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How to Manage Pain Patients in Dental Practice

Posted on 19. Apr, 2014 by .

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An interesting article appears in J Can Dent Assoc 2012;78:c83 titled “Neuropathic Orofacial Pain Patients in Need of Dental Care,” written by Gary D. Klasser and Henry A. Gremillion. It was posted online on August 17, 2012, over at http://www.jcda.ca/article/c83. The abstract of the article states

“Dental pain is a common complaint among the general population. Most pain is a result of traumatic injury or bacterial infection in pulpal and periapical tissues, and dental practitioners are successful at diagnosing these conditions and providing prompt relief. However, in some cases, patients continue to complain of persistent pain, which may be categorized as neuropathic. These people may avoid or neglect routine dental treatment or interventions to prevent precipitation, perpetuation or exacerbation of their pain condition, and practitioners may have to modify their procedures when managing the dental needs of this unique population.”

The article mentions that most dental pain is the result of traumatic injury or bacterial infection and classified as nociceptive or inflammatory. A description of the differences between nociceptive and inflammatory pain is provided. The article states that dental practitioners are very succesful at recognizing and treating these types of pain. The article then goes on to say

“However, in some cases, those who have undergone dental treatments that have been considered both clinically and radiographically successful continue to complain of persistent pain. These people may be experiencing neuropathic pain.”

The article then goes on to state that neuropathic pain may have not have a demonstrable lesion or disease and then becomes classified as dysfunctional pain. The differences of neuropathic pain compared to the two other types of pain are then described.

Neuropathic pain can sometimes lead to what is known as a phantom toothache where a patient complains of pain which they may believe be in a tooth yet the dental practitioner can’t find a clear source of this pain.

The authors then go on to describe the pathophysiology of neuropathic pain and state that complex peripheral and central mechanisms are involved which are not yet fully understood. The authors state that the initiating event is often uknown

“… although it is probable that some form of mechanical trauma, metabolic disorder, neurotoxic chemicals, infection (bacterial, viral, fungal) or tumour invasion causes a release of neurochemicals and inflammatory mediators from the peripheral tissues, primary afferent nerve endings or both. This can increase membrane excitability and decrease the activation threshold of peripheral nociceptors (a process referred to as peripheral sensitization) increasing nociceptive input into the central nervous system (CNS). This bombardment of the CNS induces synaptic plasticity characterized by spontaneous activity, expansion of receptive fields, lowering of activation thresholds, hyperexcitability of neurons in the CNS, anatomic alterations to inhibitory neurons and other neural tissues and genetic alterations (a process referred to as central sensitization).”

The article goes on to describe how when people with neuropathic orofacial pain see a dentist the treatment performed may exacerbate the pain due to a hyperexcitable trigeminal nociceptive system. This can lead to further dental treatments which may or may not be successful.  The authors state that dentists should take a comprehensive history and clinical and imaging examinations in order to rule out other potential causes of pain which includes pain from a psychologic origin.

The authors go on to state that local anesthesia should be carefully considered in patients with neuropathic orofacial pain. This is certainly an interesting article and as the authors state in the conclusion all dentists should be aware of neuropathic orofacial pain and able to recognize it. The authors argue that these patients require a team based approach with open communication between all parties.

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High-Level Evidence to Identify Diseases and Disorders Associated with Periodontal Disease

Posted on 19. Apr, 2014 by .

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An interesting article appears in J Can Dent Assoc, 2012, 78:c25, titled ” Separating Fact from Fiction: Use of High-Level Evidence from Research Syntheses to Identify Diseases and Disorders Associated with Periodontal Disease,” by Amir Azarpazhooh and Howard C. Tenenbaum. The article describes how it is known that periodontitis has been correlated with several diseases and attempts to look at the more robust associations.

In the risks of keeping wisdom teeth page http://www.teethremoval.com/risks_of_keeping_wisdom_teeth.html this has been mentioned and several studies are cited. This page states

“These potential systemic diseases that may be associated with periodontal disease include premature delivery of low-birth weight infants, coronary artery disease, coronary heart disease, renal vascular disease, stroke, diabetes, bacterial pneumonia, chronic obstructive lung disease, and Alzheimer’s disease.”

