Which analgesic to choose for dental pain

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used drugs to relieve all types of pain, including toothache. This type of medication works by blocking the production of prostaglandins, chemical mediators of the inflammatory process.

There are many different anti-inflammatory drugs on the market. The choice of the most suitable medication for the individual patient should be the prerogative of a specialist because, like any drug, they can have side effects, some of which may be serious.

Therefore, in the case of toothache, it is advisable to contact your dentist, who, taking into account the patient’s general state of health, will be able to recommend the most suitable medication.

Anti-inflammatory drugs commonly used for the treatment of toothache include those based on ibuprofen, ketoprofen, and naproxen.

Paracetamol, although primarily an antipyretic, can also help manage toothache. Paracetamol is a painkiller that does not damage the stomach and is, therefore, more suitable for individuals with stomach problems, pregnant or breastfeeding women, and children.

Who can take anti-inflammatories

In most cases, taking non-steroidal anti-inflammatory drugs is safe. However, some patients must seek medical advice first, as side effects may be more likely to occur.

Those who should seek medical advice before taking anti-inflammatory drugs include:

• Individuals who have previously experienced allergic reactions to an NSAID
• Women who are pregnant or trying to become pregnant
• Lactating women
• People over 65 and under 16 years of age
• Asthmatics
• Individuals with a history of stomach ulcers
• People with heart, liver, kidney, circulatory, or intestinal problems
• Those who are already taking other medications

Possible side effects

Like any medication, anti-inflammatory drugs can have side effects. Unwanted side effects are more likely to occur when the medicine is taken over a long period and in high doses, especially among the elderly or those in poor health.

The most common side effects of anti-inflammatories include:

• stomach pain
• stomach ulcers
• headaches
• drowsiness
• allergic reactions
• digestive difficulties

Natural anti-inflammatory analgesics

Individuals who do not want or cannot take anti-inflammatory drugs can explore the many natural alternatives available on the market. While natural remedies cannot guarantee relief from a toothache, those interested can certainly give them a try.

Among the natural remedies with anti-inflammatory properties, the best known and most widely used are:

• Cloves, which can be used in the form of essential oil to rub onto the sore area with a cotton bud
• Myrrh, for gargling
• Powdered ginger, to make a paste to rub on teeth
• Peppermint, for a mouthwash
• Boiled lettuce leaf to place on the sore area

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It is a psychological disorder related to the anxiety of coming into contact with everything related to the world of dentistry. You can have a fear of entering the dentist’s office, fear of drilling noise, fear of the smell of disinfectant typical of dental rooms, fear of getting touched in your mouth. Those phobias involve the five senses: the most common dental phobia includes them all and is the fear of dental implants.

Psychology of fear

All feelings of anxiety, extreme apprehension and fears related to the dentist are psychological phenomena arising from what the patient knows or believes he knows about dentists in general.

Very often, you are afraid of the idea that the dentist may hurt you even without having had painful experiences about it. To a large extent, the fear of the dentist is a cultural phenomenon related to the collective imagination. Often, a series of conditionings that we suffer from since childhood cause us to reject the idea of booking an appointment at the dental office. Even in the cartoons that we see as children, the dentist’s office is shown as if it were a torture chamber. It’s normal for children to grow up thinking it actually is a bad place.

The fear of pain

From a rational point of view, fear of pain is not pain, but fear. The logic of this expression is that when there is fear, there is no pain, so what has feared in itself is not the pain, but the fear itself. At this point, we must ask ourselves how to overcome it.

Fear of the dentist, how to deal with it

There are many remedies to overcome the fear of the dentist. The first step is to become aware that this is an irrational fear, most often linked to conditioning.

Here are several remedies that many dentists suggest to fight this problem:

Bach Flowers: Rescue Remedy

Among the homoeopathic remedies, the most suitable to face the fear of the dentist is the Rescue Remedy, a preparation in drops beneficial to counteract states of anxiety, panic attacks and all concerns of irrational order, such as fear of flying, examination or interview anxiety, etc.
As an alternative to Bach flowers, valerian or linden are lighter remedies. They always have to be taken in drops, a little before the visit to the dentist, because they need more time to take effect.

