COVID-19 – telephone advice to give patients managing toothache at home

telephone for dentists discussing toothacheWith patients stuck at home and advice limited to the telephone, Simran Bains lists some questions dentists may come across along with the answers they might want to consider.

NHS England and the Department of Health have recently instructed all dental practices to establish a remote urgent care service during the coronavirus outbreak. The practices should provide telephone triage for their patients with urgent needs during usual working hours and wherever possible treating with advice, analgesics and/or antibiotics.

Below are some questions you could ask the patient and some advice (which incorporates SDCEP guidelines) to give the patient to help them manage their pain at home.

Non-urgent dental care:

  • Bleeding gums
  • Broken/rubbing/loose dentures
  • Loose/lost fillings, crowns, bridges, veneers
  • Chipped teeth with no pain
  • Loose orthodontic wires.

Urgent dental treatment

Swelling

Questions:

  1. How big is the swelling and can you see it on the outside of your face?
  2. How long have you had the swelling for?
  3. Does the swelling extend to your eye/neck?
  4. Is the swelling affecting your breathing/eating/vision? *Alert*
  5. Are you able to open your mouth more than two fingers width?
  6. Is the abscess draining itself?

Advice:

  • Regular painkillers if required
  • Hot salty water mouthwash if its draining
  • Obvious facial swelling – antibiotics may be prescribed by the dentist for severe infection and swelling
  • If the patient has continuing or recurrent symptoms refer to urgent dental care centre for extraction or drainage.

Alert:

  • Head to A&E if facial swelling is affecting your breathing eating or vision.

Pain after an extraction

Questions:

  1. When did you have the tooth removed?
  2. Any associated swelling?
  3. Bad taste?

Advice:

  • Regular painkillers – reassure the patient it is normal for pain to be at its worse on days three and four
  • Rinse gently with salty-water after every meal
  • Avoid alcohol and smoking
  • Eat soft foods
  • Do not disturb the clot
  • Good oral hygiene
  • If pain is worse after a week call us back
  • Do not prescribe antibiotics unless signs of spreading infection, systemic infection or for immunocompromised patients
  • If pain is severe and uncontrollable and preventing from sleeping refer to urgent dental care centre.

Bleeding after an extraction

Questions:

  1. When did you have the tooth removed?
  2. How much blood? Constant ooze or blood-stained saliva?
  3. Have you tried any measures to stop the bleeding?
  4. Medical history – anticoagulant medication?
  5. Do you have any underlying bleeding conditions? Haemophilia?

Advice:

  • Blood-stained saliva is normal – reassure the patient
  • If active bleeding – advise the patient to sit upright, apply pressure to the extraction site by biting on a clean cotton handkerchief or a rolled up piece of gauze for 20 minutes (press firmly if no opposing tooth)
  • Avoid spitting or rinsing the mouth for 24 hours
  • If bleeding does not stop after three attempts of pressure placement then refer to urgent care centre
  • Avoid hot drinks and exercise
  • Avoid alcohol and smoking
  • Eat soft foods
  • Do not disturb the clot
  • Painkillers if required
  • If the bleeding fails to stop but is not persistent refer to urgent dental care centre
  • If the bleeding fails to stop and is persistent and patient is taking anticoagulant medication refer to maxillofacial team.

Bleeding gums

Questions:

  1. Discuss possible causes – diabetes, smoking, pregnancy, poor oral hygiene
  2. Is the bleeding localised or generalised?
  3. Do you have a bad taste?
  4. Any ulcers *Alert*
  5. Do you have any systemic symptoms eg high temperature, nausea or vomiting?

Advice:

  • Good oral hygiene
  • Brush twice a day – can initially exacerbate bleeding
  • Interdental brushes or floss
  • Rinse with chlorhexidine-based mouthwash
  • Smoking caseation.

Alert:

  • Possibly may need referral to urgent dental care centre if systemic signs and ulceration.

Trauma

Questions:

  1. Any loss of consciousness/vomiting/double vision? *Alert*
  2. Has a tooth broken/moved position/completely fallen out?

Advice:

  • Mild-moderate dental trauma – provide self-help advice on pain relief and possible antibiotics for swelling due to infection
  • Avulsed permanent tooth or severe trauma – refer to urgent dental care centre

Alert:

  • Head to A&E if trauma causing loss of consciousness/double vision or vomiting

Toothache

Questions:

  1. Which side is the pain?
  2. When did the pain start?
  3. Sharp shooting/dull throbbing?
  4. Is it affecting your sleep?
  5. Is there an associated swelling?
  6. Does it hurt when pressure is applied to the tooth?
  7. Does anything make it better/worse?
  8. Have you had a cold/sinus recently?

Advice:

  • Regular painkillers if required
  • Advise patient to rinse with cold water, this can alleviate the pain
  • Good oral hygiene with a fluoride toothpaste and reduce intake of sugary food to ensure decay does not worsen
  • If pain is severe and uncontrollable, preventing sleeping or eating refer to urgent dental care centre.

