Dental and Ocular Pain

Tomislav Jelic

Hareishun Shanmuganathan

Christian La Rivière

Shelly Zubert

Dental Pain

Epidemiology

Dental complaints represent 0.4–10.5% of emergency department (ED) visits.
Dental complaints can be categorized as (1) orofacial pain, (2) orofacial trauma, and (3) infections.
Traumatic causes are often secondary to falls, accidents, assaults, or motor vehicle collisions.

Orofacial Pain

Orofacial Trauma

Infections

Clinical Assessment of Dental Pain

Dental Caries

Represents the loss of integrity of the tooth enamel.
Pain management consists of oral NSAIDs.
Regional block may be appropriate in select situations.
Management consists of ruling out other causes (i.e., abscess) and referral to a dentist.

Postextraction Alveolar Osteitis

Otherwise known as dry socket, caused by disruption of the clot from the socket, exposing alveolar bone.
Presents in 2–5% of extractions, usually 3–4 days afterwards.
Pain management consists of NSAIDs, regional nerve block, and oil of cloves.
Regional nerve blocks are often required to provide normal saline irrigation and application of packing.
Antibiotics may be required and referral to a dentist within the next 24 hours.

Dental Abscess

Secondary to bacterial infection (Streptococcus species and oral anaerobes) from untreated dental caries.
Left untreated can spread to deep neck spaces.
Regional nerve blocks for the affected region are appropriate within the ED.
NSAIDs with the possibility of an opioid are also appropriate in pain control management.
Definitive management includes incision and drainage, tooth extraction, and antibiotics.

Ludwig’s Angina

Infection of submental, sublingual, and submandibular spaces, with elevation and displacement of the tongue, which can lead to airway compromise.
Poor dental hygiene, dysphagia, odynophagia, trismus, and edema are common signs and symptoms.
Pain management consists of opioids with close monitoring of airway compromise.
Regional blocks are not indicated in this condition.
Definitive management includes IV antibiotics, and emergent referral to ENT for surgical intervention as indicated.

Acute Necrotizing Ulcerative Gingivitis

Also known as Trench mouth.
Triad of pain, ulcerated interdental papillae, and gingival bleeding.
Etiology is poorly understood, but associated in immunocompromised hosts, with Treponema, Fusobacterium, Selenomonas, and Prevotella commonly found.
Pain management consists of systemic opioids, oral rinses with viscous lidocaine.
Definitive management includes warm saline rinses, chlorhexidine rinses, and appropriate antibiotics.

TMJ Dislocation

Secondary to direct trauma, laxity of ligaments of joint, extreme opening of the mouth, dystonic reactions.
Anterior dislocation of the condyles that become trapped in the anterosuperior eminence.
Previous dislocations predispose to further episodes.
Definitive management of joint reduction will provide analgesia.
Proper reduction will often require procedural sedation to alleviate pain, muscle spasm, and patient resistance.

Mandibular/Maxillary Fractures

Pain management consists of systemic opioids and the use of regional nerve blocks where indicated.
Management consists of ensuring there is no airway compromise and prompt referral to a maxillofacial surgeon.

Tooth Avulsions, Concussions, and Luxations

Secondary to falls, direct trauma, sporting injuries.
Definitions:
- Concussion – no displacement or loosening of teeth. There is crush injury to adjoining tissue.
- Luxation – dislocation of teeth.
  - Can be intrusive, extrusive, lateral, lingual, or buccal.
- Avulsion – loss off tooth from the socket.
Regional nerve block in the ED may provide the most comfort for the patient (see Chapter 12).
NSAIDs, soft diets are appropriate as outpatient pain management.
Stabilization of the tooth and referral to a dentist is required.