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dr.Todd
06-26-2007, 12:26 AM
Hello all,

I am a dentist in Long Beach, CA and today I saw my first RSDS pt. She was unfortunately in extreme pain. I was able to anesthetize her and get what I believe to be the offending tooth removed quite easily. I called her tonight and she is unfortunately suffering again. I am confident (and hopeful) that the pain will resolve soon.

Onto my question though... when I see her in the future, what would make her visits easier? Short appointments? Long lasting anesthetics? Nitrous Oxide? Do patients with RSDS often suffer from increased post-operative pain?

Bottom line: What should your dentist know and do to make a visit more comfortable?

:grouphug: Dr. Todd




Desi
06-26-2007, 12:49 AM
Hello all,

I am a dentist in Long Beach, CA and today I saw my first RSDS pt. She was unfortunately in extreme pain. I was able to anesthetize her and get what I believe to be the offending tooth removed quite easily. I called her tonight and she is unfortunately suffering again. I am confident (and hopeful) that the pain will resolve soon.

Onto my question though... when I see her in the future, what would make her visits easier? Short appointments? Long lasting anesthetics? Nitrous Oxide? Do patients with RSDS often suffer from increased post-operative pain?

Bottom line: What should your dentist know and do to make a visit more comfortable?

:grouphug: Dr. Todd

Hello Dr. Ok, you said that you were able to anesthetize your patient who has RSD Ok, shouldn't you have give her antibiotics first? did you? Did you also get the "Right" tooth as you posted, that";"I do believe I got the offending tooth". You mentioned that she was also in pain. well, she is going to be in pain, don't ya think since you just extracted it today! Even before I had RSD I had pain for the first 3-4 days after an extraction!!! I think the patient should tell YOU what he/she would like, be it long lasting anesthetics, or some other pain relieving medication. We are the best people to answer your questions. Did you ask her? I believe to make her more comfortable is to just listen to her, ask what SHE wants. Well, good luck Dr. and remember we are the ones who will tell YOU want helps, what doesn't. Desi

miss irie
06-26-2007, 12:50 AM
Hello. The following article was taken from the American RSDHope website, www.rsdhope.org

*****
Reflex Sympathetic Dystrophy Patients and Dentistry

by Dr. Aldino P. Maggiulli

Reflex Sympathetic Dystrophy Syndrome (RSD) usually develops after a traumatic episode. Any body part can be affected but the symptoms are mostly seen on the upper and lower extremities. Victims of an injury may develop a burning sensation or numbness on their extremities.

Their pain varies day to day. They may develop problems maneuvering their limbs and have dexterity problems. Some people affected with this syndrome face great challenges while trying to accomplish even routine functions. It is important to share any asset which can provide comfort and consistent results to those who suffer with RSD.

This article shares one such asset which was discovered in a dental setting.

It is apparent that patients with RSD can't be treated in the usual manner as other dental patients. This was discovered when a patient with RSD came to my office for routine dental treatment. The patient, who we'll call "Will" to provide confidentially entered my office on June 21, 2002. Will informed me that he bad been suffering with RSD for the past seven years. He mentioned that he had been involved in a car accident and the symptoms of the disease followed there after.

Will was diagnosed with generalized gum disease and a second appointment was made for him to return for aggressive hygiene therapy. His treatment was initiated on July 22, 2002. Traditional dental anesthesia was given and treatment was delivered to the top right and bottom right gum tissues. Will didn't tolerate the deep cleaning procedure well. He reported feeling fatigue and generalized aches. He still had to return to complete the left sides of his dentition. Will had to be motivated to continue. An agreement was made that his next appointments would be shorter. We would treat only the top left side and on a subsequent appointment treat the remaining bottom left side.

Will reluctantly returned on August 6th. Traditional dental anesthesia was given only to the top left side. The appointment time was cut in half and Will reported feeling a little better than his first visit. He wasn't tired but the aches associated with RSD persisted. A startling discovery was made on Will's third visit. He reluctantly returned for the remaining bottom left gum treatment.

Traditional dental anesthesia was given to the bottom left side. The appointment time was short, unlike his first marathon session treating two upper and lower right areas. This appointment was different in that a second dose of dental anesthesia was given to the patient before the gum treatment ended. Will, for the first time, felt great.

The decreased appointment time combined with additional local anesthesia close to the conclusion of his gum treatment made this RSD patient completely comfortable and report no post-op sensation. It's difficult to conclude any significant treatment protocol by revealing the results of just one RSD patient. This experience demonstrates that RSD patients can't be treated like traditional patients.

