#423 Dental Pain, Caries, Gingivitis, and Oral Care Tips & Tactics for Primary Care With Dr Lisa Simon

January 22, 2024 | By Kate Grant

Audio

Video

Transcripts available via YouTube

Join Lisa Simon, MD, DMD (@lisathedoc) as we discuss dental care for the PCP- from examination techniques, treatment options, emergencies in dental care, and general dental advice.  Help your patients manage caries, gingivitis, dry mouth, and temporomandibular joint (TMJ) dysfunction.  Be aware of dental side effects of medications, how to manage anticoagulants during dental procedures, and when to recommend antibiotic prophylaxis. 

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Show Segments

00:00 Introduction and Overview

09:13 Diagnosing Dental Pain and Examination Techniques

18:44 Treatment Options for Dental Pain

29:34 Complications and Emergencies in Dental Care

32:36 Post-operative Care and General Dental Advice

40:35 Dry Mouth and Treatment Options

44:05 Gingivitis

49:39 Temporomandibular Joint (TMJ) Dysfunction

55:43 Medications and Dental Side Effects

56:12 Anticoagulants and Dental Procedures

01:00:55 Endocarditis Prophylaxis

01:03:15 Joint Replacements and Antibiotic Prophylaxis

01:04:10 Oral Health in Patients with Opioid Use Disorder

Dental Pain, Caries, Gingivitis, and Oral Care Tips & Tactics for Primary Care- Pearls

1. Dental care is difficult to access for many patients due to lack of providers and high out of pocket costs, so even though PCPs are not well trained in dental care, it is important to know some basics.
2. PCPs should feel comfortable offering short term symptom relief options for dental pain including local anesthesia, pain medications (such as NSAIDS and acetaminophen), and antibiotics.  
3. Complications and emergencies of dental infections, such as Ludwig’s angina and cavernous sinus thrombosis, require immediate medical attention.
4. Preventative dental care includes maintaining good oral hygiene, avoiding sugar-sweetened beverages, and being mindful of medications that can cause dry mouth.
5. Dry mouth can be managed with lifestyle changes, saliva substitutes, sugar-free candies, and, in severe cases, cholinergic medications.

Approaching Dental Concerns in Primary Care

Primary care providers typically do not receive training in oral health, but it is important to have a basic approach to addressing patients’ dental concerns.  Smiles for Life is a great resource for providers to dive deeper.

Encourage patients to find a primary dental care provider, but be aware, dental insurance is different from medical insurance.  Dental insurance is more often like a discount plan- coverage is limited and may have high out of pocket costs.  For example, Dr Simon suggests that most dental insurance will cover the cost of an extraction, but a root canal may cost  thousands of dollars.  Acknowledge the high cost and limited access to dental care, especially for patients with financial constraints.  Consider looking into what is covered in your state under Medicaid as it will differ by location.

Basic Differential for Dental Pain

Gingivitis is inflammation of the gums, which can be asymptomatic or uncomfortable but doesn’t cause deep tooth pain.   Since the gums do not attach the teeth to the bone, gingivitis will not make teeth loose or fall out.  However, gingivitis can be a precursor to worsening dental disease like periodontitis. 

The basic tooth anatomy includes: enamel, the outer layer of tooth which is stronger than bone, dentin, the inner layer which is stronger than bone but not as strong as enamel, and pulp or the neurovascular bundle, the deepest layer, which transmits pain.

Tooth enamel and dentin is attacked by acid in the mouth, breakdown of this can cause cavities.  Only superficial damage to the enamel and dentin can be fixed with a filling.

Periodontitis is deeper inflammation around the base of the tooth which can cause bone loss, tooth loosening, and a space can develop which can predispose to abscess.  This deeper damage is what causes severe tooth pain as the nerve root gets involved (Stephens 2018).

Examination of the Teeth by the PCP

• Start with your medical skills- think about the vital signs, is the patient sick or not sick?
• When examining the mouth, use a good light source.  Open the lips fully- look for broken teeth, obvious dental decay
• Warn the patient that this may elicit pain.  Palpate the gingiva around the tooth to check for tenderness and swelling.  A  sinus tract or fistula is a potential indicator of chronic or subacute tooth infection.       
• Tap the individual teeth to identify the localized source of the problem
•  Gently move the tooth to check for mobility.

Workup

Dr Simon recommends that we skip testing for a stable patient.  Checking a CBC or getting a CT of the mouth is unlikely to change management, and likely a dentist will order their own dental xrays in office anyway.

