Managing dental pain in a GP setting

Jonathan Teoh

17/04/2019 1:17:59 PM

Advice on asking the right questions – and providing appropriate management – when patients present with toothache.

Patient with dental pain
Odontogenic pain generally arises from three main causes – dental caries, periodontal disease, and pericoronitis.

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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Rowena Ryan   18/04/2019 3:01:52 PM

Many people can't afford dental care so a lot of dental health problems present to GPs - so in fact Medicare IS already paying for dental as Prof John Spencer from Adelaide and others have pointed out.
Public dental care is limited, with long waiting lists, and can only do scaling and cleaning, extractions and arranging dentures rather than the more expensive
procedures like root canals which will save teeth.
Most of my patients in inner city Melbourne are on health care cards and pensions and many of them have untreated dental problems.
It's also important for GPs to be aware that people will use dental pain as a way
of getting scripts for opiates (in the past it was Panadeine Forte but now it's the stronger ones like Oxycodone since the oral opiods came in about 20 years ago.)
People get addicted to those drugs easily, plus sell them on the black market.
We need to either bring back the Chronic Disease Dental Scheme (which helped
so many of my patients) or bring in Denticare

Rowena Ryan   18/04/2019 3:02:29 PM

already put in