Conscious sedation

Very often, patients would like to undergo general anaesthesia to solve their fear. Many dentists (including our practice) allow patients to choose conscious sedation. In the presence of an anaesthetist the inhalation of nitrous oxide or – more effectively – the intravenous administration of benzodiazepines can completely dumb you. Actually, the patient is awake, can follow and cooperate, but is sedated and therefore cannot feel any pain.

Sedative hypnosis

Hypnosis is taking hold as an alternative to total anaesthesia or conscious sedation. The pre-intervention hypnotic techniques are based on listening to the hypnotist’s voice and have already proven to be effective in many cases. The practice of sedative hypnosis is indicated for patients who cannot be anaesthetised by medication. Some patients can’t undergo to anaesthetic for reasons related to their medical history, fear of puncture or intolerance to the type of drugs.

How to fight the fear of the dentist back

All the remedies in the world can only help, but the most significant work is the one on yourself. Every day we are faced with people who are more or less afraid of being in a dental office. The manuals teach us a lot, but only time and continuous contact with patients allows us to stay close to them and accompany them to the end of their worries.

That’s the real place to get a smile back!

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One of the most commonly prescribed antibiotics is the amoxicillin, suitable for adults, children and breastfeeding women. Amoxicillin can be taken by mouth either on an empty stomach or after eating.

Nausea, vomit and diarrhoea are among the most common side effects found in treatment with amoxicillin. It may cause skin reactions not necessarily related to penicillin allergy.

The second most used antibiotic in case of a dental abscess is a combinate antibiotic. It combines the action of amoxicillin and clavulanate. The union of the two substances is particularly useful for those bacterial resistances more challenging to combat. The dentist prescribes combinate antibiotic when amoxicillin is not sufficient.

Antibiotic without prescription

Patients, especially in a situation of acute pain, rely on do-it-yourself solutions. Often people take medicines arbitrarily, without being visited and without a prescription just because they found a suggestion on the internet. 

DIY in dentistry can be harmful. The inappropriate antibiotic may not have the desired effects, and the pain could persist. Moreover, an incorrect dosage can make the medicine useless or worse make it harmful, producing sometimes dangerous side effects. Not to mention that every time we take an antibiotic, antibiotic resistance occurs. So over time, it may become ineffective. The antibiogram is the result of susceptibility tests in which the microorganism is essayed for its susceptibility to several antibiotics.

Are you wondering how many days you should take antibiotics? Keep in mind that once you start taking them, it is never advisable to stop ahead of time. There are at least two good reasons. First, you risk not to eradicate all bacteria. Second, f you quit treatment too early the surviving bacteria could generate defences against the antibiotics themselves (antibiotic resistance).

When to prescribe antibiotics in dentistry?

Dentists prescribe antibiotics also for precautionary purposes, as pre or post-operative prophylaxis. A particular case of antibiotic prophylaxis in dentistry concerns cardiac patients, those with congenital heart defects and those with an artificial valve. In these cases, the dentist prescribes antibiotic therapy to prevent bacterial endocarditis which can occur following a simple tartar ablation.

The selection of the antibiotic mainly depends on the type of bacterium that caused the infection. It also depends on infection severity, on the presence of pathologies or allergies and any pregnancy.

Antibiotic or anti-inflammatory?

One of the most common emergencies in case of a dental abscess is the cheek swelling. This type of swelling can occur both in case of caries (endodontic abscess) as for periodontal problems (periodontal abscess) or during the eruption of wisdom teeth (pericoronitis in case of dysodontiasis)

It may not make sense to take antibiotics for wisdom teeth eruption unless an infection develops at the same time. A common anti-inflammatory will suffice to reduce swelling and keep pain under control. In any case, before taking drugs, it is always better to consult your dentist who will evaluate the actual presence or absence of an infection and the possible need for an extraction.

Are natural antibiotics effective?

If a bacterial infection of the oral cavity needs to be cured, a natural remedy may not be as effective as a drug. There is no scientific evidence to support the use of homoeopathic remedies to treat infections. However, there are natural treatments that can play an important role in counteracting the development of oral cavity infections.

We suggest the use of 

• ice to reduce inflammations and swelling 

• clove infusion to relieve pain (rinsing the mouth)

• ventilated green clay, with bactericidal and purifying properties

• essential oils, aloe vera gel, propolis and echinacea that fortify the body by acting naturally on the immune system.

Bibliography

Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults.

Cope AL, Francis N, Wood F, Chestnutt IG.