The article discussed above uses meta-analyses and systematic reviews available up to June 2011. This article states

“This high-level evidence indicates that individuals with periodontitis have a significantly higher risk of various other problems, including cardiovascular disease, diabetes mellitus, respiratory disease and preterm low-birth-weight deliveries….The diseases for which an association with periodontitis has been reported include cardiovascular disease (CVD), stroke, respiratory disease, rheumatoid arthritis, pancreatic cancer, diabetes mellitus (types 1 and 2), preterm delivery, low-birth-weight delivery, preeclampsia, osteoporosis and osteoarthritis. On the basis of an initial scan of the literature for high-level evidence, data were analyzed for only a selection of these conditions: CVD, diabetes, adverse outcomes of pregnancy, preeclampsia and respiratory disease.”

The author then goes into a more detailed analysis of 1) cardiovascular disease, 2) diabetes mellitus, 3) adverse outcomes of pregnancy, 4) preeclampsia, and 5) respiratory diseases. Many articles and possible implications are discussed in brief.

The author concludes by saying

“..it remains important to recommend periodontal treatment for all patients, whether or not they have other established general health problems, primarily to improve periodontal health in its own right. Despite some evidence for reversibility, it cannot be guaranteed that treatment of periodontitis will reduce patients’ risk for other diseases. However, the role of periodontal disease as a “risk indicator” or “marker” should not be ignored, since the presence of this condition may serve as a warning to the dentist or dental hygienist that the patient is at risk for other diseases, especially CVD, diabetes, respiratory disease and preterm and/or low-birth-weight delivery.”

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The Curious Case of a Wisdom Tooth Growing in Old Age

Posted on 12. Apr, 2014 by .

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An interesting article titled “Dentist shocked by Mary’s new wisdom,” appears in an article in This is Kent, http://www.thisiskent.co.uk/Dentist-shocked-Mary-s-new-wisdom/story-17958765-detail/story.html, January 25, 2013.

The article describes a 75 year old woman who had a wisdom tooth grow in at the age of 75. A picture of the woman with her dentist is provided in the article.

The dentist was taken a back by such a finding since it is vary rare. He decided to look up other cases on the internet and did find a case where an 84 year old man in New Zealand where a man had a wisdom tooth come in.

In the case of the 75 year old man the dentist and woman have decided to just manage the wisdom tooth and leave it in in order to avoid possible complications.

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Teenagers Turn to Strangers for Legal Advice Online After Wisdom Teeth Extractions

Posted on 05. Apr, 2014 by .

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Previously, I have posted numerous user written experiences of wisdom teeth removal. For example, you can see One Star Yelp Reviews on Wisdom Teeth, Successful and Positive Wisdom Teeth Removal Experiences, Wisdom Teeth Surgery Survey, and Wisdom Teeth Extraction Survey. Many of these experiences of wisdom teeth extractions were sent to me in a survey I have been conducting for quite some time on wisdom teeth removal. Other experiences were found from other sources such as reviews on Yelp. It has long been known by those who search for wisdom teeth (but not much discussed) that teenage patients who have wisdom teeth extracted often go online afterwards if things don’t go as planned.

It appears that some patients are hurt and injured from the extraction and turn for advice on the internet. One such website where I have seen this occur is WorldLawDirect which is a forum for people online about legal issues. I have seen 2 such cases on WorldLawDirect where teenage patients have posted their wisdom teeth story and asked for legal advice, see http://www.worldlawdirect.com/forum/consumer-complaints/71293-can-i-sue-my-dentist-17-mouth-pains.html and http://www.worldlawdirect.com/forum/medical-malpractice/51622-can-i-sue-dentist-my-nerves-were-damaged-after-recieving-local-anesthesia.html.

