Toothache, Emergency Medicine

Basics

Description

Tooth pain is caused by irritation of the root nerves located in pulpal tissue:
- The pulp is the tooths center and its neurovascular supply
Other etiologies, both inside the mouth and referred to the oral cavity, may cause oral pain

Etiology

Dental:
- Dental caries (hard structures demineralized by bacteria)
- Pulpitis (inflamed pulp secondary to infection)
- Reversible pulpitis is mild inflammation of the tooth pulp caused by caries encroaching on the pulp
- Irreversible pulpitis is the result of an untreated carious lesion causing severe inflammation of the pulp and severe, persistent, poorly localized discomfort
- Periapical abscess (necrotic pulp and subsequent abscess)
- Postextraction pain (dry socket, infection)
- Cracked-tooth syndrome (pain, cold sensitivity, crack difficult to visualize)
Periodontal disease:
- Gingivitis and periodontitis (gingivitis with loss of periodontal ligament attachment)
- Periodontal abscess (gum boil)
- Pericoronitis (gingival inflammation from malerupted tooth)
- Acute necrotizing ulcerative gingivitis (gingival pain, ulcers with/without pseudomembranes)
- Denture stomatitis
- Herpetic gingivostomatitis
- Aphthous ulcers (canker sores)
- Traumatic ulcers

Diagnosis

Signs and Symptoms

History

Tooth pain:
- May be referred to jaw, ear, face, eye, and neck (sensory distribution of 5th cranial nerve)
- Pain often associated with chewing, changes in temperature, and recumbency
Malodorous breath
Fever and chills
Foul taste in mouth
Associated symptoms
Duration of symptoms
Treatments that have already been tried

Physical Exam

Dental decay
Facial swelling or erythema
Trismus:
- Decreased maximal interincisal opening (normal opening, 35 " 50 mm)
Inspect and palpate lips, salivary glands, floor of the mouth, lymph nodes of the neck
Assess voice changes
Identify periodontal abscess
Evaluate for deep-space infection
Examine face for swelling, redness, tenderness, and increased warmth
Examine neck for adenopathy and stiffness
Teeth should be percussed for tenderness and mobility
Teeth should be examined for fracture and missing teeth
Dental numeric system used in adults:
- Maxillary: Right to left 1 " 16; mandibular: Left to right 17 " 32 (peds: A " J and K " T)
- Alternatively identification of teeth by their location is also appropriate (i.e., left rearmost, upper molar)

Essential Workup

Obtain appropriate medical and dental history
Ask about drug allergies, especially antibiotics and analgesics, and current medications
Assess need for predental procedure antibiotic prophylaxis:
- Rheumatic fever
- Cardiac valve replacements
- Orthopedic joint replacements
- Mitral valve prolapse or valvular heart disease
If physical exam conflicts with patients history and intraoral source of pain is not apparent consider other sources of pain:
- Nonodontogenic etiologies of pain
- Factitious pain/drug-seeking behavior

Diagnosis Tests & Interpretation

Lab

No lab tests needed except in patients with signs of systemic toxicity and those patients with perceptible deep-space infection
As with any other infection with symptoms of systemic toxicity, consider CBC, blood cultures, markers of inflammation like ESR or CRP

Imaging

Panoramic and periapical radiograph views if suspicion exists about dental infection or fracture
CT or MRI to evaluate deeper infections

Diagnostic Procedures/Surgery
A local or regional dental nerve block may sometimes offer both therapeutic and diagnostic benefit

Differential Diagnosis

Sinusitis
Otitis media
Pharyngitis
Peritonsillar abscess
Temporomandibular joint syndrome:
- Usually presents with pain around the ear
Trigeminal neuralgia
Vascular headache
Herpes zoster
Cardiac ischemia

Tooth eruption in a child or infant may cause oral pain, irritability, low-grade fever, diarrhea, and decreased food intake
Facial swelling with fever and leukocytes >15,000/mm3 suggests a nonodontogenic source
Children have a maximum of 20 deciduous teeth, 10 upper and 10 lower

Treatment

Pre-Hospital

Maintain patent airway in patients with severe facial swelling or trismus
The patient should be kept in a sitting position if possible

Initial Stabilization/Therapy

Airway management for deep-space infection and airway compromise
Early pain management as indicated