Cochrane Database Syst Rev. 2018 Sep 27;9:CD010136. doi: 10.1002/14651858.CD010136.pub3. Review.

PMID: 30259968

Antibiotics in Endodontics: a review.

Segura-Egea JJ, Gould K, Şen BH, Jonasson P, Cotti E, Mazzoni A, Sunay H, Tjäderhane L, Dummer PMH.

Int Endod J. 2017 Dec;50(12):1169-1184. doi: 10.1111/iej.12741. Epub 2017 Jan 16. Review.

PMID: 28005295

European Society of Endodontology position statement: the use of antibiotics in endodontics.

 Segura-Egea JJ, Gould K, Şen BH, Jonasson P, Cotti E, Mazzoni A, Sunay H, Tjäderhane L, Dummer PMH.

Int Endod J. 2018 Jan;51(1):20-25. doi: 10.1111/iej.12781. Epub 2017 Jun 14. Review.

PMID: 28436043

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These bacteria feed on carbohydrates releasing acid which corrodes the dental enamel which becomes porous and leads the untreated caries to deepen first towards the dentine and then to the dental pulp.

Therefore, tooth decay isn’t more than the tooth acid corrosion due to the result of the streptococcus mutans secretion which can be found in the form of the plaque and the tartar adhering to the tooth (these bacteria eats the sugars secreting then acids).

In its first stage the cavity is asymptomatic and it shows as a small darker spot at the enamel layer.

If it is located on the occlusal surface of the tooth it can be clinically highlighted by an explorer meanwhile if it is located between two teeth it can be highlighted by an intrabuccal x-ray where there can be found a dark spot if the caries has already at least destroyed a quarter of the dental mass.

The more this caries advances to the pulp a stronger pain arises to the teeth. It is recognizable by a dark “hole” within soggy material. It is important to remind that the caries has a pyramidal shape and what we see it’s only the tip which means that that small dark spot on the tooth can hide a very wide caries.

When the caries reaches the pulp causing pain the tooth must be devitalized.

How much does it cost to treat tooth decay?

The dental caries treatment fee is variable and the evolution stage of the disease affects the final amount. The devitalization, for example, is a much more expensive procedure than the filling. The number of the teeth involved in the carious process can also contribute to increase the fee, it can actually occur that some patients can show more than one carious dental element even at different stages of evolution.

Just for a general idea of the amount of the cost, in our dental office the fee for a basic filling is from about 80 € up to 250 € depending on the complexity of the cases. The complexity of the filling depends on how many parts of the tooth are involved in the carious process. There can be diagnosed I class simple cavities where only the occlusal surface is involved, II class cavities where the interdental surface is also involved, the mesiocclusion distal cavities (MOD) where at least three parts of the tooth are involved, V class cavities which involve the dental neck (in these cases it is much more complex to add the rubber dam) and the III and IV class cavities which involve the incisors and the canines for what concerns the aesthetical zone.

How much does it cost to treat cavities?

Average cost in Italian dental practices.

How to treat caries

As already said, treating caries can vary according to the pathology stage. For the easiest cases the dentist proceeds with a filling after cleaning the tooth removing the infected dentine, which means that the cavity caused by this procedure is filled by some composite material. If the caries has extended to the pulp it is necessary to devitalize the tooth and in some cases to protect it with a dental crown.

In both case a rubber dam must be used, that is a rubber sheet that isolates the tooth avoiding contamination caused by salivary liquids and especially the patient’s breath.

Can cavities be prevented?

Caries can be prevented by using fluorine within a procedure since the childhood or even before. Taking fluorine in pregnancy and giving it to the child until age seven, can determine such a mineralization able to preserve the teeth from the bacteria causing caries.

Once chosen this option It is important to avoid home remedies preferring to seek help from the dentist as an overdose of fluorine can provoke spots on the teeth then hard to remove.

Who hasn’t taken fluorine is condemned to tooth decay?

Absolutely not. Caries can be prevented also with a correct domestic oral hygiene, with the professional oral cleanliness and with healthy nutrition. The rules are always the same, washing teeth regularly and carefully after every meal, using the interdental floss and the water flosser, always remember to check up your dental health and to periodically undergo to professional oral cleanliness sessions.

