Hospital Dentistry

For post-operative dental pain, the dose and frequency of a non-opioid (ibuprofen and/or acetaminophen) analgesic should be optimized.  If this is not sufficient for managing pain, an opioid may be considered. If an opioid analgesic is appropriate, consider limiting the number of tablets dispensed and discuss the proper use and disposal of opioid drugs. Daily dispensing and/or delayed prescriptions may be useful strategies for appropriate use of opioids.

Sources:

Bailey E, et al. Ibuprofen and/or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth. Cochrane Database Syst Rev. 2013 Dec 12;(12):CD004624. PMID: 24338830.

Haas DA. An update on analgesics for the management of acute postoperative dental pain. J Can Dent Assoc. 2002 Sep;68(8):476-82. PMID: 12323103.

Related Resource:

Managing pain after wisdom teeth removal: Your questions answered. https://www.ismp-canada.org/download/OpioidStewardship/WisdomTeethRemoval-EN.pdf

Irreversible pulpitis or toothache occurs when the soft tissue and nerve inside the tooth (the dental pulp) becomes damaged because of decay, trauma, or large fillings. The intense pain is caused by inflammation of the dental pulp and the tissue surrounding the root – not by infection. Because this is not an infection, antibiotics do not relieve the pain and should not be used. Treatment for this condition is the removal of the damaged or diseased dental pulp, either through root canal therapy or extraction of the tooth. Inflammatory dental pain is best managed by NSAIDs.

An acute dental abscess is a localized infection that occurs due to an untreated infection of the dental pulp. Root canal therapy or extraction of the tooth, along with drainage of the abscess, is required to remove the infected tissue. Antibiotics are of no additional benefit. In the event of systemic complications (e.g., fever, lymph node involvement, or spreading infection), or for an immunocompromised patient, antibiotics may be prescribed in addition to drainage of the abscess. When antibiotics are used, consider strategies such as delayed prescriptions and/or shortened durations with reassessment for antibiotic resistance risk mitigation.

Sources:

Agnihotry A. Antibiotic use for irreversible pulpitis. Cochrane Database Syst Rev. 2016 Feb 17;2:CD004969. PMID: 26886473.

American Dental Association. Antibiotics for Dental Pain and Swelling Guideline.

Cope AL, Francis N, Wood F, Chestnutt IG. Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults. Cochrane Database Syst Rev. 2018 Sep 27;9(9):CD010136. PMID: 30259968.

Infections of orthopedic implants are uncommon events and are rarely caused by bacteria found in the mouth. Although dental procedures such as extractions cause transient bacteremia, most bacteremia of oral origin occurs with activities of daily living, including brushing, flossing, and chewing.  There is no reliable evidence that antibiotics before dental procedures prevent prosthetic joint infections. Patients should not be exposed to the adverse effects of antibiotics when there is no evidence of benefit.

There is no convincing evidence that oral bacteria from dental procedures cause infections of the following devices at any time after implantation: pacemakers;  implantable defibrillators; ventriculoatrial/ventriculoperitoneal shunts; devices for patent ductus arteriosus, atrial septal defect, and ventricular septal defect occlusion; peripheral vascular stents; prosthetic vascular grafts; hemodialysis shunts; coronary artery stents; dacron parotid patches; and chronic indwelling central venous catheters.

Sources:

Antibiotic Prophylaxis in Patients with Orthopedic Implants Undergoing Dental Procedures: A Review of Clinical Effectiveness, Safety, and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2016 Feb 17.

Baddour LM, Bettmann MA, Bolger AF, Epstein AE, Ferrieri P, Gerber MA, Gewitz MH, Jacobs AK, Levison ME, Newburger JW, Pallasch TJ, Wilson WR, Baltimore RS, Falace DA, Shulman ST, Tani LY, Taubert KA; AHA. Nonvalvular cardiovascular device-related infections. Circulation. 2003 Oct 21;108(16):2015-31. PMID: 14568887.

Hong CH, Allred R, Napenas JJ, Brennan MT, Baddour LM, Lockhart PB. Antibiotic prophylaxis for dental procedures to prevent indwelling venous catheter-related infections. Am J Med. 2010 Dec;123(12):1128-33. PMID: 20961528.

Sollecito TP, Abt E, Lockhart PB, Truelove E, Paumier TM, Tracy SL, Tampi M, Beltrán-Aguilar ED, Frantsve-Hawley J. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners–a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2015 Jan;146(1):11-16.e8. PMID: 25569493.

Sutherland, S. Science over dogma:  Dispelling myths about dental antibiotic prophylaxis for patients with total joint replacements. Ontario Dentist 2018; Jan-Feb:20-25.

Related Resources:

Consensus Statement: Dental Patients with Total Joint Replacement

Wilson, W.R., et al., Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the American Heart Association. Circulation, 2021. 143(20): p. e963-e978. PMID: 33853363.

Dental x-rays and other imaging modalities are important and necessary tools to diagnose and monitor oro-facial disorders and dental diseases. Determine the need for diagnostic imaging on an individual basis for each patient based on medical and dental history, clinical findings, and risk assessment, rather than on a routine basis.

Sources:

American Dental Association and U.S. Food and Drug Administration. The Selection of Patients for Dental Radiographic Examinations 2012.

Canadian Dental Association. CDA Position on Control of X-Radiation in Dentistry 2005.

