Principles of diagnosis and management in dental practice PDF

11/12/2019 Principles of diagnosis and management in dental practice Principles of diagnosis and management in dental practice Dental practice: overview of diagnosis and management The information included in this topic is appropriate for dental practice and may not be applicable to other areas of medicine. The general principles of managing oral and dental conditions are summarised in Box 13.1. General principles of managing oral and dental conditions (Box 13.1) Identify the disease and its cause—establish a diagnosis. Provide acute care. Address the cause to prevent recurrence. Address the effect of the disease. Restore normal function. Monitor healing. Provide ongoing monitoring and management, particularly for chronic or recurrent diseases. The process of establishing a diagnosis begins by taking a thorough history, conducting a clinical examination, and performing diagnostic tests if appropriate (see Dental practice: examination and diagnostic tests). The clinician uses this information to establish a diagnosis, based on a knowledge of oral and dental diseases, and the systemic diseases that can manifest in the mouth. Clinicians should also consider the possibility that the patient’s symptoms may be an adverse effect of a drug. It is usually possible to establish a diagnosis for dental problems before starting treatment (unless emergency or acute treatment is required). If the diagnosis is unclear, the clinician should either defer treatment while awaiting further information (eg test results), or refer the patient to a specialist (see Dental practice: referral). It is essential to identify the cause of the disease because addressing the cause is an integral part (and usually the first stage) of managing the disease. The cause may be simple (eg dental caries as a cause for pulp disease) or complex (eg a systemic disease with oral manifestations). Complex conditions may require other management in addition to dental treatment, and consultation with or referral to the patient’s medical practitioner (see Dental practice: referral). Risk factors for the disease should also be identified and modified, if possible, as part of the overall management of the patient. If the cause is not addressed, full or rapid recovery may not be achievable, or an acute condition may progress to become chronic. Once the diagnosis and cause have been established, the clinician should decide an appropriate management strategy. There is a distinction between ’management’ and ’treatment’. Treatment refers to a systematic course of medical or surgical care, whereas management encompasses the overall handling of the patient and their health issues in a sensitive manner, in addition to treatment. https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=dental-diagnosis-prescribing&sectionId=dtg3-c01-s10#dtg3-c01-s10 1/6 11/12/2019 Principles of diagnosis and management in dental practice Drug therapy or irreversible dental treatment should not be started until the diagnosis has been confirmed. The approach of ‘let’s try this and see if it helps’ or ‘just in case’ is not recommended—it may expose the patient to incorrect or inappropriate treatment, or mask signs or symptoms that could indicate a particular diagnosis. Most conditions that lead patients to visit their dentist require dental or oral treatment (see Dental practice: the process of rational treatment). Drugs are usually only needed adjunctively, with consideration of the likely benefit and potential adverse effects (see Dental practice: the role of drugs). Dental practice: taking a history When a patient attends a dental practice, establish the reason for their visit. Take a dental history, which includes an overview of the patient’s previous dental problems and treatment, and a detailed history of the presenting condition. This assists with forming a provisional diagnosis—several potential diagnoses (ie differential diagnoses) may be likely. Ask specific questions to narrow the field—open-ended questions are more effective than leading questions (eg ask the patient what particular things cause dental pain, rather than asking if hot or cold drinks cause pain). Take a medical history, which includes: age and weight, particularly for children medical conditions pregnancy and breastfeeding status a comprehensive medication history, including: prescription medicines over-the-counter and nonprescription medicines complementary medicines (eg vitamins, supplements, herbal medicines) smoking status (past or current) alcohol intake use of illicit drugs history of allergies and adverse reactions to drugs capacity assessment—assess the patient’s overall capacity to provide an accurate history, understand and consent to treatment, and understand and adhere to post-treatment care requirements. Consult the patient’s carer, medical practitioner or other healthcare practitioner, if needed to complete the history. If the patient is unsure of the medicines they are taking, ask them to obtain a current list from their medical practitioner, pharmacist or electronic health record, to bring to the next appointment. Crosscheck the medicine list with the medical history—there may be conditions the patient has forgotten to mention or has not disclosed. See also Box 13.14 for history taking in relation to use of drugs associated with osteonecrosis of the jaw. A complete history also includes the patient’s social history (eg family, occupation, recreation). At each appointment, check the patient’s history for any changes. Dental practice: examination and diagnostic tests Before starting the clinical examination, a provisional diagnosis may be evident. Target the examination and diagnostic tests to confirm the diagnosis and identify the tooth or tissues that are affected. https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=dental-diagnosis-prescribing&sectionId=dtg3-c01-s10#dtg3-c01-s10 2/6 11/12/2019 Principles of diagnosis and management in dental practice Choose tests that are evidence-based, and will aid in decision making; involve the patient in the decision to undergo a test. Diagnostic confirmation is particularly important if the dental treatment required for the provisional diagnosis is irreversible (eg root canal, tooth extraction). However, the clinical benefit of performing a diagnostic test should outweigh any associated risks. Cumulative radiation exposure, particularly in childhood and adolescence, has been associated with an increased incidence of cancer. Aim to achieve the lowest possible radiation exposure while maximising the diagnostic value of the test. For information on radiation exposure during pregnancy, see Dental treatment during pregnancy and breastfeeding. Dental practice: the process of rational treatment After taking a patient history and establishing a diagnosis, determine the therapeutic objective (eg pain relief, treating infection) and choose an appropriate treatment; involve the patient in this decision. In dentistry, drugs are usually an adjunct to dental treatment (see Dental practice: the role of drugs). Starting treatment involves: providing the patient with information about the condition and the reasons for treatment performing appropriate oral or dental treatment if required, recommending appropriate drug therapy, writing an accurate prescription (see Dental practice: the prescription) and providing the patient with the required information (see Dental practice: the prescription and the patient). Monitoring progress involves: reviewing the patient deciding whether to stop, continue or change the treatment. The above process is in line with Australia’s National Strategy for Quality Use of Medicines. Dental practice: the role of drugs Overview of drug use in dental practice In dental practice, drugs are usually an adjunct to dental treatment. Appropriate dental treatment can minimise or avoid the need for drugs (eg dental treatment of a localised odontogenic infection usually avoids the need for antibiotics). The use of drugs can often be deferred until the response to dental treatment has been reviewed. If drugs are necessary, they are more likely to be effective if the cause of the disease has been addressed and dental treatment has been provided. Drug choice is based on efficacy, safety, suitability (eg adherence issues, patient comorbidities, drug formulation), and cost. Inappropriate prescribing can lead to ineffective and unsafe treatment, exacerbate or prolong illness, distress or harm the patient, be costly, and, for antimicrobials, contribute to antimicrobial resistance in the wider community. In Australia, medication-related problems cause approximately 250 000 hospital admissions annually, and up to 400 000 presentations to emergency departments annually [Note 1]. This does not include adverse medication events for which the patient does not present to hospital. Many adverse medication events can be prevented by taking a detailed history and prescribing rationally. Patients often attend a dental appointment with an expectation of a particular treatment (eg analgesics, antibiotics), which may have been influenced by advertising, unrealistic expectations or drug dependence. Always consider alternatives to drug treatment and involve the patient in treatment https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=dental-diagnosis-prescribing&sectionId=dtg3-c01-s10#dtg3-c01-s10 3/6 11/12/2019 Principles of diagnosis and management in dental practice decisions. Patients are more likely to choose conservative treatment strategies when a shared decision-making approach is adopted. Consider the likely benefits and potential harms of drug therapy. If drug therapy is appropriate, choose an evidence-based treatment for the condition, with consideration of individual patient factors. Evaluate drug information to determine the therapeutic value; new and expensive drugs should be critically evaluated in comparison to established treatments. Note 1: Pharmaceutical Society of Australia (PSA). Medicine safety: Take care. Canberra: PSA; 2019. [URL] Off-label prescribing in dental practice ‘Off-label’ use refers to use of a drug in a manner (eg indication, dose, route of administration, patient group) that is not approved by the Australian Therapeutic Goods Administration (TGA)–listed product information. The manufacturer of the medicine does not carry