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OROFACIAL PAIN
Normal adult anatomy includes 32 permanent teeth (Fig. 154-1), and general tooth anatomy is shown in Fig. 154-2.
The differential diagnosis for orofacial pain is listed in Table 154-1.
FIG. 154-1. Identification of teeth.
FIG. 154-2. The dental anatomic unit and attachment apparatus.
TABLE 154-1 Differential Diagnosis of Orofacial Pain
PAIN OF ODONTOGENIC ORIGIN
TOOTH ERUPTION AND PERICORONITIS
Eruption of the primary teeth in infants and children may be associated with pain, irritability, and drooling, but fever and diarrhea should not be attributed to teething.
Pericoronitis is inflammation of the operculum overlying the surface of an erupting tooth and is treated with oral antibiotics, irrigation, chlorhexidine or warm saline rinses, and referral to a dentist for definitive treatment.
DENTAL CARIES AND PULPITIS
The most common cause of toothache or dental pain is periapical pathology.
Reversible pulpitis is characterized by sudden, transient pain lasting seconds, often triggered by heat or cold. In contrast, irreversible pulpitis pain lasts minutes to hours.
Management includes oral analgesia (NSAIDs and/or narcotics), warm saline rinses, and dental referral.
A local dental block with a long-acting anesthetic (ie, bupivacaine) may provide relieve until the patient can see a dentist the following day.
Although antibiotics are prescribed frequently in reversible pulpitis, evidence for their efficacy is lacking. Likewise, antibiotics do not improve symptoms in irreversible pulpitis in the absence of clear signs of infection.
PERIRADICULAR PERIODONTITIS
Periradicular periodontitis represents extension of pulp disease into adjacent tissues, which can result in a parulis (swelling of gingiva with fistula next to the tooth).
Fluctuant oral abscesses require local incision and drainage, oral antibiotics effective against mouth flora, oral analgesia, chlorhexidine or warm saline rinses, and close follow-up.
COMPLICAIONS OF ODONTOGENIC INFECTIONS
Odontogenic infections can spread readily to the facial spaces.
Ludwig’s angina is a cellulitis involving the sub-mandibular spaces and the sublingual space that can spread to the neck and mediastinum, causing airway compromise, overwhelming infection, and death.
Treatment of Ludwig’s angina includes intravenous broad-spectrum antibiotics and emergent surgical consultation for consideration of surgical intervention.
If dental infections spread to the infraorbital space, a cavernous sinus thrombosis may result.
Cavernous sinus thrombosis may produce limitation of lateral gaze, meningeal signs, sepsis, and coma.
Treatment of cavernous sinus thrombosis includes intravenous broad-spectrum antibiotics.
Administration of heparin and corticosteroids should be considered for cavernous sinus thrombosis, but a paucity of prospective data exists supporting their efficacy. Surgery is not indicated.
POSTEXTRACTION PAIN AND POSTEXTRACTION ALVEOLAR OSTEITIS (DRY SOCKET)
Periosteitis causes pain within 24 to 48 hours of a tooth extraction; it responds well to analgesics. Postoperative edema can be managed with ice packs, elevation, NSAIDs, and oral narcotics. Trismus can also occur but usually decreases after 24 hours unless an infection develops.
Postextraction alveolar osteitis (“dry socket”) occurs when the clot from the socket is displaced, typically on postoperative day 2 or 3. It presents with severe pain with foul odor and taste. Dental radiographs should be taken to rule out retained root tip or foreign body.
Treatment of postextraction alveolar osteitis consists of saline irrigation and packing of the socket with eugenol-impregnated gauze. Smoking should be avoided. Antibiotic therapy is indicated in most cases, with 24-hour d ental follow-up.
POSTEXTRACTION BLEEDING
Most cases can be stopped with direct pressure with folded gauze for 20 minutes, application of absorbable gelatin sponge, gentle suturing, or injection with lidocaine with epinephrine. If these sequential measures fail, then an oral maxillofacial surgery consult is appropriate.
POSTRESTORATIVE PAIN
NSAIDs and/or oral narcotics with dental referral are appropriate for pain after restorative procedures.
