Dental Pain in the ED



Background

The crown of a tooth is made up of three basic layers; enamel (A), dentine (B), and pulp (C). Pain results when the pulp is inflamed, which is generally caused by bacteria from decay (D), or a leaking dental restoration or “filling”.

History

  • A short, sharp pain lasting only a few seconds and occurring in response to a cold or “sweet” stimulus is likely to be reversible pulpitis
  • A dull, aching, “pulsing” pain that occurs spontaneously and in response to thermal stimuli is likely to be irreversible pulpitis. There is no swelling, but pain is debilitating, often disturbs sleep, and may last for hours. Irreversible pulpitis requires expedient dental intervention
  • Untreated pulpitis leads to pulp necrosis and death, and the pain may temporarily decrease. However, inflammation and infection of the surrounding tissues, known as apical periodontitis, will ensue as bacterial and pulp breakdown products escape from the tooth. The offending tooth will be tender to touch or pressure
  • An acute apical abscess is a common manifestation of untreated apical periodontitis and is associated with a swelling, tooth mobility, and severe tenderness to touch
  • A chronic apical abscess may be present without pain or obvious swelling if the infection is draining
  • Acute abscesses may spread as a cellulitis within soft tissue spaces to the floor of the mouth (Ludwig’s angina), leading to neck and mediastinal abscesses; this can compromise the patient’s airway.

Clinical

  • Duration and progress of pain
  • Beware if affecting swallowing, breathing, speech, or ability to open the eye
  • Beware history immunosuppression
  • Look for airway compromise or SIRS
  • Palpate for tooth sensitivity or a collection (particularly floor of mouth)
  • Beware any eye symptoms or trismus (normal mouth opening 3 patient's fingers)
  • Remember analgesia
  • Consider antibiotics (particularly if regional adenitis)

Pulpitis

  • Inflammation of the nerve of the tooth
  • Different pain history to periodontitis
  • Pain may be spontaneous, or aggravated by hot or cold stimuli
  • Initially it may be difficult to localise which tooth the pain is coming from
  • DDx may include acute sinusitis and shingles
  • Analgesics may be helpful in the short term
  • Antibiotics are not indicated
  • Tooth needs to be opened or removed by a dentist, during working hours

Periapical periodontitis

  • Inflammation of the supporting tissues of the tooth
  • Pain is usually well localised and aggravated by pressure such as biting
  • Antibiotics may be useful: use Amoxicillin (Erythromycin if allergic).[Beware Erythromycin if on warfarin]
  • Antibiotics take 24-36 hours to be effective
  • Prescribe analgesia
  • Definitive treatment will require removal of the tooth or the nerve by a dentist, during working hours

Pericornitis

  • Inflammation of the soft tissue (gum) covering an erupting tooth (usually a wisdom tooth)
  • If associated with swelling, pyrexia, trismus or cervical lymphadenopathy antibiotics will be required
  • Use Amoxicillin or metronidazole
  • Advise patient to be reviewed by their dentist, particularly if there is associated facial swelling or if it fails to resolve


Reviewed by Dr Íomhar O' Sullivan. Last review Dr ÍOS 4/04/23.