A number of studies have identified that medical practitioners have only a small or no amount of training during medical school in regard to treating dental infections or dental pain [
Without a doubt, suitable knowledge of any condition afflicting a patient is necessary to correctly diagnose, refer, and prescribe. Indeed the differential diagnosis of pain in the oral cavity can be very challenging as many different types of dental problems can present with similar signs and symptoms and sometimes the pain may not even originate from the dentition [
The objectives of this study were to create a simple but accurate treatment algorithm to help practitioners in the process of diagnosing, referring, and prescribing pain relief and/or antibiotics for patients who present complaining of dental pain.
This study utilised an exploratory qualitative design, using a convenience sampling technique with focus group discussions following the 2013 Declaration of Helsinki for medical ethics and was conducted from the period of April 2014 to December 2014. This study aimed to identify what GMPs would prefer in a treatment algorithm to effectively and appropriately refer, tentatively diagnose, and prescribe antibiotics (excluding mouth ulcers and trauma). The stakeholder group was general medical practitioners.
To find participants, 209 Family General Practice clinics were randomly contacted using information retrieved from the Australian Health Practitioners Regulation Agency (AHPRA) via letters sent to each clinic. Information about the study, consent forms, and ethics information were included in the original letters sent to the 209 clinics. Forty-three (
Profile of participants in focus groups.
General medical practitioners ( | |||||||||
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Number of focus groups | Participants per group | Female | Male | <10 years in practice | 10–20 years in practice | >20 years in practice | Participants average age group | Number of participants using therapeutic guidelines daily | Number of doctors whose workload included 50% indigenous persons |
5 | 8-9 | 19 | 24 | 11 | 9 | 23 | 40–50 years | 31 | 17 |
The facilitators conducted the discussions and audiotaped them following written consent; any potentially personal data was deleted. Focus groups were continued until saturation was achieved with 5 focus groups of 8-9 GMPs. Saturation was determined using the theory published by Cameron (2005) [ What types of dental pain complaints do you commonly see in everyday practice and how do you manage them? Would you change your management of these complaints if you knew the accepted therapeutic guidelines about dental pain? What sort of diagnostic aid would most benefit your everyday practice and how would you design it?
Audiotapes data was transcribed verbatim independently by two of the authors, crosschecked, and then analysed with thematic content analysis and checked using ATLASti (4.2) to categorise the transcripts [
Informal member (off-record) checking was done throughout the focus groups to clarify, summarise, and paraphrase. The discussion supporting the data should assist the reader in evaluating the trustworthiness of this study after analysis, member checking was performed. Here authors sent the de-identified data to two previously identified GMPs who were happy to review the data. The authors considered the effect of reflexivity on this qualitative research, in particular that it was qualitative research in dentistry [
Five focus groups were conducted from the period of April to December 2014 (see Table
The most common form of dental pain presenting to the general medical practitioners in this study was large swellings or abscesses in the oral cavity. Participants spent time discussing which presentations of pain they commonly saw. Specific concerns of the practitioners included correct referral, appropriate prescription of analgesics and antibiotics, and whether or not the patient would have access to a dentist in time. Almost all practitioners related these concerns back to a lack of continued professional development regarding emergency dental problems. In addition, practitioners felt there was not enough information about who to refer to or which forms of dental pain require antibiotics and if these antibiotics would actually penetrate into the tooth infection.
Uncertainty of whether or not they were providing the appropriate prescriptions was a common theme:
It also appeared that GMPs thought there was a significant call for continued professional education on the subject of dental emergencies in the medical setting.
One particular practitioner summarised the education issue succinctly:
Participants believed that if they had some more knowledge on the different symptoms oral pain can present with, then they would be able to triage which patients were emergencies versus which patients needed a general dental checkup. They also mentioned that they felt dentists were not involved as much as they should be with patients as GMPs are and that more contact between GMPs and dentists would benefit both disciplines and increase knowledge of best evidence based practice. Dentists were seen as a valuable source of information:
When discussing what sort of treatment algorithm design GMPs would prefer, there was at first a little confusion. A few doctors knew exactly what they wanted, but the majority of participants did not know what they would want included and what might be unnecessary.
Two focus groups brought up the fact that they often see indigenous patients and that they usually only come to the GMPs if they have a large swelling of abscess. They focused on whether or not certain types of dental infections require referral to the emergency room. All participants understood the signs and symptoms of airway obstruction but not all participants knew whether or not to refer to the emergency room if there was a large swelling but no airway obstruction.
After in-depth discussion amongst participants, all but one focus group provided a draft of possible algorithms to the facilitators. This basic picture of the algorithm was taken by the researchers and provided the basis for the algorithm provided in Figure
Antibiotics and pain relief for dental pain presenting to the general family practitioners [
Condition | Antibiotic cover | Analgesic cover |
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Severe superficial infections with swelling and/or systemic signs and symptoms | Amoxycillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, every 8 hours for 5 days |
Paracetamol 1000 mg every 4 hours (max 4 g/day) (child: as per TG) |
|
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Nonresponsive superficial infections with swelling and/or systemic signs and symptoms | Metronidazole 400 mg (child: 10 mg/kg up to 400 mg) orally, every 12 hours for 5 days and phenoxymethylpenicillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, every 6 hours for 5 days |
Paracetamol 1000 mg every 4 hours (max 4 g/day) (child: as per TG) |
Note: All patients with oral infection should be seen by a dentist within 2 or 3 days. If there is difficulty in breathing, swallowing, or opening the mouth, then urgent referral to ED is necessary and antibiotics will be given IV at the ED.
