Pulpitis

The common toothache is caused by inflammation of the dental pulp. It may be difficult for the victim to identify the offending tooth due to convergence of neurons in the trigeminal spinal tract nucleus.^9,26 The painful tooth is rarely sensitive to percussion or palpation. An obvious cause, such as a large carious lesion, is sometimes found on examination of the mouth, but often all of the teeth appear intact. If inflammation is mild, the condition is characterized by pain that is elicited only by cold or sweets and disappears within seconds when the stimulus is removed. Moderate pulpitis is characterized by sensitivity to hot as well as cold, greater discomfort, and an increasing interval between the removal of the stimulus and resolution of the pain. In its most severe form, pulpitis causes intense, continuous, and debilitating pain.^6,9,33 Emergency treatment recommendations are given in the following sections.

Periapical Osteitis

Inflammation of the supporting structures at the root of a tooth is characterized by constant, often throbbing, pain. Unlike pulpitis, the affected tooth is easily located. The victim can usually point to the exact source of the pain, or the examiner may gently tap individual teeth, observing for tenderness. The area over the apex of the tooth is usually tender to palpation, but there is no frank swelling. Although trauma to a tooth can result in periapical inflammation, the most common cause is egress of bacteria and breakdown products from the necrotic pulp. Minor swelling around the apex extrudes the tooth slightly, causing increased forces on the tooth during occlusion, and thus intensifies the pain. Emergency treatment includes an analgesic (ibuprofen 600 mg PO every 6 hours as needed for pain) or a local anesthetic and a soft diet. Ideally, the contacting areas of the opposing tooth are reduced to relieve occlusal forces.^6,9 Because this usually is impractical in the field, the victim can be given a strip of webbing or something similar to place between the teeth on the nonpainful side. This will keep the offending tooth out of occlusion and reduce the pain.

Cracked Tooth Syndrome

The victim complains of momentary, sharp pain when chewing certain foods or on releasing the bite. Often the victim reports that the tooth feels “weak” or that “it only hurts when I bite on something hard just the right way.” These symptoms occur when forces of the proper magnitude and direction open the incomplete fracture in the tooth.³⁷ The pain can vary with a cracked tooth depending on how deep the crack is and how close it comes to the pulp. Significantly, there is no pain on chewing soft foods. Often the victim has large restorations or a habit of chewing ice or clenching and grinding.²² This condition usually progresses slowly. Reducing the occlusion on the cracked tooth will relieve some pain but again is often impractical in the field. The victim should be advised to avoid chewing on the affected side and to seek definitive dental treatment as soon as possible.

Odontogenic Referred Pain

Pain originating in the pulp of the tooth can sometimes be referred to distant sites. Common referral patterns are the following: maxillary incisors to the forehead, maxillary canine to the infraorbital area, maxillary molars to the temple or ear area, mandibular anterior teeth to the mental foramen area, mandibular premolars to the posterior jaw, and mandibular molars to the angle of the jaw, the ear, or the neck. Sometimes the victim swears the pain is coming from a tooth several teeth in front or behind the source of pain. Pulpitis pain can be referred from an upper tooth to a lower tooth, or vice versa, but never crosses the midline. Many cases have been presented in the dental literature detailing how experienced practitioners have treated the wrong tooth or performed multiple dental treatments when the source of pain was not a tooth.^26,30 If in doubt about the diagnosis, ensure that you do no harm.

Maxillary Sinusitis

The pain of maxillary sinusitis can be referred to a maxillary posterior tooth. It is usually described as a relatively continuous throbbing ache that is intensified by postural change. A typical statement is, “My tooth really hurt when we were hiking down the hill. I could feel it pound with every step. When we got to camp, I lay down, but it got even worse.” The pain may be unilateral or bilateral. It is usually located in the infraorbital region and is often referred to the cheeks, frontal region, and the maxillary premolars and molars. A complaint of multiple toothaches in the maxilla, with no evidence of carious teeth, should immediately raise suspicion for maxillary sinusitis. In addition to pain, there is tenderness elicited by pressure infraorbitally or over the bony prominence above the first molar. The victim also generally has an elevated temperature and nasal or postnasal discharge.

Treatment of maxillary sinusitis includes an analgesic (ibuprofen 600 mg PO every 6 hours as needed for pain), inhalation of steam, oxymetazoline (Afrin) 0.05% 1 spray in each nostril twice a day to shrink the nasal membranes and improve sinus drainage, and an antibiotic. Appropriate choices include amoxicillin 875 mg with clavulanic acid 125 mg (Augmentin) PO twice a day for 10 days or trimethoprim 160 mg with sulfamethoxazole 800 mg (Septra DS) PO twice a day for 10 days. Azithromycin (Zithromax) 500 mg PO the first day and then 250 mg PO for 4 days is a convenient alternative.^1,19

Temporomandibular Disorder

Temporomandibular disorder (TMD) is a cluster of conditions, multifactorial in origin, and with overlapping symptoms that often respond to a variety of therapies, including placebos.³¹ If the victim answers “yes” to any of the following questions, he or she may suffer from TMD: Does it hurt to open the mouth widely or yawn? Do you have earaches or pain in front of your ear? Is your pain worse in the morning? Have you had trauma to your face or jaw? Do you have temporal pain or headaches? Has your jaw ever gotten stuck open or closed? Does your jaw pop or click on opening or closing?

Included under the term TMD are two groups of sufferers: those with primary masticatory muscle involvement (myofascial pain and dysfunction [MPD]) and those with internal derangements of the temporomandibular joint (TMJ). Patients also may present with a combination of both types. Internal derangements, traumatic injuries, and dislocation of the joint are covered in Chapter 31.