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The radicular caries are the oral diseases most frequently diagnosed in elderly patients. It can occur when the gums recede, exposing the root surface to pathogenic agents attacks, dental hypersensitivity, dry mouth or xerostomia often due to the intake of certain types of drugs, yellow teeth, caused by the dentine natural color variation or by the use of pigmenting substances.

Another frequent problem in the elderly population is the periodontitis, which can be managed and monitored even in old age, if diagnosed in its early stages preserving the patients’ natural teeth.

If the dental elements have already failed or the evolution of the disease cannot be contained, elderly patients can also replace them with removable prostheses or dental implants.

Let’s see which solution is indicated in the following cases.

Denture or implant?

Patients who have lost their natural teeth may decide to replace them with removable or fixed prostheses. The aim is to rehabilitate the correct masticatory and phonetic functions as well as to restore the beauty of the smile.

Removable prostheses, which are used to replace the whole dental arch, are made up of resin teeth laid on a resin support. The denture is not anchored to any tooth but adhered to the gums with a suction mechanism.

A removable partial prosthesis can be used in case of replacement of one or more teeth. It is anchored by some clamps to the residual natural teeth or implants.

The advantages of choosing a denture are definitely related to the low costs and short realization times. On the other hand, in addition to minor inconveniences such as injuries due to movement or to the difficulty of eating easily, the denture requires a relining procedure approximately once a year; it is the replacement of the pink part of the prosthesis laid on the mucous membranes due to bone resorption.

Denatl implants are a much more stable and comfortable solution for patients. With implantology, the teeth are replaced with artificial titanium roots anchored to the bone. This type of surgery can be also performed with low bone quantity conditions, using implants made of titanium zirconium alloys, which are thinner and shorter.

For the most severe cases, it is necessary to intervene with bone regeneration procedures.

If there are no contraindications, the dental implant is an ideal solution even for elderly patients, who will no longer have to worry about all those aspects related to the removable prosthesis and will be able to live normally their daily life.

Possible contraindications to dental implants in elderly people.

It is a common idea that the more aged is the patient the less dental implant surgery is recommended; the age is not actually a factor that affects the possibility to put an implant. This type of therapeutic procedure can be undertaken by young people as well as by elderly patients.

A possible drawback to dental implantology can be due to other kinds of conditions such as the presence of other diseases that require the use of some types of drugs.

One of these is osteoporosis treated with bisphosphonates. Who takes this type of molecules for a long time and wants to put a dental implant could face osteonecrosis, necrosis of the jawbones, which can hardly be kept under control leading to very serious consequences. This condition does not concern only elderly patients, but all those who need to take these types of drugs, especially through injections.

However, preventive protocol procedures can be implemented to avoid any complications.

In any case, the dentist will check the patient’s general state of health before recommending the implant or the removable prosthesis.

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Our advice is very clear: when it is possible, it is better to save the tooth.
The technology for dentures and dental crowns has reached excellent levels, both regarding dental aesthetics and functionality. Anyway, a prosthesis or an implant still cannot fully replace a natural tooth as the latter is organically connected to the mandibular bones to which its function is related. The “Dental system” is a complex organic mechanism of absolute precision. For this reason our practice is constantly striving to raise its qualitative standards towards conservative dentistry. In order to save our patients’ teeth in most of cases, avoiding the use dental implants as much as possible.

Saving a tooth, in addition, costs much less than its replacement with a dental implant. Suffice it to remember that saving the teeth from periodontitis has a cost 10 times lower than the average required for replacement with implants and crowns.

Conservative dentistry

In the following cases the question more frequently asked is whether or not to choose the conservative way.

Periodontitis

When the inflammation of the gingiva (gingivitis) caused by accumulation of tartar degenerates in periodontitis – most frequently due to a genetic predisposition – it would very often be sufficient to have some sessions of in depth curettages with a good periodontist. A professional and thorough cleaning of the teeth could, in many cases, save the teeth avoiding extraction and avoiding the need for a dental implant.

Caries

The tissues inside a tooth can die as a result of caries or a trauma. In these cases we proceed with root canal therapy. Sometimes the endodontic treatment fails to remove all the necrotic tissue and the infection can persist continuing to feed granulomas that manifest themselves as cysts. In the worst cases, those in which it is more difficult to intervene, it is often preferable to move in a conservative way doing an apicoectomy, as described in the blog Zerodonto.

