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