Toothache Toothache is the term used for pain that occurs in and around the teeth and jaws. The pain usually starts suddenly and it can vary from mild discomfort to a severe throbbing, which is often worse at night and may be exacerbated by hot or cold food or drinks. A tooth has two main anatomical parts. The crown of the tooth is covered with enamel and is visible in our mouths. The root is the part embedded in the jaw that anchors the tooth into its bony socket. It is normally not visible. Beneath the enamel lies a layer of dentine. Dentine is much softer than enamel, forms the bulk of the tooth, and becomes sensitive if the protection of the enamel is lost. The pulp is the innermost part of the tooth. It is made up of soft, sensitive tissue that contains the blood and nerve supply to the tooth. The pulp extends from the crown to the tip of the root. Toothache happens when the innermost layer of the tooth – the pulp – becomes inflamed. The most common reason for dental pulp inflammation is tooth decay (dental caries). Tooth decay is caused by the action of acids on the enamel surface. The acid is produced when sugars (ie, fructose, glucose, sucrose) in foods or drinks react with bacteria present in the plaque on the tooth surface. The acid produced leads to a loss of calcium and phosphate from the enamel by a process called demineralisation. Saliva acts to dilute and neutralise the acid that causes demineralisation and is an important natural defence against caries. Saliva also has the ability to remineralise areas of destroyed enamel once the acids have been neutralised. However, if the process of demineralisation exceeds remineralisation, the caries progresses and a breakdown in the enamel surface occurs leading to a cavity. Other causes of tooth pain include: • a cracked tooth, loose or broken fillings, or a recently restored tooth • a periapical abscess – pus which collects in the root as a result of an untreated cavity, injury or prior dental work • alveolar osteitis (dry socket) – pain that occurs in the tooth socket three to four days following dental extraction. OTC analgesics will help relieve the pain • pericoronitis – an infection of the soft tissue covering impacted wisdom teeth, common in adolescents, which requires immediate referral to a dentist • receding gums – contraction of the gums exposes dentine in the tooth root. • Many people also suffer from “sensitive teeth”, when the teeth are exposed to temperature extremes. The reason for the pain is unknown. People at higher risk of dental decay People considered at high risk of tooth decay (dental caries) include those: • currently undergoing orthodontic treatment • with a history of dental decay or precavitated lesion in the past three years • with decreased salivary flow causing a dry mouth TREATMENT OPTIONS Category Examples Comments Simple analgesics [GENERAL SALE] eg, paracetamol (Panadol, Paracare, Pamol suspension) Effective at relieving pain but are not anti-inflammatory so will not relieve swelling or inflammation in the area. Suitable for people with contraindications to NSAIDs. Oral non-steroidal anti-inflammatory agents (NSAIDs) Oral hygiene products Natural / herbal products / supplements [GENERAL SALE] eg, aspirin (Disprin range), ibuprofen 25s (Nurofen range), ibuprofen suspension (Fenpaed, Nurofen for Children) eg, ibuprofen + paracetamol (Maxigesic, Nuromol) [PHARMACIST ONLY MEDICINE] eg, diclofenac 25mg (Voltaren Rapid 25) eg, ibuprofen + codeine (Ibucode Plus, Nurofen Plus), paracetamol + codeine (Panadeine, Panadeine Extra) eg, interdental brushes, dental floss, mouthwashes, personal water jets, toothbrushes, toothpastes, xylitol or fluoride-containing products, sugar-free gum Clove oil, S. salivarius K12 and M18 Ibuprofen is the NSAID least likely to cause stomach irritation. NSAIDs may not be suitable for people on certain other medications or with some medical conditions (eg, asthma, kidney disease – see Refer to Pharmacist). Advise customer to stop taking if stomach upsets, increased bruising or prolonged bleeding occur. Aspirin is not recommended for adolescents or children under 12 years old (see Childhood Pain and Baby Teething: Treatment options). Avoid aspirin following dental surgery (may prolong bleeding time). See Reference Section, OTC Medicines – Precautions. Combination NSAIDs are effective for moderate pain. Warn customers that codeine is an addictive substance and should not be used for more than three days at a time. Constipation or drowsiness may also occur. Monitor sales and be alert for any customers who may be misusing codeine-containing preparations. Interdental brushes help remove plaque from between teeth and are an alternative to dental floss. Both can help reduce tooth decay by removing food and plaque from the spaces between teeth. Products containg xylitol or fluoride can decrease the risk of dental caries. Mouthwashes (antiseptics) temporarily lower the number of bacteria in the saliva but are not a substitute for regular teeth brushing. Chewing sugar-free gum stimulates saliva production which is important for buffering food acids, supplying minerals for remineralisation, and diluting and increasing clearance of food debris from around the teeth. See Oral Health: Treatment options, for product details. Clove oil applied directly to tooth with a cotton bud may act as a local anaesthetic until the person can see a dentist. Can be fatal if swallowed. Keep out of reach of children. S. salivarius K12 and M18 are oral cavity probiotics which are have activity against bacteria implicated in bad breath, gingivitis, and tooth decay. MANAGING PAIN FREE PROFESSIONAL DEVELOPMENT FOR Pharmacy assistants, technicians and students 4 Page 150 HEALTHCARE HANDBOOK 2017-2018 Common Disorders
