Dental pain management – a cause of significant morbidity due to paracetamol overdose
Br Dent J 2018; 224: 623–626 http://dx.doi.org/10.1038/sj.bdj.2018.264
Harm and benefit
In healthcare the balance between doing good and doing no harm is always a difficult one to call. The use of paracetamol as an over-the-counter analgesic is a very common occurrence for a variety of pain-relief situations, one of which is oral or dental pain. Self-medication can of course be for many reasons but one of which is fear of the dentist and this can manifest both in the reasons for the pain, i.e. failure to attend for routine and preventive care and the reason for staying away when in pain, i.e. the hope that the pain killer will negate the need to attend.
It is perhaps surprising to discover just how widespread abuse, or overdosing of paracetamol is in the UK and this paper lifts the lid on some startling statistics in terms of patients involved and numbers of hospital admissions. Not only is the health and safety of the overdosing individuals at risk but the cost to the NHS as well as the use of resources which might otherwise be redirected is considerable. This again calls into question of where the balance lies between doing good and doing no harm.
One obvious response to this research is to seek ways in which to solve the problem and to bring into safety those who misuse paracetamol. An immediate answer would be an awareness exercise in educating us all about the safe dosage limits of the drug. Interestingly a survey of dental professionals disclosed a paucity of knowledge on this too. Surely we, medical and pharmacy colleagues could play an important role in this? The ongoing need to encourage regular attendance at the dentist as well as all the familiar routes to good oral health are other obvious steps; but clearly these are failing a significant section of the population.
Better co-ordinated emergency services have been ceased upon as requiring necessary revision and there is much to be said for this too. Easier availability of out of hours pain relief may well help to curb some of the apparent need for excesses of taking pain killers over a short time period. This, of course, also comes at a cost of time, money and resources and, once again we have to look at balances of these elements. However, at the end of the day it is no surprise that it is education which once again heads the 'to do' list.
Author Q&A Laura O'Sullivan, Queens Medical Centre, Nottingham, UK
What led you to study paracetamol overdose?
While working as an on-call dental core trainee, it was almost the norm to receive at least one call from medical colleagues during an on-call week or weekend regarding patients with toothache. In most cases, these patients had taken too many paracetamol tablets, and found themselves on a medical ward receiving treatment for their overdose. Many of these patients would still be in pain when assessed by the on-call maxillofacial team. A genuine intrigue into how and why these overdoses came to be, and what became of these patients, was the main trigger for undertaking this study.
Why do you feel there is such a lack of awareness about safe self-medication?
I feel paracetamol is perceived as being a 'safe' go-to option for the initial management of dental pain by the general population, and it is this perception that perhaps lulls patients into a false sense of security when tempted to exceed the recommended doses on the packaging if their pain is not settling. Taking as few as one or two paracetamol tablets too many has the potential to cause liver damage. A clear and overt warning on paracetamol packaging about the risks of taking too many tablets would certainly send out a much-needed public health message.
Did any of the results in the study surprise you?
The number of patients affected was higher than anticipated, with an average of over three patients per week attending Accident and Emergency. It was also surprising that twice as many of these patients came through our hospital doors during the week compared to weekends. Sixty-nine percent of the patients in our study had contacted their own registered dentist or the local emergency dental service but had been unable to secure an appointment. It is a cause for concern that despite the wide availability of primary care emergency services in the area, these patients struggled to receive necessary intervention to treat their pain.