Unintentional overdose of analgesia secondary to acute dental pain

Paracetamol: unconventional uses of a well-known drug

OBJECTIVES

To describe and map what is known about unconventional uses of paracetamol through a scoping review of published literature by adopting adopted a PRISMA systematic approach methodology.

KEY FINDINGS

Four themes for unconventional uses of paracetamol emerged: (a) use of paracetamol in sleep (a-1) positive effect of paracetamol on sleep (n = 9) or (a-2) neutral or negative effect of paracetamol on sleep (n = 9); (b) use of paracetamol in sport (n = 13); (c) mixing paracetamol with drinks, waterpipe and illicit drugs (n = 5); and (d) miscellaneous uses (n = 4). Forty records were reviewed and charted. Available literature supports concern around the potential of harmful or non-medical use of paracetamol, especially among patients with a history of substance use, parents of young children or athletes.

SUMMARY

Paracetamol (acetaminophen) is one of the most popular and widely used drugs for the treatment of pain and fever. It is considered remarkably safe if used within instructions. However, there is growing evidence that paracetamol, is sometimes used outside approved indications or abused (i.e. used for non-medical reasons). This review highlights the need for enhanced pharmacovigilance and surveillance of non-medical paracetamol use and raising general public awareness of its potential dangers especially in higher than recommended doses.

Paracetamol misusing to dental pain: a case-report and recommandations for treatment

Introduction: The paracetamol is the most widely used painkiller to dental pain. Patients self-medicating with paracetamol for dental pain had 12.8 more times lead to overdose than patients with other pains. The aim of this work was to propose a standardized management in case of paracetamol overdose from a clinical case report. Observation: A 56-year-old man was referred to the General Emergency Department because he had ingested 32 grams of paracetamol in less than 24 hours due to a dental pain. He was in a state of haemodynamic and hypothermic shock. He was placed on the liver transplant list due to fulminant hepatitis. The dental check-up found juxta-pulpal carious lesions on the four wisdom teeth which were removed before the transplantation. Conclusion: Paracetamol overdose is one of the leading causes of liver failure. The estimated toxic dose was 150 mg/kg/day or about 10 g/day. N-acetylcysteine treatment should be leaded early, between 8 and 10 hours after ingestion. The paracetamol-aminotransferase, as a risk prediction tool, reproductibles methods and biomarkers can identify overdoses and lead to a faster medical care. Information campaigns and warning articles on overdosing risk must be continued to strengthen the prevention message for the population.

Provision of dental care by public health dental clinics during the COVID-19 pandemic in Alberta, Canada

OBJECTIVES

This study aims to describe dental services provided to a low income population in dental public health settings during the first wave of COVID-19 pandemic in Alberta, Canada.

METHODS

Routinely collected clinical data were recorded by dentists in electronic medical record files at Alberta's two Public Health Dental Clinics (PHDCs). Patient contact was via teledentistry or in person, respecting phased provincial pandemic restrictions. A descriptive analysis of data relating to all patients contacting PHDC with dental problems between 17 March - 31 October 2020 was undertaken and compared to equivalent pre-COVID 2019 data.

RESULTS

In the period examined, 851 teledentistry consultations and 1031 in person visits were performed. Compared to the same period in 2019, 46% fewer patients were treated, representing a decrease in dental procedures: tooth extractions (17%), silver diamine fluoride applications (17%), endodontic treatments (82%) and fillings (84%). By contrast, prescriptions increased by 66% overall; representing 76%, 121% and 44% in antibiotics, non-opioid analgesics, and opioid analgesics respectively. In both years, antibiotics were the most prescribed drugs (66% in 2019 versus 62% in 2020) followed by non-opioid analgesics (28% in 2019 versus 33% in 2020); opioids accounted for the remainder (6.5% in 2019 and 5% in 2020). The largest drug prescription increases occurred during April-May 2020, when access to care was most restricted: antibiotics and non-opioid analgesics were 300% and 738% higher than the same time in 2019.

CONCLUSIONS

Teledentistry and pharmacotherapy were used to triage and organise dental patients accessing care during the early stages of the pandemic. However, teledentistry did not replace definitive in person dental treatment, particularly for low income populations with high incidence of toothache and odontogenic infection. Reduced provision of dental procedures was accompanied by an increase in drug prescribing. Expedient access to care must be provided to address the dental needs of this population avoiding risks of further complications associated with infection and overprescribing antibiotics and opiates.

Role of Dentists in Prescribing Opioid Analgesics and Antibiotics: An Overview

Opioid analgesics and antibiotics prescribed by dentists is a useful and cost-effective measure when prescribed appropriately. Common dental conditions are best managed by extracting the offending tooth, restoring the tooth with an appropriate filling material, performing root canal therapy, and/or fabricating a prosthesis for the edentulous space. Unnecessary prescription of opioid analgesics and antibiotics to treat dental pain and bacterial infection is a growing public health concern. This article highlights the state of the literature on opioid analgesic and antibiotic prescribing practices in dentistry, the impact of opioid analgesic overdose, and prevention strategies to reduce opioid analgesics and antibiotic overprescription.

Identifying adults at risk of paracetamol toxicity in the acute dental setting: development of a clinical algorithm

Paracetamol is widely used and effective for the management of dental pain in the UK. Acute dental pain is a recognised precipitant of unintentional paracetamol overdose and in a small but significant number of cases this results in hepatotoxicity. Patients' understanding of the risks of excess paracetamol ingestion remains poor and risk of over-medication before presentation is increased due to a variety of factors including dental anxiety and fragmented provision of dental emergency services. Early recognition of overdose is crucial to preventing significant hepatotoxicity and death. Dentists have a role to play in recognising unintentional overdose cases and directing patients timeously to appropriate medical care. Guidelines on the treatment of paracetamol toxicity are readily available but our data suggests some dental settings may present a weak link in the care pathway and overdose may not be readily recognised. We have developed an algorithm and training package targeted at dentists in the acute dental setting with the aim of improving recognition of paracetamol toxicity in adults and directing onward referral appropriately. This paper also revises the key pharmacokinetics and pharmacodynamics of paracetamol and is intended to raise awareness of issues of toxicity for dentists.

Summary of: Paracetamol overdose secondary to dental pain: a case series

INTRODUCTION

There have been documented cases of serious and life-threatening health effects due to patients taking unintentional analgesia overdose secondary to dental pain. We aimed to determine firstly what proportion of unintentional paracetamol overdose cases admitted to an acute medical assessment unit (MAU) were secondary to dental pain, secondly what proportion of such cases encountered barriers to accessing emergency dental care and finally what clinical burden such cases placed on the hospital services.

METHOD

The clinical coding department provided information to allow appropriate identification and data collection from patient discharge summaries and case notes of all unintentional paracetamol overdose cases secondary to dental pain over a 24 month period (1 March 2012 to 28 February 2014).

RESULTS

One hundred and sixteen admissions were identified specifically for unintentional paracetamol overdose. Dental pain accounted for 48 (41%) of all cases. Females (67%) were twice as likely to be admitted, compared to males (33%), with a mean age of 36 years and four months. Thirty-two (63%) non-dentally registered and all nine (100%) registered patients were unable to access timely emergency dental care before their admission. Forty cases (83%) were referred to the hospital oral and maxillofacial services (OMFS). Thirty-seven (93%) patients underwent elective outpatient dental extractions and the remaining three (7%) patients were admitted for intravenous antibiotics, incision and drainage and dental extractions. All patients were treated under local anaesthetic.

CONCLUSION

Dental pain is the single most common cause of acute medical admission secondary to unintentional paracetamol overdose. Patients registered with a general dental practitioner (GDP), as well as those not registered with a GDP, had difficulty accessing timely emergency primary dental care.

The application of clinical audit to improve pain control following third molar surgery

A telephone survey was used to assess adequacy of pain control after third molar removal in a series of three audits. After each audit, factors contributing to failure to control pain adequately and poor patient compliance with our analgesic regimen were identified. Changes in practice were then introduced to remedy areas of weakness and improve outcome. Despite an apparently sound protocol for the prescription of analgesics for patients having third molar surgery, the first audit revealed that 53% of patients experienced moderate to severe pain. After the introduction of written patient instructions to clarify the use of post-operative analgesics, the second audit demonstrated that 86% had their pain managed successfully. After subsequently increasing the post-operative Ibuprofen doses from 400 mg to 600 mg, the third audit showed that 96% of patients had satisfactory pain control. The use of clinical audit with an evidence-based analgesic regimen and clear, written patient instruction has improved post-operative pain control.