any legal responsibility for off-label prescribing—should an issue arise, such as a serious adverse reaction, legal liability lies solely with the prescriber. Appropriate off-label prescribing requires sufficient evidence to support efficacy and safety, an overall favourable harm-benefit ratio and the consent of the patient [Note 2]. Note 2: For further information on off-label prescribing, see the Council of Australian Therapeutic Advisory Groups guiding principles on the quality use of off-label medicines. [URL] Overprescribing and underprescribing in dental practice It is important that the dose, duration of treatment and quantity of drugs prescribed are correct and clearly stated on the prescription. Overprescribing is wasteful, can cause unnecessary adverse effects, and increases the opportunity for overdose. Of particular concern are drugs that cause dependence or are prone to abuse (eg opioids, benzodiazepines), and drugs that have a narrow therapeutic index (ie the therapeutic dose is very close to the toxic dose). Overprescribing of antimicrobials can lead to increased antimicrobial resistance. Underprescribing is also wasteful and potentially harmful, particularly because it can result in ineffective treatment. Sporting authorities and the use of drugs in dental practice Sporting authorities prohibit the use of some drugs by athletes competing in sporting events. Some of the drugs prohibited in sport may be prescribed or administered by dentists. Most elite athletes are aware of the requirements for their particular sport. Information about drugs and their status for sporting participants is available from the Australian Sports Anti-Doping Authority (ASADA), 1300 027 232, and from the World Anti-Doping Agency (WADA). Dental practice: referral When referring a patient to another practitioner (eg specialist, medical practitioner), a written referral should be provided. The referral should outline the presenting oral or dental complaint, suspected https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=dental-diagnosis-prescribing&sectionId=dtg3-c01-s10#dtg3-c01-s10 4/6 11/12/2019 Principles of diagnosis and management in dental practice diagnosis (if known) and relevant patient details. The referral should be recorded in the patient’s history. The referring clinician should ensure the patient attends the appointment, and communicate with the other clinician about the patient’s condition. Likewise, if a medical practitioner has referred a patient to a dentist, the dentist should communicate with the medical practitioner (eg provide feedback to the medical practitioner in writing). Dental practice: clinical records Clinical records should be kept in accordance with the Dental Board of Australia guidelines on dental records. Dental treatment during pregnancy and breastfeeding Most dental treatment can be carried out safely during pregnancy. In general, elective treatment is best performed in the second trimester (ie the fourth, fifth and sixth months) of pregnancy. Elective procedures requiring general anaesthesia or intravenous sedation should be deferred until after the birth and, preferably, until after breastfeeding has stopped. If the patient is unsure if she is pregnant, defer treatment decisions until pregnancy status is known. If intraoral radiographs are necessary for assessment or diagnosis of infection or trauma, there is no reason, on radiation protection grounds, to defer them. The Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) guidelines [Note 3] state that intraoral radiographs are not contraindicated during pregnancy; however, a leaded drape is recommended when the X-ray beam is directed downwards towards the patient’s trunk (eg when taking occlusal views of the maxilla). Before prescribing a drug for a woman who is pregnant or breastfeeding, consider the general principles of drug use in pregnancy or breastfeeding, as well as the safety of the individual drug (see here). Note 3: Code of practice and safety guide for radiation protection in dentistry: Radiation protection series No. 10. Canberra: Australian Radiation Protection and Nuclear Safety Agency; 2005. [URL] Key references Code of practice and safety guide for radiation protection in dentistry: Radiation protection series No. 10. Canberra: Australian Radiation Protection and Nuclear Safety Agency; 2005. https://www.arpansa.gov.au/regulation-and- licensing/regulatory-publications/radiation-protection-series Council of Australian Therapeutic Advisory Groups (CATAG) Rethinking medicines decision-making in Australian hospitals: Guiding principles for the quality use of off-label medicines. Sydney: CATAG; 2013. https://www.catag.org.au/rethinking-medicines-decision-making-2/. Hoffmann TC, Del Mar C. Patients’ expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med 2015;175(2):274–86. Mathews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, et al. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013;346:f2360. https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=dental-diagnosis-prescribing&sectionId=dtg3-c01-s10#dtg3-c01-s10 5/6 11/12/2019 Principles of diagnosis and management in dental practice Pharmaceutical Society of Australia (PSA). Medicine safety: Take care. Canberra: PSA; 2019. https://www.psa.org.au/advocacy/working-for-our-profession/medicine-safety/ Published December 2019. © Therapeutic Guidelines Ltd (eTG December 2019 edition) Therapeutic Guidelines Limited (www.tg.org.au) is an independent not-for-profit organisation dedicated to deriving guidelines for therapy from the latest world literature, interpreted and distilled by Australia's most eminent and respected experts. © Therapeutic Guidelines Ltd https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=dental-diagnosis-prescribing&sectionId=dtg3-c01-s10#dtg3-c01-s10 6/6 11/12/2019 Principles of diagnosis and management in dental practice Principles of diagnosis and management in dental practice Dental practice: overview of diagnosis and management The information included in this topic is appropriate for dental practice and may not be applicable to other areas of medicine. The general principles of managing oral and dental conditions are summarised in Box 13.1. General principles of managing oral and dental conditions (Box 13.1) Identify the disease and its cause—establish a diagnosis. Provide acute care. Address the cause to prevent recurrence. Address the effect of the disease. Restore normal function. Monitor healing. Provide ongoing monitoring and management, particularly for chronic or recurrent diseases. The process of establishing a diagnosis begins by taking a thorough history, conducting a clinical examination, and performing diagnostic tests if appropriate (see Dental practice: examination and diagnostic tests). The clinician uses this information to establish a diagnosis, based on a knowledge of oral and dental diseases, and the systemic diseases that can manifest in the mouth. Clinicians should also consider the possibility that the patient’s symptoms may be an adverse effect of a drug. It is usually possible to establish a diagnosis for dental problems before starting treatment (unless emergency or acute treatment is required). If the diagnosis is unclear, the clinician should either defer treatment while awaiting further information (eg test results), or refer the patient to a specialist (see Dental practice: referral). It is essential to identify the cause of the disease because addressing the cause is an integral part (and usually the first stage) of managing the disease. The cause may be simple (eg dental caries as a cause for pulp disease) or complex (eg a systemic disease with oral manifestations). Complex conditions may require other management in addition to dental treatment, and consultation with or referral to the patient’s medical practitioner (see Dental practice: referral). Risk factors for the disease should also be identified and modified, if possible, as part of the overall management of the patient. If the cause is not addressed, full or rapid recovery may not be achievable, or an acute condition may progress to become chronic. Once the diagnosis and cause have been established, the clinician should decide an appropriate management strategy. There is a distinction between ’management’ and ’treatment’. Treatment refers to a systematic course of medical or surgical care, whereas management encompasses the overall handling of the patient and their health issues in a sensitive manner, in addition to treatment. https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=dental-diagnosis-prescribing&sectionId=dtg3-c01-s10#00003 1/6 11/12/2019 Principles of diagnosis and management in dental practice Drug therapy or irreversible dental treatment should not be started until the diagnosis has been confirmed. The approach of ‘let’s try this and see if it helps’ or ‘just in case’ is not recommended—it may expose the patient to incorrect or inappropriate treatment, or mask signs or symptoms that could indicate a particular diagnosis. Most conditions that lead patients to visit their dentist require dental or oral treatment (see Dental practice: the process of rational treatment). Drugs are usually only needed adjunctively, with consideration of the likely benefit and potential adverse effects (see Dental practice: the role of drugs). Dental practice: taking a history When a patient attends a dental practice, establish the reason for their visit. Take a dental history, which includes an overview of the patient’s previous dental problems and treatment, and a detailed history of the presenting condition. This assists with forming a provisional diagnosis—several potential diagnoses (ie differential diagnoses) may be likely. Ask specific questions to narrow the field—open-ended questions are more effective than leading questions (eg ask the patient what particular things cause dental pain, rather than asking if hot or cold drinks cause pain). Take a medical history, which includes: age and weight, particularly for children medical conditions pregnancy and breastfeeding status a comprehensive medication history, including: prescription medicines over-the-counter and nonprescription medicines complementary medicines (eg vitamins, supplements, herbal medicines) smoking status (past or current) alcohol intake use of illicit drugs history of allergies and adverse reactions to drugs