12.2.1.3 Management of Common Acute Head and Neck Fungal Infections

Fungal Candida infections may arise secondary to antimicrobial use, inhaler use (◘ Fig. 12.1), persistent dry mouth, or immune suppression conditions. Topical antifungals for localized oral lesions are the first line of defense, since systemic antifungals may have negative effects on liver function. Topical clotrimazole (Myclelex^®) troches are effective, when used according to directions so as to maintain good contact with the effected oral tissue.

Another more common mixed fungal infection is seen in angular cheilitis. It may be seen more frequently in cold weather or climates. Topical treatment includes application of combination of clotrimazole 1% and betamethasone (Lotrisone^®) cream. Combination topical nystatin and triamcinolone acetonide (Mycolog II^®) cream to affected areas.

Other fungal lesions to observe in athletes include tinea faciale (ringworm). Again contact sports such as wrestling are a source of contagious spread of this fungal infection. Topical application of antifungal creams to small facial lesions is effective. Monitor for other lesions. Contact athletic trainer and treating and team physician with this information regarding contagious skin lesions.

12.2.1.4 Management of Common Autoimmune Mucosal Lesions

Autoimmune lesions that are painful or contribute to dehydration can be treated in acute phase with topical steroids. Simple and multiple aphthous ulcers can be painful and interfere with eating and drinking. Examples of topical ointment or gels include triamcinolone (Kenalog^®) and 0.05% fluocinonide gel. For multiple intraoral lesions, dexamethasone (Decadron^®) 0.5 mg/ml elixir may be indicated for topical effects. It should be used topically by rinsing, expectorating, and not swallowing to avoid systemic steroid effects. These are considered weak corticosteroid agents and are not listed on the World Anti-Doping Agency (WADA) Prohibited List.

12.2.2 Management and Guidelines for Oral Analgesics (Adults)

Analgesics for oral pain can be selected based on severity of pain and expected duration of pain. Most oral/dental analgesic treatments are for short-term acute conditions.

The athlete’s status for training, performance, or recovery should also be considered in devising pain management strategies. For all analgesics routinely use the lowest effective dose for the least amount of time to obtain pain control and reduce adverse and side effects. Always review with patient other analgesics he or she may be already taking in order to avoid overdosing or adding to addictive potential. Consult with lead team physician, if needed, to check for duplicate prescriptions in the case of opioid-containing analgesics.

12.2.2.1 Analgesics for Mild to Moderate Acute Pain Management

Nonaddicting acetaminophen (APAP) and nonsteroidal anti-inflammatory drugs (NSAIDS) are first choices for mild to moderate acute pain control. NSAIDS have an additional anti-inflammatory effect.

Acetaminophen maximum dosage recommended by the Food and Drug Administration (FDA) for adults is 4000 mg/24 h.

Johnson & Johnson the producer of acetaminophen (Tylenol^®) suggests not to exceed ten tablets of 325 mg (3250 mg) or six tablets of 500 mg (3000 mg) in a 24 h period. This dosage limit is due to the concern that individuals may be taking other drugs simultaneously that also contain acetaminophen. Combination drugs containing acetaminophen are limited to 300-325 mg per tablet. Athletes should be advised to avoid taking multiple acetaminophen-containing products together in order to avoid daily overdosing. Simultaneous alcohol consumption should also be discouraged, because of detrimental effects on the liver. Inform the athlete that severe, even life-threatening liver injury will occur when they exceed consuming above therapeutic doses. As with all medications, they should report any adverse effect during use of acetaminophen. The effect of acetaminophen on bleeding when consumed at proper dosage in otherwise healthy individual is minimal. If additional drugs are also needed to treat a condition, athletes should let all healthcare providers know if they are taking acetaminophen.

12.2.2.2 NSAIDS (Nonsteroidal Anti-inflammatory Drugs)

Aspirin (ASA) acts as an analgesic and an anti-inflammatory.

Dosage recommendations for adults: take 1 or 2 325 mg tablets every 4 h or 3 tablets every 6 h, but do not exceed 12 tablets in 24 h. Aspirin is also a nonreversible platelet-binding agent, which may contribute to prolonged bleeding after an injury. Bleeding or platelet effect gradually reverses itself as new platelets form over 10 days. This can be very significant in athletes since impaired clotting may lead to more bleeding in musculoskeletal injuries that are often seen in sports, especially hemarthrosis and deep tissue bruises. Recent studies recommend various time durations for delay of oral surgery procedures following ASA consumption [6, 7].

Contraindications of aspirin usage include but are not limited to pregnancy, breastfeeding, allergy history, gastric ulcer, asthma and nasal polyps, drug interactions, concomitant blood thinners, defects in blood clotting system, active peptic ulcers, and compromised renal conditions. An important side effect presents as gastrointestinal distress. There are many drug interactions with ASA, and the list should be checked before using ASA. Interactions with aspirin can be of major significance in individuals taking other medication that interfere with clotting mechanisms such as clopidogrel (Plavix^®) and warfarin (Coumadin^®). Alcohol should be avoided while taking ASA to avoid increased chance of gastric bleeding. Additionally, other NSAIDS and steroids may also interact negatively with ASA in some individuals. Always check for other aspirin-containing medications that the athlete may already be using. The prescriber should also be aware of the athlete who may be taking low dose aspirin to reduce probability of cardiovascular disease. This is often under reported by the patient [8].

