eTG Oral and dental guidelines

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Welcome to this Australian Prescriber podcast. I'm Dr Justin Coleman, a GP on the Tiwi Islands, just one cyclone's width north of Darwin. And my knowledge of today's topic consists of the fact that I'm related to three dentists, one of whom is my dentist. So if I inadvertently poke fun at that profession, it's not at you my dear dental listeners, it's at him.

So we're here to talk all things teeth and we may drift laterally into some nearby soft tissues at some point. And we're talking today about the Therapeutic Guidelines’ Oral and Dental new edition that has come out. And with me, I have Dr Lee Fong, and Lee is a GP in Newcastle. He's also on the review panel for the Oral and Dental guidelines, the eTherapeutic Guidelines. And he has only a slightly better qualification than myself in that he's the actual son of a dentist. So welcome to the podcast, Lee.

Thank you very much for having me.

It's a delight to have you and it's nice in some ways to be talking to another GP, in the sense that I suspect neither you nor I will have the depth of knowledge of a dentist. So we can ask each other all sorts of questions which GPs like to ask.

Absolutely.

We'll be covering things like acute dental pain and infections and maybe moving wide of the teeth, looking at tongue and gum diseases and teething pain in children and then if we get time, a little about surgical antibiotic prophylaxis. All these topics are some of the new and changed things in the new guidelines, so we wanted to bring your attention to them. But we'll start with probably the most common thing that I see on the Tiwi Islands, which is acute dental pain. And of course we should preface nearly every single answer to every one of these topics by, if pain persists, see your dentist.

So I think it's understood by GPs that if people have things going wrong in their mouth, they really should see a dentist who have more experience than we do and also lots of sharp instruments to do stuff about it that we can't. But let's face it, it's not often easy to get to a dentist if you live on a small island, it's particularly hard, where there's no dentist here and so we GPs are left holding the can for at least some time. And then there's of course financial and waiting list access to dentists as well, which can be a problem for our patients. So talking about acute dental pain, what sort of analgesics are recommended? What can we do about someone who presents to us with toothache?

Well, the most common sort of pain when it comes to dentistry is inflammatory. So usually the use of an anti-inflammatory medication is the go. One thing that I learnt from being on the panel, I was surrounded by a who's who in the dental world of Australia I think, the combination of an anti-inflammatory with paracetamol being used concurrently is essentially the first line when it comes to analgesia.

And I think opioids, which often we are asked to prescribe, really don't seem to have such a strong role in dental pain.

No. And there was quite a strong emphasis really on trying to hold back on opiates as much as you can. For very strong dental pain, then there may be an indication. But certainly the recommendation is to limit it, both in terms of dose and duration. So one suggestion, for example, with oxycodone, was to try and hold it to no more than three days.

Okay. And the pain is often of course due to an infection, things like root canal infections. Obviously again, the proviso applies, see your dentist as soon as possible, but what sorts of things in addition to pain relief should or could we be doing in that situation? And I guess in particular, we're thinking to do or not to do with the antibiotics?

Well, I might just preface the answer by saying for us GPs, when we're looking at dental problems, the fantastic thing about the new guidelines is that there is a specific chapter for us, which is actually called, Triaging Dental Presentations for Medical Practitioners. And it's just got a list of all the things that we would commonly encounter, one of which is acute dental pain. If you go to that subheading, then it will then take you to another fantastic table, which is a guide to differentiating and managing acute dental pain. And it's a brilliant table where it's like a dummy's guide to dental plan essentially, where it divides types of presentation of pain into the common causes depending on the symptomatology. And then it has the initial management that we could provide as medical practitioners. And then a little bit of a hint about what the dentist will do once they get their hands on the patient.

