By George Terwilliger, MD
Dental problems are among the more common reasons people visit the Emergency Department (ED). In Brattleboro, between 2 and 3% of ED visits are for dental pain. While some of these cases are due to trauma, by far, most are related to dental decay and could have been almost completely prevented with good diet and good dental hygiene.
An acute dental pain emergency usually results from a long history of poor diet (prolonged daily exposure to sweets) and poor dental hygiene (inadequate brushing, not flossing and not getting regular dental care.) The problems usually start in infancy. The worst situation occurs in children given juice or milk in bottles, often sucking on them while asleep, causing rapid dental decay. In 2009, 421 Vermont children under the age of 5 years had such severe dental decay that they required operating room treatment at a cost of 2.7 million dollars.
Most dental problems in the ED are in adults with whom the opportunity for prevention passed long ago. Unfortunately, treatments available in the ED are somewhat limited. Most ED physicians lack the specialized skills to provide definitive dental care. Most dental pain requires the skills of dental professionals: fillings, root canals, and tooth extractions. As in most EDs, there is no dentist available at the BMH ED.
Common Types of Dental Pain:
- Caries, or cavities, hurt with brushing and cold/hot/sweet food or drink. Pain stops when exposure stops. It is easy to localize to one tooth. This does not need an ED visit. Make a dental appointment.
- Pulpitis. The result of infection penetrating through a cavity down to the pulp (tooth root) where the nerves are. It can be hard to tell exactly which tooth is hurting. In early cases the pain comes and goes with the same pain triggers as with cavities. In more severe cases, the pain does not ease when the triggers are stopped. Eventually, the root dies and the pain may also stop for a few hours or days. Later, more severe infection and pain commonly develops. In order to stop the pain and save the tooth, a root canal procedure is needed. In the ED, a nerve block can provide several hours of pain relief and antibiotics can be prescribed which might slow the infection somewhat.
- Apical abscess. When the pulp infection spreads to surrounding tissue a collection of pus can form causing constant pain that is easy to localize to the offending tooth. The pain is constant and worsens with chewing. Often, there will be swelling in the gums, cheek, or lip. Sometimes, there is a visible pocket of pus that can be drained in the ED. Whether or not the abscess is drained, the tooth needs the attention of a dentist or oral surgeon for likely removal. Pain relief is difficult without drainage or removal of the tooth.
- Deep-space infections can complicate tooth infections and can be very dangerous. They involve the face and neck and may produce fever and chills as well as difficulty talking, swallowing, or opening the mouth. ED treatment is essential and may include blood tests and CAT scan to assess extent of infection. IV antibiotics and even admission to the hospital may be necessary. An oral surgeon will need to remove the offending tooth.
- Pericoronitis. An erupting third molar (Wisdom tooth) can cause pain, swelling and infection of the gum. Antibiotics may be prescribed by the ED physician but a dentist will be needed for definitive treatment.
- Sinusitis. Sometimes a sinus infection will cause pain in some teeth mimicking a dental infection. An ED physician can prescribe antibiotics but sometimes a dentist is still needed to make sure it is not related to a dental infection
- Dental trauma. This needs a dentist or oral surgeon, perhaps urgently. However, there are some temporary measures that might be indicated and done in the ED that will help save the tooth and relieve pain.
Obstacles to Treating Dental Pain
Dental pain can be difficult to treat. There is no simple pill to take it away. Most cases of dental pain need a dental procedure to fix the underlying cause. In most cases, an antibiotic is of limited usefulness. The best pain medicine for most people with dental pain is an anti-inflammatory medicine such as ibuprofen (Motrin, Advil) or naproxen (Aleve). In many cases, the pain can be nearly eliminated for several hours with a dental block, an injection of long-acting anesthetic.
Treating the pain with opiates such as hydrocodone (Vicodin) or oxycodone (Percocet) is problematic. They may only give partial relief and they have side effects such as sedation and dependency. Everyday we deal with people who are addicted to opiates. Some of them have physical problems related to their addiction. Others present to the ED under false pretenses with the primary goal of seeking opiates to fuel their substance abuse problem. More and more, we are recognizing that the problem isn’t that these drug-seekers are bad people; the main problem is that these drugs can be very bad for some people. It is estimated that roughly 13% of the general public are prone to developing opiate dependence if exposed to opiates. It is for this reason that ED physicians must be judicious in prescribing opiates. The benefit of relieving pain must be weighed carefully against the potential for causing or fueling an opiate dependency.
George Terwilliger, MD, is the Site Director for the Emergency Department at Brattleboro Memorial Hospital.
Next week: Dental Care in the ED Part II: Referral and Reimbursement Issues.