- Published on
Emergency and Acute Medicine – Toothache
Toothache is a common presentation caused by irritation of the nerve endings within the dental pulp, which contains the tooth’s neurovascular supply. Although most causes are odontogenic, pain may also originate from non-dental sources and be referred to the oral cavity via the distribution of the trigeminal nerve.
The most common etiologies are dental in origin. Dental caries, resulting from bacterial demineralization of tooth structures, can progress to pulpitis, which may be reversible or irreversible depending on severity. Reversible pulpitis causes mild inflammation and transient pain, whereas irreversible pulpitis leads to severe, persistent, and poorly localized pain. If untreated, this may progress to a periapical abscess involving necrotic pulp and surrounding tissues. Other dental causes include periodontal disease (gingivitis and periodontitis), periodontal abscess, pericoronitis (often associated with partially erupted wisdom teeth), cracked-tooth syndrome, postextraction complications such as dry socket, and mucosal conditions such as aphthous ulcers or herpetic gingivostomatitis.
Patients typically present with localized or referred tooth pain that may radiate to the jaw, ear, face, eye, or neck. The pain is often exacerbated by chewing, temperature changes, or lying flat. Associated symptoms may include foul taste, bad breath, fever, or facial swelling. A detailed history should include onset, duration, prior treatments, and associated systemic symptoms.
Physical examination should be thorough and systematic. Findings may include visible dental decay, gingival inflammation, swelling, or trismus (reduced mouth opening). The clinician should inspect and palpate oral structures, assess for lymphadenopathy, and evaluate for signs of deep-space infection such as floor-of-mouth swelling or voice changes. Percussion of teeth may reveal tenderness, and examination for fractures, mobility, or missing teeth is essential. Facial and neck examination should assess for cellulitis, warmth, and stiffness.
Diagnosis is primarily clinical. Laboratory tests are generally not required unless there are signs of systemic toxicity or deep-space infection, in which case inflammatory markers and cultures may be considered. Imaging such as panoramic or periapical radiographs may help identify abscesses or fractures, while CT or MRI is reserved for suspected deep infections. Dental nerve blocks can provide both diagnostic and therapeutic benefit in selected cases.
Management focuses on pain control and treatment of the underlying cause. NSAIDs are first-line therapy for uncomplicated dental pain, with opioids reserved for severe cases. Local or regional dental nerve blocks using long-acting anesthetics such as bupivacaine can provide effective relief. If infection is present, antibiotics are indicated, with penicillin as first-line therapy and clindamycin for penicillin-allergic patients or suspected anaerobic infections.
Localized abscesses should be incised, drained, and irrigated, followed by saline rinses and prompt dental follow-up. Most patients can be discharged with appropriate analgesia, antibiotics if indicated, and referral to a dentist or oral surgeon. However, admission is required for serious complications such as deep-space infections (e.g., Ludwig angina), facial cellulitis near the eye, significant trismus, inability to maintain hydration, or systemic toxicity.
Key clinical pearls include recognizing that dental pain can be referred from non-dental sources such as sinusitis, temporomandibular joint disorders, or even cardiac ischemia. Failure to identify deep-space infections can lead to life-threatening complications, so careful assessment is essential. Prompt dental follow-up is critical, as emergency department treatment is only temporizing and does not address the definitive underlying pathology.
0 Comments
