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

Abstract

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.

La prise en charge des urgences odontologiques dans le centre hospitalier Métropole Savoie après un an de fonctionnement d’une ligne d’astreinte

“…Les patients qui fréquentent les services hospitaliers d'odontologie sont généralement à risque du fait des maladies qu'ils présentent ou des traitements qu'ils suivent [7,8]. Le plan de traitement en urgence pour les patients polymédicalisés a été adapté en fonction des risques médicaux liés à leur pathologie ou à leur traitement.…”

Pharmacology: Inflammatory definitions

“…Pilocarpine is derived from the Jaborandi plant which is the only known source of pilocarpine in the world. 1 Pilocarpine hydrochloride is a direct acting cholinergic parasympathomimetic agent which stimulates secretion by exocrine glands such as the salivary, sweat, lacrimal, and respiratory mucous glands. Pilocarpine is used widely for the management of glaucoma, radiation induced xerostomia, drug induced xerostomia, Sjogren's syndrome, and xerostomia associated with cGVHD (Chronic graft-versus-host disease).…”

“…Pilocarpus species are found exclusively in South America, mainly in the forests of northern Brazilian states. 1 Jaborandi was first introduced to western medicine in 1873 when Symphronio Coutinho, a Brazilian doctor took the leaf sample to France. He routinely used Jaborandi leaves in his practice as a diphoretic and sialagogue.…”

“…2 Because of its commercial value, this species was exploited without control and by the 1990s it was considered an endangered species in Brazil. 1 During the dry season collectors go into the forest and strip the leaves from branches by hand. Excessive and frequent collection of leaves from the same plant does not allow full development of new leaves leading to high plant mortality and reduction in the size of new leaves.…”

“…1 They state correctly that paracetamol has been shown to reduce swelling, but confuse the issue by stating that it does not exhibit the antiinflammatory effects noted in NSAIDs (non-steroidal anti-inflammatory drugs). The traditional classification of NSAIDs with 'anti-inflammatory' effects versus the so-called analgesic-antipyretic drugs without 'anti-inflammatory' effects found in Anglo-Saxon literature and enthusiastically supported by the pharmaceutical industry is conceptually wrong.…”