capacity assessment—assess the patient’s overall capacity to provide an accurate history, understand and consent to treatment, and understand and adhere to post-treatment care requirements. Consult the patient’s carer, medical practitioner or other healthcare practitioner, if needed to complete the history. If the patient is unsure of the medicines they are taking, ask them to obtain a current list from their medical practitioner, pharmacist or electronic health record, to bring to the next appointment. Crosscheck the medicine list with the medical history—there may be conditions the patient has forgotten to mention or has not disclosed. See also Box 13.14 for history taking in relation to use of drugs associated with osteonecrosis of the jaw. A complete history also includes the patient’s social history (eg family, occupation, recreation). At each appointment, check the patient’s history for any changes. Dental practice: examination and diagnostic tests Before starting the clinical examination, a provisional diagnosis may be evident. Target the examination and diagnostic tests to confirm the diagnosis and identify the tooth or tissues that are affected. https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=dental-diagnosis-prescribing&sectionId=dtg3-c01-s10#00003 2/6 11/12/2019 Principles of diagnosis and management in dental practice Choose tests that are evidence-based, and will aid in decision making; involve the patient in the decision to undergo a test. Diagnostic confirmation is particularly important if the dental treatment required for the provisional diagnosis is irreversible (eg root canal, tooth extraction). However, the clinical benefit of performing a diagnostic test should outweigh any associated risks. Cumulative radiation exposure, particularly in childhood and adolescence, has been associated with an increased incidence of cancer. Aim to achieve the lowest possible radiation exposure while maximising the diagnostic value of the test. For information on radiation exposure during pregnancy, see Dental treatment during pregnancy and breastfeeding. Dental practice: the process of rational treatment After taking a patient history and establishing a diagnosis, determine the therapeutic objective (eg pain relief, treating infection) and choose an appropriate treatment; involve the patient in this decision. In dentistry, drugs are usually an adjunct to dental treatment (see Dental practice: the role of drugs). Starting treatment involves: providing the patient with information about the condition and the reasons for treatment performing appropriate oral or dental treatment if required, recommending appropriate drug therapy, writing an accurate prescription (see Dental practice: the prescription) and providing the patient with the required information (see Dental practice: the prescription and the patient). Monitoring progress involves: reviewing the patient deciding whether to stop, continue or change the treatment. The above process is in line with Australia’s National Strategy for Quality Use of Medicines. Dental practice: the role of drugs Overview of drug use in dental practice In dental practice, drugs are usually an adjunct to dental treatment. Appropriate dental treatment can minimise or avoid the need for drugs (eg dental treatment of a localised odontogenic infection usually avoids the need for antibiotics). The use of drugs can often be deferred until the response to dental treatment has been reviewed. If drugs are necessary, they are more likely to be effective if the cause of the disease has been addressed and dental treatment has been provided. Drug choice is based on efficacy, safety, suitability (eg adherence issues, patient comorbidities, drug formulation), and cost. Inappropriate prescribing can lead to ineffective and unsafe treatment, exacerbate or prolong illness, distress or harm the patient, be costly, and, for antimicrobials, contribute to antimicrobial resistance in the wider community. In Australia, medication-related problems cause approximately 250 000 hospital admissions annually, and up to 400 000 presentations to emergency departments annually [Note 1]. This does not include adverse medication events for which the patient does not present to hospital. Many adverse medication events can be prevented by taking a detailed history and prescribing rationally. Patients often attend a dental appointment with an expectation of a particular treatment (eg analgesics, antibiotics), which may have been influenced by advertising, unrealistic expectations or drug dependence. Always consider alternatives to drug treatment and involve the patient in treatment https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=dental-diagnosis-prescribing&sectionId=dtg3-c01-s10#00003 3/6 11/12/2019 Principles of diagnosis and management in dental practice decisions. Patients are more likely to choose conservative treatment strategies when a shared decision-making approach is adopted. Consider the likely benefits and potential harms of drug therapy. If drug therapy is appropriate, choose an evidence-based treatment for the condition, with consideration of individual patient factors. Evaluate drug information to determine the therapeutic value; new and expensive drugs should be critically evaluated in comparison to established treatments. Note 1: Pharmaceutical Society of Australia (PSA). Medicine safety: Take care. Canberra: PSA; 2019. [URL] Off-label prescribing in dental practice ‘Off-label’ use refers to use of a drug in a manner (eg indication, dose, route of administration, patient group) that is not approved by the Australian Therapeutic Goods Administration (TGA)–listed product information. The manufacturer of the medicine does not carry any legal responsibility for off-label prescribing—should an issue arise, such as a serious adverse reaction, legal liability lies solely with the prescriber. Appropriate off-label prescribing requires sufficient evidence to support efficacy and safety, an overall favourable harm-benefit ratio and the consent of the patient [Note 2]. Note 2: For further information on off-label prescribing, see the Council of Australian Therapeutic Advisory Groups guiding principles on the quality use of off-label medicines. [URL] Overprescribing and underprescribing in dental practice It is important that the dose, duration of treatment and quantity of drugs prescribed are correct and clearly stated on the prescription. Overprescribing is wasteful, can cause unnecessary adverse effects, and increases the opportunity for overdose. Of particular concern are drugs that cause dependence or are prone to abuse (eg opioids, benzodiazepines), and drugs that have a narrow therapeutic index (ie the therapeutic dose is very close to the toxic dose). Overprescribing of antimicrobials can lead to increased antimicrobial resistance. Underprescribing is also wasteful and potentially harmful, particularly because it can result in ineffective treatment. Sporting authorities and the use of drugs in dental practice Sporting authorities prohibit the use of some drugs by athletes competing in sporting events. Some of the drugs prohibited in sport may be prescribed or administered by dentists. Most elite athletes are aware of the requirements for their particular sport. Information about drugs and their status for sporting participants is available from the Australian Sports Anti-Doping Authority (ASADA), 1300 027 232, and from the World Anti-Doping Agency (WADA). Dental practice: referral When referring a patient to another practitioner (eg specialist, medical practitioner), a written referral should be provided. The referral should outline the presenting oral or dental complaint, suspected https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=dental-diagnosis-prescribing&sectionId=dtg3-c01-s10#00003 4/6 11/12/2019 Principles of diagnosis and management in dental practice diagnosis (if known) and relevant patient details. The referral should be recorded in the patient’s history. The referring clinician should ensure the patient attends the appointment, and communicate with the other clinician about the patient’s condition. Likewise, if a medical practitioner has referred a patient to a dentist, the dentist should communicate with the medical practitioner (eg provide feedback to the medical practitioner in writing). Dental practice: clinical records Clinical records should be kept in accordance with the Dental Board of Australia guidelines on dental records. Dental treatment during pregnancy and breastfeeding Most dental treatment can be carried out safely during pregnancy. In general, elective treatment is best performed in the second trimester (ie the fourth, fifth and sixth months) of pregnancy. Elective procedures requiring general anaesthesia or intravenous sedation should be deferred until after the birth and, preferably, until after breastfeeding has stopped. If the patient is unsure if she is pregnant, defer treatment decisions until pregnancy status is known. If intraoral radiographs are necessary for assessment or diagnosis of infection or trauma, there is no reason, on radiation protection grounds, to defer them. The Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) guidelines [Note 3] state that intraoral radiographs are not contraindicated during pregnancy; however, a leaded drape is recommended when the X-ray beam is directed downwards towards the patient’s trunk (eg when taking occlusal views of the maxilla). Before prescribing a drug for a woman who is pregnant or breastfeeding, consider the general principles of drug use in pregnancy or breastfeeding, as well as the safety of the individual drug (see here). Note 3: Code of practice and safety guide for radiation protection in dentistry: Radiation protection series No. 10. Canberra: Australian Radiation Protection and Nuclear Safety Agency; 2005. [URL] Key references Code of practice and safety guide for radiation protection in dentistry: Radiation protection series No. 10. Canberra: Australian Radiation Protection and Nuclear Safety Agency; 2005. https://www.arpansa.gov.au/regulation-and- licensing/regulatory-publications/radiation-protection-series Council of Australian Therapeutic Advisory Groups (CATAG) Rethinking medicines decision-making in Australian hospitals: Guiding principles for the quality use of off-label medicines. Sydney: CATAG; 2013. https://www.catag.org.au/rethinking-medicines-decision-making-2/. Hoffmann TC, Del Mar C. Patients’ expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med 2015;175(2):274–86. Mathews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, et al. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 2013;346:f2360. https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=dental-diagnosis-prescribing&sectionId=dtg3-c01-s10#00003 5/6 11/12/2019 Principles of diagnosis and management in dental practice Pharmaceutical Society of Australia (PSA). Medicine safety: Take care. Canberra: PSA; 2019. https://www.psa.org.au/advocacy/working-for-our-profession/medicine-safety/ Published December 2019. © Therapeutic Guidelines Ltd (eTG December 2019 edition) Therapeutic Guidelines Limited (www.tg.org.au) is an independent not-for-profit organisation dedicated to deriving guidelines for therapy from the latest world literature, interpreted and distilled by Australia's most eminent and respected experts. © Therapeutic Guidelines Ltd https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=dental-diagnosis-prescribing&sectionId=dtg3-c01-s10#00003 6/6 11/12/2019 Antimicrobial drugs used in dentistry Antimicrobial drugs used in dentistry Antimicrobial drugs used in dentistry For a discussion of the principles of antimicrobial use, see here. For a discussion of antimicrobial hypersensitivity, see here. Table 13.1 provides a summary of antibacterials used in dental practice, and includes links to practical information on their use. Antibacterial drugs used in dentistry (Table 13.1) Susceptible dental pathogens relevant Drug class Antibacterial to clinical use beta lactams: cephalosporins moderate-spectrum cefalexin Staphylococcus species cephalosporins cefazolin Streptococcus species beta lactams: penicillins narrow-spectrum benzylpenicillin Peptoniphilus (formerly penicillins Peptostreptococcus) species phenoxymethylpenicillin Actinomyces species most Streptococcus species many oral anaerobes (eg Fusobacterium species) narrow-spectrum dicloxacillin Staphylococcus species penicillins with antistaphylococcal activity flucloxacillin Streptococcus species moderate-spectrum amoxicillin Peptoniphilus (formerly penicillins Peptostreptococcus) species ampicillin Actinomyces species most Streptococcus species many oral anaerobes (eg Fusobacterium species) https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=antimicrobial-drugs-dentistry 1/2 11/12/2019 Antimicrobial drugs used in dentistry Susceptible dental pathogens relevant Drug class Antibacterial to clinical use broad-spectrum penicillins amoxicillin+clavulanate Staphylococcus aureus (beta-lactamase inhibitor combinations) Bacteroides fragilis Peptoniphilus (formerly Peptostreptococcus) species Actinomyces species most Streptococcus species many oral anaerobes (eg Fusobacterium species) other folic acid antagonists trimethoprim+sulfamethoxazole Staphylococcus aureus, including community-associated methicillin- resistant S. aureus (CA-MRSA) glycopeptides vancomycin methicillin-resistant Staphylococcus aureus lincosamides clindamycin most anaerobic bacteria (eg Peptoniphilus [formerly lincomycin Peptostreptococcus] species, Porphyromonas gingivalis, Prevotella oralis, Bacteroides fragilis) some aerobic bacteria (eg Staphylococcus aureus, most Streptococcus species) nitroimidazoles metronidazole most anaerobic bacteria (eg Peptoniphilus [formerly Peptostreptococcus] species, Porphyromonas gingivalis, Prevotella oralis, Bacteroides fragilis) tetracyclines doxycycline broad-spectrum antibacterial activity Published December 2019. © Therapeutic Guidelines Ltd (eTG December 2019 edition) Therapeutic Guidelines Limited (www.tg.org.au) is an independent not-for-profit organisation dedicated to deriving guidelines for therapy from the latest world literature, interpreted and distilled by Australia's most eminent and respected experts. © Therapeutic Guidelines Ltd https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=antimicrobial-drugs-dentistry 2/2 11/12/2019 Drugs used to treat acute pain in dentistry Drugs used to treat acute pain in dentistry Introduction to drugs used to treat acute pain in dentistry This topic covers practical information on drugs used to treat acute pain in dentistry. For comprehensive drug information, including precautions, contraindications, adverse effects and drug interactions, consult an appropriate drug information resource. If prescribing an analgesic drug or local anaesthetic, consider the benefit–harm profile of the drug in the individual patient; this requires knowledge of the patient’s medical history and concomitant medications, including prescription, over- the-counter and complementary medicines. For a more comprehensive discussion of analgesic drugs, see Principles of analgesic and anti- inflammatory drug use for musculoskeletal conditions in adults and Acute pain: a general approach. For information on local anaesthetics used in dentistry, see Local anaesthetics in dentistry. For a more comprehensive discussion of local anaesthetics, see Regional and local administration of local anaesthetics and opioids. Nonsteroidal anti-inflammatory drug use in dentistry Overview of NSAIDs Nonsteroidal anti-inflammatory drugs (NSAIDs) include nonselective cyclo-oxygenase (COX) inhibitors and COX-2–selective inhibitors (the latter group is sometimes referred to as coxibs). Table 13.2 shows NSAIDs commonly used in dentistry. NSAIDs commonly used in dentistry (Table 13.2) NSAID Frequency of oral administration [NB1] nonselective ibuprofen 3 or 4 doses daily naproxen 1 or 2 doses daily [NB2] COX-2 selective celecoxib 1 or 2 doses daily NSAID = nonsteroidal anti-inflammatory drug; COX = cyclo-oxygenase NB1: The frequency of administration gives an indication of the drug's half-life (eg ibuprofen has a short half-life so requires frequent dosing). NB2: Immediate-release naproxen is dosed twice daily and modified-release naproxen is dosed once daily. NSAIDs are the preferred drug class for acute dental pain; however, they can cause significant renal, cardiovascular, gastrointestinal, respiratory and haematological adverse effects—these are summarised in Table 13.3. https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=drugs-pain-dentistry 1/11 11/12/2019 Drugs used to treat acute pain in dentistry The risk of harm from NSAIDs increases with increasing age, higher doses, longer durations of treatment, and concomitant use of some drugs. Major adverse effects of NSAIDs (Table 13.3) System Adverse effects renal impaired kidney function, acute kidney failure increased blood pressure, fluid retention, worsening of heart failure, cardiovascular thrombosis, myocardial infarction, stroke, cardiovascular death oesophageal, gastric, duodenal and small bowel ulceration, upper gastrointestinal abdominal pain, gastric erosions, gastrointestinal bleeding bronchospasm in patients with NSAID-exacerbated respiratory disease respiratory [NB1] haematological impaired platelet function [NB1] NSAID = nonsteroidal anti-inflammatory drug NB1: This adverse effect occurs with nonselective NSAIDs, but not COX-2–selective NSAIDs. Assessing whether NSAID use is appropriate General information NSAIDs are the preferred analgesics for acute dental pain because of their anti-inflammatory actions, efficacy for bone pain and ability to reduce opioid requirements, nausea and vomiting, and improve pain relief when used as a component of multimodal analgesia [Note 1]. Before prescribing an NSAID, weigh these potential benefits against the potential harms in the individual; the risk of harm depends on patient factors (see below) and the NSAID used (see Choosing an analgesic regimen for patients at risk of NSAID-related toxicity). Consider accessing the patient’s electronic health record to obtain more information on their health status. If unsure of the safety of short-term NSAID use for a patient, consult a medical practitioner. There is a low risk of harm when NSAIDs are used short-term by healthy people who are not taking other medicines. However, even in these patients steps should be taken to minimise harm; see here. Conversely, NSAID use is contraindicated in some people and should be avoided in others because of a significant risk of harm—see Box 13.2 for patients who should not be prescribed an NSAID by a dentist. If paracetamol is not expected to provide sufficient analgesia in these patients, consider alternative pain management strategies or refer the patient to a medical practitioner. https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=drugs-pain-dentistry 2/11 11/12/2019 Drugs used to treat acute pain in dentistry Patients who should not be prescribed an NSAID by a dentist (Box 13.2) patients with severe kidney impairment (eGFR of less than 30 mL/min) patients with severe heart failure patients with an active gastrointestinal ulcer or gastrointestinal bleeding patients with bleeding disorders patients taking corticosteroids or anticoagulants patients with multiple risk factors for increased NSAID toxicity (eg elderly patients with a history of gastrointestinal bleeding) eGFR = estimated glomerular filtration rate; NSAID = nonsteroidal anti-inflammatory drug Deciding whether it is safe to prescribe NSAIDs in patients with risk factors for NSAID-induced renal, cardiovascular or gastrointestinal toxicity is more complex. Consider the cumulative risk of NSAID toxicity if more than one risk factor is present. The use of NSAIDs in elderly patients and pregnant or breastfeeding women requires extra consideration. Note 1: Although most of the evidence for NSAIDs as part of multimodal analgesia comes from postoperative pain, the findings are considered relevant for most acute pain settings. Renal toxicity Acute kidney injury is a serious adverse effect associated with all NSAIDs. Risk factors for NSAID- induced acute kidney injury include: older age pre-existing kidney impairment volume depletion (eg dehydration, sepsis) or effective arterial volume depletion (eg due to heart failure, cirrhosis, nephrotic syndrome) current use of angiotensin converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), diuretics or other nephrotoxic drugs. The risk of acute kidney injury is cumulative—for example, the risk is significantly increased if an NSAID is co-administered with an ACEI plus a diuretic, or if an older patient taking an NSAID develops an acute