I was pleased to have the research I undertook published looking at how irreversible pulpitis, one of the most common causes of acute dental pain, is managed in North East England. Gemmell, A., Stone, S. & Edwards, D. Investigating acute management of irreversible pulpitis: a survey of general dental practitioners in North East England.Br Dent J 228,521–526 (2020).
This paper comes at a extraordinary time in dentistry where we are not able to see patients for face to face treatment. Many of us are triaging patients remotely, hoping that the acute symptoms of pulpitis they are suffering will reduce, as the tooth becomes necrotic through reassurance and anti-inflammatories. From the research, antibiotics were frequently being used in general dental practice as the first line approach in the management of irreversible pulpitis in 25% of cases. This transgresses from NICE guidelines on antibiotic prescribing.
We know pulpitis is an inflammatory reaction in the dental pulp to microbes often from dental caries. The inflammation of the pulp in the enclosed space of the pulp chamber is the cause of the acute pain patients feel, which is then exacerbated by thermal stimuli further irritating the pulp. The only predictable way to resolve this pain is to remove the tooth or access into the pulp chamber and allow decompression of the gasses that have built up in this enclosed space. In the current climate, we can not do this and hope that the anti-inflammatories we prescribe will help reduce the acute symptoms until the inflammation reduces and the tooth becomes necrotic. Once the pulp system in the tooth is necrotic, the pain may temporarily subside... until the microbes and toxins in the pulp space are no longer limited to being inside the tooth and start irritating the periapical tissues.
Initially, as with pulpitis, the periapical tissues become inflamed (periapical periodontitis) and as such, antibiotics will not be effective and advice continues to be anti-inflammatories. Only once there is infection (swelling/ suppuration/ pyrexia) are antibiotics going to be effective at managing these symptoms.
Another area that the research highlighted was that rubber dam was far from universally utilised during endodontic procedures. The benefits of rubber dam are well known, however, in a post COVID-19 world, rubber dam usage is likely to be more important than ever. In reducing potentially virus laden saliva from the aerosol we generate, the use of rubber dam may become a more routine step in our standard operating procedures.
Dentists need to be able to access teeth to remove inflamed pulp tissue to relieve their patients of pain. I hope this is something we are able get back to routinely doing soon.
