PEARLS:

Patients with dental pain can have no dental problems at all, and be medication seeking, or can have cellulitis, abscess, or spreading infection causing airway compromise.

Give dental pain patients antibiotics, regardless of whether you I&D them or not while they await an appointment with a specialist.

Post-extraction complications like bleeding and dry socket syndrome are common and can typically be managed in the Urgent Care (UC) without requiring transfer to the ED or urgent follow up with a specialist.

ANATOMY:

There are 32 teeth, all numbered.

Describe them as anterior and posterior

Posterior teeth are the ones most commonly infected after previously developing a dental cary (cavity).

Anterior teeth are more likely to have trauma.

Differential Diagnosis of Tooth Pain:

The most common cause is infection. An infected cavity travels through the enamel, into the dentin and as it nears or enters the pulp causes a toothache. You can have pain without swelling, but if there is swelling, there is an infection.

Cracked tooth syndrome

Referred pain from maxillary sinus infection or other process in the face or neck.

Trigeminal neuralgia or other neuropathy

TMJ pain

If there is no swelling or pain on apical palpation of the tooth, infection is less likely and should prompt consideration of the other diagnoses.

Cellulitis vs Abscess

Cellulitis is usually earlier on in the infectious process. It is characterized by diffuse skin redness and swelling. It is usually caused by aerobic bacteria. Always treat cellulitis with antibiotics.

That cellulitis can go on to form an abscess once it localizes later in the course. Once there is an abscess, there is both aerobic and anaerobic bacteria with purulence. These must be I&D’d.

With skin abscesses, the treatment is I&D and there is usually not treatment with antibiotics. However, all dental abscesses should be treated initially with antibiotics. I&D if severe or persistent.







Antibiotic choice:

Cellulitis without abscess: penicillin 500mg QID, amoxicillin 500mg TID or 875mg BID or TMP-SMX (Bactrim) 875mg BID.

Pen-allergic? Clindamycin 300mg PO TID or QID.



Antibiotics takes 24-48 hours to kick in, so follow the patient up the next day.

Patients usually need more than acetaminophen or ibuprofen for pain.

Part of the reason to put all dental patients on antibiotics while they await their dentist appointment is to increase the effectiveness of the local anesthesia the dentist or oral surgeon will use. Local anesthetics don’t work as well in raging infections, so dentists will often put patients on antibiotics for a week or so prior to removing the tooth to make their anesthesia more effective.

Progression of Infection:

Infections of upper and more anterior lower teeth tend to have swelling that spreads to the cheek and are less likely to cause trismus, airway or swallowing problems.

The second and third molars, however, have roots that point in towards the lingual plate and infections here can result in swelling that extends into submandibular space which can extend into the lateral pharyngeal and pterygomandubular space and can lead to trouble swallowing and breathing. You can see uvular deviation. These are more serious infections that need to be transferred to a hospital for admission for airway monitoring, IV antibiotics and often extra-oral I&D in the operating room. If these infections spread bilaterally, the result is Ludwig’s Angina.

Ludwig’s Angina

Occur when an inferior and posterior tooth infection spreads into the bilateral submandibular spaces.

Causes swelling of the submandibular space, elevation of the tongue and airway compromise. Often the skin below the chin has an erythematous, brawny edema to it.

Ludwigs Angina is an emergent airway issue that requires a CT scan and often intubation.

These patients require transfer to the ED via ambulance immediately.

Root Canals

A root canal is necessary when a cavity has spread so deep through the roots of the tooth that is has broken through the enamel into the dentin and into the pulp. A simple filling is not enough because the infection will persist underneath it and will eventually abscess. A root canal is required.

A root canal is a deep filling in which a drill is used to drill down through the enamel, into the dentin and pulp to clean out the entire infection. The nerve and the blood supply to the tooth are removed and then a filling is placed that not only fills in the crown, like a normal cavity filling, but also fills down into the root.

If the tooth is cracked, a root canal can fail and cracked teeth often require removal. Molar teeth often need to have a crown placed on top of the root canal filling to make sure the tooth does not crack and cause the root canal filling to fail.

CASE #1: A 47 yo healthy woman presents to the UC with 3 days of dental pain of one of the lower teeth on the left hand side and she presents with some swelling of the face.

UC Management: Oral antibiotics, pain medicine and a referral to a dentist or oral surgeon in the next 1-3 days. The dentist will take an x-ray to determine if the tooth is savable or not and may perform an I&D. Swelling of the face does not change management in the UC setting.

Physical exam findings that change management to require transfer to an ED:

Eye swollen shut

Severe trismus

Airway compromise

CASE #2: A 47 yo woman with h/o diabetes and a history or cancer with a chemotherapy treatment yesterday who presents with 3 days of dental pain with some swelling. No fever, vital signs stable.

UC Management: The same as in case #1. Remember that diabetics don’t fight off infection like other people, so this person really needs to be seen today or tomorrow. Recent chemotherapy also requires stronger antibiotics. This patient does not need emergent transfer to the ED, but does need very close follow up and antibiotics.

**Remember: Cancer patients or elderly women who have taken bisphosphonates are at risk for osteonecrosis of the jaw after having a tooth pulled. These patients need close follow up with a reliable and experienced oral provider.

2 complications of recent tooth extraction we are likely to see in UC:

Bleeding:

Make sure there’s not a systemic problem, i.e. a patient with a history or von Willebrand’s disease or hemophilia.



Check medication list: baby aspirin 81 mg doesn’t usually cause problems, the full adult dose of 325mg though, can cause bleeding problems, as can clobidogrel (Plavix), warfarin (Coumadin) and the other anti-coagulants.



Hemostasis products like Collogen plugs, Surgicell or gel foam can be pushed down into the tooth socket to stop the bleeding.



For minor oozing after dental procedures, dentists often recommend biting down on a black tea bag. Tea has tannic acid in it that can help with clot formation.



Look for a Liver Clot in the tooth socket . Normally the clot that forms after an extraction is flush with the gum line. If you get a clot that has grown out of the gum line (an looks like a small piece of liver sitting where the tooth used to be), this is a Liver Clot and these clots will keep oozing despite direct pressure with gauze or a tea bag. These clots need to be scooped out and the socket irrigated, and then the body will form a new clot that will likely be more effective.



Consider giving some local anesthetic with epinephrine for both pain control and vasoconstriction, the scoop out the clot, irrigate the socket, then pack the socket with gel foam, Surgicell or other and then suturing the socket closed with the gel foam in place with a figure-of-eight suture.



If you can achieve hemostasis, these patients do not have to be transferred to the ED or to urgently follow up with their surgeon.