PERIODONTAL PATHOLOGY
PERIODONTAL ABSCESS
Periodontal abscesses are treated similarly to other oral abscesses.
ACUTE NECROTIZING ULCERATIVE GINGIVITIS (ANUG)
ANUG (“Vincent disease” or “trench mouth”) is the only periodontal disease in which bacteria invade non-necrotic tissue.
ANUG presents with pain, ulcerated or “punched-out” interdental papillae, gingival bleeding, fever, malaise, and fetid breath. It occurs mainly in patients with lowered resistance due to HIV, malnourishment, and stress.
Treatment of ANUG consists of oral metronidazole and chlorhexidine mouth rinses and addressing predisposing conditions. Symptomatic improvement can be expected <24 hours.
FACIAL NEURALGIAS
Trigeminal neuralgia is discussed in Chapter 142, Headache and Facial Pain.
SOFT TISSUE LESIONS OF THE ORAL CAVITY
ORAL CANDIDIASIS
Oral candidiasis lesions consist of removable white, curd-like plaques on an erythematous mucosal base. Risk factors include extremes of age, immunocompromised states, use of intraoral prosthetic devices, concurrent antibiotic use, and malnutrition.
Treatment of oral candidiasis is with oral antifungal agents such as clotrimazole troches or nystatin oral suspension, or fluconazole (see Chapter 94, Human Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome).
APTHOUS STOMATITIS
Aphthous stomatitis is a common pattern of mucosal ulceration triggered by cell-mediated immunity. The painful lesions typically resolve in 48 hours when treated with topical steroids, although some larger, deeper lesions (Aphthous major) may take weeks to heal.
HERPES SIMPLEX
Herpes gingivostomatitis causes painful ulcerations of the gingiva and mucosal surfaces. Fever, lymphadenopathy, and tingling often precede the eruption of numerous vesicles, which then rupture and form ulcerative lesions.
If acyclovir or valacyclovir is initiated during the prodromal phrase of herpes gingivostomatitis, the clinical duration and severity may be attenuated (see Chapter 93, Disseminated Viral Infections).
VARICELLA ZOSTER
Herpes zoster occurs in the trigeminal nerve distribution 15% to 20% of the time.
Painful paresthesias precede the appearance of a painful vesicular eruption that does not cross the midline. The lesions last 7 to 10 days (see Chapter 93, Disseminated Viral Infections).
Isolated intraoral lesions occur uncommonly.
If the ophthalmic branch of the trigeminal nerve is involved, it represents an ophthalmology emergency (see Chapter 151, Ocular Emergencies).
HERPANGINA AND HAND-FOOT-AND-MOUTH DISEASE
Herpangina and hand-foot-and-mouth disease are both caused by infection with coxsackievirus A species.
Herpangina is a typically seasonal (summer/autumn) infection that presents with high fever, sore throat, headache, and malaise, followed by eruption of oral vesicles, which rupture to form painful, shallow ulcers on the soft palate, uvula, and tonsillar pillars. Unlike herpes infection, the gingiva is spared.
Hand-foot-and-mouth disease causes vesicles to initially form on the soft palate, gingiva, tongue, and buccal mucosa. The vesicles then rupture, leaving painful ulcers surrounded by red halos. Lesions may also appear on the buttocks, palms, and soles.
Treatment of herpangina and hand-foot-and-mouth disease is supportive and consists of hydration and acetaminophen or ibuprofen.
TRAUMATIC ULCERS AND PYOGENIC GRANULOMA
Traumatic ulcers result from direct trauma to the oral mucosa by ill-fitting dental appliances, hot foods, or traumatic oral hygiene. Improvement results from removal of the inciting factor and supportive care.
A pyogenic granuloma is a benign connective tissue tumor that can result from chronic trauma to the gingiva. One form can occur during pregnancy (pregnancy tumor) and should be removed if it does not resolve spontaneously 2 to 3 months postpartum.
MEDICATION-RELATED SOFT TISSUE ABNORMALITIES
Gingival hyperplasia is a common side effect of many medications, most notably phenytoin, cyclosporine, and calcium channel blockers, especially nifedipine.
