Discussion
The health care system across the world have been challenged for
controlling the infection due to novel COVID-19 pandemic including the
service of pain management. In dental profession, the condition
prevalent worldwide is tooth pain due to which quality of life has been
reduced along with limitation of daily activities.2,
3, Tooth pain is basically a symptom of pulpal and periapical tissue
infection and when actively inflamed it leads to release of various pain
mediators such as potassium (k+), hydron (H+), histamine, bradykinine,
serotonin 5(HT), nitric oxide, prostaglandin and leukotriens.
Sensitization of nociceptors (free nerve ending) by these pain mediators
activates peripheral and central hyperalgesia mechanism resulting in
moderate to severe pain called symptomatic irreversible pulpitis.6
The best management of severely inflamed pulp of irreversible nature is
either with extraction or definitive endodontic treatment after
immediate pulp extirpation (pulpotomy) as emergency procedure to relieve
pain.7.8 But due to COVID 19 pandemic, protocol of
management changed since 23 march 2020 and focus was mainly on the using
the pharmacological treatment for the relief of pain or infection by
using any remote consultation methods (i.e. by telephone or video
call).3
The pharmacological strategy of pain management is the use of systemic
drugs such as analgesic and anti inflammatory drugs (NSAIDS),
acetaminophen, opioids and steroids. Most of the clinicians in clinical
practice prescribed NSAIDs as they act either selectively or
nonselectively on cyclooxygenase enzyme which is responsible in
formation of pain mediators from arachidonic acid released from the cell
membrane after tissue injury. However NSAIDS are not effective on all
the pain mediators like leukotrienes, nitrogen oxide radicals resulting
in their skewed success.9,10,11
Symptomatic irreversible pulpitis is also associated with various
inflammatory mediators, like those arising from bacterial by-products,
primed immune cells influx and cytokine network activation, so a wide
variety of steroids can be utilised as adjunct to endodontic therapy for
their ability to alleviate dental pain. The steroids like Dexamethasone
having good anti inflammatory and analgesic properties and has been used
in endodontic practice since long based on experimental and clinical
investigations .12,13,14,15
The use of steroid was first described by stalwart as early as 1956 for
management of pain before and after endodontic
procedure.16 Use of dep medrol in untreated
irreversible pulpitis cases have resulted in the reduction of PGE2, IL-8
and cytokinin level.17 The reduction of bradykinin
synthesis level by induction in the formation of kinase II or ACE was
demonstrated by Hargeaves KM and CostelloA 18 after administration of glucocorticoids.Glassman et al 19 compared the efficacy of
Dexamethasone with placebo when given systemically 1 hour and 4 hours
after endodontic treatment of symptomatic irreversible pulpitis and
result were statistically significant.
During the COVID-19 pandemic, the analgesic drug regimens presented here
can be advised to patients with mild and moderate dental symptoms using
over-the-counter drugs or by tele prescription. In adults, where
paracetamol or ibuprofens (standard or higher dose) alone are not
effective, both drugs can be taken together as long as the criteria of
maximum dose or frequency are met. As an alternative, to control and
minimize the severe endodontic pain, opioids or corticosteroids may be
required.14.15 The management options presented here
focuses on pain alleviation or to decrease infection and follow up care
by telephone or video call (teleconsultation). Patients should only be
referred for emergency dental care when above mentioned drugs cannot
manage symptoms by themselves. Unless urgent or emergency care is
required, the patient should be encouraged to manage their symptoms at
home.
It is essential to minimize the number of patients referred to higher
centers designated for emergency care in order to reduce the COVID-19
transmission risk among both healthcare workers and patients as well as
to lessen the pressure on these services. Patients with dental pain and
infection may need to self-manage for longer than normal during the
COVID-19 pandemic. In all the cases presented here, referral to
designated emergency care providers was sought if the symptoms did not
resolve with prescribed pharmacological treatment.
Steroids have their own contraindications and adverse effects, so these
should be used judiciously and risk benefit ratio should be assessed
particularly in patients of ulcerative colitis, pyogenic infection,
peptic ulcer, renal insufficiency hypertension, diabetes mellitus,
tuberculosis, pregnancy. Steroids also are contraindicated in patients
with systematic fungal infection and those with known allergy to the
drug.13,16