Thanks to Will's help, the conclusion to draw is that it is best to give RSD patients short dental appointments. RSD sufferers tire easily and their symptoms may be exacerbated by lengthy dental procedures.

The progression of treatment recorded also shows that two doses of local anesthesia are beneficial; one before treatment and one prior to the conclusion of dental treatment. The two dose application allowed this patient comfortable treatment and no fatigue or generalized ache post operatively. It should be noted that this two dose technique has worked consecutively for Will on multiple appointments since this writing, Will has even had a three unit bridge placed without complications and without increasing the symptoms felt with RSD.

dr.Todd
06-26-2007, 12:59 AM
Thanks for the article miss irie,

I read that about an hour before I posted and that's exactly what got me thinking about the topic. I just want to make sure that she is as comfortable as possible and was looking for some first hand advice that others may have from their personal experience.

dreambeliever128
06-26-2007, 01:05 AM
I admire you for coming on here and wanting to know what you could do to make your RSD patient more comfortable with pulling a tooth or any dental work and what might keep them from being in more pain with the RSD later.
You are the first Dr. or Dentist that I have seen come on here to ask about this. There might have been others but I haven't seen any before. I wish there were more like you. I can't praise you enough.

Some patients don't always know what would work for them to keep the RSD from going into a flare or being made worse. I would say the more you learn about RSD and what keeps it from flaring and what causes it to get worse might help.

You also might read about more meds that you could use to help keep the pain to a low amount.

The article Miss Irie put up is a good one and I'm sure there will be more to come on and tell you some of their experience with dental work and RSD.

Also give her more time, the pain might die down on it's own, it could be just maximized by the RSD but not the RSD itself.

I have a PCP that reads up on medical problems that his patients have and he dives right in to take care of them when they can't find specialist to do the job. That's what makes me think you are a good Dentist. One who cares.

Ada

dr.Todd
06-26-2007, 01:11 AM
Thanks Ada. That really means a lot to me. I am here to learn. All to often as medical care providers we get caught up treating diseases and not the patient. I am here to hear about the your experiences of treatment and how I can do it better.

Dr. Todd

HopeLivesHere
06-26-2007, 01:31 AM
Thanks so much for caring. In my case I took the responsibility for what I needed.
I had a crown done 2 years ago.
My dentist wanted my pain management doctor to come to his office to give me anesthesia because he was afraid to stick me with a needle to give me the block I needed. My pain management doctor said "no way."

I told him to just give me the block but he refused.
So he told me to take a lot of my pain meds and he did the crown without anesthesia.
It really hurt when he drilled out that tooth without novocaine :eek:
It hurt for a few days, but like someone said, it would hurt even if I didn't have RSD. But a little valium or xanax would help a lot.
You are a caring doctor to make yourself knowledgable about RSD.

By the way, I had surgery in Long Beach 3 weels ago.

There is a dentist in New Jersey named Mark who has severe RSD.
He only visits occasionally. I wish he were here now to talk to you.
His story is very sad.

Thanks for your kindness, Glad someone found us who does not have RSD !!
Hope

shiney sue
06-26-2007, 01:46 AM
Just courious do you ever work with folks who have Sjogren's Syndrome
and Micro-valve?? Do not in any way want to take this away from RSD.
Im in Mo. do i check with who,to make sure i'm headed in righ direction.
Good for you to want help from people who have problems hope you keep
posting. Sue

artist
06-26-2007, 02:59 AM
Well done Dr. Todd for braving the lion's den.

:Thanx:

I don't recall either a dentist or doctor visiting us here in a professional capacity before, though we've had at least one dentist in our forum with RSD (where is Markdoc anyway, guys??)

Major kudos!!
all the best :)

allentgamer
06-26-2007, 04:51 AM
Hi Dr Todd!

Wow! I wish more health professionals would think like you do. It would make our worlds a little bit better for sure.

It has been 2 years since I had a root canal done, and I still have a sensitive painful spot on my jaw. If anything just brushes the skin there it causes a sharp intense pain. The tooth has pretty much fallen apart, but I would rather have that problem then go through another round with a dentist. Probably would need a surgeon at this point though :(

I agree with the shorter visits, and the second anesthesia given after the work is done, or just before it is completed. I would also agree about even giving some pain meds, or something to relax the patient before hand.

