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DENTAL ANATOMY

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The relevant dental anatomy is shown in Figure 152-1.

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OROFACIAL PAIN

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Tooth Eruption and Pericoronitis

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Eruption of the primary teeth (“teething”) in children may be the primary cause of pain, irritability, and drooling, but NOT fever and diarrhea; therefore, other causes of these latter symptoms must be excluded. Give the child a frozen, damp towel to suck on and acetaminophen 15 mg/kg orally (PO) every 6 hours to control symptoms. Topical anesthetics should be used with great caution in young infants due to its potential to depress the gag reflex.

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Adults and teens may experience pericoronitis (pain and local inflammation) with the eruption of the third molars (“wisdom teeth”). Prescribe penicillin VK 500 mg PO four times daily or clindamycin 300 mg PO four times daily, ibuprofen 400 to 800 mg PO three times daily (with or without hydrocodone 5 mg/acetaminophen 325 mg one to two tablets PO four times daily), and warm saline mouth rinses. Refer the patient to an oral surgeon or a general dentist for consideration of third molar extraction.

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Dental Caries and Pulpitis

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Dental caries are caused by bacteriogenic acid eroding through the enamel. Examination may reveal a grossly decayed tooth, although occasionally there is no visible pathology—in these cases, localization may be accomplished by percussing individual teeth with a metallic object. If dental caries are not treated, pulpitis is the result. Reversible pulpitis is characterized by sudden, transient pain lasting seconds, often triggered by heat or cold. In contrast irreversible pulpitis pain lasts minutes to hours. Although antibiotics such as penicillin VK 500 mg PO four times daily or clindamycin 300 mg PO four times daily are commonly prescribed for pulpitis, their efficacy is controversial. Treat with ibuprofen 400 to 800 mg PO three times daily, hydrocodone 5 mg/acetaminophen 325 mg one to two tablets PO four times daily, and warm saline mouth rinses. A dental block may also be performed for short-term pain relief. Refer to a dentist for definitive management. If an abscess is present, antibiotics and incision and drainage should be considered.

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Facial Space Infections

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Odontogenic infections can spread readily to the facial spaces. Therefore, it is imperative to exclude deep-space involvement whenever a dental infection is encountered. Ludwig's angina is a cellulitis involving both submandibular spaces and the sublingual space that can spread to the neck and mediastinum, causing airway compromise, overwhelming infection, and even death. If dental infections spread to the infraorbital space, a cavernous sinus thrombosis may result. This condition may present with limitation of lateral gaze, meningeal signs, sepsis, and coma. Administer intravenous antibiotics and obtain emergent surgical consultation for both conditions, with anticoagulation ...

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