CONTINUING OTC EDUCATION Caring for children’s teeth •• Always supervise and assist children aged less than eight to brush their teeth. •• Begin caring for your child’s teeth as soon as they have erupted. •• Use just a smear of normal-strength fluoride toothpaste either on a cloth (very young children) or a child-size toothbrush, up until age six. •• For children older than six years, use a pea-sized amount of toothpaste. •• Brush twice a day, morning and last thing before going to bed, for two minutes. Spit out extra toothpaste, but avoid rinsing with large amounts of water as this will wash away protective fluoride. •• Help children to floss their teeth when two teeth touch (usually when the back teeth appear). •• Replace a toothbrush when worn, or at least every three months. •• Breast milk is best for babies. Never give infants sweet drinks in their bottle and never dip dummies in sweetened substances. •• Use a training cup instead of a bottle as soon as the child can drink from one. •• Parents should avoid sharing spoons with their children or putting their child’s dummy in their own mouth to avoid the transfer of dental caries-causing bacteria. • with eating disorders • with enamel defects • without exposure to fluoride, either through a drinking source or supplements • with poor oral hygiene or who smoke • who eat a high sugar or high carbohydrate diet • who are unable to afford dental treatment, or who seek it rarely • who consume sugar-laden sports gels or drinks during prolonged exercise. Good oral hygiene is important for everyone, not just those at risk (see Oral Health). Regular dental check-ups (six monthly to yearly) may help prevent major dental surgery later on (eg, root canals) or gum problems such as gingivitis (see Oral Health). OTC analgesics may partially or temporarily alleviate toothache or other types of dental pain until the person is able to see a dentist. Fluoride helps prevent tooth decay and many town water supplies in New Zealand are fluoridated. Refer anybody wanting information on fluoride supplements to a pharmacist. Children’s teeth Taking good care of children’s teeth while they are young helps to prevent dental problems later in life. Early childhood caries (ECC) is the form of tooth decay that affects the teeth of infants and young children and has been identified as an important health problem in New Zealand. It can cause problems with low selfesteem and speech development and have lifelong implications. ECC is caused by long and frequent exposure of a child’s teeth to sugar. Encourage parents to regularly inspect their child’s mouth for signs of dental decay, and to take them to a dental clinic if they have any obvious cavities or are complaining of pain. Free basic oral health services are available to New Zealand children from birth until their 18th birthday (see www.healthysmiles.org.nz or ask at the child’s school). For baby teething advice see Childhood Pain and Baby Teething. To complete the work book assessment visit pharmacytoday.co.nz Refer to PHARMACIST The following questions aim to identify customers who would benefit from further input from a pharmacist. Your initial assessment may have already provided some answers. Decide if any further questions still need to be asked and refer any “yes” answers to a pharmacist. • Does the person have any other health conditions (eg, immunosuppression, diabetes, is pregnant or breastfeeding)? • Does the person take any other medication, either prescribed by a doctor or bought from a shop or supermarket (including herbal/ complementary medications)? • Is the person a child? • Does the person have a cold or fever, obvious inflammation or abscess? • Is there any swelling around the tooth, jaw or face? • Has the person sustained a facial injury (eg, mouth trauma)? • Has the person had any dental extractions previously? • Does the person drink unfluoridated water? • Does the person have any allergies to medicines? Initial assessment Visually, there are not usually any outward signs of a toothache, and a good history from your customer or a child's caregiver plus the answers to the Refer to Pharmacist questions will help you decide if the condition is treatable in a pharmacy. Most toothaches are not; however, analgesics may be sold to temporarily relieve the pain until a person can see a dentist. For people prone to cavities or with concerns about their teeth, offer advice about good oral hygiene (see Oral Health), and consider the use of probiotics (see Probiotics) such as S. salivarius K12 and M18. Mouthwashes may also help, but these should not be used as a substitute for good teeth brushing. WIN ONE OF SEVEN $500 CASH PRIZES Page 151
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