• The location of the painful tooth or area - have the patient place his or her finger on the tooth or area that is giving them pain.

• Whether or not the pain is continuous or intermittent.

• Whether or not the pain is spontaneous and or provoked by heat, cold, sweets, or a combination of these stimuli.

• Whether or not the pain lingers after the stimulus that provoked it has been removed.

• The character of the pain (sharp, dull, throbbing).

• How, when, and where the traumatic injury occurred.

• Intra- and extraoral swelling.

• Lymphadenopathy.

• Teeth with loose or broken fillings, and/or gross decay.

• Fractured and/or loose teeth.

• Intruded, extruded, laterally luxated (displaced), or avulsed teeth.

• Soft tissue inflammation or lesions. In addition, the teeth should be evaluated for pain when they are individually percussed with the handle of a dental instrument.

• Reversible pulpitis
  - sharp, intermittent pain of short duration that is provoked by hot, cold, sweets, or biting. The pain does not linger when the stimulus is removed.

• Irreversible pulpitis
  - throbbing, continuous pain that, in most instances, is spontaneous. If the pain is initiated by cold, hot or sweets, it lingers after the stimulus is removed. The tooth may also be very tender to percussion.

• Periradicular abscess
  - intra- and or extraoral swelling associated with involved tooth. Systemic symptoms (fever, lymphadenopathy, etc.) may also be present.

• Pericoronitis
  - pain, inflammation, and swelling of tissue covering a partially erupted lower third molar. The patient may exhibit trismus, lymphadenopathy, and fever.

• Periodontal abscess
  - inflamed, swollen gingival tissue around the neck of a tooth. Purulent exudate or blood appears when the tissue is palpated. The tooth may be tender to percussion and loose.

• Fractured anterior tooth
  - portion of crown of tooth is missing; pulp may or may not be exposed. The tooth may be loose and the patient may complain of pain when cold water, food, or air comes in contact with it.

• Traumatic injury

• - tooth is laterally luxated, intruded, extruded, or completely avulsed from its alveolar socket.

• Canker sores (aphthous ulcers)
  - painful ulcers with a gray center and erythematous halo found as 1-3 separate lesions on movable oral mucosa.

• Cold sores (oral herpes)
  - clear vesicles that rupture forming multiple shallow, painful ulcers, frequently on the lips.

• Reversible pulpitis
  - with an excavator, remove any loose filling material, debris, and easily removable decay from the tooth. Dry the cavity with cotton pellets and pack with a thick mix of zinc oxide-eugenol packed into the cavity, have the patient bite down and grind his or her teeth, remove the excess. Rx: Motrin 800mg TID.

• Irreversible pulpitis
  - same treatment as above. However, irreversible pulpitis is a true toothache which, in most cases, requires a dental officer's care. Rx: Motrin 800mg TID.

• Periradicular abscess
  - if the intraoral swelling is fluctuant, incise and drain the area. Skin refrigerant or ice can be used as a topical anesthetic. Rx: Motrin 800mg TID, Penicillin VK (PCN VK) 500mg QID (loading dose of 1 to 2 gm) if systemic symptoms are present, and warm saline rinses QID.

• Pericoronitis
  - gently irrigate under the flap of tissue covering the erupting crown of the tooth with 3 percent hydrogen peroxide using a syringe with a curved blunted 18 gauge needle. Continue this irrigation on a daily basis until the patient can be seen by a dental officer. Rx: Motrin 800mg TID, PCN VK, and warm saline rinses.

• Periodontal abscess
  - gently remove debris between gingiva and neck of tooth and irrigate as above. If area is swollen, establish drainage by placing a thin instrument (scaler) into area between tooth and gingiva. Rx: Motrin 800mg TID and saline rinses; PCN if systemic symptoms are present.

• Fractured anterior tooth
  - gently remove any remaining fractured pieces of tooth structure. If the tooth is not painful, smooth the rough edges with an emery board. If it is painful or the pulp is exposed, cover the tooth with Stomahesive adapted to the adjacent teeth. Rx: Motrin 800mg TID.

• Traumatized tooth
  - leave intruded tooth alone; reposition laterally luxated, extruded, or avulsed tooth (use the adjacent teeth as a guide), and stabilize by adapting Stomahesive to the tooth and its adjacent teeth. If the avulsed tooth cannot be replanted, place it into Hank’s balanced salt solution (HBSS), sterile saline, or milk for storage until the patient can be seen by a dental officer.

• Canker sores
  - place a topical steroid (0.1% Triamcinolone acetonide) on the lesions. Cocoa butter ointment, lanolin based lip preparations, or petrolatum (Vasoline) as an emollient may be palliative.

• Cold sores
  - place a topical anesthetic (2% Lidocaine viscous) on the lesions. Warn the patient not to spread the infection to open wounds (especially on fingers) or the eyes. Both oral herpes and aphthous ulcers last for 10-14 days and recur.

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Operational Medicine 2001

Health Care in Military Settings

This web version is provided by The Brookside Associates Medical Education Division.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

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