You are an exceptional doc, and I wish I lived close enough to make an appointment :)

Sydney
06-26-2007, 10:45 AM
What a "breath of fresh air" to find a dentist on this forum. It is a dentist who saved my life from the ravages of facial pain and I will ever be thankful for his expertise and quality care and concern. You are ever so kind to be concerned about doing what we call in education" best practices" for treating a patient with RSD. I have both RSD and fibromyalgia and must receive special treatment for my dental care. Also, I am aware of the consequences of dental procedures which can cause painful reactions due to both conditions.
From experience I can tell you that short procedures are best for the patient. Also, from experience I can tell you that any extraction (at least in my situation) caused extended periods of pain far beyond normal. My facial pain specialist (dentist) gave me injections directly into the gums to calm down the nerves which became hyper - excited due to the extractions. His injections provided almost immediate relief. (Thus, do not be surprised if your patient experiences continued pain) Also, I know that I cannot have any root canals as they are even more apt to cause nerve irritation. Thus I will choose to have an extraction and follow up injections.
You may want to consult with facial pain specialists in the area to see if they have suggestions on how to treat RSD and/or fibro patients.

I could write a book about these conditions and how they have a nervous system connection and we must be concerned about dental and medical treatment. My chronic pain condition began in my face from a dental procedure.
Thank you for your concern and interest. I do hope you continue to check in on this as well as other forums. There is also a dentistry forum here.
Best wishes,
Sydney

buckwheat
06-26-2007, 11:58 AM
Hi Doc,

My dentists is fabulous like you are you. :wink:

He only uses Marcaine on me.

Thanks for caring about us. Hugs, Roz

http://www.postgradmed.com/issues/1999/08_99/smith.htm

dr.Todd
06-26-2007, 02:38 PM
Thanks all for the warm welcome.

There is not a lot of literature out there as relates to RSD and dental treatment, so I've been spending a lot of time sifting through the research.

I saw the patient first thing this morning and she is already doing much better. :Dancing-Chilli: :Dancing-Chilli:


A few things that may be helpful to those of you whose medications are drying out your mouth (like my patient): Keep your mouth moist (water with a little lemon juice, sugar-free gum or candies, suck on ice, etc), talk to your dentist about prescribing a prescription strength fluoride toothpaste and an antibacterial mouthwash like chlorhexidine.

And though it may be painful, I highly recommend getting infected teeth addressed. The last thing anyone needs is a constant site of infection (goes for periodontitis as well). Many dental schools have a clinic devoted to oral facial pain that may be of some assistance in more complex cases. And most any oral surgeon can remove teeth under general anesthesia.

Thanks again for all the kind words. My thoughts are with all of you.
Dr. Todd

dr.Todd
06-26-2007, 02:44 PM
Also, I use marcaine at the end of most surgical procedures (RSD or not). It's great stuff for post-op pain!

DiMarie
06-26-2007, 03:27 PM
Dr.Todd
Not only RSD but many chronic pain patients need special attention.
dental needs are an anxiety issue to non-issu patients let alone this with high pr special needs pain addressed.

My daughter would have not the short term novacain used as it did not numb well. Also, enzymes in valium can reduce the effectivness. She also needed nitrous. If the patient is in need of a tooth pulled, a back one, my daughter would go to an oral surgeon and versed or twilight was used.

Antibioics and pain medication started immediatly.
ALSO, many patients have a pain contrac; a prior phone call, not post op one to the Pain doctor would reslove any problems medicating pain post op.

I had a PCP taht was manageing meds refused the oral surgeon to provide a script post op for tylenol III for a tooth that was in terrible shape.
I had to camp out in his officewith a crying patient to request him provide the script for pain. By this time the pain wa so high, it was extremly difficult to control. THAT WAS MEAN AND UNCALLED FOR!

ANother thing is Alodynia, hyper pain signals. When a terry cloth goes across the skin it can feellike a million picks of needles or terrible pain. The brain has received so many pain signals over an extended time that it reads pain HYPER.

You are to be commended. To find a dentistthat will take the challange of a difficult patient is tough, nearly impossible. The last reg. dentist I had used for our family their center for 35 years, since I was in high school; told me right out my adult daughter had too much pain and jumped around he would not treat her.Thankfully he could contril the abscess, and then the referral to the oral surgeon again helped.
New PCp for pain at that time was very helpful.

Thanks for your concern, check on some of the other forums for MS MD, Chronic pain and other issues, even children that have ADHD, bipolar or mental health issues are more challanging. More rewarding too.
Dianne

PS I made ice bags of frozen peas, or 1 part Alcohol and two parts water for slushy to use on pain area.

