Outcomes to evaluate care for adults with acute dental pain and infection: a systematic narrative review.

OBJECTIVE: To identify outcomes reported in peer-reviewed literature for evaluating the care of adults with acute dental pain or infection. Design Systematic narrative review. SETTING/PARTICIPANTS: Primary research studies published in peer-reviewed literature and reporting care for adults with acute dental pain or infection across healthcare settings. Reports not in English language were excluded. STUDY SELECTION: Seven databases (CINAHL Plus, Dentistry and Oral Sciences Source, EMBASE, MEDLINE, PsycINFO, Scopus, Web of Science) were searched from inception to December 2020. Risk of bias assessment used the Critical Appraisal Skills Programme checklist for randomised controlled trials and Quality Assessment Tool for Studies of Diverse Design for other study types. OUTCOMES: Narrative synthesis included all outcomes of care for adults with acute dental pain or infection. Excluded were outcomes about pain management to facilitate treatment, prophylaxis of postsurgical pain/infection or traumatic injuries. RESULTS: Searches identified 19 438 records, and 27 studies (dating from 1993 to 2020) were selected for inclusion. Across dental, pharmacy, hospital emergency and rural clinic settings, the studies were undertaken in high-income (n=20) and low/middle-income (n=7) countries. Two clinical outcome categories were identified: signs and symptoms of pain/infection and complications following treatment (including adverse drug reactions and reattendance for the same problem). Patient-reported outcomes included satisfaction with the care. Data collection methods included patient diaries, interviews and in-person reviews. DISCUSSION: A heterogeneous range of study types and qualities were included: one study, published in 1947, was excluded only due to lacking outcome details. Studies from dentistry reported just clinical outcomes; across wider healthcare more outcomes were included. CONCLUSIONS: A combination of clinical and patient-reported outcomes are recommended to evaluate care for adults with acute dental pain or infection. Further research is recommended to develop core outcomes aligned with the international consensus on oral health outcomes. PROSPERO REGISTRATION NUMBER: CRD42020210183

Dental therapeutic guideline adherence in Australia

© 2020 Leanne TeohBackground: Dentists prescribe a variety of medicines, the most common being antibiotics, analgesics and anxiolytics. Drugs have a limited role in dentistry, usually being recommended as an adjunct to dental treatment. In Australia, the Therapeutic Guidelines Oral and Dental are the national prescribing guidelines. Literature shows that dentists worldwide tend to overprescribe antibiotics and do not prescribe in accordance with guidelines. The aims of this thesis were to establish current dental prescribing patterns, determine reasons behind and influences on prescribing decisions, and to design and implement a targeted intervention to optimise dental prescribing. Methods: A three-phase project was conducted. In Phase 1, publicly available data on dispensed dental medicines (2013-2016) was accessed from the Department of Health to analyse dental prescribing trends in Australia. Phase 2 involved two studies of dentists to determine reasons for prescribing decisions: 1. postal survey (n=1,468; response rate=26%) of dentists in Victoria and Queensland and 2. individual qualitative interviews (n=15) of dentists in Victoria. Phase 3 involved designing and conducting a pilot intervention with the aim of improving prescribing. The intervention comprised targeted education and a dental-specific clinical-decision prescribing tool. Participants (n=26) self-recorded their prescriptions for 12 weeks, with the intervention delivered at the six-week mark. Effectiveness was evaluated by comparing total number of prescriptions, indications for prescribing and prescription regimens before and after the intervention. Results: Phase 1 (Chapter 3): Dentists in Australia make some inappropriate prescribing choices, and prefer moderate- to broad-spectrum antibiotics over more appropriate narrow spectrum options, as recommended in the guidelines. The use of opioids and benzodiazepines increased over the study period, indicating need for more education about abuse potential as well as the appropriate role of opioids in dental pain. Phase 2 (Chapter 4): Antibiotics were overprescribed in approximately 55% of cases. Between 16-27% of dentists would preference other analgesics over NSAIDs for dental pain, and almost half (46%) of the participants who prescribed anxiolytics did so inappropriately, with regimens and choices outside the guidelines. Surveys showed a significant proportion of dentists tended to overprescribe antibiotics, prescribe for incorrect clinical indications and inappropriately preference other analgesics and opioids for dental pain over NSAIDs. Several non-clinical factors, such as time pressure and patient expectations, influenced prescribing. Phase 3 (Chapters 5 and 6): Comparing prescribing after the intervention to before revealed a 41% reduction in prescribing of antibiotics and a 45% reduction in inappropriate prescribing. Prescribing of paracetamol/codeine reduced by 57%. For the three most commonly prescribed antibiotics (amoxicillin, metronidazole and phenoxymethylpenicillin), there was an improvement in the accuracy of prescriptions ranging from 0-65% to 75-100% using Australian therapeutic guidelines as reference. Conclusions: Australian dentists overprescribe antibiotics; many factors that influence prescribing (both clinical and non-clinical). Data on prescribing choices and reasons for inappropriate prescribing can inform future dental education and the development of stewardship programs for dental practice. Targeted interventions addressing specific misconceptions and areas that are lacking can produce positive changes with public health benefits. The context-specific intervention that was developed shows substantial promise for implementation into dental practice

