Charlotte Currie, Clinical Fellow in Oral Surgery, takes a look at the current evidence on why patients often resort to self-medication with painkillers, and encourages dentists to be on the look-out for patients who might be at serious risk of overdose.
Anyone who has suffered with toothache will appreciate the pain intensity associated with a diagnosis such as symptomatic irreversible pulpitis or apical periodontitis, yet patients, and in particular, problem orientated dental attenders, can often live with this pain for a long period of time before seeking dental care.
Therefore it is any wonder that they understandably resort to attempted self-care, for example over the counter pain relief and in extreme cases attempting to extract their own teeth?
Analgesic usage for dental pain: what’s the problem?
Unfortunately dental pain is amongst the most common causes for hospital admission due to unintentional analgesic overdose, particularly with paracetamol. Patients taking paracetamol for dental pain are over ten times more likely to overdose compared to patients using paracetamol for other acute pain conditions.
In addition, patients who are admitted to hospital with unintentional paracetamol overdose have been shown to have an increased mortality compared to intentional overdose, the exact reason for this is disputed, but could be due to delayed presentation, the staggered pattern of overdose, or a delayed diagnosis.
Ask your patients about pain relief used for toothache
For this reason it’s vitally important that dentists consider possible analgesic overdose in patients attending with acute dental pain. In the early stage of a paracetamol overdose the patient will be asymptomatic, and therefore may not realise the potential harm and the need to seek urgent medical care.
Equally because they are feeling generally well, other than their current toothache, they may not inform their dentist of the number of analgesics they have taken. It would be very prudent, therefore, for dentists to actively question as part of the medical history process about the pain relief patients have used.
Specifically they should focus on how often they have used it and for how long they have used it. If this questioning does not occur a potential overdose could be missed until the patient develops symptoms which can take up to 24 hours from the overdose.
Unable to access emergency dental care?
The reasons why patients delay seeking care for acute dental pain are currently unknown, however in those patients admitted with unintentional paracetamol overdose the majority were unable to access emergency dental care in a timely manner.
This raises the question of why could they not access the care they needed? Is it that we need more commissioning for urgent dental care, or perhaps patients need better signposting to the services that are already available?
Why do dental patients overdose on painkillers?
The other question that needs definitive answers is why do dental patients overdose on analgesics? Is it because of confusion over brand names and combinations of different types of analgesics in some brands?
Or is it because of the pain intensity and patients feeling the need to take more analgesics in an attempt to combat this? Either way we clearly need to be looking to identify the reason for unintentional overdose and providing appropriate interventions to prevent it, for example patient education in this area.
Regulations on sales of paracetamol have been introduced by the MHRA in 1998 to reduce paracetamol pack sizes, and again in 2009 to limit the number of packs possible to purchase. The 1998 measures have reduced the number of deaths associated with paracetamol overdose, however appear to have had no effect on the number of hospital presentations for non-fatal paracetamol overdoses.
How can dentists help improve patient care?
But the key question remains unanswered: why do dental patients overdose on analgesics? And, why do they delay seeking dental care for toothache? Is it just to do with access to urgent care, or is there more to it than that?
It’s vitally important that we try to answer these questions to improve patient care and reduce their risk of adverse events such as unintentional overdose and other serious consequences of delayed presentation such as infection leading to hospital admission, which is also increasing.
In the meantime it would be highly advisable to ask patients presenting for urgent dental care about their analgesic use in order to identify potential unintentional overdose.
A useful guide is available from the British National Formulary’s Emergency Treatment of Poisoning and will help dentists to identify those at risk and then refer them on appropriately to A&E.
Clinical Fellow in Oral Surgery, Newcastle University, School of Dental Sciences
Campaigning for better oral health
The BDA campaigns on a range of issues for better working lives for dentists and we work to improve the oral health of the nation.
Find out more about our work on sugar and children’s oral health, teeth whitening, antibiotic prescribing, and oral cancer.