Tooth sensitivity

Questions:

  1. Is the pain localised?
  2. Type of pain?
  3. Sensitive to hot and cold?
  4. How long does it last?

Advice:

  • Rub sensitive toothpaste directly on affected area and don’t rinse afterwards, leave on overnight
  • Orajel may help ease the pain
  • Avoid stimuli (cold/acidic foods or drink).

Wisdom tooth pain

Questions:

  1. Is there a swelling at the back of the mouth in the wisdom tooth region?
  2. Do you have a bad taste in your mouth?
  3. Is your cheek/face swollen?
  4. Do you find it difficult to swallow?
  5. Is there any difficulty in opening your mouth/any pain?
  6. Have you had similar symptoms before?
  7. How are you managing the pain?

Advice:

  • Keep the area clean with a small headed toothbrush or single tufted toothbrush
  • Rinse two to three times a day with warm salt water or chlorhexidine mouthwash
  • Paracetemol/Ibuprofen if required
  • Obvious facial swelling – antibiotics may be prescribed by the dentist for severe infection and swelling
  • Regular pain killers if required
  • Ask patient to call back in 48-72 hours if their symptoms have not resolved
  • If the patient feels unwell, has limited mouth opening (less than two fingers) and difficulty swallowing consider referral to maxillofacial team.

Ulcers

Questions:

  1. How long as the ulcer been present?
  2. Ascertain if an ulcer has been persistent for more than two weeks and is not painful *Alert*
  3. Do you suffer with mouth ulcers regularly?
  4. Have you traumatised the skin or gum in the mouth?
  5. What provokes and relives the symptoms?
  6. Do you have anaemia, gastro-intestinal symptoms or skin conditions or take any medication?

Advice:

  • Reassure the patient – traumatic ulcers are usually sore but resolve in a week or two
  • Other causes include anaemia, gastro-intestinal disorders, iron and vitamin deficiencies, immune conditions, dermatoses, stress and medication
  • Oral hygiene advice – brush twice a day, salt water/chlorhexidine mouthwash different time to brushing
  • Local pain relief using mouthwashes or topical gels – Paracetemol/Ibuprofen, benydamine hydrochloride mouthwash or topical anaesthetic gels
  • Good oral hygiene
  • If due to rubbing dentures – try Fixodent to secure loose dentures. Any sharp or rough edges can be adjusted at home using an emery board. Leave dentures out if too sore to wear
  • Avoid precipitating factors eg spicy food
  • Avoid smoking.

Alert

  • Any non-healing and non-painful ulcer present for two weeks or more requires urgent dental assessment to exclude oral cancer – consider referral to urgent dental care centre.

Teething

Questions:

  1. Age of child?
  2. Have you noticed any teeth coming through?
  3. Can you feel any teeth with your finger?
  4. Is the child eating/taking in fluids?
  5. Is the child sleeping at night?
  6. Does the child have a fever?
  7. Have you given the child pain relief?

Advice:

  • Teething begins around six months and children can experience pain in the mouth during teething, which may effect their sleeping, and eating
  • Ensure the child is adequately hydrated
  • Liquid Paracetemol/Ibuprofen (sugar free), lidocaine topical gel can help relieve symptoms of pain relief and pyrexia
  • Pureed food, cool liquids and teething aids can be helpful – advise patient to avoid pureed sweet foods eg fruit purees as can lead to decay.

TMJ pain

Questions:

  1. Do you have chest and jaw pain worse on exertion? *Alert*
  2. Is there loss of vision? *Alert*
  3. Have you been particularly stressed lately?
  4. Are you conscious of grinding or clenching your teeth?
  5. Do you have multiple teeth pain?
  6. Is the pain worse around the jaw joint or temples
  7. Have you noticed clicking/crunching pain in your jaw joint when opening or closing your mouth?
  8. Does anything make the pain better/worse?
  9. Do you take antidepressants or antipsychotic medication?

Advice:

  • Reassure the patient – clenching/grinding of teeth is common in periods of stress or due to some medications (as listed above)
  • Soft diet for two weeks
  • Limit opening of mouth when yawning or eating – place hand under chin
  • Avoid recurrent chewing habits eg chewing gum/nail biting
  • Ibuprofen gel – rub onto skin
  • Warm/cold compress over affected area
  • Massaging sore areas of face eg temples

Alert:

  • Loss of vision with temporal pain may be at risk of giant cell (temporal) arteritis – seek urgent medical attention

Lost filling/crowns

Questions:

  1. Can the crown be placed back on the tooth comfortably without falling off?
  2. Has the tooth broken inside the crown?
  3. Is the remaining tooth sharp causing soreness to soft tissues resulting in an ulcer?
  4. Have you taken pain relief?
  5. Where is the lost filling/crown?

Advice:

  • Analgesics if required
  • Can buy temporary cement/filling kit from chemist
  • Soft diet
  • Avoid hot/cold foods
  • Good oral hygiene and a low sugar diet will help prevent decay in the underlying tooth
  • Soft toothbrush and sensitive toothpaste
  • If patient has inhaled fragment then refer to maxillofacial department.