CLINICAL RELEVANCE

This paper demonstrates the usefulness of clinical audit for the monitoring and improvement of pain control and analgesic prescribing regimens following oral surgery, which in turn may improve patient experience and outcome.

Storage and wastage of drug products in Jordanian households: a cross-sectional survey

OBJECTIVE

Appropriate household storage and use of drug products can reduce drug wastage and unnecessary hazards. We aimed to quantify the amounts and types of medications that were stored in Jordanian households and the extent of drug wastage in terms of the amount and cost of these medications.

METHODS

The setting was households in Amman, Jordan. This was a cross-sectional survey study using a pre-piloted questionnaire. Family members were interviewed in person about use of drug products, and where drug products were stored. The main outcomes were types, storage methods, cost and quantities of drug products in every household.

KEY FINDINGS

Two hundred and forty-three households were approached, out of which 219 agreed to participate. A total of 2393 (mean 10.9, SD 5.2) drug products were recorded from the 219 households surveyed. A significant positive correlation was noted between the number of drug products in a household and family size (r = 0.19, P < 0.01), the level of the mother's education (r = 0.24, P < 0.01), the level of the father's education (r = 0.28, P < 0.01) and income (r = 0.14, P = 0.034). Eighty nine (40.6%) households had at least one child younger than 6 years of age, and 1122 (46.9%) drug products were stored in unsafe places in the houses, within the reach of children. More than a quarter of drug products (1509, 27.2%) were not in their original containers, 360 (15%) were unused since dispensing, 261 (10.9%) had expired and 44 (1.8%) had no clear expiry date. We estimated that the cost of drug wastage in the 219 households was US$5414. Paracetamol (202, 8.4%), diclofenac (98, 4.1%) and amoxicillin (79, 3.3%) were the most commonly reportedly stored individual drugs.

CONCLUSION

Drug products are stored in large quantities in Jordanian households. Unsafe storage practices have the potential to pose safety hazards, especially to children.

Medications prescribed in emergency departments for nontraumatic dental condition visits in the United States

BACKGROUND

Prior research has documented factors associated with nontraumatic dental condition (NTDC) visits to emergency departments (EDs), but little is known about the care received by patients in EDs for NTDC visits.

OBJECTIVE

We examined national trends in prescription of analgesics and antibiotics in EDs for NTDC visits in the United States.

RESEARCH DESIGN

We analyzed data from the National Hospital Ambulatory Medical Care survey from 1997 to 2007. We used a multivariable logistic regression model to examine factors associated with receiving analgesics and antibiotics for NTDC visits in EDs.

RESULTS

Overall 74% received at least 1 analgesic, 56% received at least 1 antibiotic, and 13% received no medication at all during NTDC visits to EDs. The prescription of medications at EDs for NTDC visits steadily increased over time for analgesics (odds ratio=1.11/y, P<0.0001) and antibiotics (odds ratio=1.06/y, P<0.0001). In the multivariable analysis, self-pay patients had significantly higher adjusted odds of receiving antibiotics, whereas those with nondental reasons for visits and children (0-4 y) had significantly lower adjusted odds of receiving a prescription for antibiotics in EDs for NTDC visits. Children (0-4 y), adults (53-72 y), and older adults (73 y and older) had lower adjusted odds (P<0.001) of receiving analgesics.

CONCLUSIONS

Nationally, analgesic and antibiotic prescriptions for NTDC visits to EDs have increased substantially over time. Self-pay patients had significantly higher odds of being prescribed antibiotics. Adults over 53 years and especially those 73 years and older had significantly lower odds of receiving analgesics in EDs for NTDC visits.

Accidental staggered paracetamol overdose: An interesting case report

Paracetamol is one of the most commonly used drugs both over the counter and on prescription. Liquid paracetamol is available over the counter all over the world. Most commonly available concentrations are 120 mg/5 ml and 250 mg/5 ml. Many parents and healthcare professionals assume that doses available in different countries are similar. However, 500 mg/5 ml bottle is available in some countries including the United Kingdom. This leaves a potential for accidental overdose with therapeutic intent. We have reviewed the experience of diagnosing and managing an interesting case of paracetamol over dosage caused by several ingestions over 24 hours period (staggered paracetamol over dosage). It highlights the importance of communication between health professionals and parents while managing common medical problems.

