ORIGINAL RESEARCH


https://doi.org/10.5005/jp-journals-10015-2067
World Journal of Dentistry
Volume 13 | Issue 4 | Year 2022

Emergency Pain Management of Untreated Pulpitis during COVID-19 Lockdown by Telephonic Communication


Akhil Rajput1, Umesh Kumar2, Nikhil Sinha3, Gulshan Kumar4, Ruchi Vashisht5, Krishan Gauba6, Anup Kanase7

1Departmet of Dentistry, BSA Medical College and Hospital, Rohini, Delhi, India

2,5Unit of Endodontics, Oral Health Science Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

3Private Practitioner, Delhi, India

4Private Practitioner, Chandigarh, India

6Oral Health Science Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

7Department of Orthodontics Maulana Azad Institute of Dental Sciences, Delhi, India

Corresponding Author: Umesh Kumar, Unit of Endodontics, Oral Health Science Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, e-mail: odharmani911@gmail.com

ABSTRACT

To evaluate the beneficial effects of orally administered corticosteroids in alleviating the pain of symptomatic pulpitis.

Materials and Methods: Out of the 87 patients who contacted the expert panel telephonically during the period of COVID-19 lockdown, 55 patients complaining of moderate to severe dental pain were included in the study and thus advised to take oral tablets of paracetamol 650 mg postmeal thrice a day for 3–5 days along with a single oral dose of 4 mg of dexamethasone. The patients were asked to report their pain status after every 24 hours for at least 72 hours. In case of severe pain not controlled by these medicines even after 3 days, two tablets of dispersible ketorolac tromethamine (10 mg) were advised once on the fourth day, followed by a single tablet three times a day for another 3 days. In case the pain did not subside within 3 days of taking the second line of treatment, or there was a development of swelling/lymphadenopathy, the patient was advised to get the tooth extracted.

Results: Out of 55 patients taking a single dose of dexamethasone, 47 (85.45%) patients reported a “significant” reduction of pain within 24–72 hours. The remaining eight patients (14.55%) in which severe pain was not controlled by paracetamol and dexamethasone even after 3 days, two tablets of ketorolac tromethamine (10 mg) were advised. Six patients (75%) reported a “significant” reduction in the pain, while two (25%) patients still in pain were advised tooth extraction and were referred to the emergency department of the tertiary care center.

Conclusion: For the pain felt by patients diagnosed with symptomatic irreversible pulpitis, systemic corticosteroids administration is an adequate strategy in controlling pain for up to 48–72 hours, the time during which the pain is felt most.

How to cite this article: Rajput A, Kumar U, Sinha N, et al. Emergency Pain Management of Untreated Pulpitis during COVID-19 Lockdown by Telephonic Communication. World J Dent 2022;13(4):358-361.

Source of support: Nil

Conflict of interest: None

Keywords: Corticosteroids, COVID-19, Irreversible pulpitis, Teledentistry

INTRODUCTION

The first case of Coronavirus disease 2019 (COVID-19) was reported in December 2019 from China. Within 3 months, it had affected more than 170 countries around the globe and countries worldwide have imposed lockdown to limit the spread of COVID-19.1 All elective surgeries and routine dental procedures were also suspended, and only emergency cases were being treated by dentists across the globe. Fear of contracting COVID-19 resulted in avoidance behavior of dental care, especially because no effective drug or vaccine was available. As a result of this, patients suffering from dental pain would seek teleconsultation for pharmacological management of pain. There are no guidelines available to treat patients with very severe pain resulting from irreversible pulpitis without actually seeing them in the clinic. Temporary pain management became the priority until further appropriate treatment could be provided.2,3 So the people were encouraged to telephonically contact the dentists for suggestions to manage their dental pain. The most common over-the-counter drug available to manage pain is nonsteroidal anti-inflammatory drugs. However, steroids are more effective in reducing pain and facial swellings resulting from inflammation.4 Gallatin et al. have concluded that the intraosseous injection of slow-releasing methyl-prednisolone can temporarily relieve the symptoms of irreversible pulpitis until definitive treatment is available.5 Current literature does not document any guidelines to manage patients with irreversible pulpitis without any dental intervention. However, seeing patients in dental clinics becomes quite difficult during the phases of natural disasters, epidemics, or pandemics. Thus, this study was planned on patients who were contacted telephonically from 22nd March 2020 to 01st July 2020 to evaluate the beneficial effects of orally administered corticosteroids in alleviating the pain of symptomatic irreversible pulpitis.