12.2.2.3 Non-ASA NSAIDS

Non-ASA NSAIDS include but are not limited to over-the-counter (OTC) ibuprofen (Advil^®), naproxen sodium (Aleve^®), and prescription etodolac (Ultradol^®) which act as analgesic and anti-inflammatory agents. Usage of these NSAIDs contribute to anticlotting effects similar to ASA; however this category of NSAIDS has a reversible effect on platelets and therefore a reversible effect on bleeding when the drug is discontinued.

Dosage information is seen in box “NSAID Analgesics.”

Dosage guidelines suggest using the lowest possible dose of ibuprofen for the least possible time to accomplish adequate pain control and minimize adverse and side effects. Continue to monitor the patient, and modify dose and use for shortest duration as appropriate for pain control.

Contraindications to NSAIDS include evaluating athlete’s history for allergies, asthma with nasal polyps, pregnancy, breastfeeding, concomitant blood thinners, defects in blood clotting system, active peptic ulcers, and compromised renal conditions.

Duration of use is important in anticipating peptic ulcers or “delayed healing.” There are increasing numbers of reviews correlating some delay in healing of soft tissue and perhaps bone secondary to the reduction in the inflammatory process of these drugs. It still needs to be clarified whether dosage, duration, or genetics are factors in these possible adverse effects [9–11].

There is a black box warning initiated in 2005 by the Food and Drug Administration.

Other adverse effects include but are not limited to renal, cardiovascular, hepatic, and respiratory function.

Use of acetaminophen-NSAID combination agents continues to be evaluated. Publications support their combined use as another method of acute pain control [12–15]. Potential success of this combination would contribute to reduced prescriptions for opioid and opioid combination drugs.

12.2.2.4 Analgesics for Moderate to Severe Acute Pain Management

Opioids and opioid combination drugs are indicated for moderate to severe acute pain control. Opioid-containing analgesics are considered banned substances by some sporting organizations, and their use is limited in these cases.

Side effects are dose-dependent. Therefore lower doses express fewer or less severe side effects. The most common side effects and adverse effects are dizziness, sedation, nausea, vomiting, and constipation. Other important adverse and side effects one should monitor include respiratory depression, tolerance, and addiction.

Addictive potential is of great concern for all athletes and their healthcare providers. Opioid chemical addiction is related to multiple factors. The varied opioid receptor sites in the brain and nervous system include sites for analgesia (kappa and delta), sedation (kappa), and euphoria along with respiratory depression and reduced GI motility (mu). These receptors and others contribute to several other effects. With prolonged use of these opioid drugs, tolerance develops, and higher dosages are required to obtain the same effects of pain relief and euphoria, which also contributes to abuse and addiction.

The team dentist who prescribes opioid medications for dental or oral pain in athletes must be aware that these patients may be taking opioids for other concurrent injuries and should prescribe accordingly to minimize contributing to overdose, abuse, and addiction. Misuse of opioids is correlated with several different individual profiles. Pain, concussions, and concurrent alcohol use correlated with misuse in an NFL player study [16]. Misuse of opioids by adolescent athletes is higher in those with a current history of substance abuse [17].

In the USA, any opioid-containing agents fall into Schedule II DEA classification, because of their abuse potential. This requires written prescriptions without refills. Emergency prescriptions must follow state prescribing regulations. Some sports medicine teams request that all opioid prescriptions go through one provider for their athletic team. This provides for better monitoring of multiple opioid prescriptions and their contributions to misuse and overdosage.

12.2.2.5 Opioid Combination Drugs

Also for moderate to severe pain, acetaminophen or NSAID combination with opioids has the same issues as each of these agents creates independently. The combination agents allow for lower doses of opioids and therefore less adverse opioid effects for equivalent pain control.

The same concerns about addiction exist for the opioid combination drugs as the individual opioid analgesics. Same guidelines for selecting analgesic dosage apply for opioid-containing drugs and recommend to routinely use the lowest effective dose for the least amount of time to obtain pain control and reduce adverse and side effects

12.2.2.6 Concomitant Use of Other Addictive Drugs

Athletes, especially those with frequent travel schedules through time zones such as younger and professional athletes, may be using hypnotic drugs to combat disrupted sleep patterns. Zolpidem (Ambien^®) and eszopiclone (Lunesta^®) belong to a class of hypnotic drugs to treat insomnia. They are not currently banned by the World Anti-Doping Agency (WADA). These drugs also have an addictive profile. Dentists must be aware that the athlete may be taking these drugs, which add to the addictive and depressive potential, when they are used alone or in combination with opioid-containing drugs.

12.2.3 Local Anesthetics for Analgesia

Local anesthetics are used for pain control during dental procedures and for short-term pain control, when definitive care may be delayed.

The commonly used local anesthetics, including those combined with epinephrine, are not banned during elite athletic competitions governed by the World Anti-Doping Agency (WADA: website ► www.​wada-ama.​org/) policies. (WADA LIST-2015)