Dental Pain in the ED

Background

The crown of a tooth is made up of three basic layers; enamel (A), dentine (B), and pulp (C). Pain results when the pulp is inflamed, which is generally caused by bacteria from decay (D), or a leaking dental restoration or “filling”.

History

• A short, sharp pain lasting only a few seconds and occurring in response to a cold or “sweet” stimulus is likely to be reversible pulpitis
• A dull, aching, “pulsing” pain that occurs spontaneously and in response to thermal stimuli is likely to be irreversible pulpitis. There is no swelling, but pain is debilitating, often disturbs sleep, and may last for hours. Irreversible pulpitis requires expedient dental intervention
• Untreated pulpitis leads to pulp necrosis and death, and the pain may temporarily decrease. However, inflammation and infection of the surrounding tissues, known as apical periodontitis, will ensue as bacterial and pulp breakdown products escape from the tooth. The offending tooth will be tender to touch or pressure
• An acute apical abscess is a common manifestation of untreated apical periodontitis and is associated with a swelling, tooth mobility, and severe tenderness to touch
• A chronic apical abscess may be present without pain or obvious swelling if the infection is draining
• Acute abscesses may spread as a cellulitis within soft tissue spaces to the floor of the mouth (Ludwig’s angina), leading to neck and mediastinal abscesses; this can compromise the patient’s airway.