Other well-known oral lesions from medications include stomatitis and ulcerations secondary to chemotherapeutic agents and xerostomia-induced mucosal abnormalities from anticholinergics, antidepressants, and antihistamines.
SEXUALLY TRANSMITTED DISEASES
Oral-genital contact can result in STD-related lesions.
Gonorrhea can cause pharyngitis, with or without pustules or exudates, while human papillomavirus (HPV) can cause oral condyloma. The primary syphilis chancre can appear in the mouth as well.
Treatment is similar to that of genital lesions from these organisms (see Chapter 89, Sexually Transmitted Diseases).
LESIONS OF THE TONGUE
Benign migratory glossitis (“geographic tongue”) is a common benign finding marked by multiple circumscribed zones of erythema found predominantly on the tip and lateral borders of the tongue. The lesions wax and wane with stress and menstrual cycle. It is usually asymptomatic, but topical oral steroids may provide relief for symptomatic cases.
Strawberry tongue appears as red spots on a white-coated background. It is associated with several conditions, including Kawasaki’s disease and Streptococcus pyogenes infection. If it is due to the latter, it responds to antibiotics effective against group A streptococci.
ORAL CANCER
Leukoplakia is a white patch that cannot be scraped off and is not secondary to another condition. It is the most common precursor for oral cancer, although most lesions are benign.
Erythroplakia is a red patch that cannot be classified as secondary to any other disease, and it has a greater potential for cancer than leukoplakia.
Symptoms and signs of oral cancer include pain, paresthesias, persistent ulcers, bleeding, lesion rigidity, induration, lymphadenopathy, and functional impairment.
Risk factors for oral cancer include tobacco (including chewing tobacco) use, alcoholism, sun exposure, general malnutrition, chronic iron deficiency anemia, candidiasis, immunosuppressive states, and various viruses (eg, HIV, HPV, herpes).
The most common site for oral cancer is the tongue (50%), with the floor of the mouth accounting for 35% of cancers.
Lesions that do not resolve with palliative treatment in 10 to 14 days should be referred for biopsy.
OROFACIAL TRAUMA
DENTOALVEOLAR TRAUMA
DENTAL FRACTURES
The Ellis classification of dental fractures is shown in Fig. 154-3.
Ellis class 1 fractures involve only the enamel of the tooth. These injuries may be smoothed with an emery board or referred to a dentist for cosmetic repair.
Ellis class 2 fractures (70% of tooth fractures) involve the creamy yellow dentin underneath the white enamel. The patient complains of air and temperature sensitivity. The exposed dentin must be thoroughly dried and promptly covered with a temporary dental dressing such as zinc oxide/eugenol paste with dental referral <24 hours.
Ellis class 3 fractures are tooth-threatening fractures that involve the pulp and can be identified by a red blush of the dentin or a visible drop of blood after wiping the tooth.
Ideally, a dentist should evaluate the patient with an Ellis class 3 fracture immediately. If a dentist is not immediately available, the tooth may be temporarily covered with a dental dressing such as zinc oxide/eugenol paste until the patient is seen within 24 hours. Oral analgesics may be needed, but topical anesthetics are contraindicated. The use of prophylactic antibiotics is controversial.
In patients under the age of 12 years, the protective dentinal layer is thin. A visible blush of pulp under this thin dentinal layer thus indicates that the pulp is at risk, and should be treated like an Ellis class 3 fracture.
FIG. 154-3. Ellis classification for fractures of teeth.
CONCUSSIONS, LUXATIONS, AND AVULSIONS
Concussion injuries involve tenderness to percussion with no mobility.
Dental trauma with tenderness to percussion and mobility without evidence of dislodgment is called subluxation, which has a higher incidence of future pulp necrosis.
Management of concussion injuries and subluxation includes NSAIDs, soft diet, and referral to a dentist.
Extrusive luxation occurs when a tooth is partially avulsed from alveolar bone. Treatment involves gentle repositioning of the tooth to its original location and splinting with zinc oxide periodontal dressing (Fig. 154-4) with dental referral <24 hours.