MATERIALS AND METHODS

This study comprised seven expert panel of dentists practicing in the government and private set-ups in the northern part of India. All panel members were engaged in caring for patients with acute and chronic pain and had enough experience and training in managing patients with dental pain. The study was prospective in nature and patients were followed for 5 days after treatment was prescribed. At the time of the first telephonic communication by the patients, they were video-called, and the respondents were asked to indicate the numeric value on the segmented scale that best describes their pain intensity. The numeric pain scale (Fig. 1) was shown to them during video call, and their response was recorded. Only patients who complained of severe pain on a verbal numeric pain rating scale attributed to irreversible pulpitis were included in the study. Severe pain was defined as those having 8–10 scores on a 10-point numeric rating scale. The cause of the pain was ascertained to be irreversible pulpitis after concluding the history of dental pain described by the patient. The response to the following questionnaire leads us to reach the provisional diagnosis of irreversible pulpitis:

Fig. 1: 10-point visual analog scale

Patients who are allergic to any medications, are diabetic, are taking analgesics for reasons other than dental pain or are already on some medicines to treat present dental pain were excluded from the study. Pain in already root canal-treated teeth or those with concomitant facial swelling were also excluded from the study. Only those patients who could be contacted on a video call and were able to answer the questionnaire and follow instructions were made part of the study.

Of the total number of calls received by the panel for dental pain, only 55 patients were found to be deemed fit as per the inclusion criteria mentioned above. These 55 patients were advised to take oral tablets of paracetamol 650 mg postmeal thrice a day (8 hourly) for 3 days along with a single daily oral dose of 4 mg dexamethasone for 3 days. Patients with known sensitivity to dexamethasone or any medical condition which contradicted use of steroids were not included in the study. The outcomes observed were the severity of pain reported before and after giving dexamethasone using the same scale as was used before to categorize pretreatment pain. The patients were asked to report their pain status after every 24 hours till 72 hours. In case of severe pain not controlled by these medicines even after 3 days, a stat dose of 20 mg followed by 10 mg 12 hourly dosages of dispersible ketorolac tromethamine was advised for 3 days. Posttreatment pain score on a visual analog scale of <5 was considered a significant improvement in pain. In case the pain did not subside (VAS score >5) within 3 days of taking the second line of treatment (i.e., ketorolac tromethamine), or if there was a development of swelling, the patient was advised to contact the nearby emergency center for further management (Table 1 and Fig. 2). All the patients who were relieved by the first or second line of treatment were also instructed to visit the dental office in person once they felt safe from a COVID point of view.

Table 1: The number of patients with initial level of pain and after treatment regimen
Total patients: 55
After 1–6 hours of PCM None responded
24 hours after PCM plus DEXA 11
responded
After 2 days PCM plus DEXA 32
responded
After 3 days PCM plus DEXA 04
responded
After 3 days PCM plus DEXA and two tab. of ketorolac 06
responded
Referred to emergency in person 02

Fig. 2: Number of patients and their respective treatments

RESULT

Out of 55 patients taking 4 mg dexamethasone, 47 (85.45%) patients reported a “significant” reduction of pain within 72 hours. A total of 11 patients responded with a single dose of 4 mg dexamethasone, that is, after 24 hours, 32 patients responded after two doses, that is, after 48 hours and four patients responded after three doses, that is, after 72 hours. Of the remaining eight patients (14.55%), six patients responded to the second line of treatment. The remaining two patients who didn’t respond to the second line of treatment also, were told to contact the nearby emergency setting in person following the COVID protocol (Table 2).

Table 2: Timeline showing flow of patient’s telephonic communication across the study period
Patients characteristics N (%)
Patients suggestive of symptomatic irreversible pulpitis 55 (63.21%) of total 87
Patients reported significant relief from pain after 24–72 hours of taking PCM-650 + 4 mg dexamethasone 47 (85.45%) of total 55
Patients reported relief from pain after taking PCM-650 +4 mg dexamethasone + ketorolac tromethamine (10 mg) 06 (10.9%) of total 55
Patients that needed tooth extraction 02 (3.65%) of total 55

The initial trends are to be followed, a single oral dose of 4 mg of dexamethasone can be useful in temporarily alleviating the pain of symptomatic irreversible pulpitis.