So for example, the first thing on the list is if you have intermittent dental pain, when you have a tooth that's exposed to a stimulus, it could be hot or cold, sweet foods or drinks, but it's a pain that after the stimulus has taken away, the pain resolves. So the likely cause of that is reversible pulpitis, the initial management, well, number one, avoid any food or drink that causes the pain. And here's an interesting thing to come next, if there's an obvious cavity then stick an inert material on it and that can be chewing gum or even, and this was a new one for me, Blu-Tack. I presume that you're not going to swallow the Blu-Tack.

That is a wonderful thing. I happened to have published a tip many years ago. I used to do a GP tips column in a medical newspaper on using Blu-Tack for just such a thing. And before I published it, I actually Googled what happens if you swallow Blu-Tack because I did think I didn't want to really harm people. And it turns out that there's been plenty of volunteers subjects who have swallowed Blu-Tack, Lee, and they've all lived to tell the tale. I think it eventually goes through the motions and seems to come at the other end without causing too much damage. So I did know about the Blu-Tack and in fact, it's probably more readily available these days than chewing gum. Chewing gum sort of peaked in the 1960s in American baseball players and I think it's gone downhill ever since, hasn't it?

It might well have. But certainly if it comes to reversible pulpitis, those are some of the options. Specifically it notes that when you have this pain that comes and it goes after exposure to a stimulus, then antibiotic therapy isn't actually indicated and in fact analgesia isn't really indicated either. I guess it's because you have a pain that's there and then it goes, and so trying to take something for it prophylactically doesn't really work so well, so essentially that just needs to be seen by a dentist.

On the other hand, if you have a severe dental pain that's experienced after exposure to a stimulus, but then persists as a dull throbbing type ache after the stimulus is removed, then that's a different kettle of fish and then you're moving into probably irreversible pulpitis. At that point, you're starting to think you do need some sort of analgesia, you throw the anti-inflammatory at them, still going to use your Blu-Tack or your chewing gum, but still at this point, antibiotic therapy is not indicated. Even though when they go and see the dentist, they're quite likely to need an extraction or some sort of root canal treatment.

The next sort of level is when you have a dull ache and it's just there and it's not triggered by stimulus, it's just there, might get worse when you bite on it and then you've probably got an infected root canal system. You're still sticking with the anti-inflammatories, but if the infection remains localised and the definition of localised is that you don't have any systemic features and you don't have any facial swelling, then you still don't need antibiotic therapy for the patient, if they're going to be seen by a dentist within 24 hours. If it's going to be more than 24 hours though, then the antibiotic therapy is a reasonable thing to do.

Oh, that's interesting because I would say by far the majority of my patients really for the most of my career, really wouldn't have had the chance to see a dentist within 24 hours. So even if there is no fever and no swelling, you're still saying it's a reasonable thing to at least consider an antibiotic in that instance?

That's right. So even if it's localised, so again, you don't have the facial swelling, you don't have the systemic features, but if they're not going to see a dentist within 24 hours, then it's a reasonable thing to do. If there are systemic features clearly, or there are indications that it isn't localised, so you have the facial swelling, then it is very reasonable to start antibiotic therapy.

And just to recap, for those of us who can't quite remember, what antibiotics are first line in this instance?

It's metronidazole, plus either penicillin or metronidazole plus amoxicillin or Augmentin.

Well I can tick that down as something I have definitely learned so far on this podcast. We'd better move on though. So let's look away from the teeth and look at oral mucosal diseases. And I notice there's a reorganised and expanded chapter in the guidelines and also, very helpfully, some photos to aid recognition of common conditions because they can be difficult to differentiate. And there's a list of red flag features for oral lesions that warrant further referral to a specialist. What are some of those red flags, Lee?

So there's a long list. Just as an example, oral ulcers that have lasted for more than a couple of weeks, ulcers that recur, pigmented lesions. The thing that Therapeutic Guidelines has done is to make it pretty easy though and sort of say, "Look, there's some things that you can manage, we can manage as GPs, some things that you shouldn't be managing and you really should be referring off." And that's everything that's really in the red flag list. For the things that we can manage, there's a great little list of a description of them, pictures and what do we do about it. So it makes it really clear and keeps it very simple, which I like.