Aphthous Ulcers

It is thought that aphthous ulcers may represent a local immune response with various triggers such as stress; trauma; immunosuppression; nutritional deficiencies of vitamin B₁₂, folic acid, or iron; acidic foods; and food allergies; to name a few. The lesions are round or ovoid in shape with a yellowish center and a red border and usually occur on nonkeratinized, movable mucosa (Figure 30–1). They can be quite painful. The victim usually gives a history of similar ulcerations. There are three types of aphthous ulcers. Minor aphthae are less than 0.6 cm (0.2 inch) in size and usually last 10 to 14 days. Major aphthae are larger than 0.6 cm (0.2 inch) and may last weeks or months. Herpetiform aphthae are clusters of small, shallow ulcers that resemble intraoral herpes.

FIGURE 30-1 Aphthous ulcer on the tongue.

Many treatments have been proposed, but none has been found predictably effective. The best approach appears to be application of a topical corticosteroid to reduce pain and hasten healing by 3 to 4 days. Mix fluocinonide (Lidex) 0.05% ointment with Orabase and place the mixture gently over each ulcer 6 to 8 times per day, especially after meals and before bedtime. Do not mix the medications until you are ready to apply them, and do not rub the mixture into the lesions. Other options include premixed preparations, such as Kenalog in Orabase, applied to the ulcer 6 to 8 times per day, which is more convenient but delivers only about 10% of the antiinflammatory effect, or dexamethasone (Decadron) elixir (0.5 mg/5 mL, rinse with 5 mL for 2 minutes and expectorate 4 times a day). Finally, a systemic corticosteroid (prednisone, 40 mg PO once daily for 3 days, then taper) may be used for a very severe case. If these preparations are not available, tincture of benzoin or a topical anesthetic (viscous lidocaine 2%) can be applied to the dried surface of the ulcer before meals and at bedtime to control the pain.^15,45

Traumatic Ulcers

Traumatic ulcerations are similar to aphthous ulcers but are usually more irregular in outline and lack the red border. They occur from chronic rubbing such as from a sharp tooth against the tongue or an ill-fitting denture against the palate. Topical anesthetic (viscous lidocaine 2%) can be used, but the most important treatment is to remove the source of irritation.

Bisphosphonate-Related Osteonecrosis of the Jaws

Oral bisphosphonates such as alendronate (Fosamax) are widely used to treat osteoporosis, and intravenous bisphosphonates, such as zoledronic acid (Zometa) are used to manage skeletal involvement in various cancers. A side effect of these medications can be delayed healing of exposed bone in the maxillofacial region. Altered bone metabolism persists long after the medications have been discontinued. Bisphosphonate-related osteonecrosis of the jaws (BRONJ) may occur after bone is exposed by acute trauma, by chronic trauma such as from an ill-fitting dental prosthesis, from dental surgery, or after tooth extraction. The incidence after tooth extraction in patients that have taken oral bisphosphonates is less than 1%. The risk for BRONJ in patients that have received intravenous therapy is estimated between 0.8% and 12%.³

The diagnosis of BRONJ is made when exposed, necrotic bone persists for at least 8 weeks in a patient currently or previously treated with a bisphosphonate who has no history of radiation treatment to the jaws. Small lesions may be asymptomatic (Figure 30-2, online), whereas some exposed areas become infected, as evidenced by pain, erythema of the surrounding soft tissue, and possible purulent drainage. Prevention of BRONJ focuses on avoiding bone exposure in patients at risk. Emergency management consists of eliminating pain, controlling infection, and limiting the progression of bone necrosis. Asymptomatic lesions are treated with an antibacterial mouth rinse such as chlorhexidine. BRONJ that is painful and infected is treated with an antibacterial mouth rinse as well as an antibiotic, such as penicillin V potassium 500 mg PO 4 times a day, cephalexin (Keflex) 500 mg PO 4 times a day, or clindamycin 150 mg PO 4 times a day, and pain control. Evacuation for surgical care is indicated in cases of BRONJ complicated by any one of the following: pathologic fracture, extraoral fistula, or necrosis extending to the inferior border of the mandible.^3,27,38

FIGURE 30-2 Two small areas of bisphosphonate related osteonecrosis of the jaw (BRONS).

Mucocele

Mucocele, or mucous retention phenomenon, occurs when the duct of a minor salivary gland is blocked or traumatized, resulting in accumulation of saliva beneath the mucosa. It most commonly occurs in the lower lip. A mucocele in the floor of the mouth is called a ranula. Most mucoceles are a few millimeters in diameter, lie just under the surface, and have a translucent or bluish tint. They often form, spontaneously drain, then reform again and again. Most will eventually disappear without surgical intervention. No emergency treatment is necessary (Figure 30-3).

FIGURE 30-3 Mucocele commonly occurs on the inside of the lower lip.

Viral Infections

Herpes labialis (cold sore, fever blister) is the most common oral viral infection. It is characterized by yellow, fluid-filled vesicles that rupture to leave ragged ulcers on the lips (Figures 30-4 and 30-5). Other locations for recurrent herpetic outbreaks include the palate, tongue, and buccal mucosa. The victim can be given valacyclovir (Valtrex) 2 g PO twice daily for 1 day, with doses taken about 12 hours apart.⁴³ It is important to begin treatment as soon as the victim becomes aware of a prodromal “tingle” or paresthesia. There is some evidence that the same regimen of valacyclovir can prevent outbreaks from occurring.^8,29 However, more conservative methods, such as the use of sun-blocking agents on the lips, are preferred.⁴⁴

FIGURE 30-4 Herpes labialis in the healing stage.

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