DISCUSSION

The healthcare system across the world has been challenged in controlling the infection due to novel COVID-19, including the service of pain management. In the dental profession, the condition prevalent worldwide is tooth pain, due to which quality of life has been reduced along with the limitation of daily activities.2,3 Tooth pain is basically a symptom of pulpal and periapical tissue infection, and when actively inflamed it leads to the release of various pain mediators such as potassium (k+), hydron (H+), histamine, bradykinin, serotonin 5 (HT), nitric oxide, prostaglandin, and leukotrienes. Sensitization of nociceptors (free nerve ending) by these pain mediators activates peripheral and central hyperalgesia mechanism resulting in moderate to severe pain called symptomatic irreversible pulpitis.6

The best management of severely inflamed pulp of irreversible nature is either with extraction or definitive endodontic treatment after immediate pulp extirpation (pulpotomy) is an emergency procedure to relieve pain.7,8 But due to COVID-19, the protocol of management changed since 23rd March 2020 as the main focus was then the prevention from COVID-19 and so both the dental professionals and the patients were in favor of deferring definitive treatment and receive only pharmacological treatment to manage pain. This led to an increase in remote consultation methods, that is, by telephone or video call during COVID-19.3

The pharmacological strategy of pain management is the use of systemic drugs such as analgesic and nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, opioids, and steroids. Most of the clinicians in clinical practice prescribe NSAIDs as they act either selectively or nonselectively on the cyclooxygenase enzyme, which is responsible for the formation of pain mediators from arachidonic acid released from the cell membrane after tissue injury. However, NSAIDS are not effective on all the pain mediators like leukotrienes, nitrogen oxide radicals resulting in their skewed success.9-11

Symptomatic irreversible pulpitis is also associated with various inflammatory mediators, like those arising from bacterial by-products, primed immune cells influx, and cytokine network activation, so a wide variety of steroids can be utilized as an adjunct to endodontic therapy for their ability to alleviate dental pain. The steroids like dexamethasone have good anti-inflammatory and analgesic properties and have been used in endodontic practice for a long based on experimental and clinical investigations.12-15

The use of steroids was first described by stalwart as early as 1956 for the management of pain before and after the endodontic procedure.16 Use of dep Medrol in untreated irreversible pulpitis cases have resulted in the reduction of PGE2, IL-8 and cytokinin level.17 The reduction of bradykinin synthesis level by induction in the formation of kinase II or ACE was demonstrated by Hargeaves KM and Costello A18 after administration of glucocorticoids. Glassman et al.19 compared the efficacy of dexamethasone with placebo when given systemically 1 hour and 4 hours after endodontic treatment of symptomatic irreversible pulpitis, and the result was statistically significant.

During the COVID-19, the analgesic drug regimens presented here can be advised to patients with mild and moderate dental symptoms using over-the-counter drugs or by tele prescription. In adults, where paracetamol or ibuprofen (standard or higher dose) alone are not effective, both drugs can be taken together as long as the criteria of maximum dose or frequency are met. As an alternative, to control and minimize the severe endodontic pain, opioids or corticosteroids may be required.14,15 The management options presented here focus on pain alleviation or to decrease infection and follow-up care by telephone or video call (teleconsultation). Patients should only be referred for emergency dental care when above-mentioned drugs cannot manage symptoms by themselves. Unless urgent or emergency care is required, the patient should be encouraged to manage their symptoms at home.

It is essential to minimize the number of patients referred to higher centers designated for emergency care in order to reduce the COVID-19 transmission risk among both healthcare workers and patients as well as to lessen the pressure on these services. Patients with dental pain and infection may need to self-manage for longer than normal during COVID-19. In all the cases presented here, referral to designated emergency care providers was sought if the symptoms did not resolve with prescribed pharmacological treatment.

Steroids have their own contraindications and adverse effects, so these should be used judiciously and risk-benefit ratio should be assessed, particularly in patients of ulcerative colitis, pyogenic infection, peptic ulcer, renal insufficiency hypertension, diabetes mellitus, tuberculosis, and pregnancy. Steroids also are contraindicated in patients with systematic fungal infections and those with known allergies to the drug.13,16

The major limitations of this study are the small sample size, the diagnosis was totally subjective, and the treatment was based on the patient’s compliance. The outcome also could vary depending on the patient’s ability to understand and follow the pain scale over the telephone. More studies are thus warranted on elucidating the exact reasons for the results obtained in this study.

CONCLUSION

Adequate management of endodontic pain is not only a moral and ethical imperative, but it also takes the edge off subsequent physical and psychological complications. Nevertheless, the impact of a particular anti-inflammatory drug in large-scale clinical situations on endodontic pain is not answered due to a lack of evidence. Within the limitation of this study, the pain felt by patients diagnosed with symptomatic irreversible pulpitis, the systemic corticosteroids administration was found effective in controlling pain arising from symptomatic irreversible pulpitis, particularly during the initial 24–72 hours, the time during which most of the patients report severe pain.

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