Treating Tooth Infection Early

I have had my share of tooth infections and this is what I have learned so far:

1) Once it’s abscessed nothing works but a root canal or extraction
2) early on, regular dosed antibiotics do nothing.

There are options – loading doses and topical

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Evista / Raloxifen For Fibromyalgia Pain and Fatigue – Why Has No One Confirmed It?

Raloxifen is a estrogen look alike used for osteoporosis. Is is similar to tamoxifen so helps to prevent breast cancer. Like birth control pills, has a slight stroke risk.

I have a relative who had been on raloxifen for Osteoporosis. It, in combination with other meds has been relatively effective. Her sister has had a fracture, worse hearing loss, and was at one point diagnosed with Fibromyalgia.

It turns out, and article with no referencing to, described raloxifen as a treatment for fibromylagia pain and fatigue in a double blind trial. The study was never repeated and came on it by accident. Pain was cut to more than half in 4 months and fatigue helped as well.

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Quadratus Lumborum Post IsometricTreatment

Techniques involving post isometric relation stretching of Quadratus Lumborum clinic use.

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Gabapentin Fails Again – Does Not Work in Chronic Pelvic Pains

While gabapentin might work in post herpetic neuralgia and diabetic neuropathy, it does not work well in spinal pains/sciaticas and so forth. Now it has been shown not to work in chronic pelvic pains as well.

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Bruxism with Antidepressant SSRI’s -Quetiapine Helps

Usually when subjects brux (teeth clench) of antidepressants, one has to stop antidepressants as the alternative is higher dose clonazepam (1 mg)
Bruxism – How do You Treat Besides Splints

Quetiapine 25-50 mg helps considerably as well.

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Chronic Pain – Doing One Thing at a Time to See What Works is Silly – Need For Critical Mass

Even Opioids, if placebo is removed, can only give you 1/10 reduction in pain. Want to push it for more?  Well, I suspect some opioid deaths are included here. From what I have seen, various approaches ( Tai Chi, acupuncture, Cognitive- behavioural, exercise, journaling,etc) can do some effect in studies but only help temporarily or a bit because of human nature and poverty. Can’t afford long term CBT or acupuncture, quit exercise in cold weather etc.

People who do well do several approaches at one. Doing that will allow you to reach what I call critical mass. Once you reach a certain point of betterment, improvement is much more than can be expected from the culmination of the three – you reach critical mass and improvement in activities of daily living flourishes.

People who try one thing at a time often say it didn’t help that much and end up being discouraged. Don’t do that!

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Phantom Rectal Pain

This is such a trying condition that when I came across this poster abstract I felt I needed to post it here.

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New Opioid “Guidelines” Not Always Work And What do with Opioid Induced Hyperalgesia

Would opioid guidelines always work on cancer patients?The answer is NO. –  13.7% do not respond to usual doses and only half of those will get any benefit from increasing the dose. If one were to extrapolate, this would mean 7% of opioid users would need higher than usual doses of opioids to respond.  I guess this is why the new rules are only suggestions and not hard and fast regulations. Now, if only College regulators could handle these implications… Opioid induced hyperalgesia might be helped by switching opioid.

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Waistband Back Pain

I see often older men wearing belts who solemnly come in with nerve-like pain level at low back and flank level. I tell them I can treat this – but they are going to laugh – because what is a good portion of the pain is cluneal nerves crushed by the waistband  as it crosses the wing of the hip ilium. Muscles become tight, facets and sacroiliac pulled out of alignment, iliac crest starts to rub on ribs, and the pains go down hill from there. Lack of sleep and low resultant testosterone make it worse. Treating the pain is now a mess because you have to work ribs out of pelvis and deal with Quadratus lumborum spasms. These tissues also get tenderized by chronic back pains and need treatment in their own right.

