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:
- If physical exam conflicts with patient's 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
Pediatric Considerations
- 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
[Outline]
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)
Pediatric Considerations
Teething infants may be helped by over-the-counter topical anesthetics and oral analgesics
[Outline]
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
FOLLOW-UP RECOMMENDATIONS
Regular and routine dental evaluations
[Outline]
- 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.
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