that complaint.

So the take home messages really are that antibiotics are almost never indicated unless there's spread of an infection. That using simple analgesia whilst awaiting dental referral is the primary mode of analgesia, where you may or may not consider local anaesthetics depending on the timing of when the person can see the dentist and dentists are really helpful at determining the differential diagnosis of dental or facial related pain.

Absolutely. That's a very good summary of what we've been talking about, Ashlea.

That's all the time that we've got for this episode. Thanks for joining us on the Australian Prescriber Podcast.

Thank you, Ashlea.

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The views of the hosts and guests on the podcast are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm Ashlea Broomfield and thanks for joining us on the Australian Prescriber Podcast.