When the tooth is laterally displaced with a fracture of the alveolar bone, the condition is called lateral luxation.
Although manual relocation is possible, the treatment of lateral luxation is best done in consultation with a dentist in the emergency department (ED), especially if the alveolar fracture is significant.
An intrusive luxation occurs when the tooth is forced below the gingiva and often has a poor outcome. Treatment is similar to that of subluxations.
Dental avulsion is a dental emergency in which a tooth has been completely removed from the socket.
Primary teeth in children should not be replaced because of potential damage to the permanent teeth. Intruded primary teeth should be left alone.
Permanent teeth that have been avulsed for less than 3 hours must be immediately reimplanted in an attempt to save the periodontal ligament fibers.
If reimplantation at the scene is not possible due to risk of aspiration, the tooth should be rinsed and placed in a nutrient solution, such as Hank’s solution, sterile saline, milk, or saliva and the tooth transported immediately with the patient to the ED.
Upon arrival in the ED, the socket can be gently irrigated with sterile normal saline prior to reimplantation if the root is still moist.
If the root of the tooth has been dry for longer than 20 minutes, it may be soaked in various solutions prior to implantation in attempt to improve outcome.
The root should not be handled. Upon arrival in the ED, the clot in the socket should be removed and the socket gently irrigated with sterile normal saline.
Early consultation with a dentist is imperative, but reimplantation with gentle pressure should not be delayed while awaiting the arrival of the specialist.
After reimplantation, adults should receive doxycycline 100 milligrams PO bid for 7 days. Children <12 years old should receive penicillin VK (25-50 milligrams/kg/d) in divided doses 4 times a day for 7 days.
If a patient arrives with an empty socket and the tooth cannot be located, adjacent tissue should be searched. Radiographs may be necessary to exclude displaced or aspirated teeth.
If a patient arrives with an empty socket and the tooth cannot be located, adjacent tissue should be searched. Radiographs may be necessary to exclude displaced or aspirated teeth.
FIG. 154-4. Reimplantation and stabilization of an avulsed tooth. A. Tooth is rinsed. B. Tooth is placed back into socket. C. Splint material is mixed thoroughly. D. Splint material is shaped and made ready for application. E. Packing is molded over reim-planted tooth and two adjacent teeth to each side.
SOFT TISSUE TRAUMA
Stabilization of dental injuries and an aggressive search for retained foreign bodies should take place before repair of lacerations.
Most intraoral mucosal lacerations will heal by themselves; however, they should be repaired if they are gaping or if flaps are present. Treatment consists of achieving good anesthesia, debridement, irrigation, and close approximation (rather than a tight tissue seal) with 5-0 absorbable sutures. Antibiotics are only prescribed for the largest lacerations, and 48-hour follow-up is indicated.
Tongue lacerations that gape widely, actively bleed, are flap shaped, or involve muscle should be closed. Lacerations may be repaired with 4-0 absorbable sutures. Extreme care must be taken to precisely repair the edges of dorsal lacerations because malapproximation will result in clefts in the tongue that will require revision. Extensive lesions or those in uncooperative patients may require operative repair.
Lip lacerations are potentially complex because of the possible involvement of the vermilion border (the transition between lip tissue and the skin of the face), which must be aligned precisely with 6-0 nonabsorb-able sutures to avoid a noticeable cosmetic defect.
Violated deep muscle layers and intraoral lesions must be closed as well. Prophylactic penicillin VK or clindamycin should be prescribed.
The repair of through and through lacerations is controversial. Some advocate first repairing the intraoral laceration, and then irrigating the wound before finally closing the external laceration, using both superficial and deep sutures if necessary. Others advocate leaving the intraoral lacerations open. Prophylactic antibiotics are indicated.
A cosmetic surgeon should be consulted to repair extensive lip lacerations.
Laceration of the maxillary labial frenulum does not usually require repair.
The lingual frenulum is very vascular and usually should be repaired with 4-0 absorbable sutures.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 240, “Oral and Dental Emergencies,” by Ronald W. Beaudreau.