illness associated with dehydration. To choose an appropriate analgesic regimen for patients at increased risk of renal toxicity, see here. Cardiovascular toxicity Although all NSAIDs can cause cardiovascular toxicity, not all are equally likely to do so—evidence is evolving. Furthermore, the relationship between duration of NSAID use and onset of toxicity is not fully understood. It is clear that the risk of cardiovascular toxicity increases with longer durations of therapy and higher doses. Short-term use (ie less than 5 days) of NSAIDs does not significantly increase the risk of cardiovascular events, and can reduce the requirement for opioids. Risk factors for increased cardiovascular toxicity with NSAID use include: https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=drugs-pain-dentistry 3/11 11/12/2019 Drugs used to treat acute pain in dentistry established cardiovascular disease (eg myocardial infarction, stroke) risk factors for cardiovascular disease (including smoking, older age, elevated blood pressure, dyslipidaemia and diabetes). If a decision is taken to use an NSAID in a patient at increased risk of cardiovascular toxicity, see here for suitable choices. Gastrointestinal toxicity Risk factors for increased gastrointestinal toxicity with NSAID use include: older age history of upper gastrointestinal bleeding or peptic ulcer disease Helicobacter pylori infection current use of drugs that increase the risk of upper gastrointestinal bleeding or perforation (eg anticoagulants, antiplatelet drugs, selective serotonin reuptake inhibitors [SSRIs], serotonin and noradrenaline reuptake inhibitors [SNRIs], systemic corticosteroids) significant comorbidity smoking. If a decision is taken to use an NSAID in a patient at increased risk of gastrointestinal toxicity, see here for suitable choices. Elderly people Assess the need for NSAIDs in elderly people particularly carefully. Elderly people are generally at increased risk of renal, cardiovascular and gastrointestinal adverse effects of NSAIDs. Elderly people are also more likely to have comorbidities and take other drugs that increase their risk of NSAID- related adverse effects. If a decision is taken to use an NSAID in an elderly patient, see here for suitable choices; NSAIDs with a short half-life are preferred (see Table 13.2). Women who are pregnant or breastfeeding If possible, avoid NSAIDs throughout pregnancy. The safety of NSAID use during the first 8 weeks of pregnancy is uncertain. NSAIDs should not be used beyond 32 weeks of gestation because they can be associated with adverse maternal and fetal outcomes. Do not use NSAIDs in pregnant women beyond 32 weeks’ gestation. There are fewer data on the use of COX-2–selective NSAIDs than nonselective NSAIDs in pregnancy, so if a decision is taken to use an NSAID in a pregnant woman up to 32 week’ gestation, a nonselective NSAID is preferred. Small amounts of NSAIDs are excreted into breast milk; however, these amounts are unlikely to cause harm to breastfed infants. Ibuprofen is the preferred NSAID for women who are breastfeeding. Advise breastfeeding mothers to feed their baby just before taking their medication, to minimise the amount of drug in the breastmilk. Before prescribing an NSAID for a woman who is pregnant or breastfeeding, consider the general principles of drug use in pregnancy or breastfeeding, as well as the safety of the individual drug (see https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=drugs-pain-dentistry 4/11 11/12/2019 Drugs used to treat acute pain in dentistry here). Choosing an analgesic regimen for patients at increased risk of NSAID-related toxicity Consult with a medical practitioner if unsure of the safety of short-term use of an NSAID for a particular patient. Recognise patients that should not be prescribed NSAIDs by a dentist (see Box 13.2). If paracetamol is not expected to provide sufficient analgesia in these patients, consider alternative pain management strategies or refer the patient to a medical practitioner. Recognise patients at increased risk of renal toxicity, and: consult a medical practitioner to determine if NSAID use is appropriate, unless paracetamol alone is expected to provide sufficient analgesia. Recognise patients at increased risk of cardiovascular toxicity, and: consider that ineffective pain relief can cause tachycardia, which may cause adverse cardiovascular effects avoid diclofenac and COX-2–selective NSAIDs other than celecoxib use celecoxib or ibuprofen (naproxen can be used, but has a higher risk of gastrointestinal adverse effects) but limit treatment to 5 days if celecoxib, ibuprofen and naproxen cannot be used, use paracetamol alone for mild to moderate pain (see here for children or here for adults), or, in adults, paracetamol with oxycodone for severe pain (see here). Recognise patients at increased risk of gastrointestinal toxicity, and: avoid nonselective NSAIDs (eg ibuprofen, diclofenac, naproxen) use a COX-2–selective NSAID (eg celecoxib) [Note 2] if a COX-2–selective NSAID cannot be used, use paracetamol alone for mild to moderate pain (see here for children or here for adults), or, in adults, paracetamol with oxycodone for severe pain (see here). In patients who have had NSAID-induced bronchospasm: avoid nonselective NSAIDs (eg ibuprofen, diclofenac, naproxen) use a COX-2–selective NSAID (eg celecoxib). Note 2: COX-2–selective NSAIDs have a lower risk of gastrointestinal adverse effects than nonselective NSAIDs; however, this advantage may be reduced if the patient is taking low-dose aspirin concurrently. Practical advice to minimise harms when prescribing short-term NSAIDs for acute dental pain To minimise harms in all patients prescribed short-term NSAIDs for acute dental pain, advise the patient to: take the NSAID regularly (rather than as required) using the lowest effective dose use the NSAID for the shortest duration possible, and not more than 5 days—the risk of adverse effects may increase after 5 days of use https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=drugs-pain-dentistry 5/11 11/12/2019 Drugs used to treat acute pain in dentistry combine the NSAID with paracetamol and, as soon as possible, stop the NSAID then use paracetamol alone seek review if the NSAID is still required after 5 days to avoid inadvertent long-term use. It is no longer advised that NSAIDs be taken with food to reduce adverse effects, because there is no evidence to support this approach. Additionally, taking NSAIDs with food delays the peak concentration, reduces the rate of absorption, and can result in less effective relief of acute pain. Paracetamol use in dentistry Paracetamol has analgesic and antipyretic actions and a low incidence of adverse effects compared with other analgesic drugs. However, in overdose, it can lead to severe hepatotoxicity (see Toxicology: paracetamol). Although generally less effective than nonsteroidal anti-inflammatory drugs (NSAIDs) for acute dental pain, paracetamol is the drug of choice when NSAIDs are contraindicated because of its favourable safety profile. Paracetamol is used in combination with other analgesics for the treatment of acute dental pain because this can result in enhanced pain management, or synergistic analgesia. As a component of multimodal analgesia, paracetamol reduces the requirement for opioids. Paracetamol is available in multiple formulations (eg immediate-release, modified-release) and in combination with other drugs. Therefore, patients should be advised to consider the paracetamol content of all their medications, to avoid inadvertent ingestion of higher than recommended doses. In adults with significant liver disease, or who are underweight, cachectic or frail, reduced doses are often inappropriately used. This may result in inadequate analgesia and, consequently, use of more harmful analgesics. Therapeutic doses are not hepatotoxic in these patient groups, but there is an increased risk of liver damage if supratherapeutic doses (ie doses greater than 4 g in 24 hours) are inadvertently taken. In obese children, the dose of paracetamol should be calculated using ideal body weight rather than actual body weight (see also Table 13.14). When prescribing paracetamol, the dose should be stated in grams or milligrams rather than the number of tablets or volume of liquid, unless the exact formulation to be administered has been specified. Opioid use in dentistry Overview of opioid use in dentistry In combination with nonopioid analgesics and nonpharmacological measures (eg dental treatment), an opioid may be used for acute severe nociceptive dental pain in adults (eg pain associated with major trauma, severe postoperative pain). Opioids should not be used for pain that is chronic, neuropathic or nociplastic, or for pain in children, except by specialists. Safe prescribing of opioids in dentistry requires the practitioner to: be familiar with the indications for which opioid use is appropriate be familiar with the suitability of opioid use in specific populations (eg elderly or frail patients, opioid-tolerant patients) because there is significant interpatient variability in the response to https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=drugs-pain-dentistry 6/11 11/12/2019 Drugs used to treat acute pain in dentistry opioids weigh potential benefits of opioid use in an individual against potential harms be familiar with the opioids suitable for use in dentistry and the formulations in which they are available (see Choice of opioid in dentistry) know how to manage potential drug interactions and adverse effects, and provide appropriate verbal and written education to patients about sedative effects (see Harms of opioids used in dentistry) prescribe the lowest dose for the shortest duration possible, because long-term opioid use often starts with the use of opioids to treat acute pain consider the legislation about prescriptions and prescribing drugs of dependence. Prescribe the lowest dose of opioid for the shortest duration possible, because long-term opioid use often starts with the use of opioids to treat acute pain. Harms of opioids used in dentistry Generally, when given in equianalgesic doses, opioids have a similar spectrum and incidence of adverse effects; however, there can be significant interpatient variability. Elderly or frail patients may be particularly sensitive to opioids, so require careful