significance of medical history and non odontogenic oral pain Patricia Thomson BDS MSc MJDF MFDS The emergency patient taking medication Information on drug therapy relating to dental treatment can be obtained by telephoning ID: 931741
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Slide1
The emergency dental patient:significance of medical history and non odontogenic oral pain
Patricia Thomson BDS, MSc, MJDF, MFDS
Slide2The emergency patient taking medication
Information on drug therapy relating to dental treatment can be obtained by telephoning
Liverpool: 0151 794 8206
Slide3The phobic emergency patient
Can present with urgent problems
Use your best communication skills to try to get them to accept treatmentIf need sedation, and not urgent, can prescribe regime of ibuprofen/paracetamol while waiting for SCI Gateway referral, or referral to Albion clinic for sedation(6-8 weeks w/l)Prescribe 5mg Diazepam, and bring back in 2 hours for RxEstablish how many painkillers taken and refer to hospital if suspected overdoseSevere emergency, such as floor of mouth swelling, severe trismus, phone S. General ward 62 (Glasgow) or Monklands (
Lanarkshire) for immediate admission
Slide4Medication-related Osteonecrosis of the jaw- MRONJ
Drugs involved:
Antiresorptive
drugs
–
bisphosphonates and denosumab- used either alone or in combination with other drugs to manage disorders such as osteoporosis, but also various bone pathologies, and the spread of various cancers to bone
Other
anti neoplastic drugs- anti
angiogenic
- have recently been developed that are also implicated-unknown long term impact. Can be used in combination with
antiresorptives
MRONJ
usually seen in individuals who:
- have been taking these drugs for over 5 years- higher risk
- especially if taken in combination with STEROIDS for extended periods
- take IV forms of the drugs (usually oncology patients)
-then undergo invasive surgical procedures such as
xns
Slide5MRONJ
http://
www.sdcep.org.uk
/
wp
-content/ uploads/2017/04/SDCEP-Oral-Health- Management-of-Patients-at-Risk-of-MRONJ- Guidance-
full.pdf
For oral bisphosphonates, routine conservative dentistry is not a problem, and even surgical treatment has a low risk of MRONJ at <1%
Slide6mronj
Bisphosphonates are retained in the body, so need to ascertain if patient has ever taken them
Try to conserve teeth if possible, even if root treat and cover root surface, rather than extract in higher risk patients. Do not use antibiotics or antiseptics after xns, and review after 8 weeksSome feel should have a drug holiday if taking for >4 years, and other risk factors, till soft tissue healing has occurred, but this decision is made by physicianIf a patient is receiving Denosumab
injections, should delay extractions in the period after injection- discuss with oncologist if given for cancer treatment Discuss risks with patient before treatment
Slide7mronj
In summary:
Assess risk level and record in patient’s notes
Discuss risk with patient
Low risk: treat as usual
Higher risk (usually cancer patients): attempt to use conservative treatments, or consider consulting with oral surgery/special care dentistry specialist if xns requiredRefer only if other medical complications that would warrant referral anyway
Review
xns
after 8 weeks and refer if no healing
Slide8Medical history:
anticoagulant or antiplatelet drugs
SDCEP guidelines on “Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs” August 2015Assess risk of bleeding, and if low or higher risk, general advice is: delay Rx till off drug if possible, early morning, early in week appointment, atraumatic Rx,
haemostasis established, emergency contact details supplied Anticoagulants- WARFARIN:Can treat if INR below 4, and within 72 hours of checking. Refer to secondary care if INR above 4, and emergency treatment needed
Antiplatelets (single or dual – eg aspirin and clopidogrel):Limit initial treatment, be aware of prolonged bleeding, establish haemostasis, poss with sutures. Do not interrupt antiplatelet medicationBe wary if combining aspirin/warfarin,
clopidogrel/warfarin or even triple drug combinations
Slide9Novel oral anticoagulants- dabigatran, rivaroxaban, apixaban
.
