Tooth Eruption and Pericoronitis
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. Adequate hydration, by giving the child a frozen, damp towel to suck on and acetaminophen 15 milligrams/kilogram orally (PO) 6 hours usually will control symptoms. Topical anesthetics should be used with great caution in young infants due to its potential to depress the gag reflex.
Adults and teens may experience pericoronitis (pain and local inflammation) with the eruption of the third molars (“wisdom teeth”). Penicillin VK 500 milligrams PO 4 times daily or clindamycin 300 milligrams PO 4 times daily, ibuprofen 400 to 800 milligrams PO thrice daily (with or without hydrocodone 5 milligrams/acetaminophen 325 milligrams 1 to 2 tablets PO 4 times daily), and warm saline mouth rinses will be beneficial until the third molar can be extracted by an oral surgeon or general dentist.
Dental Caries and Pulpitis
Dental caries are caused by bacteriogenic acid eroding through the enamel. Examination sometimes finds a grossly decayed tooth, although frequently 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 (penicillin VK 500 milligrams PO 4 times daily or clindamycin 300 milligrams PO 4 times daily) are commonly prescribed for reversible pulpitis, their efficacy is controversial. Ibuprofen 400 to 800 milligrams PO thrice daily, hydrocodone 5 milligrams/acetaminophen 325 milligrams 1 to 2 tablets PO 4 times daily, warm saline mouth rinses, and referral to a dentist for definitive management are all reasonable. Antibiotics do not appear to improve toothache in irreversible pulpitis, but pain control and dental referral as listed above are appropriate. If an abscess is present, antibiotics, incision and drainage should be considered. (see below).
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 angina is a cellulitis involving the 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. Intravenous antibiotics and emergent surgical consultation are mandatory for both conditions, with anticoagulation added for cavernous sinus thrombosis. (See Chapter 153 “Neck and Upper Airway Disorders” and Chapter 150 “Face and Jaw Emergencies.”)
Postextraction Pain and Postextraction Alveolar Osteitis (Dry Socket)