II. Pathophysiology
- Tooth enamel (outer tooth layer) is not alive and has no pain sensitivity
- Pain in an intact, non-infected tooth implies exposed dentin or pulp
- Dental Caries erode through enamel and dentin, to inflame the tooth pulp (Pulpitis)
- Reversible Pulpitis (early) is transiently painful to cold and pressure and is treated with dental fillings
- Irreversible Pulpitis (late) is unprovoked, persistent, unrelenting pain and is treated with root canal or extraction
- Pulpitis may become infected or develop an abscess (but Pulpitis itself is not modified by Antibiotics)
III. Causes: Dental
- See Burning Mouth Syndrome
- Dental Caries (reversible or Irreversible Pulpitis)
- Apical Periodontitis or Apical Abscess
- Periodontal Cellulitis
- Pericoronitis (associated with wisdom Tooth Eruption)
- Acute Necrotizing Ulcerative Gingivitis
- Atypical Odontalgia (idiopathic Tooth Pain)
- Food lodged between teeth
- Other Dentoalveolar disorders (e.g. infection, cancer, autoimmune disorders)
-
Dental Trauma
- Tooth Fracture
- Tooth Luxation
- Tooth Avulsion
- Post-surgical (e.g. after root canal or extraction)
- Cracked tooth (or split root syndrome)
- Barodentalgia (air trapped under filling)
- Form of Barotrauma seen in scuba divers
- Iatrogenic (Radiation Therapy, Chemotherapy)
- Pediatric additional causes
- Primary Tooth Eruption or Teething (age 6 months to 2 years old)
- Permanent Tooth Eruption (age 5.5 years to 7 years)
IV. Differential Diagnosis
- Neuropathic
- Trigeminal Neuralgia
- Postherpetic Neuralgia
- Glossopharyngeal neuralgia
- Migraine Headache or Cluster Headache
- Vascular
- Temporal Arteritis (Giant Cell Arteritis) may cause Jaw Claudication
- Cavernous Sinus Thrombosis
- Myocardial Ischemia or infarction (lower jaw)
- Bone and joints
- Osteomyelitis
- Temperomandibular joint dysfunction
- Systemic illness
- Xerostomia causes predisposing to oral pathology
- Systemic Lupus Erythematosus
- Tuberculosis
- Ear, throat, sinus or Salivary Gland referred pain
V. Management
-
Analgesics
- NSAIDs in combination with Acetaminophen
- Example: Ibuprofen 600 mg every 6 hours AND Acetaminophen 1000 mg every 6 hours
- Hydrocodone (Vicodin) may be considered for refractory pain
- Try to avoid Opioids for Dental Pain
- Wisdom Tooth Extraction is the start of Chronic Opioid use in many young adults
- NSAIDs in combination with Acetaminophen
- Acute Dental Pain management
- See Inferior Alveolar Block
- See Periapical Block (Supraperiosteal Dental Anesthesia)
- Temporize (e.g. temporary filling) until definitive dental management
- Referred pain
-
Antibiotics are only indicated for signs of infection (fever, localized swelling, purulent drainage, Trismus, abscess)
- Without signs of infection, Antibiotics are not indicated in Pulpitis (either reversible or irreversible)
- Runyon (2004) Acad Emerg Med 11(12): 1268-71 +PMID: 15576515 [PubMed]
VI. References
- Claudius, Behar and Trahini in Herbert (2015) EM:Rap 15(5): 5-7
- Broderick and Deak (2015) Crit Dec Emerg Med 29(1): 2-8
- Amsterdam in Marx (2002) Rosen's Emergency Med, p. 897
- Degowin (1987) Bedside Diagnostic Exam, p. 74-5
- Delaney (2017) EM:Rap 17(9): 5-7
- Douglass (2003) Am Fam Physician 67(3):511-6 [PubMed]