monitoring. Harms associated with opioids include: adverse effects—serious adverse effects (eg opioid-induced ventilatory impairment, accidental death) are more likely to occur when opioids are used in high doses or concomitantly with other sedative drugs (eg benzodiazepines, alcohol, cannabis). Table 13.4 lists adverse effects that can occur with short-term opioid use; for a more detailed discussion of the adverse effects of opioids, see here aberrant behaviour (eg diversion, nonmedical use, abuse, addiction)—the risk of opioid abuse is high; in some studies, opioid abuse was reported in more than 20% of patients taking long- term opioids for chronic noncancer pain risk of overdose—increased opioid prescribing rates have been associated with a significant increase in the number of fatalities involving opioids neuroadaptive and physiological changes (eg opioid tolerance, opioid dependence, opioid- induced hyperalgesia)—may occur after 7 to 10 days of use. Adverse effects with short-term use of opioids (Table 13.4) [NB1] System Adverse effects opioid-induced ventilatory impairment (excessive sedation with or without a decrease in respiratory rate [NB2]), which is more marked during sleep respiratory accidental death increased risk of sleep-disordered breathing (central or obstructive apnoea) cough suppression delirium, sedation, dysphoria or euphoria, miosis, impaired cognition neurological other adverse effects can occur in patients with renal impairment https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=drugs-pain-dentistry 7/11 11/12/2019 Drugs used to treat acute pain in dentistry System Adverse effects bradycardia, vasodilation and hypotension (including postural cardiovascular hypotension)—usually only seen after the use of large intravenous doses during anaesthesia or if the patient is hypovolaemic pruritus [NB3] dermatological widespread urticaria—suggests an allergic response gastrointestinal nausea, vomiting, constipation, spasm of the sphincter of Oddi urinary retention and difficulty with micturition, increased external urinary sphincter tone, decreased detrusor muscle tone NB1: For a more detailed discussion of the adverse effects of opioids, see here. NB2: A decrease in respiratory rate is an unreliable indicator of opioid-induced ventilatory impairment, which can coexist with a normal respiratory rate. Sedation is a more sensitive indicator of opioid-induced ventilatory impairment. NB3: Opioid-induced pruritus is not associated with a rash and is thought to be due to an action on opioid receptors. Adverse effects can be limited by using the lowest dose for the shortest duration possible. Provide appropriate verbal and written education to patients and their carers about the sedating effects of opioids, including: not to drive or operate machinery how to recognise the signs of excessive sedation (eg not being able to stay awake or be roused from sleep) to seek medical attention if they become excessively sedated (because this can be an early indicator of ventilatory impairment) or experience other concerning adverse effects. Advise patients and their carers of the sedating effects of opioids. Constipation is a frequent adverse effect of opioids—advise patients to obtain a stimulant laxative (eg docusate with senna) if it becomes an issue. Choice of opioid in dentistry Immediate-release opioids commonly used for acute pain management in dentistry include oxycodone, tramadol and tapentadol. Tramadol and tapentadol are sometimes referred to as atypical opioids, because they have multiple mechanisms of action in addition to mu-opioid receptor agonism. Despite significant clinical experience with its use, codeine is no longer recommended for pain management because its use is associated with more harm than benefit. Table 13.5 summarises the advantages and disadvantages of opioids commonly used in dentistry. Advantages and disadvantages of immediate-release opioids commonly used in dentistry (Table 13.5) Opioid Advantages and disadvantages Commonly used in pain management https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=drugs-pain-dentistry 8/11 11/12/2019 Drugs used to treat acute pain in dentistry Opioid Advantages and disadvantages preferred opioid for severe acute nociceptive dental pain in these guidelines because of: widespread experience with its use oxycodone fewer drug interactions than tramadol more predictable pharmacokinetics and greater efficacy than codeine alternative in patients who cannot tolerate other opioids or who are allergic to opiate derivatives tramadol wide range of potential adverse effects and drug interactions, including serotonin toxicity [NB1] alternative in patients who cannot tolerate other opioids or who are allergic to opiate derivatives tapentadol more potent opioid effect than tramadol immediate-release oral formulations are not available on the PBS No role in pain management there is no good evidence that codeine (even in doses of 60 mg) is any more effective than paracetamol or NSAIDs, or improves analgesia when combined with paracetamol or an NSAID codeine-containing preparations have been abused codeine is a prodrug that is metabolised to morphine—there is significant interpatient variability in this conversion, and some patients experience either minimal analgesic effect or morphine toxicity codeine there is a known increased risk of toxicity in certain patient groups, including: patients who are ultrarapid metabolisers of codeine breastfeeding mothers children younger than 12 years children 12 to 18 years who have recently had a tonsillectomy and/or adenoidectomy for obstructive sleep apnoea [NB2] NSAID = nonsteroidal anti-inflammatory drug; PBS = Pharmaceutical Benefits Scheme NB1: Signs of serotonin toxicity include altered mental status (eg agitation, anxiety, restlessness, confusion), autonomic stimulation (eg increased heart rate, increased blood pressure, fever, sweating, dilated pupils) and neuromuscular excitation (eg tremor, clonus, hyperreflexia, myoclonus, rigidity). NB2: For more detail, see the Therapeutic Goods Administration (TGA) Medicines Safety Update for codeine. [URL] Key references Nonsteroidal anti-inflammatory drugs used in dentistry Bally M, Beauchamp ME, Abrahamowicz M, Nadeau L, Brophy JM. Risk of acute myocardial infarction with real- world NSAIDs depends on dose and timing of exposure. Pharmacoepidemiol Drug Saf 2018;27(1):69–77. https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=drugs-pain-dentistry 9/11 11/12/2019 Drugs used to treat acute pain in dentistry Bally M, Dendukuri N, Rich B, Nadeau L, Helin-Salmivaara A, Garbe E, et al. Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data. BMJ 2017;357:j1909.. Bhala N, Emberson J, Merhi A, Abramson S, Arber N, Baron JA, et al. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet 2013;382(9894):769–79. Moore RA, Derry S, Wiffen PJ, Straube S. Effects of food on pharmacokinetics of immediate release oral formulations of aspirin, dipyrone, paracetamol and NSAIDs - a systematic review. Br J Clin Pharmacol 2015;80(3):381–8. Rainsford KD, Bjarnason I. NSAIDs: take with food or after fasting? J Pharm Pharmacol 2012;64(4):465–9. Schmidt M, Sorensen HT, Pedersen L. Diclofenac use and cardiovascular risks: series of nationwide cohort studies. BMJ 2018;362:k3426. Schug SA, Palmer GM, Scott DA, Halliwell R, Trinca J, APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, editors. Acute pain management: scientific evidence. 4th ed. Melbourne: Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine; 2015. http://fpm.anzca.edu.au/resources/publications US Food and Drug Administration (FDA). FDA strengthens warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart attacks or strokes. Silver Spring, MD: FDA; 2015. https://www.fda.gov/drugs/drug- safety-and-availability/fda-drug-safety-communication-fda-strengthens-warning-non-aspirin-nonsteroidal-anti- inflammatory Opioids used in dentistry Ballantyne JC. Opioids for the treatment of chronic pain: Mistakes made, lessons learned, and future directions. Anesth Analg 2017;125(5):1769–78. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. JAMA 2016;315(15):1624–45. Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists (ANZCA). Statement on principles for identifying and preventing opioid-induced ventilatory impairment (OIVI). Melbourne: ANZCA; 2018. http://www.anzca.edu.au/resources/endorsed-guidelines/oivi-statement Kleinert R, Lange C, Steup A, Black P, Goldberg J, Desjardins P. Single dose analgesic efficacy of tapentadol in postsurgical dental pain: the results of a randomized, double-blind, placebo-controlled study. Anesth Analg 2008;107(6):2048–55. Lalic S, Ilomaki J, Bell JS, Korhonen MJ, Gisev N. Prevalence and incidence of prescription opioid analgesic use in Australia. Br J Clin Pharmacol 2019;85(1):202–15. Macintyre PE, Huxtable CA, Flint SL, Dobbin MD. Costs and consequences: a review of discharge opioid prescribing for ongoing management of acute pain. Anaesth Intensive Care 2014;42(5):558–74. Macintyre PE, Loadsman JA, Scott DA. Opioids, ventilation and acute pain management. Anaesth Intensive Care 2011;39(4):545–58. https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=drugs-pain-dentistry 10/11 11/12/2019 Drugs used to treat acute pain in dentistry Macintyre PE, Schug SA. Acute pain management: a practical guide. Boca Raton, FL: CRC Press; 2015. Penington Institute. Australia’s annual overdose report 2017. Melbourne, Australia: Penington Institute; 2017. http://www.penington.org.au/australias-annual-overdose-report-2017/ Schug SA, Palmer GM, Scott DA, Halliwell R, Trinca J, APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, editors. Acute pain management: scientific evidence. 4th ed. Melbourne: Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine; 2015. http://fpm.anzca.edu.au/resources/publications Therapeutic Goods Administration (TGA). Codeine-containing products - use in children and ultra-rapid metabolisers. Medicines Safety Update 2017;8(5):3. https://www.tga.gov.au/publication-issue/medicines-safety-update-volume-8- number-5-october-november-2017#codeine Paracetamol use in dentistry Schug SA, Palmer GM, Scott DA, Halliwell R, Trinca J, APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, editors. Acute pain management: scientific evidence. 