The use of herbal preparations as complementary and alternative medicine (CAM) in a sample of patients with cancer in Jordan

PURPOSE

This study sought to describe the type, frequency, purpose and pattern of herbal preparation use as complementary medicine in a sample of patients with cancer in Jordan.

METHOD

The study took the form of a cross-sectional survey of patients attending the outpatient departments at King Hussein Cancer Centre (KHCC), a specialist cancer centre in Amman. The method was based on using a semi-structured questionnaire.

RESULTS

A total of 1138 patients with cancer were interviewed, out of which 404 (35.5%) reported using botanicals based complementary and alternative medicine (CAM) primarily bought form Jordan (85.1%) and used in the crude form as infusions (73.3%). Only 6.8% used herbal products in a dosage form. Most of CAM users were above 40 years of age (63.1%). Recommendation of a friend was the main factor that prompted them to use CAM (41.8%).

CONCLUSION

This study revealed that CAM use is common among patients with cancer in Jordan.

Overuse of non-prescription analgesics by dental clinic patients

Background

Many patients present to dental clinics for treatment of painful conditions. Prior to seeking treatment, many of these patients will self-medicate with non-prescription analgesics (NPA), and some will unintentionally overdose on these products. The objective of this study is to describe the use of NPA among dental patients.

Methods

All adult patients presenting to an urban dental clinic during a two-week period in January and February of 2001 were approached to participate in this research project. Trained research assistants using a standardized questionnaire interviewed patients. Patient demographics and the NPA usage over the 3 days preceding the office visit were recorded. We defined a supra-therapeutic dose as any dose greater than the total recommended daily dose stated on package labeling.

Results

We approached 194 patients and 127 participated. The mean age of participants was 35.5 years, 52% were male. Analgesic use preceding the visit was reported by 99 of 127 patients, and most (81/99) used a NPA exclusively. Fifty-four percent of NPA users were taking more than one NPA. NPA users reported using ibuprofen (37%), acetaminophen (27%), acetaminophen/aspirin combination product (8%), naproxen (8%), and aspirin (4%). Sixteen patients reported supra-therapeutic use of one or more NPA (some ingested multiple products): ibuprofen (14), acetaminophen (3), and naproxen (5).

Conclusion

NPA use was common in patients presenting to a dental clinic. A significant minority of patients reported excessive dosing of NPA. Ibuprofen was the most frequently misused product, followed by naproxen and acetaminophen. Though mostly aware of the potential toxicity of NPA, many patients used supra-therapeutic dosages.

Paracetamol overdose as a result of dental pain requiring medical treatment – two case reports

Two cases of unintentional paracetamol overdose are presented. Over a one month period these patients presented to an Accident and Emergency (A&E) department with symptoms of paracetamol toxicity, following the ingestion of large quantities of analgesia for the self treatment of dental pain. In one case the patient had no access to a dentist. Both patients required admission under the care of the medical on-call team and required anti-toxicity treatment to prevent permanent liver injury. Subsequent referrals were made to the oral and maxillofacial surgery team who provided emergency dental treatment and advice on further dental care. This paper highlights the significant signs and symptoms of paracetamol overdose about which dental practitioners should be aware. It also describes the management principles required to prevent potentially life threatening liver damage. Discussion is also made of the potential impact on patients struggling to cope with pulpal pain without access to a general dental practitioner.

Prevalence of over-the-counter drug-related overdoses at Accident and Emergency departments in Northern Ireland--a retrospective evaluation

BACKGROUND AND OBJECTIVES

One major concern associated with misuse/abuse of over-the-counter (OTC) products is the potential for over-dosage. The aim of this research study was to evaluate, over a 3-month period, OTC medicine-related overdoses (those involving OTC drugs only and OTC drugs in combination with other drugs) that led to patients presenting at the Accident and Emergency (A & E) departments in four Belfast hospitals.

