4.18 Dental Pain - Periapical abscess
The patient complains of dull constant facial or dental pain, often associated with facial swelling and cellulitis and accompanied by signs of systemic toxicity. Dental caries may or may not be apparent. Percussion of the offending tooth causes increased pain. Hot and cold sensitivity may no longer be present because of necrosis of the pulp. There may be increased mobility of the tooth and an examining finger in the soft tissues of the mouth, face, or neck may even palpate a fluctuant abscess.
What to do:
- Adequate pain medication should be administered and prescribed for continued pain relief. A combination of acetaminophen with codeine or oxycodone usually suffices. Add nonsteroidal anti-inflamatory analgesia.
- Depending on the level of toxicity, the patient should initially either be treated with parenteral or oral penicillin, and a 10-day course of penicillin VK 500mg qid should be prescribed. Erythromycin or clindamycin may be substituted in the penicillin-allergic patient.
- If a fluctuant abscess cavity is present, then perform incision and drainage at the most dependent location and, when possible, insert a drain for 24 hours.
- Instruct patients to apply warm compresses to the affected area and seek followup care from a dentist within 24 hours.
What not to do:
- Do not insert an obstructing pack (i.e. cotton soaked with oil of cloves) into a tooth cavity when an abscess or cellulitis is present.
- Do not prescribe aspirin if you anticipate that a tooth will need to be extracted.
Dental pain may be refered to the ear, the temple, the eye, neck or other teeth. Conversely, what appears to be dental pain may in fact be due to overlying maxillary sinusitis or otitis. Diabetes and valvular heart disease increase the risk from bacteremia, and local extension of infection can lead to retropharyngeal abscess, Ludwig's cellulitis, cavernous sinus thrombosis, osteomyelitis, mediastinitis and pulmonary abscess.
An acute periodontal (as opposed to periapical) abscess causes localized painful fluctuant swelling of the gingiva, located either between the teeth or laterally, and is associated with vital teeth that are not sensitive to percussion. Treatment consists of local infiltrative anesthesia and drainage by subgingival curettage. In severe cases or where there is fever, prescribe doxycycline 100mg bid x10d, instruct patients to rinse the mouth with warm walt water, and consult a dentist for further treatment.
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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD