SAN DIEGO—The numerous pathologies that cause dental pain can be dizzying. But the approach to tooth pain in the emergency department can be framed with a relatively simple approach that can result in more precise immediate care and more accurate referrals, according to Joan Noelker, MD, MACM, assistant professor in emergency medicine at Washington University in St. Louis. During her Monday presentation at ACEP18, Dr. Hoelker provided a straightforward approach to identifying and managing conditions related to teeth discomfort.
Numerous dental and nondental conditions cause tooth discomfort. Superficial injuries such as a chipped tooth or enamel rarely cause pain, and usually require minimal emergency department treatment. Conditions affecting the dentin usually result in heat/cold discomfort. Constant, debilitating pain likely involves the interior pulp portion of the tooth, requiring a more immediate referral to a dentist. Underlying bone involvement requires a surgical consultation for a potentially emergent situation.
Dr. Noelker grouped the dental etiologies into several categories. Traumatic tooth injuries require careful evaluation for associated damage to bony structures. Infections are among the more common conditions seen in the emergency department, ranging from minor infections that are managed with oral antibiotics, to serious conditions like trench mouth or Ludwig’s angina. A CT with contrast may be needed, along with IV antibiotics and emergent surgery.
Inflammatory processes include conditions such as stomatitis and patients with ear, nose, and throat cancer conditions with a post-radiation inflammatory reaction. Suspect neoplastic causes in patients with normal appearing teeth who are complaining of dental pain. A sinus malignancy or a cancer forming in the floor of the mouth may be the culprit. Referred tooth pain may be caused by a cardiac issue or other serious source.
Dental bleeding is rarely life threatening, even when the patient is on anticoagulants. After ensuring airway patency, simple direct pressure on the site will generally control nearly all forms of dental bleeding. Dr. Noelker suggested that the easiest and most effective approach is to have the patient bite down with moderate pressure on a gauze if the opposing teeth are available. Keep suction nearby as the bleeding may cause patient distress. The emergency physician may need to consider adjunctive therapy if the bleed is not readily controlled, such as wetting the gauze with tranexamic acid, using Surgicell, or injecting a mixture of epinephrine and lidocaine to the site. Review the patient’s history for any bleeding disorders. If the patient is on thinners, determining which one the patient is prescribed will help determine the appropriate reversal agent.
Effective pain management strategies beyond opioid and nonopioid strategies include topical anesthetics and dental blocks. A combination of 10% lidocaine mixed with 20% benzocaine applied topically can be effective in calming tooth pain. Five common dental blocks also can be used by the emergency physician to control deep-seated tooth pain, including the inferior alveolar nerve block.