Ed Treatment/Procedures

Appropriate analgesia
NSAIDs are 1st-line therapy for uncomplicated dental pain
Opiate analgesics are an alternative therapy
Dental anesthetic field block:
- Injected along the buccal surface of the affected tooth
- Specific nerve block for multiple teeth
- Long-acting anesthetic (e.g., bupivacaine)
Antibiotics if dental infection is present:
- Penicillin is the antibiotic of choice if patient is not allergic
- Clindamycin for patients with penicillin allergy or for predominance of anaerobes
Localized periapical and periodontal abscesses should be incised, drained, and irrigated:
- Drain may be placed for 24 hr
Saline rinses at home 4 times a day and dental referral in 24 hr

Medication

Antibiotics:
- Ampicillin/sulbactam 1.5 " 3 g IM/IV q6h (peds: 300 " 600 mg/kg/d [max. 3 g] IV div. q6h)
- Clindamycin: 150 " 450 mg PO q6h (peds: 15 " 30 mg/kg/24 h [max. 2 g] q6h):
  - IV dose 300 " 900 mg (peds: 25 " 40 mg/kg/24 h div. q8h)
- Penicillin VK: 500 mg PO q6h (peds: 25 " 50 mg/kg/24 h [max. 3 g] q6h)
- Penicillin G potassium aqueous: 4 mU IM/IV q4h (peds: 250,000 " 400,000 U/kg/d IM/IV div. q4 " 6h, max. 24 mU/d)
Analgesics:
- Acetaminophen: 500 mg PO/PR q4 " 6h (peds: 10 " 15 mg/kg/dose; do not exceed 5 doses/24 h); do not exceed 4 g/24 h
- Acetaminophen and codeine no. 3: 1 " 2 tablets PO q4 " 6h (peds: elixir " codeine 12 mg/5 mL)
- Oxycodone 5 mg ± with acetaminophen 325 mg: 1 or 2 tablets PO q6h (peds: 0.05 " 0.15 mg/kg (oxycodone) per dose [max. 5 mg]); not available in liquid preparation
- Ibuprofen: 400 " 800 mg PO q8h (peds: 10 mg/kg PO q6h)
- Ketorolac: 30 mg IV, 30 " 60 mg IM q6h (peds: 1 mg/kg/dose IM/IV)
- Morphine sulfate: 2 " 8 mg SC or IM/IV q2h (peds: 0.1 mg/kg/dose SC or IM/V q2h)

Teething infants may be helped by over-the-counter topical anesthetics and oral analgesics

Follow-Up

Disposition

Admission Criteria

Suspicion of deep-space infections (e.g., Ludwig angina, retropharyngeal abscess)
Facial cellulitis proximal to the eye
Extensive trismus
Inability to maintain nutrition and hydration
Evidence of systemic toxicity

Discharge Criteria
Patients with toothache and localized dental infections can be discharged from the ED
Issues for Referral
Patients treated in the ED should be referred to a dentist or dental surgeon promptly

Followup Recommendations

Regular and routine dental evaluations

Pearls and Pitfalls

Mistaking a deep infection for local infection
Failing to identify source of referred pain to the mouth

Additional Reading

Annino DJ Jr, Goguen LA. Pain from the oral cavity. Otolaryngol Clin North Am. 2003;6:1127 " 1135.
Lockhart PB, Hong CH, van Diermen DE. The influence of systemic diseases on the diagnosis of oral diseases: A problem-based approach. Dent Clin North Am. 2011;55:15 " 28.
Rodriguez DS, Sarlani E. Decision making for the patient who presents with acute dental pain. AACN Clin Issues. 2005;16:359 " 372.
Van Meter MW, Dave AK. Oral Nerve Block. Emedicine. Available at http://emedicine.medscape.com/article/82850-overview. Accessed on February 3, 2013.

Codes

ICD9

521.00 Dental caries, unspecified
522.0 Pulpitis
525.9 Unspecified disorder of the teeth and supporting structures
522.5 Periapical abscess without sinus
521.81 Cracked tooth
523.10 Chronic gingivitis, plaque induced
523.9 Unspecified gingival and periodontal disease

ICD10

K02.9 Dental caries, unspecified
K04.0 Pulpitis
K08.8 Other specified disorders of teeth and supporting structures
K04.7 Periapical abscess without sinus
K03.81 Cracked tooth
K05.10 Chronic gingivitis, plaque induced
K05.6 Periodontal disease, unspecified

SNOMED

27355003 Toothache (finding)
80967001 Dental caries (disorder)
32620007 Pulpitis (disorder)
196341005 Periapical abscess (disorder)
109747007 Cracked tooth (disorder)
2556008 Periodontal disease (disorder)
66383009 Gingivitis (disorder)

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