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Skin Nerve treatment in CRPS

Injecting skin nerves where constricted in the skin can significantly relieve pain in Complex Regional Pain Syndrome – a secret as is only published as a letter

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Vitamin B12 Injections For Chronic Pain

Below is a study poster presented to the Canadian Pain Society showing benefits of frequent B12 Injections. Unfortunately, a study found men with smoking history have a 3 times lung cancer rate so I have now restricted B12 injection use to women.

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Beta-adrenergics Prevent Post Thoracotomy Pains

Post-thoracotomy pains are the worst post-operative pains, occurring in high frequency and can be severe. Surprisingly, asthma beta-adrenergic stimulants greatly reduce any neuropathic pain, though not muscular pains, postsurgery. It suggest beta-adrenergic circuits, thought to be involved in descending inhibition, might be important.

I wrote about how beta-adrenergic agents might be involved in downward inhibition:
Antidepressants Just Don’t Work on Descending Inhibition

The fact beta-adrenergic agents prevent post thoracic neuropathic pains here:
Eur J Pain. 2015 Nov;19(10):1428-36. doi: 10.1002/ejp.673. 
Effects of β2 agonists on post-thoracotomy pain incidence.
Salvat E et al

“The chronic use of β2 -agonists was an independent predictor of thoracic neuropathic pain (but not of non-neuropathic pain) and was associated with a five-fold decrease in the relative incidence of neuropathic pain [OR = 0.19 (0.06-0.45)].”

beta adrenergic agents were found to work as well as antidepressant in animal model of diabetic neuropathy:
Choucair-Jaafar, Nada, et al.
The antiallodynic action of nortriptyline and terbutaline is mediated by β2 adrenoceptors and δ opioid receptors in the ob/ob model of diabetic polyneuropathy.
Brain research 1546 (2014): 18-26.

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Medial Knee Pains – in Adductors – What Can You Do?

Pain and spasm on the inside of the knee in adductors is not uncommon – – especially in the heavy set with stairs. A brutal stretch massage can relieve but takes effort and willingness of subject to deal with the pain.

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Kinesio Taping May Reduce Post Thoracotomy Pain

Post thoracotomy pains have to be one of the banes of chest surgery occurring in high frequency. Now simple taping might reduce it.

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Postural Orthostatic Tachycardia Syndrome (POTS) – More Complex in Chronic Pain

POT’s is a syndrome where one is unable to maintain blood pressure standing and so often faint –  and is often associated with attacks of tachycardia.

Finding this situation in a chronic pain patient, greatly complicates the situation, and makes pain recovery less likely. I find myself scratching my head about where to go.

  • Association of POTS with autonomic neuropathy brings up issue that certain Fibromyalgia cases have small fiber neuropathy. Autoimmune mechanisms are involved and question lies, which ones would respond to IV gamma globulins or Plasmaphoresis – certainly the ones with frank Chronic Demyelinating Inflammatory Polyneuropathy (CIDP) but what about milder forms? Prednisone steroid pulses work in early CRPS and could help some autonomic neuropathy (certainly in CIDP) – but when to try? Measuring certain antibodies might help but in some situations testing is rare or unavailable.
  • Association of a case of POTS with chairi malformation brings up association of certain FM cases with treatable chairi syndrome cases. Our MRI testing is either unavailable or untrustworthy.
  • Large association of POTS with Ehlers-Danlos hypermobility syndrome makes pain issues much more likely. Saw one case of CRPS caused by superficial radial nerve injury from unstable distal radius. Does one dare try prolotherapy to an already painful site?
  • Body- wide serotonin in POTS is low  and POTS is associated with  high suicide risk, adding a deeply troubling challenge to pain in POTS cases.
  • Treatment of associated sleep apnea with CPAP may be complicated. Ordinary CPAP might not work and BIPAP might need to be tried. The anxiety that is associated might limit mask use and in one case, clonazepam 1 mg hs had to be used to reduce nightmares and  ensure CPAP use.
  • Cases are found of CRPS and POTS helped by treatment of bacterial overgrowth. Is this why Cefadroxil antibiotic cured one CRPS case?
  • Using Naltreoxone dual opioid blocker /mild stimulator could help CRPS and POTS but how does one get subjects off opioids first?
  • Rare POTS cases found deficient in thiamine, B12 and Vitamin D offer rare cures. These deficiencies also flare Fibromylagia. Treatment of the POTS with local measures and Flourinef and or Midodrine can help.