Evolution in Dentistry

Dentistry evolves in two directions: on the one hand, the most advanced prosthetic materials and the most advanced techniques are studied to ensure an ever greater precision in the practice of guided implantology through the use of computers and microscopes. On the other hand the techniques of intervention aimed at preserving the natural teeth for longer and in a healthier state.

To read all the studies on conservative dentistry produced by the most renown specialists in Italy and abroad, we refer to the scientific blog Zerodonto.

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In the past it was thought that late eruption of wisdom teeth could preclude the alignment of other teeth, or even cause a misalignment. Today it has been shown that the wisdom tooth alone is unable to cause the misalignment of the anterior teeth. This occurs regardless of the presence of the wisdom teeth.  Masticatory forces cause misalignments.

Crooked teeth, although being more difficult to reach with the toothbrush, can easily be attacked by the bacteria that cause decay and cavities. However it must also be said that if a wisdom tooth is crooked and inclined towards the previous one, it almost always risk to cause a decay in that tooth. This kind o caries are often difficult to treat. In these cases it is recommended to extract the wisdom tooth as a preventive measure.

It is proven that the wisdom tooth is unnecessary for chewing so when it represents a problem the first thought is to extract it. In fact, the chewing process involves all the teeth up to the seventh one. The self–cleansing action that normally occurs on the teeth during chewing does not involve the wisdom teeth. This makes them more susceptible to decay.

As oral hygiene is difficult at the level of the wisdom tooth, infections and gum inflammation may occur. Fever and sore throat are also possible (lower third molar dysodontiasis).

When a wisdom tooth hurts, the pain is due to a decay that reached the pulp chamber (the nerve) or to the inflammation of the gum around the tooth. In the latter case the symptoms are generally gum swelling and pain. But also earache, difficulty in swallowing and the inability to open the mouth very wide. In case of necrotic tissues, bad breath could be caused by abscesses or sores.

At what age do wisdom tooth-related problems show?

The first problems related to the wisdom tooth are due to its eruption which usually begins in adolescence, around 17 years old. Cases requiring extraction have a wider age variable from around 35 years, up to 50 and in some cases even 60 years.

Wisdom tooth and pain, what to do?

We usually recommend patients at the initial stage of the wisdom tooth eruption, who experience moderate pain, avoiding hard, cold and hot food. When the pain increases you can take an analgesic, but don’t exceed the recommended dose – remember, analgesics only have effect on the symptoms.

Some suggest keeping the gums clean by rubbing them with a cotton wool wad soaked with hydrogen peroxide, or doing the same thing with a syringe without needle. Usually, however, in absence of specific problems, the pain disappears in a few days. When pain is not caused by the natural and physiological development of the wisdom tooth, it could depends on infections or on orthodontic-related problem. In this cases the only remedy is to schedule a visit to the dentist who will evaluate the situation and decide what to do.

When should the wisdom tooth be removed?

Sometimes it is necessary to remove it because it can obstruct the mouth completely. Apart from the burning sensation caused by infections it can even damage the surrounding teeth or tissues. It could even cause holes or serious injuries to gums or cheeks. When such a risky situation occurs, you need to extract it.

Wisdom tooth removal – how is it usually performed?

Wisdom tooth extraction is usually carried out as for that of any other permanent tooth. Dental forceps are used to tilt the tooth in its alveolus. The applied force loosens the gum intake and allows the extraction. The problem with this canonical technique is that its application often causes a fracture of the tooth. This entail the an operating session that can last up to two hours. This would be the time necessary to remove all the fragments of the broken tooth from the alveolus. Is not infrequent, after the problematic extraction of a wisdom tooth, the occurrence of alveolitis, i.e. the inflammation of the alveolar bone, the bone cavity in which the roots of the teeth are housed.

Wisdom tooth extraction in a few minutes

A fracture occurs when the the forceps move the tooth towards a “lateral” direction. There is, however, a technique – we use in our study – which allows you to extract the wisdom teeth without forceps, using elevators.

Using the elevator instead of the forceps, allows you to push the tooth directly from the bottom to the top, with no lateral movements. The patient will be extremely satisfied with the quick wisdom tooth removal. A painless extraction. Above all, there are no major complications because using levers will avoid breaks, so there will be no residual fragments.

This technique is less traumatic, painless, quick and safe. Therefore we recommend it to all our patients and in general to everyone requiring the extraction of a tooth.

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