Treatment algorithm for dental infections for medical practitioners [
The strengths of this study were its relatively high sample size, and that selection of participants was unbiased, and that 44% of participants reported that at least 50% of their patient load were indigenous patients. Many GMPs (73%) reported using Therapeutic Guidelines (TG) on a daily basis; however, it was not known which TG was used. Limitations included the long period of data collection and the fact that a number of groups of GMPs were not included in the study. For example, it was not specifically known for how long each practitioner had worked, as the pre-focus group questionnaire only asked for an average timeline of work experience (e.g., 1–10 years). Inclusion of an equal number of experienced GMPs and new graduates would have given the focus groups a broader range of discussion points as to how they gathered information using evidence based medicine such as using the internet, articles, or textbooks. Utilising a purposive sampling technique would enable a wide range of GMPs to participate, and possible targeting for gender, ethnicity, religion, political views, age, and education could be controlled for, but further observations would probably only yield minimal information.
The results of the analysis showed that the participants had a wide range of experiences with dentists and patients with dental infections, and the algorithm was designed to reflect this wide range of possible presenting complaints. Results appear to be transferable to different groups of GMPs, ranging from those with little to no experience with dental infections to those that have worked in practices that see dental emergencies daily such as emergency departments. Post-analysis member checking identified some distortions in the data that were removed and validated the views of the focus groups. A number of participants noted that their patient base consisted of equal to or more than 50% of indigenous patients. Considering that the most common dental problem experienced by medical practitioners was large swellings or abscesses, this may indicate the level of dental access in these areas. The algorithm may therefore be applicable to rural and remote areas which statistically have more instances of abscesses, but further validation of the algorithm is recommended [
Continued professional development is mandatory for medical practitioners worldwide and involves practitioners taking online or hands-on courses in certain medical disciplines to maintain up-to-date knowledge in clinical practice. Many GMPs felt that there were not enough development courses available regarding dental infections and dental emergencies. The United States currently has a well-established module to address CPD for dental emergencies and this could be modified for Australian and other national guidelines [
As a general dental surgeon, the main author may have introduced bias into the results but overall the data was considered to be overall unaffected by the facilitator.
It is obvious that medical practitioners already understand what sort of situations require emergency referrals but it appears that reinforcement of the signs and symptoms of dental emergencies would be useful and this has been designed and provided to work in conjunction with treatment algorithm.
The purpose of the treatment algorithm was to provide medical practitioners with a greater understanding of the signs and symptoms each dental condition can present with. Many of the GMPs at the focus groups (72%) requested that a text-based interpretation of the algorithm be supplied. Its purpose was not to act as a sole diagnostic tool but to aid in situations when there is confusion as to who to refer to and whether or not the case is a true dental or surgical emergency.
Any pain lingering for less than one minute does not generally involve the nerve. Stimulus is cold or sweet but can also include acidic and spicy ones [
There are a few different causes of this presentation of pain. Pain on hot stimuli and inability to sleep represent severe inflammation of the nerve [
Fleeting, intense, and sharp pain occurring on cold or sweet that almost immediately disappears when stimuli is removed is pathognomonic of dentine hypersensitivity [
Throbbing tooth without initiating stimuli is characteristic of a symptomatic necrotic nerve and requires referral to a dentist but it is not a surgical emergency [
Pain on tilting one’s head forward and the absence of any other dental pain are pathognomonic of an inflammation of the maxillary or frontal sinus. Antibiotics, steam inhalation, and nasal sprays/solutions are useful [
Pain worsening 1–4 days after extraction is most likely due to a dry socket (alveolar osteitis) which is a lack of healing and not a bacterial infection. Antibiotics are not indicated. The socket can be rinsed with saline solution to remove debris. A dressing of eugenol and iodine (Alvogel
Any abscess or swelling requires timely referral. Conditions that compromise the airway or nervous system or where a delay could result in the death or permanent impairment of health are surgical emergencies [
Diagnosis of dental pain can be difficult, especially when one has not had any formal training. The treatment algorithm presented gives general family practitioners a simple method to determine oral pain typically presenting to the medical office and may aid in saving time. The majority of the general family practitioners within the focus group believed the treatment algorithm had clinical and theoretical uses and it benefited them during consultations. All cases require referral to a dentist or the emergency department or maxillofacial unit, to determine the definitive diagnosis, but the physician and the patient may benefit from a more accurate referral and peace of mind regarding the cause. Followup research as to the long-term utility of this treatment algorithm would be useful to determine its validity.
Currently, Dr. Ava Elizabeth Carter does not work with Griffith University but the two co-authors are associated with the university. The research was conducted by Griffith University staff and thus credit must be assigned to this institution.
Dr. Ava Elizabeth Carter affirms that all authors have no financial affiliation (e.g., employment, direct payment, stock holdings, retainers, consultant ships, patent licensing arrangements, or honoraria) or involvement with any commercial organization with direct financial interest in the subject or material discussed in this paper, and none of such arrangements existed in the past three years. To the best of the authors’ knowledge, no conflict of interests exits.