Acute Pain Relief for Dental Disease 

Dental pain suggests the infection is in the pulp of the tooth (the neurovascular bundle), meaning damage is already deep and a definitive treatment is a tooth extraction or a root canal.  Antibiotics and analgesia will provide short-term term relief, but without source control, it is likely that the infection will persist and the pain will recur.  Dr Simon encourages us to appreciate that there is limited access to dental care due to availability of dentists and high out of pocket costs, so many patients struggle to access definitive care.

• Dr Simon suggests that a dental block can provide immediate pain relief.  2% lidocaine injection with a 25 to 27 gauge needle directly into the root of the identified tooth.  (Don’t inject into an abscess).  
•  Short-term analgesia typically 800mg ibuprofen three times daily  with acetaminophen 1g 3-4x daily is appropriate. 
•  Typically patients do not need opioids to manage dental pain, but if a patient with chronic pain is  already on opiates, Dr Simon recommends using your clinical judgement if increasing the opioid dose for a short time may be appropriate.
• Small amounts of topical anesthetics like benzocaine can be relieving.
• Dr Simon recommends PCPs feel comfortable prescribing antibiotics for palliative/pain relief while waiting to see a dentist for definitive treatment.   She finds a course of antibiotics- while not definitive/does not get source control of the infection, does reduce inflammation and can give a good 4-6 weeks of pain relief.  Penicillin VK QID and amoxicillin are first line.  Clindamycin should be used for truly penicillin allergic patients due to clostridium difficile risk.  (Lockhart 2019)

Dental societies recommend against antibiotics for dental pain, but Dr Simons highlights that these guidelines are aimed at dentists who are in a position to provide definitive solutions (ADA 2019).  However, as a primary care provider, antibiotics are an appropriate form of harm reduction while the patient finds a dentist.  

Dental Emergencies

Identify patients as sick/not sick by looking for systemic inflammation (fever, tachycardia, respiratory distress, etc) and initiate supportive care and antibiotics.  Look for facial swelling, redness that suggests a spread from the dental abscess into the skin.  Be aware of rare life threatening complications of dental infections that spread through fascial planes:

·       Ludwig’s angina – streptococcal infection and swelling which can spread around the airway.  Look for respiratory distress, tripoding posture, trismus, and a typical bullfrog face appearance.  This can be a surgical airway emergency (Kawataki 2021).

·       Cavernous sinus thrombosis – an infection typically arising in the canine teeth which have the longest roots so the infection can ascend intracranially causing neurologic deficits.  Look for flattening of the nasal labial folds and difficulty with eye-opening (Bali 2015).

Post Dental Extraction Care/Dry Socket

“Dry socket”  is a complication of tooth extraction that can cause severe pain.  Typically patients will describe worsening pain 3 to 4 days after an extraction.    This occurs if the clot falls out of he extraction site, exposing the underlying bone.   Pain can be severe, and antibiotics are not the treatment.  Temporarily, the PCP can pack the defect with iodinated gauze and then direct them back to a dentist.  Patients should be advised not to rinse out the clots after an extraction (Mamoun 2018).

Preventative Dental Self-Care

• Avoid tobacco
• Avoid sugary sweetened beverages
• Dr Simon’s expert opinion is that non-sugary carbonated drinks eg seltzer or carbonated water are low risk for caries. 
• Regular tooth brushing and flossing make the most difference to removing food from the teeth, and have the most impact on reducing risk of caries.
• Dr Simon’s expert opinion is that mouthwash is not essential and can be regarded as personal preference.
• Whitening strips temporarily make the teeth more porous and likely to absorb any stains from coffee or red wine.

Dry Mouth

The tongue can look dry and sometimes shiny with loss of papilla.  Reduced saliva in the mouth puts the patient at risk of caries.  The typical appearance is tooth decay at the base of the teeth. 

Risk factors include:

• Smoking
• Age
• Medications/Polypharmacy: higher risk of dry mouth in patients taking antihistamines, anticholinergics, and multiple medications in combination. De-prescribe if possible.
• Comorbidities like Sjogren’s Syndrome

Management of dry mouth includes frequent sipping of water, artificial saliva as gels or rinses, and sucking sugar-free candy to elicit more saliva flow (Gonsalves 2008).

Gingival Disease

Inflammation of the gums (gingivitis) will typically improve with improved dental hygiene.  

There is an association with increased estrogen status such as pregnancy or puberty.   Combined oral contraceptives (with estrogen) do not seem to increase gingivitis risk (Taichman 2005).