They have a rapid onset (1-2 hrs) and relatively short half lives (5-13 hrs)Procedure with low risk of bleeding complications
:Treat without interrupting their medication, and with all the normal precautionsProcedure with higher risk of bleeding complications:Advise them to - miss apixaban
/dabigatran morning dose, but take next dose min 4 hours after haemostasis - delay rivaroxaban daily dose till 4 hours after haemostasis - all normal precautions including avoiding NSAIs- use Paracetamol -Emergency appt: if already taken NOAC that day, delay procedure till later in the dayInjectable anticoagulants eg heparin: Consult with GMP/specialist if low or higher risk- be wary of recent medical events
eg DVT
Slide10Bleeding risk with other medical conditions
Liver disease
Kidney failure
Advanced heart failure (results in liver failure)
Bone marrow disorders
HaemophiliaHigh risk if received chemo/radiotherapy to head and neck in last 3 months, or total body irradiation less than 6 months ago.
In these
cases where
patients are also taking anticoagulant medication, this presents an additional risk, and the GMP or specialist should be consulted
Slide11Antibiotic prophylaxis against infective endocarditis
New advice released August 2018 by SDCEP.
To facilitate the implementation of NICE Clinical Guideline 64 from 2016:“Antibiotic prophylaxis against IE is not recommended routinely for people undergoing invasive dental procedures”
The vast number of people at increased risk of IE will not be prescribed prophylaxisSome groups will require special consideration and will require liaison with their cardiologist to determine need for prophylaxis
Slide12Antibiotic prophylaxis and the emergency
SDCEP recommend that patients from the special consideration sub group have their risk determined when they are registered with your practice, so that relevant info is available should an emergency develop.
However, you may not have this information so:
-ensure patients at increased risk of IE are treated promptly to stop IE developing
-it may be necessary to make a shared decision with the patient regarding antibiotic prophylaxis based on the patient’s values and preferences in the absence of a cardiologist’s opinion
Slide13others
RECENT MI:
-No elective dental treatment for 3 months after an MI. Ideally no general anaesthetic for the first 6 months. DEMENTIA:FGDP Dementia-Friendly Dentistry, Good Practice Guidelines-consent can be given if: the patient has the capacity to give consent, it is voluntary , based on appropriate information and understood
-can be given in the later stages of dementia by family member/carer with power of attorney-in emergency situations, “best interests” principle may be used
Slide14Non odontogenic orofacial pain
Slide15Non odontogenic orofacial pain
Slide16Trigeminal nerve
The largest sensory nerve in the body
Over half the sensory cortex is responsive to any stimulation of this system
Sensory supply to face scalp and mouth
Many patients find it very difficult to cope with pain in the trigeminal system
Nociceptive neurons converge from the tooth pulp, TMJs, muscles of mastication, oral cavity and facial skin ➤➤extensive pain referral
Slide17Pain types
There is evidence that chronic pain can induce changes in large scale neuronal network connectivity and result in structural brain changes.
So chronic pain may cause the endogenous pain modulatory system to function aberrantly and present as a disease of the peripheral and central nervous systems.
Slide18The biopsychosocial model of pain
Systemic disease, psychological and environmental factors all play a role in the patient’s pain experience
Slide19Pain history- Socrates
Slide20Pain history
Slide21Non odontogenic acute facial pain
Slide22Serious conditions that present as orofacial pain
The examination must exclude neoplasia as a cause of orofacial pain. Often patients present because they fear they have cancer.
Red flags for occult neoplasia are:Over 50 years oldSudden recent onset and intense pain, motor or sensory neuropathy
Painless persistent lymphadenopathyPainless trismusWorsening trismus despite therapy
Developing spontaneous asymmetryTrigeminal neuralgia in patients under 50 could be multiple sclerosis
Slide23INFection: Maxillary
sinusitis
Often mimics odontogenic pain- pain may be localised to the max sinus, or may mimic toothache in the max sinus regionOne week after URT infectionPain worse on lying down or bending overUsually viral in origin, so Rx focused on relief of symptoms- topical decongestants (<7 days) and steam inhalationsAntibiotics if patient systemically unwell, fever or evidence of spreading infection, or present for over 7 days (SDCEP guidelines)
Chronic cases- refer to ENT
Slide24Other causes of acute non odontogenic facial pain
Slide25Chronic non odontogenic orofacial pain