This is the protocol for Dental Pain:Dental Pain
Let’s break it down!
Dentistry isn’t one of the prime areas of expertise for your average medic, but that’s not going to stop people from coming in with dental complaints. It’s probably been a while since you’ve reviewed dental anatomy, so watch this super fast 2-minute video on the basics:
Now that we have that out of the way, let’s break down our common dental pain culprits:
Deep Decay: To put simply, these are just really deep cavities. Cavities, which are formerly known as “tooth decay”, are permanently damaged areas of the tooth caused by a buildup of plaque. It usually only affects the enamel, which is painless. But if the cavity begins to spread into the dentin and the pulp (as will happen if you don’t get a filling), then that would be known as a Deep Decay and that is painful.
Tooth Fractures (Crown/Root): This is pretty self-explanatory, but it’s actually a fairly complex topic. There are many different types of tooth fractures (Ellis I, Ellis II, Ellis III….. etc.) and while some of them are painful, a good portion of them are painless…it all depends on whether or not the dentin or pulp is involved. The key thing to understand about this though is that tooth fractures won’t always be as easy to see as what they are in the protocol pictures. You will actually have to physically examine them if somebody comes in with a dental pain complaint. This topic is probably complex enough to become worthy of its own protocol, so if you want to see a 5-minute video on how an ER physician approaches tooth fractures, check out the video below:
Pericoronitis: Popularly known as a “Wisdom tooth infection” and is usually an indication for an emergent wisdom tooth extraction. When soft tissue is impacted by wisdom teeth, there becomes an overlapping of gum tissue that dentists will call an Operculum. Bacteria and debris will often get caught in between the tooth and this gum tissue and cause inflammation …which of course can be very painful.
Periapical Abscess: This is just a collection of pus at the root of the tooth, which is commonly caused when bacteria gets through to the pulp of your tooth via a deep cavity. As you can see from the two bottom pictures in the protocol, these are pretty easy to spot:
Barodontalgia: Also referred to as “flyer’s toothache” or “tooth squeeze”. During changes of ambient pressure, such as in-flight or while diving, air bubbles can be become entrapped and expand inside a cavity or dental filling which causes significant pain. It usually resolves itself after descent or ascent to normal pressure. Not really common, but definitely interesting.
When it comes to dental pain, it’s usually fairly obvious that the teeth are the problem. On rare occasions, dental pain can be a sign of myocardial infarction (heart attack), but for the most part we’re just talking about teeth here.
Still, it’s helpful to be able to diagnose the root cause of the pain. The type of pain or sensation that the patient feels can directly correlate to the extent of their injury. For example, if your patient has no pain or sensitivity along their teeth, then you can probably rest assured that the enamel has remained intact. If the enamel deteriorates or breaks for whatever reason, then the dentin will be exposed (Not always easy to see). Although the dentin doesn’t actually contain any blood vessels or nerves, it’ll still transmit signals of pain to the pulp in response to heat/cold or percussion.
If the patient is in excruciating pain from the start, then you might suspect that the pulp is involved with the dental condition. None of this is set in stone, but it’s something that can help give you an idea of what’s going on, especially if your physical exam is difficult to perform.
Dental pain is, for sure, one of the worst kinds of pain someone can have. Although the pain often varies depending on the condition, our role as medics will typically be to control pain until definitive dental management can be performed by a dentist. Tylenol and NSAIDS (Ibuprofen, Meloxicam) are mostly recommended for dental pain, but often it’s not enough. The next step would be opiates, which would include Morphine and Fentanyl. You may very well need to utilize these for breakthrough pain management, but for the most part, this is overkill and doesn’t provide a long-term solution.
There is the possibility of performing a nerve block if you’re specifically trained on it, but there’s actually a much simpler solution that’s not specifically mentioned in the Pain Management protocol. It’s an over the counter drug called Eugenol. At your local pharmacy, you might find something that looks like this:
Eugenol is a natural anesthetic and anti-bacterial agent that also works well to reduce inflammation in the mouth. It’s actually most commonly found in clove oil, which some people have recommended buying as is and putting a drop or two into the affected area (although I would probably stick with something more professional). It doesn’t seem to have made its way into the standard of care just yet, but with so many success stories out there (including one with one of my own patients), it’s hard to dismiss it’s potential. Below this is a kind of funny amateur video reviewing the product and demonstrating how to use it:
Ok, so we know pain management is going to be something that we’re going to utilize for almost all of these conditions, but antibiotics aren’t for everyone. Generally speaking, experts have suggested that unless you see an actual formed abscess, the problem is most likely inflammatory as opposed to infectious, and antibiotics won’t be useful. The most common infection that we would treat with antibiotics would be periapical abscesses, but there’s not even good data to support the use of antibiotics for these patients (due to poor blood supply to the roots and lack of antibiotic penetration). The best treatment for these patients would actually be incision and drainage of the abscess. Your PA may be comfortable with you performing that procedure, but if not, then antibiotics are going to be your go-to for the time being.
The type of bacteria involved in dental infections can be a mix of both aerobic and anaerobic pathogens, so we want broad-spectrum antibiotics. There seems to be an ongoing battle between Clindamycin and Augmentin for the title of best dental infection antibiotic, but it seems like Clindamycin is winning. It has good oral bioavailability and good penetration to the bone 💀. If for whatever reason the soldier can’t take PO antibiotics, then Ceftriaxone is still a decent option 💉
1st Place: 2nd Place: 3rd Place:
Many of these soldiers will already have a dentist tracking what’s going on and they just need some additional pain management or antibiotics for a post-op infection, which definitely doesn’t require an evacuation unless you’re unsuccessful at handling it. HOWEVER…..if this is a NEW dental condition for the soldier (fracture, avulsion, impacted wisdom tooth, etc.), then they should most definitely be referred to dental as soon as tactically feasible.
Good luck out there!
- MedicineNet: Pericoronitis
- Merck Manual: Periapical Abscess
- EMRAP: Dental Infections
- Stapczynski JS, Tintinalli JE. Tintinallis Emergency Medicine: a Comprehensive Study Guide, 8th Edition. New York: McGraw-Hill Education; 2016.
- Advanced Tactical Paramedic Protocols Handbook. 10th ed., Breakaway Media LLC, 2016.