4th ed. Melbourne: Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine; 2015. http://fpm.anzca.edu.au/resources/publications Published December 2019. © Therapeutic Guidelines Ltd (eTG December 2019 edition) Therapeutic Guidelines Limited (www.tg.org.au) is an independent not-for-profit organisation dedicated to deriving guidelines for therapy from the latest world literature, interpreted and distilled by Australia's most eminent and respected experts. © Therapeutic Guidelines Ltd https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=drugs-pain-dentistry 11/11 11/12/2019 Corticosteroids used in dentistry Corticosteroids used in dentistry Introduction to corticosteroids used in dentistry This topic covers practical information on using corticosteroids in dentistry. For comprehensive drug information, including precautions, contraindications, adverse effects and drug interactions, consult an appropriate drug information resource. For a more comprehensive discussion of corticosteroids, see Principles of immunomodulatory drug use for rheumatological diseases in adults. If prescribing a corticosteroid, consider the benefit–harm profile of the drug in the individual patient; this requires knowledge of the patient’s medical history and concomitant medications, including prescription, over-the-counter and complementary medicines. Corticosteroids are used in the management of many dental and oral mucosal inflammatory conditions. In dentistry, routes of administration of corticosteroids include: topical (on the oral mucosa) intradental (within a tooth) systemic (oral, intramuscular or intravenous administration). The route of administration should be tailored to the clinical situation. In dentistry, intradental or topical corticosteroids are preferred because they are associated with fewer systemic adverse effects, and a local effect is often sufficient. Local intraoral injection of corticosteroids is not appropriate nor recommended for dental procedures. Topical corticosteroids used in dentistry In dentistry, topical corticosteroids (eg creams, ointments, mouthwashes, sprays) are used to manage the symptoms of immune-mediated oral mucosal diseases, including conditions that present with recurrent or persistent oral ulceration. Although there is substantial clinical experience with intraoral use of topical corticosteroids, this practice is off-label and supported by little published evidence. In the general practice setting, only mild or moderate potency corticosteroid creams or ointments should be used. Potent or very potent creams or ointments, or other formulations of topical corticosteroids, should not be started without specialist advice. Table 13.6 lists the relative potency of corticosteroid creams and ointments. Prolonged or sustained use of moderate, potent or very potent topical corticosteroids requires regular monitoring. Use of these higher potency corticosteroids increases the risk of systemic absorption, either through the oral mucosa or if inadvertently swallowed. Adrenal suppression has been documented with the use of high-potency topical corticosteroids. Local adverse effects include superimposed candidiasis, mucosal atrophy, capillary fragility, telangiectasia, delayed wound healing and altered pigmentation. Predisposing factors for candidiasis include immune compromise, smoking, denture use and hyposalivation. Properties of topical corticosteroids used on the oral mucosa (Table 13.6) https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=corticosteroids-dentistry 1/3 11/12/2019 Corticosteroids used in dentistry Comparative potency Drug [NB2] Strength on oral mucosa [NB1] Suitable to prescribe without specialist advice mild hydrocortisone acetate 1% triamcinolone acetonide 0.02% moderate betamethasone valerate 0.02%, 0.05% Do not prescribe without specialist advice betamethasone valerate 0.1% methylprednisolone aceponate 0.1% potent betamethasone dipropionate 0.05% mometasone furoate 0.1% betamethasone dipropionate 0.05% in optimised vehicle very potent clobetasol propionate [NB3] 0.025 to 0.05% NB1: Topical corticosteroids are more potent when applied to the oral mucosa than when applied to the skin. NB2: All formulations in this table are available as both a cream and an ointment. NB3: Clobetasol propionate as a cream or ointment is not registered for use in Australia, but is available via the Special Access Scheme or compounding pharmacies. Use only under specialist supervision. Select a topical corticosteroid based on potency, lesion size and location, and the patient’s preference and ability to adhere to instructions. Creams are water-based and easily applied to the oral mucosa, whereas oil-based ointments may be more difficult to apply; however, patients may have a preference because of taste, texture and ease of use. The patient’s pharmacist or medical practitioner may not be familiar with intraoral use of topical corticosteroids. Provide patients with written instructions that can be shared with their healthcare practitioner to explain the practice. See Box 13.3 for instructions on application of topical corticosteroids to the oral mucosa. Patient instructions for applying a topical corticosteroid to the oral mucosa (Box 13.3) It is not necessary to dry the mucosa first. Apply a pea-sized amount of the cream or ointment to a clean fingertip, then smear a thin layer onto the affected area. Hold in the mouth for 1 to 2 minutes without swallowing, and then spit out excess. Follow the dentist’s instruction for frequency of application. Ideally, apply the corticosteroid after meals or oral hygiene practices. Although the cream will be labelled ‘For external use only’, use on the oral mucosa is safe— systemic absorption from the mouth is minimal if used as instructed. Intradental corticosteroids used in dentistry Intradental corticosteroid and antibiotic combinations can be used to manage pulp and periapical diseases, which are caused by bacteria and inflammation. Dental treatment is also required. Two forms of corticosteroid and antibiotic combinations are commercially available for intradental use —a water-soluble paste and a hard-setting cement. The form used depends on the condition being treated and where the compound is to be placed. https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=corticosteroids-dentistry 2/3 11/12/2019 Corticosteroids used in dentistry Combination corticosteroid and antibiotic pastes (eg triamcinolone with clindamycin or demeclocycline) can be used within the root canal system of a tooth (intracanal application). Pastes can be used: during endodontic treatment to reduce periapical inflammation and pain associated with irreversible pulpitis or an infected root canal system to prevent and manage several forms of inflammatory root resorption (eg internal inflammatory resorption, external apical inflammatory resorption, external lateral inflammatory resorption) to reduce external replacement resorption following tooth avulsion and intrusive luxation injuries. Combination corticosteroid and antibiotic cements typically contain other substances (eg calcium hydroxide, zinc oxide, eugenol). To prepare the cement, a powder and liquid are mixed to form a paste. The paste is placed on the dentine or exposed pulp, and sets to form a hard cement. Cements can be used: within the crown of a tooth as part of a cavity lining or base as an indirect pulp cap as a direct pulp cap as a pulpotomy agent before restoring cavities in teeth that have reversible pulpitis. Systemic corticosteroids used in dentistry Systemic corticosteroids are rarely appropriate for treating oral or dental conditions because they are associated with significant adverse effects—local applications are usually effective (see Topical corticosteroids). Systemic corticosteroids should only be prescribed by a dental specialist; indications for systemic corticosteroids include: severe postoperative swelling severe trauma periapical nerve sprouting and acute apical periodontitis following removal of acutely inflamed pulp inflammatory mucosal disease. Do not routinely use systemic corticosteroids for the control of postoperative pain and swelling. Published December 2019. © Therapeutic Guidelines Ltd (eTG December 2019 edition) Therapeutic Guidelines Limited (www.tg.org.au) is an independent not-for-profit organisation dedicated to deriving guidelines for therapy from the latest world literature, interpreted and distilled by Australia's most eminent and respected experts. © Therapeutic Guidelines Ltd https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=corticosteroids-dentistry 3/3 11/12/2019 Mouthwashes and other topical formulations used in dentistry Mouthwashes and other topical formulations used in dentistry Introduction to mouthwashes and other topical formulations used in dentistry This topic covers practical information on using mouthwashes and other topical formulations in dentistry. For comprehensive drug information, including precautions, contraindications, adverse effects and drug interactions, consult an appropriate drug information resource. If prescribing a mouthwash or another topical formulation, consider the benefit–harm profile of the drug in the individual patient; this requires knowledge of the patient’s medical history and concomitant medications, including prescription, over-the-counter and complementary medicines. Mouthwashes used in dentistry Antiseptic mouthwashes decrease the number of microorganisms in the oral cavity and can be used for periodontal disease, dental caries, and pre- and post-procedural mouth rinsing. Fluoride mouthwashes have significant benefits in patients at high risk of dental caries, but should only be used on the recommendation of a dentist. Anti-inflammatory and analgesic mouthwashes provide symptomatic relief of some inflammatory oral mucosal diseases (see Benzydamine). Lubricating mouthwashes (eg artificial salivary products, sodium bicarbonate) can provide temporary symptomatic relief of dry mouth. Alcohol-containing mouthwashes may be associated with oral cancer, and should be avoided if possible. In addition, patients with oral mucosal disease and dry mouth should avoid alcohol- containing mouthwashes because they cause profound drying of the oral mucosa. Topical antiseptics for intraoral use Overview Antiseptic mouthwashes decrease the number of microorganisms in the oral cavity. Antiseptic mouthwashes can reduce plaque formation but do not reduce existing plaque, which must be removed with