Sickcall visit: Toothache and Facial Pain

The most common complaint of dental patients reporting to sickcall is a toothache or facial pain caused by a cavity, inflammation of the tissues supporting the tooth, trauma, or oral lesions. Proper treatment is based on a correct diagnosis. The GMO should treat the patient's signs and symptoms and if possible, the cause of the emergency. The following guidelines are provided to assist in the diagnosis and management of dental emergencies.

Using the S.O.A.P. (subjective, objective, assessment, and plan) format, the GMO should document the patient's chief complaint, clinical findings, differential diagnosis, and treatment plan. When recording the dental history, the GMO should question the patient regarding the following points:

The GMO should keep in mind that the patient might not be able to identify which tooth is hurting, the pain may be referred from one area to another, and the pain may not be odontogenic in origin.

Clinical exam and important diagnostic findings

Differential diagnosis

Using the findings from the dental history and clinical exam, the GMO should attempt to determine the etiology of the emergency and render a diagnosis. The following is a differential of the most common dental emergencies.

• Reversible pulpitis
  with an excavator, remove any loose filling material, debris, and easily removable decay from the tooth. Dry the cavity with cotton pellets and pack with a thick mix of zinc oxide-eugenol packed into the cavity, have the patient bite down and grind his or her teeth, remove the excess. Rx: Motrin 800mg TID.

• Irreversible pulpitis
  same treatment as above. However, irreversible pulpitis is a true toothache which, in most cases, requires a dental officer's care. Rx: Motrin 800mg TID.

• Periradicular abscess
  if the intraoral swelling is fluctuant, incise and drain the area. Skin refrigerant or ice can be used as a topical anesthetic. Rx: Motrin 800mg TID, Penicillin VK (PCN VK) 500mg QID (loading dose of 1 to 2 gm) if systemic symptoms are present, and warm saline rinses QID.

• Pericoronitis
  gently irrigate under the flap of tissue covering the erupting crown of the tooth with 3 percent hydrogen peroxide using a syringe with a curved blunted 18 gauge needle. Continue this irrigation on a daily basis until the patient can be seen by a dental officer. Rx: Motrin 800mg TID, PCN VK, and warm saline rinses.

• Periodontal abscess
  gently remove debris between gingiva and neck of tooth and irrigate as above. If area is swollen, establish drainage by placing a thin instrument (scaler) into area between tooth and gingiva. Rx: Motrin 800mg TID and saline rinses; PCN if systemic symptoms are present.

• Fractured anterior tooth
  gently remove any remaining fractured pieces of tooth structure. If the tooth is not painful, smooth the rough edges with an emery board. If it is painful or the pulp is exposed, cover the tooth with Stomahesive adapted to the adjacent teeth. Rx: Motrin 800mg TID.

• Traumatized tooth
  leave intruded tooth alone; reposition laterally luxated, extruded, or avulsed tooth (use the adjacent teeth as a guide), and stabilize by adapting Stomahesive to the tooth and its adjacent teeth. If the avulsed tooth cannot be replanted, place it into Hank’s balanced salt solution (HBSS), sterile saline, or milk for storage until the patient can be seen by a dental officer.

• Canker sores
  place a topical steroid (0.1% Triamcinolone acetonide) on the lesions. Cocoa butter ointment, lanolin based lip preparations, or petrolatum (Vasoline) as an emollient may be palliative.

• Cold sores
  place a topical anesthetic (2% Lidocaine viscous) on the lesions. Warn the patient not to spread the infection to open wounds (especially on fingers) or the eyes. Both oral herpes and aphthous ulcers last for 10-14 days and recur.

If the emergency treatment is successful, the patient's acute signs and symptoms should subside, and follow up care by a dental officer can be delayed until routine dental treatment is available. However, if a definitive diagnosis cannot be made, or appropriate care cannot be rendered because of a lack of expertise, instruments or materials, the GMO should manage the patient's signs and symptoms (analgesics for pain, antibiotics for infection, and antipyretics for fever). If the acute problem does not resolve, the patient should be referred to a dental officer for definitive care. In addition, patients who present with intractable facial pain, rapidly spreading fascial space infections, and or fractures of facial bones require immediate referral to a dental officer.

References

1. Cassidy RE. Diagnosis and Immediate Treatment of Dental Emergencies by Military Physicians. National Naval Dental Center, Bethesda.

2. Submarine Force Independent Duty Corpsman Dental Syllabus, Naval Undersea Medical Institute, 20 July 1989.