Are teething gels safe or even necessary for our children? A review of the safety, efficacy and use of topical lidocaine teething gels

Lidocaine-based teething gels have been widely available in Australia for decades in both commercial preparations and those compounded by pharmacies. However, many case reports have highlighted potential risks and toxicity associated with lidocaine-based teething gels when used in infants and young children, including seizures, respiratory arrest and death. The Australian and New Zealand Society of Paediatric Dentistry and the American Academy of Paediatrics do not recommend topical agents for teething, and the US Food and Drug Administration does not recommend topical lidocaine for this purpose due to concerns of toxicity. Literature supporting the efficacy of lidocaine for teething is scant and difficult to interpret due to the flawed design of the trials conducted and varied formulations used. This opinion article aims to summarise the available literature showing the limited effectiveness and associated risks of topical lidocaine gels for use in teething. In light of these findings, the authors recommend that regulatory bodies such as the Australian Therapeutic Goods Administration review the efficacy and safety of this type of medicine and consider removing the indication for teething or limiting the age of use to older children

Where are oral and dental adverse drug effects in product information?

Objectives: Oral adverse drug reactions are common and are associated with some of our most frequently used medicines. It is important to identify and manage oral adverse drug effects promptly as they not only negatively impact dental health, but also adversely affect medication adherence, clinical outcomes and patient quality of life. This study assessed the location of oral drug-induced adverse effects in the registered drug company product information (PI) of the top 100 most commonly used drugs in Australia as dispensed on the Pharmaceutical Benefits Scheme in 2018. Method: Publicly available data on dispensed medicines were accessed from the Australian Commonwealth Department of Health, to determine the top 100 medicines. The drug company PI for each of these drugs was manually searched to find their oral adverse effects. The number, type and location of the oral adverse drug reactions (ADRs) were recorded. Key findings: Oral ADRs were commonly found varying in nature and severity. However, they were difficult to find as there is no dedicated section for oral/dental adverse effects in the PI and the section they are in is inconsistently applied. Conclusions: We recommend that regulatory authorities such as the Therapeutic Goods Administration in Australia create an additional section for oral/dental adverse effects so they are easier to find, which may assist health professionals detect recognise and report adverse drug effects manifesting in the oral cavity

A review and guide to drug-associated oral adverse effects—dental, salivary and neurosensory reactions. Part 1

Numerous adverse drug reactions (ADR) manifest in the oral cavity and orofacial region. Dentists and other health professionals commonly encounter and manage these adverse effects however, due to lack of awareness and training, they are not always recognised as being drug-induced nor reported to pharmacovigilance agencies. The broad diversity and increasing number of medications for which dental pharmacovigilance is needed can be overwhelming for all health professionals. Thus, the aim of this review and guide was to outline the common medications associated with orofacial side effects so as to improve recognition, management and reporting of ADR. Adverse effects discussed in Part 1 include drug-induced bruxism, tardive dyskinesia, hairy tongue, gingival enlargement, hypersalivation, xerostomia, tooth discolouration and taste disturbance

A review and guide to drug-associated oral adverse effects—oral mucosal and lichenoid reactions. Part 2

Dental practitioners and other health professionals commonly encounter and manage adverse medicine effects that manifest in the orofacial region. Numerous medicines are associated with a variety of oral adverse effects. However, due to lack of awareness and training, these side effects are not always associated with medicine use and are underreported to pharmacovigilance agencies by dentists and other health professionals. This article aims to inform health professionals about the various oral adverse effects that can occur and the most commonly implicated drugs to improve the management, recognition and reporting of adverse drug effects. This article follows on from Part 1; however, the focus here is on lichenoid reactions and oral mucosal disorders including oral aphthous-like ulceration, mucositis and bullous disorders such as drug-induced pemphigus, pemphigoid, Stevens-Johnson syndrome and toxic epidermal necrolysis