At a glance
- Many Americans do not have a primary dental provider.
- The majority of dental and oral pain seen in primary care is carious in nature.
- Dental trauma is a common occurrence, with as many as 25% of 12-year-olds injuring their permanent teeth.
- The three most common forms of dentoalveolar trauma seen in primary care are avulsion, luxation, and fracture.
For various reasons, many Americans fail to establish a primary dental provider or are without dental insurance or access to preventive services. As a result, these patients often turn to primary-care clinicians for their dental and oral urgent-care needs.1
Most oral and dental complaints are accompanied by significant pain or require immediate intervention to prevent permanent complications. In other instances, the oral mucosa, which is highly vascularized, will bleed profusely when traumatized, causing great alarm to the patient, parent, or caregiver. In instances of significant trauma, such as airway obstruction and mandible or maxilla fractures, patients may present to the ER.
To help prevent major complications, clinicians must be aware of the common oral or dental emergencies, effective treatment methods, and follow-up protocol.
History and physical
When a patient presents with an oral or dental emergency, the following information should be documented:
- Time of injury; length of time that has elapsed
- Did the patient lose consciousness at any time following the injury? (If so, a neurology referral is recommended.)
- Patient’s current mental status
- Since the injury first occurred, has the patient experienced any nausea, vomiting, headache, pressure- or temperature-related dental pain, or bleeding from the nose or ears?
- Any history of bleeding disorders
- Tetanus vaccine and booster history
- Is the patient immunocompromised?
- The need for prophylactic antibiotic treatment
A thorough examination, including vital signs and mental status, should be performed on all patients presenting with oral or dental emergencies. Pupils should be evaluated for size and reaction to light. Check for periorbital or facial edema. The oral cavity and surrounding tissue, as well as the oral mucosa, palate, and frenum, should be inspected for lacerations, edema, bruising, fracture, foreign bodies, or tooth fragments.2 Tears of the frena are highly indicative of physical abuse and warrant careful consideration in most cases of dental and oral trauma. Palpate for regional lymphadenopathy.3 A complete head and neck exam should be performed to rule out complications of head trauma, ocular damage, airway obstruction, and cervical spine injuries.
The most common causes of oral soft-tissue injuries are impalement; self-mastication, often during falls or seizures; and animal bites. Intraoral impalement injuries may bleed profusely but often heal spontaneously without sequelae.
Tongue lacerations require suturing only if the wound edges are not approximated or are >1 cm. Suturing may be required if the injury occurs on the lips. In severe cases, the patient should be referred for reconstructive surgery for optimal outcome.
Significant bacteria normally exist in the oral mucosa; therefore, use of antibiotics is not generally warranted. Where the tear is large or when contamination by extrinsic bacteria has occurred, oral amoxicillin can be prescribed. The recommended dose for adults is 250-500 mg every eight hours for five to seven days. Children should be given a daily dose of 40 mg/kg, divided into three doses.
Dental caries and pain
Although most dental or oral pain seen in primary care is carious in nature, a thorough history of any concurrent illnesses should be assessed, including signs and symptoms of sinusitis, headache, temporomandibular joint dysplasia, and oral mucosa lesions.3 Dental decay is inflammatory and infectious but initially painless when confined to the tooth enamel. Without prompt treatment, the dentin may become affected, resulting in sensitivity to hot, cold, or sweet stimuli. If left untreated, pulpitis may develop, eventually causing necrosis of the pulp and abscess.3,4
Dental pain can be classified as pulpal when it is diffuse, abrupt, throbbing, and aggravated by extremes in temperature. It endures after the stimulus is removed. At this point, pulp necrosis is suspected.
Periapical pain is localized, more severe, and longer-lasting. This spontaneous pain occurs when pressure is applied to the tooth. Edema and tenderness of the gingiva also may be present.5 If an abscess develops, the patient should be evaluated for facial edema and constitutional symptoms of fever and malaise. Left untreated, an abscess can progress from local infection to a fulminating deep-space infection with resultant airway obstruction, a possibly severe medical crisis. Patients should be referred to a dentist for the necessary root canal of the necrosed pulp or tooth extraction.
Guidelines for appropriate management of odontalgia are continually being updated. The current treatment regimen for routine dental pain is nonsteroidal anti-inflammatory drugs (NSAIDs). These agents reduce the number of narcotic prescriptions and ER visits and lessen habitual dental pain.