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DHEA – for Depression in Elderly – Seemed Like a Good Idea..

Antidepressants are poorly tolerated in elderly and DHEA, found to be low in elderly, has been found to help with depression. I suspect part of its effect is through androgen stimulation as some is converted to such.  I have patients order DHEA from USA and have it sent C/O my office as I thought it would legitimize its import.  Had a visit today from 2 men from Canada Customs who made it clear that wasn’t so.

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Is It Worth Checking For Anxiety – Depression in Osteoarthritis?

Cost-utility Analysis suggests not. I am not a big fan of attributing chronic pain to anxiety-depression – (sorry Dr. Sarno)… Recent analysis suggests in osteoarthritis it is not cost -effective to spend special time on anxiety depression

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Botulinum For Joint Pains

Study did meta-analysis of multiple article and found at 1 or 2 months will drop pain by 1.1/10 with no difference between 100 or 200 units. Often there is significant inflammation around the knee – anserine bursa being an obvious one. Botulinum, not being directly injected into it would have zero benefits there. Steroid is very forgiving and would effect inflamed areas close by. I contend they should be both injected at same time.

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Lateral Patellar Knee Injection Technique Best

I’ve always liked the anterior knee injection using a 2 inch needle but have had to accept the recent statistics put forth by Durolane injectable lubricant that lateral injection mid patellar is better

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Refractory Migraine Eliminated by Pulse Radiofrequency to Superior Cervical Ganglion -Good for Chronic Neck Pain as well

Awe inspiring case of chronic migraine headaches eliminated by pulsed radiofrequency (low burn) to a neck sympathetic ganglion.

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Confirmed Again – Local + Steroid Injections Help Post Herpetic Neuralgia

Local steroid/local injections can greatly attenuate shingles and post shingles pain yet has received very little notice.

I wrote about it in a couple blog notes:
Alternate Approaches to Post-Herpetic Neuralgia (PHN)

Early Fix For Herpetic Zoster/Shingles – Inject the Spots With Local and Steroid

Now a controlled trial found pains in 12.8% of injection treated group versus 47.8% in the standard treatment group (P<0.001)
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CRPS – Why Are Doctor Too Dumb to Use Prednisone Steroids?

The most successful treatment for CRPS especially early is Prednisone. It is even used in wrist fracture situation. Yet this fact seems not all that well known as is the fact one should continue the course for 8 weeks. Needless suffering though ignorance.

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Effectiveness of Sacroiliac (SI) Joint Steroid Injection

Steroid injection of SI joints can be very helpful. It is more common than one would think as is seen in post-traumatic cases, in celiac disease, in various colitis, and in certain Fibromyalgia misdiagnosed subgroups. I highlight this study so patients can see its benefits.

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Opioid Death Fueled by Illegal Chinese Fentanyl NOT Prescriptions

Recent Article diagrammatically demonstrates where  opioid deaths have been coming from

So spend less time looking at medical opioid prescriptions and more at illicit fentanyl trade. All doctors are now under tremendous pressure to cut their dose of  opioids for chronic pain sufferers from organizations that feel they have to do something even when it is not the issue. Just don’t do something – stand there! (instead)

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Elderly with Resistant Post Herpetic Neuralgia – What do You Do?

Not a new study but the benefits  mandated that I include it. Study presented were 2 cases in their 80’s with severe Post Herpetic Neuralgia – one on face, other T8-10 that tried everything including spinal stimulator without effect. Pain level was 10/10. Relief was gradually obtained by increasing doses of Nabilone, starting with 0.5 mg hs and working up over 1 year to 4 mg hs – got pain down to 4/10 without opioids. Having gone generic, cost is not prohibitive .

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