Vincent’s angina or “trench mouth” is an acute polymicrobial bacterial infection of the gums. It is a rare condition, associated with prolonged poor oral hygiene.  The patient is typically systemically unwell with severe pain. It is treated by antibiotics (Karr 1919)

 Gingival hyperplasia is simply hypertrophic tissue.  It is not painful.  It can be associated with nifedipine and other calcium channel blockers or anti-epileptic drugs.  The treatment is  to stop the medication and the gums may recede.  Gums can be excised by an experienced dentist or oral surgeon if continuing on medication is essential (Lafzi 2006).

Temporomandibular Joint Pain (TMJ Dysfunction)

The TMJ joint has two compartments and allows the jaw to slide forwards and backwards, as well as opening and closing. There is a cartilaginous disc in the middle. Patients often complain of pain in the joint area but pain can radiate to the ear or muscles of mastication.  Palpate for muscle tenderness in temporalis, masseter and pterygoids.  Acknowledging the patient’s discomfort and using simple management is usually best (Matheson 2023).

Treatment options:

• Consider a bite guard, not everybody tolerates them, but they can give a night-time resting position that provides pain relief.   Dr Simon suggests just trying the inexpensive over the counter bite guard first to see if it’s reasonably tolerable for the patient, before they consider purchasing an expensive one from their dentist.
• Heat or Ice
• Dr Simon recommends exercises to progressively stretch the muscles, aiming to increase mouth opening from two finger widths to three finger widths.
• Soft diet can help
• TMJ surgery is similar to arthroscopy is a last resort

Potpourri of Dental Questions

Bisphosphonates

Osteonecrosis of the jaw (ONJ) is a rare condition, which has an increased associated risk with intravenous bisphosphonates given to oncologic patients at high doses for bony metastases as compared to oral or IV bisphosphonates used for osteoporosis.  Development of ONJ is also associated with higher risk dental procedures such as extraction/surgery.

If possible, complete needed dental extractions prior to initiating bisphosphonates, but if this is realistically not going to happen in a timely manner, do not delay osteoporosis treatment unnecessarily.   Continue good oral hygiene and dental care through treatment.   Bisphosphonates have a very long half life (years), so stopping them briefly prior to dental treatment confers no risk reduction for ONJ.  Basic dental care like fillings and cleanings combined with short term bisphosphonate use for osteoporosis (3-5 years) are low risk for developing ONJ (Kawahara 2021).

Antithrombotics

Patients should continue taking antiplatelets or anticoagulants during routine dental procedures.  The clotting risk for patients is higher than the localized bleeding risk.  Localized haemostasis is possible as the area is easily visualized.  Sutures can help reduce bleeding as does pressure by biting on a gauze.  For patients taking warfarin, it is appropriate to check the INR 48- 72 hours before the procedure to make sure it is not supratherapeutic (Wahl 2016, Chahine 2019). 

Antibiotic prophylaxis

The American Dental Association 2008 Guidelines recommend antibiotics for endocarditis prophylaxis in the following situations: any prosthetic cardiac valve, a history of endocarditis, a transplant with a valve regurgitation, or unrepaired cyanotic congenital heart disease.

The  UK NICE Guidelines (2016) made recommendations that nobody requires antibiotics prior to dental treatment for endocarditis prophylaxis.

Antibiotics generally are not necessary as prophylaxis for those with a prosthetic joint who require dental manipulation (ADA 2014).

Dental Health in Opioid Use Disorder

Patients on medications for opioid use disorder (e.g., methadone or buprenorphine) may express concerns about dental health.  The provider should validate their experiences, encourage dental visits, and offer general oral health recommendations.  Dr Simons does not feel buprenorphine increases the risk of dental disease, in spite of the 2022  FDA statement.  

Links

1. https://www.smilesforlifeoralhealth.org/   Free dental educational modules for non-dentists

Goal

Listeners will develop a simplified approach to managing dental pain  prior to signposting them to their dentist. 

Learning objectives

After listening to this episode listeners will…  

1. Able to perform a basic dental and mouth exam and principles of dental hygiene
2. Identify dental emergencies
3. Set patients expectations about dental pain treatment
4. Be aware of some common gum conditions
5. Prescribing issues for the dental patient. 

Disclosures

Dr. Simon reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Grant CE, Simon L, Williams PN, Watto MF. “#423 Dental Pain:Caries, Gingivitis, and Oral Care Tips & Tactics for Primary Care”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast January 22, 2024.