ALSO confirm tooth problem with xrays. Once a sister had a tooth pulled and it was actually comning from a bad sinus problem. Rule out fascial neuralgia nerves making the tooth painful too.

buckwheat
06-26-2007, 03:45 PM
Hi Again Doc,

Here is a clinical trial which relates RSD and dental somewhat. I wish I knew how the results ended with this drug. Hugs, Roz

Official Title: Neurotropin for Acute Dental Pain and for Chronic Neuropathic Pain
Further study details as provided by National Institutes of Health Clinical Center (CC):Primary Outcome Measures:
Efficacy of Neurotropin for acture pain.

Total Enrollment: 100 Study start: September 2000

Patients with Reflex Sympathetic Dystrophy, re-named Complex Regional Pain Syndrome, type I (CRPS-I), have chronic, post-traumatic pain that spreads beyond the distribution of any single peripheral nerve without evidence of major peripheral nerve damage. A similar disorder, Causalgia, re-named CRPS-II, presents with clear evidence of nerve injury. No successful drug treatment exists for these disorders. Neurotropin is a non-protein extract of cutaneous tissue from rabbits inoculated with vaccinia virus. Neurotropin has been used extensively in Japan to treat reflex sympathetic dystrophy and other painful conditions; however, the drug has not undergone clinical therapeutic testing in the United States. This protocol is to carry out double-blind, placebo-controlled, crossover studies about clinical efficacy of Neurotropin for acute pain in dental outpatients and for chronic pain in outpatients with CRPS-I or II.

http://www.clinicaltrials.gov/ct/show/NCT00006289?order=2

dr.Todd
06-26-2007, 04:26 PM
I just want to alleviate the fears of a few of you who have mentioned how I should go about diagnosis and treating specific dental issues. My emergency exams always start outside the mouth; palpation of muscles, lymph nodes, review of medical Hx, radiographs (PA and BWX), etc. Appropriate antibiotics and pain meds are Rx'd in cases when called for. I dont even want to look in the mouth until I have checked everything else.

As you might imagine, managing emergencies in a dental office with an already full schedule can be quite a challenge.

Thanks again for all the tips and leads. Frozen peas are a great idea!

:grouphug:
Dr. Todd

artist
06-26-2007, 05:29 PM
Frozen peas are a great idea! Dr. Todd

Hi Doc Todd,
Whoa!! Specifically -
NO ICE FOR RSD SUFFERERS!!
Don't care what the medical profession says, about 98% of the RSD forum members agree that ice *promotes* RSD symptoms. This forum has a history going back about 10 years, through several incarnations, and that is "The First Rule of RSD Tx".

I can tell you that if anyone put ice on my RSD arm I'd be right back with my Big Red Balloon arm of 2 years ago - and ice hurts me like freezing hell.

And one other thing, very important: research shows that applying clinical amounts of antioxidant before and after surgery - of any kind - can help to stop the RSD spreading to previously unaffected areas. Much of the research has been done on Colles fracture (which, incidentally, is how my RSD started), using vitamin C, but it applies to all surgery nonetheless. It's such a simple precaution, but the statistics are staggering. Most of us take antioxidants now anyway as a matter of course, but look at the literature, surgery needs megadoses.

OK, I'm done! Just remember...no ice...no ice....no ice...NO ICE !!!!! :)
all the best.

Linmarie
06-26-2007, 07:40 PM
Hi Doc Todd,
I wish all medical professionals were as concerned as your are. I have a dentist (in Placentia) and I explained RSD to him. He has done 5 crowns on me. The worst pain for me was from the shots. It lasted for days and my face was even bruised once. I do the shorter visits and he and the hygenist are gentle with me. Once, I had to stop a cleaning early because the pain was flaring too much. I didn't want to quit before it was finished but knew I had to. Now, they are more gentle with me. Please understand that we are not necessarily afraid of dentists as are alot of dental patients but know our bodies and limits (try to, anyways). It didn't used to bother me to go to the dentist, now I dread it. I need some perodiontal work but keep putting it off.
Linmarie

DiMarie
06-26-2007, 08:10 PM
Hi Doc Todd,
Whoa!! Specifically -
NO ICE FOR RSD SUFFERERS!!
Don't care what the medical profession says, about 98% of the RSD forum members agree that ice *promotes* RSD symptoms. This forum has a history going back about 10 years, through several incarnations, and that is "The First Rule of RSD Tx".

I can tell you that if anyone put ice on my RSD arm I'd be right back with my Big Red Balloon arm of 2 years ago - and ice hurts me like freezing hell.

And one other thing, very important: research shows that applying clinical amounts of antioxidant before and after surgery - of any kind - can help to stop the RSD spreading to previously unaffected areas. Much of the research has been done on Colles fracture (which, incidentally, is how my RSD started), using vitamin C, but it applies to all surgery nonetheless. It's such a simple precaution, but the statistics are staggering. Most of us take antioxidants now anyway as a matter of course, but look at the literature, surgery needs megadoses.