And those sorts of things would be presumably something like oral thrush?

Yes. Oral thrush, recurrent aphthous ulcerations, oral mucositis. Probably the thing that I picked up was to use on aphthous ulcers, just grabbing some hydrocortisone 1% cream is perfectly fine and just whack some of that on. So I love that as a tip.

Oh gosh. Okay. I no longer have to tell people putting on their lips to try to avoid swallowing the stuff, if you're allowed to put it in their mouth. So that is quite interesting. One of the other situations we see fairly regularly as a GP is someone who's had a tooth extraction or some sort of oral surgery the day before and they find it hard to get back into their dentist because they're a long way away or they're booked out or something. So I see there's a section on local non-pharmacological measures that we can do for some of these things fairly simply. What's in there?

Yeah, that's right. Well probably the first thing to note is that after oral surgery, like an extraction for example, you can expect that swelling and pain is going to increase in the first 48 hours. And in fact it may take 72 hours to reach a peak. So an increase in pain is pretty normal. That's the first point to make. The second point is that the incidence of infection after oral surgery is actually surprisingly low. And even when it comes to things like pulling out wisdom teeth, I think the proper term now is third molar extraction, but even for those, the incidence of infection is under 5% so running about 2 to 5%. So infection is actually a pretty unlikely thing.

The suggestion then is a lot to do with reassuring the patient. If you're confident there's no significant complications that are happening. Local measures you can take include using a cold compress intermittently 20 minutes at a time for the first 24 hours. You can rinse your mouth gently with warm saline, you can use non-opioid analgesics, anti-inflammatory, for example, plus paracetamol. And if in doubt you can get in touch with the dentist that did the procedure.

Yeah, that certainly all makes sense and I think it is something we fairly regularly face in general practice. So that's good advice. Another thing we see a little is people coming in with dry sockets, they've had an extraction and the extraction goes just fine, but then a couple of days later they come in, in a lot of pain. What's the treatment for that?

So yeah, look, it's relatively not an uncommon presentation, so it occurs with about 5% of tooth extractions. So you get pain in and around the extraction socket, it's increasing for one to four days after the extraction. So the way you recognise it is by seeing disintegrated clot within the socket and often there's a bit of a smell associated with it as well. Probably the main point to make is that there is no place for antibiotic therapy. So it's not an infection, antibiotics aren't going to help. It's going to sort itself out essentially over two to three weeks. The main thing to do is irrigation of the socket with warm sterile saline, to get rid of all the debris that’s stuck in there and non-opioid analgesics, again, the anti-inflammatory plus paracetamol. And a dressing that could be applied by the dentist.

Looking at teething pain in children, something a bit out of left field, there's a new section added which also talks about tooth eruption. For teething pain, the age-old remedy has been, if you're not into wearing an amber necklace, which I still feel cannot possibly work for anyone, the traditional thing to use is a teething gel. What's happened there?

So the recommendation is not to use teething gels now. There's apparently a lack of evidence really as far as efficacy and concerns about potential for harm. So some teething gels, for example, contain salicylates and that can cause systemic toxicity. Also, some of them contain local anesthetics and you can certainly get adverse effects with those as well. In extreme examples, seizures, cardiac effects and death. The amber teething necklaces, they're basically thought to be a choking and a strangulation hazard, so not recommended either. And so it comes back to rubbing the gums with a ‘clean’ finger, definitely has to be a clean finger, teething rings and cold compresses. And a quick note on the teething rings, they should be cold but not frozen. Oh, and of course paracetamol.

So Lee Fong, what do we do when someone comes to us and they've knocked their tooth out at a game of footie or playing ultimate frisbee and they have an avulsed tooth, what's the basic first aid for that?

