4.17 Dental Pain - Pulpitis
The patient develops an acute toothache with sharp and throbbing pain, often worse wth recumbent position. The patient may or may not be aware of having a cavity in that tooth. Initially the pain is decreased by heat and increased by cold, but as the condition progresses, heat makes the pain worse, while ice will dramatically relieve it. (A patient might come in holding a cup of ice and not allow examination unless ice can be kept on the tooth.) Physical exam may reveal dental cavities (caries) or an extensive tooth restoration without facial or gingival swelling.
What to do:
- Administer a strong analgesic such as oxycodone in combination with acetaminophen or aspirin (Percocet, Percodan) and prescribe additional medication for home use, including nonsteroidal anti-inflammatory analgesia. Severe pain may require a nerve block.
- If a cavity is present, insert a small cotton pledget soaked in oil of cloves (eugenol). The cotton should fill the cavity without rising above the opening (where it would strike the opposing tooth).
- Refer the patient to a dentist within 12 hours for definitive therapy (removal of caries, removal of pulp, or removal of the tooth).
What not to do:
- Do not prescribe antibiotics without signs of cellulitis or abscess formation.
As a patient's condition progresses from pulpitis to pulpal necrosis, the patient experiences excruciating pain caused by fluid and gaseous pressure within a closed space. Heat increases the volume and hence the pain, while cold reduces it.
Intractible pain usually responds to nerve block techniques with injection of long-acting local anesthetics. If a patient refuses a nerve block or a nerve block fails to relieve pain, consider the possibility that the patient is drug seeking. At the same time, remember that some people have extreme phobias about dental injections. When in doubt, err on the side of compassion.
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