Toothache is well known for being an unbearable intense pain, keeping patients awake at night, stopping them eating and drinking as they'd like, and having a significant impact on their day to day life.
However around one third of those suffering from toothache are problem-orientated dental attenders, only seeking dental care when toothache strikes, and often after suffering with it for a prolonged period of time.
Analgesic overdose for dental pain: what can we do about it?
It's therefore perhaps not that surprising that this group of patients are more vulnerable to unintentional paracetamol overdose, with reports that 38% of overdose patients attending A&E in Nottingham are caused by dental pain.
And this isn't the first study to highlight the problems associated with analgesic overdose in patients suffering from dental pain see for example, Siddique et al (2015), Daly FF et al (2004) and Vogel et al (2007)
Thankfully no long-term harm came to the patients in the study, however two thirds did require admission for treatment.
The potential harm of the overdose, and the consequent attendance and admission are completely preventable, so what can we do about it?
Just over half of the patients in this paper reported being registered with a dentist but being unable to get an emergency appointment with them, so it remains that there may be problems with commissioning for emergency dental care services, however 22% had made no attempt at contacting a health professional, instead self-medicating with analgesics leading to an overdose.
We need to understand why these patients avoid seeking care for dental pain so we are able to encourage attendance at the right place and the right time.
Why don't patients seek dental treatment earlier?
Interestingly, only 25% of the patients admitted were reviewed by the maxillofacial team, and out of these the majority declined dental treatment whilst in hospital, instead opting to see their dentist on discharge, what we don't know is how many of these patients then did seek definitive dental care?
And of those who weren't reviewed by the maxillofacial team, what advice were they given about their dental treatment needs by the medical teams looking after them; and did they then seek further care?
The majority of patients attended with a dental infection requiring treatment, however it's worth noting that 21% had overdosed due to postoperative dental pain.
Guidance for dentists on analgesics
This means, as dentists, we must ensure that we are giving our patients thorough postoperative advice regarding analgesic use, taking into account the treatment they've had done, and also their medical history.
The WHO analgesic ladder should be followed, with non-opioid analgesics, such as paracetamol and ibuprofen being first line measures for dental post-operative pain.
The Scottish Dental Clinical Effectiveness Programme have produced guidelines on drug prescribing in dentistry and dentists should refer to these and the British National Formulary for doses and medical history considerations.
Dental pain in children: analgesic overdoses
It's not just adults who attend A&E for dental pain, we also know that children attend frequently too – see Currie et al (2016) and Marshman et al (2017).
Out of children attending A&E some present for dental trauma, but there is also a significant number attending for toothache.
Those attending with dental pain are significantly more likely to delay seeking treatment, and are more likely to be prescribed medication in A&E rather than be referred onto another specialty for treatment, compared to dental trauma patients.
Unfortunately, children are also included in those who are admitted for analgesic overdose due to dental pain.
Children's dental health has been widely discussed in the media recently, and a recent study has found that parents tend to underuse dental services for their children's dental pain, but instead contact multiple health professionals outside of dentistry.
In London, oral and dental pain is also the most common reason parents seek over the counter pain medication from pharmacies, with one in 10 children attending showing signs and symptoms indicative of requiring emergency dental treatment.
Unfortunately, only 30% of these children had seen a dentist prior to attending a pharmacy for analgesia. The estimated annual cost to the NHS for inappropriate health service use for oral pain in children is over £3 million.
With dental pain patients being at a risk of unintentional analgesic overdose it is prudent that all dental professionals include a thorough investigation of analgesic use as part of their patient history, as I've previously discussed in another blog.
Look out for staggered analgesic overdoses
A staggered analgesic overdose has a higher mortality rate than a single overdose – see Craig et al (2011) and Gyamlani et al (2002) , therefore any patients at risk must be referred on for further assessment and treatment urgently.
Patients who have taken a staggered overdose often do not display any signs or symptoms so may be unaware that they have taken an overdose and the associated risk.
Early symptoms can include nausea and vomiting, however these often settle within 24 hours and might be mistaken for nausea associated with the dental pain they are experiencing.
Understanding why patients don't attend the dentist earlier
O'Sullivan et al have clearly highlighted an important issue associated with problem-orientated dental attendance, and dental avoidance, so where do we go from here?
There are probably areas of commissioning in urgent dental care to consider, and a thorough understanding of problem orientated attendance will help us understand how we can improve dental services to encourage these patients to attend a dentist, rather than self-medicate.
However immediate action can certainly be within patient education of safe analgesic dosing, and thorough post-operative advice and investigation of potential overdose in patients attending for emergency dental care.
Charlotte Currie, Clinical Fellow in Oral Surgery
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