I will now review these 2 cases to compare and contrast the similarities. In the first case a 17 year old female had four wisdom teeth removed during spring break. She complained that she did not receive antibiotics after surgery and states her parents looked online and found information to suggest antibiotics should be taken after surgery. I have explored the issue of taking antibiotics after wisdom teeth before such as over at http://www.teethremoval.com/antibiotic_resistance.html In this I currently refer to 2 studies in the Journal of Oral and Maxillofacial Surgery which suggests taking antibiotics before surgery may be more effective than after but also suggests that prophylactic antibiotics before surgery may not be universally needed. Carrying on with the explanation, the girl states that she suffered from lock jaw after the surgery and had significant pain. She states that upon consultation with another doctor it was determined she developed dry socket and an infection. She further states

“Here I am, two months later, and part of my lip goes numb, I have tooth fragments behind my upper right extraction site, with part of my gum missing. I have a soreness that will partly go away, but I can’t bite my top lip, or smile without the gums under my top lip hurt to the point of tears, and the sides of my gums as well, and I cannot chew on my left side due to the fact my back tooth feels like it’s going to pop out of my mouth.”

She also states that she had 11 unnecessary fillings before the four wisdom teeth were extracted bringing the total amount of surgery and fillings to around $33,000 which was paid by insurance. She simply wants to know if this is malpractice and if she can sue. Several users on the post then give some brief comments about whether or not a legal case can be brought and their suggestions.

In case 2 an 18 year old (sex unclear) reports having local anesthesia while having wisdom teeth removed and then developing double vision. He also states he developed nerve damage other his complaints are not clear. Again several users on the forum comment with their suggestions.

So overall, it appears that some teenagers after wisdom teeth removal are going online for legal advice from strangers. The strangers then offer a few comments about the merits of the case and what they suggest. I suppose this practice will continue….

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Recent Stories on Wisdom Teeth Removal Death

Posted on 29. Mar, 2014 by .

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I have recently posted about 2 potential deaths from wisdom teeth removal that occurred this year in 2014. The first one is an 18 year old man in Maine (see Eighteen Year Old Music Student in Portland Dies After Wisdom Teeth Removal). The second is a 24 year old woman who went into a coma in Hawaii (see Mother of Two in Hawaii in a Coma After Wisdom Teeth Surgery).

These stories got some play in various media outlets. For example, Mike Adams of NaturalNews.com wrote an article titled “Wisdom teeth surgery a deadly dental scam: Young mother falls into coma following visit to dentist” see  http://www.naturalnews.com/044415_wisdom_teeth_extraction_dental_scam_death_risk.html#ixzz2xOPQYbzy. In the article Mike says

“Across virtually the entire industry of conventional dentistry, this dangerous surgery scam is pushed on patients with unethical fear tactics that claim asymptomatic wisdom teeth — teeth with no symptoms, pain or problems — must be surgically removed “because they are there.””

Mike then goes on to mention the two recent death cases and says that dentists put profits over the safety of their patients and are unethical.  He does say

“Finally, I’m not saying that all surgeries or wisdom teeth extraction procedures are unnecessary.”

He however, doesn’t really go into the reasons for what would make removing wisdom teeth necessary. He does say that dentists don’t fully disclose all the risks and says you should look into this yourself. However, I would argue it would be difficult to look into all the risks yourself without access to medical journal articles and the knowledge to do so which for a teenager would pose a large challenge.

An opinion letter appears in the Forecaster, March 24, 2014, titled “Letter: The problem is there may not be a problem,” see http://www.theforecaster.net/news/print/2014/03/24/letter-problem-there-may-not-be-problem/192331 which also discusses the recent wisdom teeth death of the 18 year old man. This letter is written by an orthopedic surgeon who knows little about wisdom teeth surgery. He does speculate that removing many wisdom teeth is unnecessary citing some studies and guidelines.  He states

“As a practicing orthopaedic surgeon, I can relate that a number of techniques and practices I was taught in good faith 20 years ago are now known to be ineffective or even harmful. This is true across the field of medicine. After all, 300 years ago common practice included “bloodletting” patients when they were sick, leading to the death of our first president, George Washington.”

Why I think it is useful for these articles to say that many wisdom teeth surgeries are unnecessary citing studies and guidelines by other groups, it is important to remember that some wisdom teeth surgeries are needed and necessary even when their are risks with the surgery. Being able to better define this gray area is important so that one can better make an informed decision.

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