OK, I'm done! Just remember...no ice...no ice....no ice...NO ICE !!!!! :)
all the best.


Artist I don;t have RSD in my face, nor did my daughter,
Sorry it hurts your arm and body, or others. It is so helpful when one can tolerate it.

For migraines, and tooth problems we had to use ICE for the pain. It confused the nerves and helped calm pain signals. Especially the back of my skull cervogenic aches.

When my Left foot RSd is bad, I have to do the same thing, lay the foot on ice pack to take the burning mostly, and swelling down.

My daughters RSD arm needed an incline; wet towles and a fan blowing on it.

Hope everyone is having a calm day,
Dianne

artist
06-26-2007, 08:20 PM
Hi again,

Just wanted to add a couple of links to the Dutch research findings - they are streets ahead when it comes to dedicated research into RSD/CRPS and associated neuropathies. Not specifically dental, but for a really informed overview, this is a good starting point:
http://www.rsdcanada.org/parc/englis...anderlaan.html (http://www.rsdcanada.org/parc/english/therapy/drvanderlaan.html)

and pdf download:
"The Evidence Based Guidelines Development (EBGD) Guidelines on Complex Regional Pain Syndrome type I (CRPS-I) dealing with the diagnosis and treatment of CRPS-I" published in Nov.2006:
http://pdver.atcomputing.nl/english.html

all the best :)

artist
06-26-2007, 08:25 PM
Hi there Dianne,

Gosh, you're one of the lucky ones! Yes, yes wouldn't it be great if I could tolerate it; but not only can I not, it severely worsens my condition. Others have this too. I realize it's the standard treatment for many things, and there's no real substitute either, but....heyho...

Just do a search through the forum for "no ice" - you'll get the picture, lol! There's lots of literature about it, even a quick Google on RSD CRPS "no ice" brings up a ton of stuff.....
all the best :hug:

shiney sue
06-26-2007, 08:33 PM
But Also Thanks To All Of You For Helping A Dentist Fraidycat,
Wow Thanks,thanks, :d Sue

artist
06-26-2007, 08:55 PM
Thanks for the thanks Sue - but what a great opportunity we've been given (thanks again Dr. Todd) - we may be hurtin' but we ain't dumb....we know a good thing when we see it :p
all the best!

dr.Todd
06-26-2007, 09:04 PM
Just to give you all an idea about the information out there for dentists; I went through my 2002 edition of "Dental Management of the Medically Compromised Patient" and there was not a single thing in there about CRPS. This is the primary textbook for addressing systemic disorders from a dental perspective. Maybe the next edition will have it! Thanks again to all of you for the information and advice!

Dr. Todd:) :) :)

artist
06-26-2007, 09:19 PM
Hey DocTodd,

OMG really?

Well, you gotta get to bed, but I think you'd better check in here now and then - I think this is going to be One Long Thread...:D

all the best.

Jenmedic
06-27-2007, 07:13 AM
The fact that CRPS is not mentioned in the dental text is really not a surprise to me, Dr. Todd.

Unfortunately, I've had to explain my condition to most medical professionals...including medical doctors. Most look at me like I'm crazy, or making it up, until I explain it to them in medical terms and they begin to understand. I usually explain that while practicing my trade that I never knew about it either and probably would have the same reaction they are. Then, when I came down with it, it all became too clear.

Kudos to you again Dr. Todd! I also have a very progressive and caring dentist. She uses different types of treatments, my favorite of which is an herbal neck and shoulder pack that they will heat up for patients. VERY relaxing, and stops alot of the neck tension, and subsequent muscle pain. I even bought one for home! My CRPS is in my right arm, so all we have to do dentally is NOT hit, bump, or otherwise bother it.
One thing that might help patients is to cover their affected part with a soft, light blanket. For myself, the air conditioning in most medical offices causes problems, as it comes from above and blows down on patients, which really ticks off my arm. It really helps to not only protect the limb, but to remind staff that jostling can hurt.

I also have a problem that is particular to the dentist's chair! I have thoracic spine problems, and discovered the hard way a few times that having the doc raising and lowering the chair into position causes me horrible muscle spasms!! (which scared both me and the dentist!) After the first time or two, we figured it out, and I now have a note in my chart that states DO NOT raise or lower chair with patient in it. It's the little things that can make the biggest difference...

artist
06-29-2007, 10:36 PM
Bump........