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Tooth Pain

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Tooth Pain, Facial Pain Due To Dental Origin, Odontalgia, Orofacial Pain, Toothache, Dental Pain

  • Pathophysiology
  1. Tooth enamel (outer tooth layer) is not alive and has no pain sensitivity
  2. Pain in an intact, non-infected tooth implies exposed dentin or pulp
    1. Dental Caries erode through enamel and dentin, to inflame the tooth pulp (Pulpitis)
    2. Reversible Pulpitis (early) is transiently painful to cold and pressure and is treated with dental fillings
    3. Irreversible Pulpitis (late) is unprovoked, persistent, unrelenting pain and is treated with root canal or extraction
    4. Pulpitis may become infected or develop an abscess (but Pulpitis itself is not modified by antibiotics)
  • Causes
  • Dental
  1. Dental Caries (reversible or Irreversible Pulpitis)
  2. Apical Periodontitis or Apical Abscess
  3. Periodontal Cellulitis
  4. Pericoronitis (associated with wisdom Tooth Eruption)
  5. Acute Necrotizing Ulcerative Gingivitis
  6. Atypical Odontalgia (idiopathic Tooth Pain)
  7. Food lodged between teeth
  8. Dental Trauma
    1. Tooth Fracture
    2. Tooth Luxation
    3. Tooth Avulsion
    4. Post-surgical (e.g. after root canal or extraction)
    5. Cracked tooth (or split root syndrome)
    6. Barodentalgia (air trapped under filling)
      1. Form of Barotrauma seen in scuba divers
  9. Pediatric additional causes
    1. Primary Tooth Eruption or Teething (age 6 months to 2 years old)
    2. Permanent Tooth Eruption (age 5.5 years to 7 years)
  • Differential Diagnosis
  1. Neuropathic
    1. Trigeminal Neuralgia
    2. Postherpetic Neuralgia
    3. Glossopharyngeal neuralgia
    4. Migraine Headache or Cluster Headache
  2. Vascular
    1. Temporal Arteritis (Giant Cell Arteritis) may cause Jaw Claudication
    2. Cavernous Sinus Thrombosis
    3. Myocardial Ischemia or infarction (lower jaw)
  3. Bone and joints
    1. Osteomyelitis
    2. Temperomandibular joint dysfunction
  4. Systemic illness
    1. Xerostomia causes predisposing to oral pathology
    2. Systemic Lupus Erythematosus
    3. Tuberculosis
  5. Ear, throat, sinus or Salivary Gland referred pain
    1. Acute Sinusitis (Maxillary)
    2. Acute Pharyngitis
    3. Aphthous Ulcer
    4. Sialadenitis or Sialolithiasis
    5. Otitis Media
    6. Otitis Externa
  • Management
  1. Analgesics
    1. NSAIDs in combination with Acetaminophen
      1. Example: Ibuprofen 600 mg every 6 hours AND Acetaminophen 1000 mg every 6 hours
    2. Hydrocodone (Vicodin) may be considered for refractory pain
      1. Try to avoid Opioids for Dental Pain
      2. Wisdom Tooth Extraction is the start of Chronic Opioid use in many young adults
        1. Harbough (2018) JAMA 320(5):504-6 +PMID:30088000 [PubMed]
  2. Acute Dental Pain management
    1. See Inferior Alveolar Block
    2. See Periapical Block (Supraperiosteal Dental Anesthesia)
    3. Temporize (e.g. temporary filling) until definitive dental management
  3. Referred pain
    1. See Lower Cervical Intramuscular Injection
  4. Antibiotics are only indicated for signs of infection (fever, localized swelling, purulent drainage, Trismus, abscess)
    1. Without signs of infection, antibiotics are not indicated in Pulpitis (either reversible or irreversible)
    2. Runyon (2004) Acad Emerg Med 11(12): 1268-71 +PMID: 15576515 [PubMed]
  • References
  1. Claudius, Behar and Trahini in Herbert (2015) EM:Rap 15(5): 5-7
  2. Broderick and Deak (2015) Crit Dec Emerg Med 29(1): 2-8
  3. Amsterdam in Marx (2002) Rosen's Emergency Med, p. 897
  4. Degowin (1987) Bedside Diagnostic Exam, p. 74-5
  5. Delaney (2017) EM:Rap 17(9): 5-7
  6. Douglass (2003) Am Fam Physician 67(3):511-6 [PubMed]