Related Resource:

Image Gently. http://www.imagegently.org/Procedures/Dental

Dental restorations (fillings) fail due to excessive wear, fracture of material or tooth, loss of retention, or recurrent decay. The larger the size of the restoration and/or the greater the number of surfaces filled increases the likelihood of failure. Restorative materials have different survival rates and fail for different reasons, but age should not be used as criteria for failure. Drilling to remove and replace fillings can weaken teeth. If feasible, repair of small defects, rather than replacement of a filling, can save tooth structure and increase the lifespan of restorations at a lower cost.

Amalgam dental restorations release small amounts of mercury. Judicious management of mercury waste in dentistry is mandated in Canada. Randomized clinical trials demonstrate that the mercury present in amalgams does not produce illness. Removal of such amalgams if the restoration is otherwise sound is unnecessary, expensive, and subjects the individual to absorption of greater doses of mercury than if left in place. Furthermore, placement of composite resin restorations is known to cause a transient increase in urinary Bisphenol-A levels, for which there are unknown health effects. High-quality evidence suggests higher failure rates in composite resins versus amalgam restorations.

Sources:

Blum IR et al. Factors influencing repair of dental restorations with resin composite. Clin Cosmet Investig Dent. 2014 Oct 17;6:81-7. PMID: 25378952.

Canadian Dental Association. CDA Position on Dental Amalgams 2005, Revised 2014, 2021.

Composite Resin versus Amalgam for Dental Restorations: A Health Technology Assessment. Ottawa: CADTH; 2018 Mar.

Gordan VV, et al. Alternative treatments to replacement of defective amalgam restorations: results of a seven-year clinical study. J Am Dent Assoc. 2011 Jul;142(7):842-9. PMID: 21719808.

Dentists are required to provide services within the context of provincial directives from the provincial health authority. When directives prohibit non-essential dental visits, urgent care must be provided to relieve pain and treat infections. Critical dental services should be prioritized to minimize harm to patients from delaying care and be provided in a way that protects patients and dental personnel. The latter includes interim stabilization of the dental problem; minimization of aerosol-generating procedures; and use of appropriate PPE and other IPAC measures as advised by provincial health authorities/regulators. Strategies should be developed to monitor patients whose care has been cancelled or delayed.

Sources:

Banakar M, Bagheri Lankarani K, Jafarpour D, Moayedi S, Banakar MH, MohammadSadeghi A. COVID-19 transmission risk and protective protocols in dentistry: a systematic review. BMC Oral Health. 2020 Oct 8;20(1):275. PMID: 33032593.

Centers for Disease Control and Prevention. Guidance for Dental Settings: Interim Infection Prevention and Control Guidance for Dental Settings During the Coronavirus Disease 2019 (COVID-19) Pandemic.

Kranz AM, Gahlon G, Dick AW, Stein BD. Characteristics of US Adults Delaying Dental Care Due to the COVID-19 Pandemic. JDR Clin Trans Res. 2021 Jan;6(1):8-14. PMID: 32985322.

Meng L, Hua F, Bian Z. Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine. J Dent Res. 2020 May;99(5):481-487. PMID: 32162995.

Virtual care minimizes exposure of patients and staff to COVID-19 and its variants. It allows patients to avoid crowds and unnecessary travel and supports physical distancing measures in clinics, hospitals, and other facilities. In addition, virtual care allows more timely and accessible care, especially when challenges such as distance, disability, or frailty exist.

Virtual care cannot replace the need for in-person physical examination and assessment of many oral disorders. In-person care may be required for patients whose condition is not stable or is deteriorating. Virtual care may not be appropriate for patients with low digital health literacy or the inability to access a digital device.

For effective virtual care, appropriate infrastructure, provider funding, protection of privacy, and thorough preparation of the patient are needed.

Sources:

Canadian Medical Association. Virtual Care Playbook. 2020.

Greenhalgh T, Wherton J, Shaw S, Morrison C. Video consultations for covid-19. BMJ. 2020 Mar 12;368:m998. PMID: 32165352.

Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. BMJ. 2020 Mar 25;368:m1182. PMID: 32213507.

Monaghesh E, Hajizadeh A. The role of telehealth during COVID-19 outbreak: a systematic review based on current evidence. BMC Public Health. 2020 Aug 1;20(1):1193. PMID: 32738884.

Robiony M, Bocin E, Sembronio S, Costa F, Arboit L, Tel A. Working in the era of COVID-19: An organization model for maxillofacial surgery based on telemedicine and video consultation. J Craniomaxillofac Surg. 2021 Apr;49(4):323-328. PMID: 33581957.

Antibiotic resistance has increased because of the widespread use of antibiotics over many years. It is a significant global threat to health. Opioid misuse has also become a serious problem in recent years. During a pandemic phase where only “essential” dental care is permitted or advised, it may be necessary to prescribe antibiotics or analgesics without examining the patient in person. When managing new dental infections and/or dental pain on an emergency basis, if the concern has not resolved after the preliminary course of therapy, the patient should be re-examined to determine the next steps.

Sources:

Palmer NOA, Seoudi N. The effect of SARS-CoV-2 on the prescribing of antimicrobials and analgesics by NHS general dental practitioners in England. Br Dent J. 2021 Jan 21:1–6. PMID: 33479515.

Shah S, Wordley V, Thompson W. How did COVID-19 impact on dental antibiotic prescribing across England? Br Dent J. 2020 Nov;229(9):601-604. PMID: 33188343.