Rosen & Barkin's 5-Minute Emergency Medicine Consult (718 page)

• Obtain appropriate medical and dental history
  
• Ask about drug allergies, especially antibiotics and analgesics, and current medications
  
• Assess need for predental procedure antibiotic prophylaxis:
  
  • Rheumatic fever
    
  • Cardiac valve replacements
    
  • Orthopedic joint replacements
    
  • Mitral valve prolapse or valvular heart disease
    
• If physical exam conflicts with patient’s history and intraoral source of pain is not apparent consider other sources of pain:
  
  • Nonodontogenic etiologies of pain
    
  • Factitious pain/drug-seeking behavior
    

• No lab tests needed except in patients with signs of systemic toxicity and those patients with perceptible deep-space infection
  
• As with any other infection with symptoms of systemic toxicity, consider CBC, blood cultures, markers of inflammation like ESR or CRP
  

• Panoramic and periapical radiograph views if suspicion exists about dental infection or fracture
  
• CT or MRI to evaluate deeper infections
  

A local or regional dental nerve block may sometimes offer both therapeutic and diagnostic benefit

• Sinusitis
  
• Otitis media
  
• Pharyngitis
  
• Peritonsillar abscess
  
• Temporomandibular joint syndrome:
  
  • Usually presents with pain around the ear
    
• Trigeminal neuralgia
  
• Vascular headache
  
• Herpes zoster
  
• Cardiac ischemia
  

• Tooth eruption in a child or infant may cause oral pain, irritability, low-grade fever, diarrhea, and decreased food intake
  
• Facial swelling with fever and leukocytes >15,000/mm
  ³
  suggests a nonodontogenic source
  
• Children have a maximum of 20 deciduous teeth, 10 upper and 10 lower
  

TREATMENT

• Maintain patent airway in patients with severe facial swelling or trismus
  
• The patient should be kept in a sitting position if possible
  

• Airway management for deep-space infection and airway compromise
  
• Early pain management as indicated
  

• Appropriate analgesia
  
• NSAIDs are
  1st-line
  therapy for uncomplicated dental pain
  
• Opiate analgesics are an alternative therapy
  
• Dental anesthetic field block:
  
  • Injected along the buccal surface of the affected tooth
    
  • Specific nerve block for multiple teeth
    
  • Long-acting anesthetic (e.g., bupivacaine)
    
• Antibiotics if dental infection is present:
  
  • Penicillin is the antibiotic of choice
    if patient is not allergic
    
  • Clindamycin for patients with penicillin allergy or for predominance of anaerobes
    
• Localized periapical and periodontal abscesses should be incised, drained, and irrigated:
  
  • Drain may be placed for 24 hr
    
• Saline rinses at home 4 times a day and dental referral in 24 hr
  

• Antibiotics:
  
  • Ampicillin/sulbactam 1.5–3 g IM/IV q6h (peds: 300–600 mg/kg/d [max. 3 g] IV div. q6h)
    
  • Clindamycin: 150–450 mg PO q6h (peds: 15–30 mg/kg/24 h [max. 2 g] q6h):
    
    • IV dose 300–900 mg (peds: 25–40 mg/kg/24 h div. q8h)
      
  • Penicillin VK: 500 mg PO q6h (peds: 25–50 mg/kg/24 h [max. 3 g] q6h)
    
  • Penicillin G potassium aqueous: 4 mU IM/IV q4h (peds: 250,000–400,000 U/kg/d IM/IV div. q4–6h, max. 24 mU/d)
    
• Analgesics:
  
  • Acetaminophen: 500 mg PO/PR q4–6h (peds: 10–15 mg/kg/dose; do not exceed 5 doses/24 h); do not exceed 4 g/24 h
    
  • Acetaminophen and codeine no. 3: 1–2 tablets PO q4–6h (peds: elixir–codeine 12 mg/5 mL)
    
  • Oxycodone 5 mg ± with acetaminophen 325 mg: 1 or 2 tablets PO q6h (peds: 0.05–0.15 mg/kg (oxycodone) per dose [max. 5 mg]); not available in liquid preparation
    
  • Ibuprofen: 400–800 mg PO q8h (peds: 10 mg/kg PO q6h)
    
  • Ketorolac: 30 mg IV, 30–60 mg IM q6h (peds: 1 mg/kg/dose IM/IV)
    
  • Morphine sulfate: 2–8 mg SC or IM/IV q2h (peds: 0.1 mg/kg/dose SC or IM/V q2h)
    

Teething infants may be helped by over-the-counter topical anesthetics and oral analgesics

FOLLOW-UP

• Suspicion of deep-space infections (e.g., Ludwig angina, retropharyngeal abscess)
  
• Facial cellulitis proximal to the eye
  
• Extensive trismus
  
• Inability to maintain nutrition and hydration
  
• Evidence of systemic toxicity
  

Patients with toothache and localized dental infections can be discharged from the ED

Patients treated in the ED should be referred to a dentist or dental surgeon promptly

Regular and routine dental evaluations

• Mistaking a deep infection for local infection
  
• Failing to identify source of referred pain to the mouth
  

• Annino DJ Jr, Goguen LA. Pain from the oral cavity.
  Otolaryngol Clin North Am
  . 2003;6:1127–1135.
  
• Lockhart PB, Hong CH, van Diermen DE. The influence of systemic diseases on the diagnosis of oral diseases: A problem-based approach.
  Dent Clin North Am
  . 2011;55:15–28.
  
• Rodriguez DS, Sarlani E. Decision making for the patient who presents with acute dental pain.
  AACN Clin Issues
  . 2005;16:359–372.
  
• Van Meter MW, Dave AK. Oral Nerve Block.
  Emedicine.
  Available at
  http://emedicine.medscape.com/article/82850-overview
  . Accessed on February 3, 2013.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Aphthous Ulcer
  
• Facial Fracture
  
• Periodontal Abscess
  
• Peritonsillar Abscess
  
• Retropharyngeal Abscess
  
• Temporal–Mandibular Joint Injury/Syndrome
  

CODES

• 521.00 Dental caries, unspecified
  
• 522.0 Pulpitis
  
• 525.9 Unspecified disorder of the teeth and supporting structures
  

BASICS

• Torticollis is a symptom, not a disease
  
• “Twisted neck” (L.
  tortus
  , twisted +
  collum
  , neck)
  
• A fixed or dynamic posturing of the head and neck
  
• Synonym(s): Cervical dystonia, wry neck
  

Local

• Acute wry neck:
  
  • Develops overnight without provocation
    
  • Most prevalent
    
  • Self-limited, symptoms resolve in 1 to 2 wk
    
  • Cervical spine disease
    
  • Fracture
    
  • Dislocation, subluxation
    
  • Infections
    
  • Spondylosis
    
  • Tumor
    
  • Scar tissue–producing injuries
    
  • Ligamentous laxity in atlantoaxial region
    
• Inflammatory disease causing muscular damage:
  
  • Myositis
    
  • Lymphadenitis
    
  • Tuberculosis
    
  • Myasthenia gravis
    
  • Neuritis of the auriculotemporal branch of the trigeminal nerve
    
• Infections of surrounding soft tissues:
  
  • Nasopharyngeal abscess
    
  • Retropharyngeal abscess
    
  • Cervical adenitis
    
  • Tonsillitis
    
  • Meningitis
    
  • Mastoiditis
    
  • Sinusitis