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Managing dental pain in a GP setting

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Dental pain is a common presentation in medical general practices, with one in seven people attending a medical service in the past 12 months experiencing a toothache, but it can be difficult to successfully diagnose such pain outside of a dental setting.
 
Understanding dental disease
Odontogenic pain generally arises from three main causes:

• dental caries
• periodontal disease
• pericoronitis (which is commonly associated with wisdom tooth eruption)

Dental caries, also known as tooth decay, is the destruction of tooth tissue from acid release by bacteria in dental plaque. Dental caries creates a direct pathway for bacteria to irritate pulp tissue. The subsequent inflammatory response (pulpitis) and progression to pulp death (pulp necrosis) is a common cause of dental pain.
 
Periodontal disease is inflammation of the supporting tissues of the teeth caused by specific bacteria, resulting in destruction of the periodontal ligament and alveolar bone. Periodontal disease is not typically symptomatic until the late stages, often resulting in a periodontal abscess.  
 
Pericoronitis occurs where the soft tissues surrounding a partially erupted tooth, typically a wisdom tooth, becomes inflamed and can progress into an infection. The soft tissue that covers the partially erupted tooth is prone to plaque accumulation and trauma from the opposing tooth due to the inability to clean this area.
 
These conditions require local intervention to resolve pain with treatment options, depending on the diagnosis.
 
Symptoms and pain relief
Patients’ symptoms reflect the type of dental disease that has occurred. Most dental disease presents as an inflammatory response in the earlier stages, and infection spreading to surrounding tissues occurs only when there is significant infection of the tooth and gingival tissues.
 
The key to correct management in a general medical practice setting lies in determining if there is spreading infection. Four questions can be asked:
 

• Is the tooth sensitive to hot/cold drinks or food?
• Is the pain aggravated by biting or eating?
• Is the pain constant and does it keep you up at night?
• Does the area feel and/or look swollen?

Symptoms associated with sensitivity or local irritation can be managed with analgesia, preferably a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen, and referral to a dentist for assessment and treatment to resolve symptoms. Where there is spreading infection with obvious intraoral or facial swelling, antibiotics can be prescribed and a referral to a dentist for immediate local treatment can be made.
 
It is recommended that careful consideration is given when writing prescriptions for antibiotics for dental pain. The inappropriate use of antibiotics can contribute to patient morbidity and antimicrobial resistance. Treatment with antibiotics alone, without interceptive dental treatment, can lead to more severe episodes of acute odontogenic infection with risk of airway compromise.
 
As a general rule, the inflammatory nature of most dental disease means NSAIDs are the primary medication for pain relief, with antibiotics given only if there is an obvious abscess or swelling present.
 
Asking simple questions can help identify if the odontogenic problem is of inflammatory or infective nature.
 
A version of this column was first published in VicDoc.

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dental pain general practice toothache

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