mechanical cleaning. Antiseptic mouthwash is not required as part of a standard oral hygiene routine (see Oral hygiene for more information). The use of antiseptic mouthwashes in periodontal disease is controversial. They are only effective against supragingival plaque, and are not effective beyond the gingival crevice or periodontal pocket. Patients should be informed that the principal treatment for chronic periodontal disease is professional intervention with debridement of involved teeth and meticulous oral hygiene. Although they are not https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=mouthwashes-dentistry 1/4 11/12/2019 Mouthwashes and other topical formulations used in dentistry appropriate as the sole treatment for periodontal disease, antiseptic mouthwashes can be beneficial in some circumstances (eg for short-term use in patients with gingivitis or necrotising gingivitis when inflammation restricts normal toothbrushing). Chlorhexidine Chlorhexidine is bactericidal and fungicidal, and has activity against some viruses. Chlorhexidine adsorbs onto oral surfaces so is effective over a prolonged period. It prevents plaque formation on a clean tooth surface, but does not reduce pre-existing plaque. Intraoral chlorhexidine formulations include mouthwash (as chlorhexidine gluconate in concentrations of 0.12% and 0.2%), gel and a slow-release formulation for local delivery into periodontal pockets. It was previously thought that chlorhexidine mouthwash was inactivated by the detergent sodium lauryl sulfate used in standard toothpaste; however, research has shown this is not the case. Although it is unlikely that there is an interaction between sodium lauryl sulfate and chlorhexidine gel, further evidence is required to confirm this. Chlorhexidine can cause skin reactions, irritate mucosal surfaces and interrupt wound healing. Intraoral use can cause a burning sensation, altered taste and increased calculus formation; it can also cause brown discolouration of the teeth, tongue, buccal cavity and margins of dental restorations. Extrinsic staining is not permanent and can be professionally removed from the teeth. Chlorhexidine is usually recommended for short periods of up to 2 weeks to minimise adverse effects. Chlorhexidine allergy has been reported, sometimes so severe as to be life threatening. If a patient reports a history of allergy to chlorhexidine, it must be avoided via all routes of administration, including topical application. Hydrogen peroxide Topical hydrogen peroxide has antiseptic properties. Short-term use of low-concentration hydrogen peroxide mouthwash (eg 1.5%) does not adversely affect the hard or soft tissues of the mouth. However, higher concentrations (eg 30 to 35%), such as in tooth-bleaching products, can cause mucosal burns. Reversible hypertrophy of the papillae of the tongue can occur with continued use of hydrogen peroxide mouthwash. Other topical antiseptics Cetylpyridinium chloride is a quaternary ammonium compound with surfactant, detergent and antibacterial properties; intraoral formulations include mouthwash, gargle and lozenges. Some formulations combine cetylpyridinium chloride with a local anaesthetic or an anti-inflammatory. Povidone-iodine has antibacterial, antifungal and antiviral properties; intraoral formulations include mouthwash and gargle. Povidone-iodine can cause irritation of skin and mucous membranes. It is absorbed through damaged skin so application over a large area of broken skin is not recommended. Povidone-iodine should not be used during pregnancy or lactation because it can cause hypothyroidism in the neonate. Mouthwashes containing essential oils (eg eucalyptol, menthol, thymol, methyl salicylate) have been found to have antiseptic properties and reduce plaque formation, but there is limited independent evidence of benefit. Triclosan is not recommended. https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=mouthwashes-dentistry 2/4 11/12/2019 Mouthwashes and other topical formulations used in dentistry Topical intraoral benzydamine Benzydamine is a nonsteroidal anti-inflammatory drug (NSAID) with analgesic properties, used for temporary relief of painful inflammatory oral mucosal conditions. Benzydamine formulations include mouthwash, intraoral gel and spray, in concentrations of 0.15 to 1%. Some formulations combine benzydamine with an antiseptic. Local adverse reactions of benzydamine, such as numbness, burning, erythema and rash, have been occasionally reported. Systemic adverse reactions are uncommon. Topical remineralising agents Fluoride Fluoride significantly reduces the incidence of dental caries. Topically applied fluoride promotes enamel remineralisation through the formation of fluoride-containing apatites (eg fluorhydroxyapatite, fluorapatite), which are more resistant to future acid challenge than the carbonated hydroxyapatites of normal tooth enamel. Fluoride ions have an antimicrobial effect at very high concentrations. Formulations with a low pH (eg acidulated phosphate fluoride) also have some antimicrobial activity. Fluoride formulations include toothpaste, mouthwash, gel, foam and varnish. The recommended concentration of fluoride toothpaste varies according to age and risk of dental caries (see Fluoride). Casein phosphopeptide–amorphous calcium phosphate Casein phosphopeptide–amorphous calcium phosphate (CPP-ACP) contains bioavailable calcium and phosphate ions, which combine with fluoride to promote enamel remineralisation. CPP-ACP formulations include sugar-free chewing gum, paste and varnish, some of which also contain fluoride. Avoid CPP-ACP in patients with allergies to milk proteins. For more information on the use of CPP- ACP for dental caries, see here. Key references Araujo MWB, Charles CA, Weinstein RB, McGuire JA, Parikh-Das AM, Du Q, et al. Meta-analysis of the effect of an essential oil-containing mouthrinse on gingivitis and plaque. J Am Dent Assoc 2015;146(8):610–22. Boffetta P, Hayes RB, Sartori S, Lee YC, Muscat J, Olshan A, et al. Mouthwash use and cancer of the head and neck: a pooled analysis from the International Head and Neck Cancer Epidemiology Consortium. Eur J Cancer Prev 2016;25(4):344–8. Boyle P, Koechlin A, Autier P. Mouthwash use and the prevention of plaque, gingivitis and caries. Oral Dis 2014;20 Suppl 1:1–68. Brayfield, A, editor. Martindale: the complete drug reference. 39th ed. London: Pharmaceutical Press; 2017 Elkerbout TA, Slot DE, Bakker EW, Van der Weijden GA. Chlorhexidine mouthwash and sodium lauryl sulphate dentifrice: do they mix effectively or interfere? Int J Dent Hyg 2016;14(1):42–52. https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=mouthwashes-dentistry 3/4 11/12/2019 Mouthwashes and other topical formulations used in dentistry Farah CS, McIntosh L, McCullough MJ.. Mouthwashes. Aust Prescr 2009;32(6):162– 4. https://www.nps.org.au/volumes/32/issues/6. Haas AN, Wagner TP, Muniz FW, Fiorini T, Cavagni J, Celeste RK. Essential oils-containing mouthwashes for gingivitis and plaque: Meta-analyses and meta-regression. J Dent 2016;55:7–15. James P, Worthington HV, Parnell C, Harding M, Lamont T, Cheung A, et al. Chlorhexidine mouthrinse as an adjunctive treatment for gingival health. Cochrane Database Syst Rev 2017;3:CD008676. McCullough MJ, Farah CS. The role of alcohol in oral carcinogenesis with particular reference to alcohol-containing mouthwashes. Aust Dent J 2008;53(4):302–5. Serrano J, Escribano M, Roldan S, Martin C, Herrera D. Efficacy of adjunctive anti-plaque chemical agents in managing gingivitis: a systematic review and meta-analysis. J Clin Periodontol 2015;42 Suppl 16:S106–38. US Food and Drug Administration (FDA). FDA drug safety communication: FDA warns about rare but serious allergic reactions with the skin antiseptic chlorhexidine gluconate. Silver Spring, MD: FDA; 2017. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-warns-about-rare-serious- allergic-reactions-skin-antiseptic Van Leeuwen MP, Slot DE, Van der Weijden GA. Essential oils compared to chlorhexidine with respect to plaque and parameters of gingival inflammation: a systematic review. J Periodontol 2011;82(2):174–94. Published December 2019. © Therapeutic Guidelines Ltd (eTG December 2019 edition) Therapeutic Guidelines Limited (www.tg.org.au) is an independent not-for-profit organisation dedicated to deriving guidelines for therapy from the latest world literature, interpreted and distilled by Australia's most eminent and respected experts. © Therapeutic Guidelines Ltd https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=mouthwashes-dentistry 4/4 11/12/2019 Dental caries Dental caries Pathology and diagnosis of dental caries Dental caries (tooth decay) is a pathological process resulting in localised destruction of tooth tissue. Dental plaque (a complex biofilm of mixed bacteria and their by-products) is a prerequisite for dental caries development. Frequent exposure to dietary sugar and carbohydrates leads to an increase in the population of cariogenic bacteria in the biofilm. Cariogenic bacteria produce organic acids, which lower the pH of the biofilm, resulting in enamel demineralisation (loss of carbonated hydroxyapatite). Figure 13.2 and Photo 13.1 show the stages of dental caries. Stages of dental caries (Figure 13.2) Diagram showing dental caries and its sequelae 1. carious ‘white spot’ 2. initial cavity 3. large cavity involving the pulp 4. periapical abscess https://tgldcdp-tg-org-au.salus.idm.oclc.org/viewTopic?topicfile=dental-caries 1/8 11/12/2019 Dental caries Early carious lesions and cavities (Photo 13.1) Early carious lesions present as white spots on the tooth that have a relatively intact surface. Early diagnosis of carious lesions maximises the opportunities for their arrest and reversal. They can be accurately assessed and monitored by either traditional methods (eg visual and radiographic techniques), or newer technologies involving laser and light-induced fluorescence. Continued subsurface demineralisation leads to cavitation. If untreated, cavitation gradually progresses through the enamel and dentine towards the dental pulp, leading to: pulpitis pulp necrosis infection of the root canal system apical periodontitis periapical abscess (see Localised odontogenic infections) spreading odontogenic infection. https://tgldcdp-tg-org-au.salus.idm.oclc.org/vie

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