METHODS

A data collection sheet was designed to capture the information required from the A & E records in each hospital. A retrospective week-by-week data collection, reviewing A & E records, took place over a 3-month period (starting on 1 December 2002). All data related to cases presenting at the A & E departments because of drug overdoses (either accidental or deliberate according to Read Clinical Classification) were included in the study. Data were coded and entered into a custom designed SPSS database for analysis, using Chi square and Fisher exact tests.

RESULTS

OTC drug-related overdoses comprised 40.1% of all overdoses, of which 24.0% were OTC-only overdoses. Those who overdosed on OTC drugs (solely or combined with other drugs) were mainly female (62.3%) and in the age category 31-50 years (44.9%; P <0.05). The majority (n=215) of OTC-related overdoses were intentional, whereas only 28 were accidental. Of those who attended the A & E departments and had an overdose history, one-third overdosed on OTC-related products and two-thirds overdosed on OTC drugs only.

CONCLUSIONS

OTC drugs accounted for a significant proportion of overdose presentations at the A & E departments in Northern Ireland. Higher awareness of the potential of OTC product use in overdose cases (intentional or accidental) is recommended for both the public and health care professionals.

Over-the-counter analgesics in older adults: a call for improved labelling and consumer education

The use of analgesics increases with age and on any given day 20-30% of older adults take an analgesic medication. Over-the-counter (OTC) analgesics are generally well tolerated and effective when taken for brief periods of time and at recommended dosages. However, their long-term use, use at inappropriately high doses, or use by persons with contraindications may result in adverse effects, including gastrointestinal haemorrhage, cardiovascular toxicity, renal toxicity and hepatotoxicity. Many OTC drugs are also available through a prescription, for a broader range of indications and for longer durations of use and wider dose ranges, under the assumption that healthcare providers will help patients make safe choices about analgesics. Safe and effective use of medications is one of the greatest challenges faced by healthcare providers in medicine. More than 60% of people cannot identify the active ingredient in their brand of pain reliever. Additionally, about 40% of Americans believe that OTC drugs are too weak to cause any real harm. As a result of a recent US FDA policy, the conversion of prescription to OTC medications will result in a 50% increase of OTC medications. To reduce the risks of potential adverse effects from OTC drug therapy in older adults, we propose that the use of analgesics will be enhanced through the use of patient and healthcare provider education, as well as improved labelling of OTC analgesics. Improved labelling of OTC analgesics may help consumers distinguish common analgesic ingredients in a wide variety of preparations and facilitate informed decisions concerning the use of OTC drugs.

The use of over-the-counter drugs among surgical and medical patients

INTRODUCTION

An increasing number of drugs are sold directly to the consumers without a prescription from pharmacies and from non-pharmacies such as supermarkets and gas stations.

AIM OF STUDY

To analyse the consumption of over-the-counter drugs (OTCs) among patients recently discharged from two hospital departments. Furthermore, to describe where the drugs had been bought and to which extent OTCs used prior to admission were recorded in the hospital files.

METHOD

Patients were visited within 1 week after discharge and interviewed about OTC use. Home inventories were inspected. Hospital files and discharge letters were examined.

RESULTS

In totally, 83 surgical and 117 medical patients were included (n=200). Whereas the home inventories of 187 patients comprised 587 OTCs, 13 patients (7%) stored no OTCs. Of the patients, 134 (67%) used OTCs daily and 132 patients (66%) used OTCs on demand; 79 patients (40%) stored a total of 157 OTCs not currently used. Analgesics were used by 138 patients (78%). Acetaminophen was the OTC used most frequently. Of the 240 OTCs used daily, 238 (99%) had been purchased from pharmacies and 169 (70%) had been prescribed. Of the 430 OTCs used daily or on demand, 348 (81%) had been recommended verbally or prescribed by health care professionals. Among the 206 OTCs used daily prior to admission, 162 (79%) were recorded in hospital files, whereas only 41 (24%) of 173 OTCs used on demand were recorded.

CONCLUSION

Two of three surgical and medical patients use OTCs daily. Most OTCs are used with the consent of health care professionals and are purchased from pharmacies. Pre-admission OTC use is incompletely recorded in the hospital files. If information was systematically collected from pharmacies and general practitioners, the number of recall biases concerning OTC use in the medication histories may be reduced.