Dental Emergencies
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.
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Whether or not the pain is continuous or intermittent.
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Whether or not the pain is spontaneous and or provoked by heat, cold,
sweets, or a combination of these stimuli.
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Whether or not the pain lingers after the stimulus that provoked it has
been removed.
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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
Hanks 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
-
Cassidy RE. Diagnosis and Immediate Treatment of Dental Emergencies by Military
Physicians. National Naval Dental Center, Bethesda.
-
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).
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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
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