Dental Emergencies

Toothache and Facial Pain

Clinical exam

Treatment regimens

Dental History

Differential diagnosis

Final points

Sickcall visit: Toothache and Facial Pain

The most common complaint of dental patients reporting to sickcall is a toothache or facial pain caused by a cavity, inflammation of the tissues supporting the tooth, trauma, or oral lesions. Proper treatment is based on a correct diagnosis. The GMO should treat the patient's signs and symptoms and if possible, the cause of the emergency. The following guidelines are provided to assist in the diagnosis and management of dental emergencies.

Dental History

Using the S.O.A.P. (subjective, objective, assessment, and plan) format, the GMO should document the patient's chief complaint, clinical findings, differential diagnosis, and treatment plan. When recording the dental history, the GMO should question the patient regarding the following points:

  • 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.

The GMO should keep in mind that the patient might not be able to identify which tooth is hurting, the pain may be referred from one area to another, and the pain may not be odontogenic in origin.

Clinical exam and important diagnostic findings

  • 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.

Differential diagnosis

Using the findings from the dental history and clinical exam, the GMO should attempt to determine the etiology of the emergency and render a diagnosis. The following is a differential of the most common dental emergencies.

  • 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.

Treatment regimens

  • 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.

Final points

If the emergency treatment is successful, the patient's acute signs and symptoms should subside, and follow up care by a dental officer can be delayed until routine dental treatment is available. However, if a definitive diagnosis cannot be made, or appropriate care cannot be rendered because of a lack of expertise, instruments or materials, the GMO should manage the patient's signs and symptoms (analgesics for pain, antibiotics for infection, and antipyretics for fever). If the acute problem does not resolve, the patient should be referred to a dental officer for definitive care. In addition, patients who present with intractable facial pain, rapidly spreading fascial space infections, and or fractures of facial bones require immediate referral to a dental officer.

References

  1. Cassidy RE. Diagnosis and Immediate Treatment of Dental Emergencies by Military Physicians. National Naval Dental Center, Bethesda.

  2. Submarine Force Independent Duty Corpsman Dental Syllabus, Naval Undersea Medical Institute, 20 July 1989.

Reviewed and updated by CDR Lee Prusinski, DC, USN, Chairman, Oral Medicine Department, Naval Dental School, National Naval Dental Center, Bethesda, MD and CDR Matthew W. Pommer, Jr., DC, USN, MED-631, Head, Standards Branch, Bureau of Medicine and Surgery, Washington, DC (1999).

Preface  ·  Administrative Section  ·  Clinical Section

The General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C., 20372-5300

This web version of The General Medical Officer Manual, NAVMEDPUB 5134 is provided by The Brookside Associates Medical Education Division.  It contains original contents from the official US Navy version, 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 Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense. All material in this version is unclassified. This formatting © 2006 Medical Education Division, Brookside Associates, Ltd. All rights reserved.

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