So when it comes to a tooth that is missing, there's a few things to consider. The first one is that if it's a baby tooth, you shouldn't whack it back in. And so there's a bit of a guide in Therapeutic Guidelines to help you distinguish between a primary tooth, a baby tooth, and a secondary tooth. So that's the first thing. The second thing is it's really all about what they call the periodontal ligament. I hope I pronounced that correctly. So it's the bit in the root. You really want those cells to survive. And that's essential if the tooth is going to have the best chance of reimplantating without complications and hanging around for a few more years.

So the suggestion is if the tooth is dirty, then give it a bit of a rinse with milk or saline, don't scrub it, don't rub it, and then pop it back into the socket. The sooner you get it back in, the better it's going to be, the greater the chance of it sticking. Within 15 minutes is fantastic. If you get it back in straight away for whatever reason, then you can preserve those cells of the periodontal ligament, in milk. If you pop the tooth in milk for up to six hours, that's dairy milk. And so most sporting clubs nowadays have a tub of Tetra Pak milk that they keep exactly for that purpose.

If you don't have any milk, you can just grab some plastic wrap, get the person who's lost their tooth to spit into it and then pop the tooth into that and wrap it up. You get maybe an hour out of that, but certainly it's better than nothing. And another thing is, after you pop the tooth back in, you can put a temporary splint on to hold the tooth in position. If you've got some aluminium foil, that works really well, a bit of Blu-Tack, that'll work as well and then ask the patient to bite down and keep it in position.

Very good. Does the same apply if you have a bit of a chip off your tooth, how carefully do you need to guard that?

So if you've had some damage to the tooth as opposed to a completely avulsed tooth, it depends a bit on the degree of damage to the tooth. So if you've got exposure of dentine only, so in other words, that thing we talked about before, reversible pulpitis, if you have exposure to a stimulus, hot, cold, sweet and it hurts and then you remove the stimulus, then the pain goes away, then you don't really need to do very much. Just ask the patient to go and see the dentist as soon as possible. No antibiotics, not even really analgesia. On the other hand if there's exposure of the pulp and the way that you will know that is that you'll probably see like a little red dot, a little bit of soft tissue in the area of the fracture or within the cavity and then we're looking at more like irreversible pulpitis, in other words, severe pain that persists even after you remove the stimulus. Then that needs much more urgent dental treatment, preferably within 24 hours to prevent further damage or infection of the tooth.

Thank you very much for that. I'm talking with Lee Fong, a GP from Newcastle. And let's finish now looking at anything new around surgical antibiotic prophylaxis because I think that section has been updated and like most sections involving antibiotics, it's a fairly rapidly evolving field as evidence comes to light. So what's the latest on prophylaxis for surgical procedures?

The one-line summary is surgical antibiotic prophylaxis is rarely indicated for dental procedures. Which is kind of, I have to admit, when we have patients that come to us, so often they seem to say that they need antibiotics because the dentist has said they need it or they assume the dentist has said they're going to need it. But when we have a look at what the recommendations are, there's this great table in the guidelines now where it has a list of procedures and they are tooth extraction, wisdom teeth removal, procedures involving insertion, dental implants, periodontal surgery, soft and hard tissue removal, and next to that it says, "Is surgical antibiotic prophylaxis indicated?" And in big capital letters it has, NO.

Underneath that there's one more type procedure which is oral maxillofacial procedures and then you might have some exceptions. And then the third thing that's listed is dental procedures not listed above, "Is surgical antibiotic prophylaxis indicated? And again in be capital letters, NO.

That's a table even I can follow I think.

So, just a little caveat to that is for people who are profoundly immunocompromised and invasive dental procedure is needed, then it probably is worth just checking with the treating specialist to see whether or not prophylaxis may be required.

Lee Fong, it's been a pleasure talking to you, not least because you hardly used any words which I didn't understand, which I don't think is the case if I was talking to an expert dentist. Thank you so much for talking to us. You're currently holidaying in Japan, so that's twice the difficulty, but we very much appreciate it. Thanks for your input today.

You're very welcome.

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My guests’ views are their own and don't represent Australian Prescriber and my views are certainly all mine.