Dental painBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6539 (Published 05 November 2013) Cite this as: BMJ 2013;347:f6539
- Yvonne MacAuley, senior house officer, executive registrar1,
- Patrick O’Donnell, general practitioner2,
- Henry F Duncan, consultant in endodontics3
- 1Dublin Dental University Hospital, Lincoln Place, Dublin 2, Ireland
- 2Graduate Entry Medical School, University of Limerick, Limerick, Ireland
- 3Division of Restorative Dentistry and Periodontology, Dublin Dental University Hospital, Trinity College Dublin, Ireland
- Correspondence to: Y MacAuley
- Accepted 15 August 2013
A 40 year old woman presents complaining of severe dental pain and swelling, and is unable to contact her dentist. She reports that the pain started three days ago and has increased in intensity since, with her face becoming swollen in the last 24 hours.
What you should cover
Nature and severity of the pain
Dental pain occurs as a result of inflammation of the pulp (pulpitis) (see figure⇓). This is generally caused by bacteria from decayed teeth or defective dental fillings. Dental pain can be practically grouped into five progressive pain categories. A short pain history and examination is required to categorise this pain.
1. A short, sharp pain lasting only a few seconds and occurring in response to a cold or “sweet” stimulus is likely to be reversible pulpitis. This is generally not a severe problem, and the pulp of the tooth can be saved. Antibiotics and analgesics are not required, but the patient should be advised to attend a dentist.
2. A dull, aching, “pulsing” pain that occurs spontaneously and in response to thermal stimuli is likely to be irreversible pulpitis. There is no swelling, but pain is debilitating, often disturbs sleep, and may last for hours. Irreversible pulpitis requires expedient dental intervention. Antibiotics and analgesics are ineffective.
3. Untreated pulpitis leads to pulp necrosis and death, and the pain may temporarily decrease. However, inflammation and infection of the surrounding tissues, known as apical periodontitis, will ensue as bacterial and pulp breakdown products escape from the tooth. The offending tooth will be tender to touch or pressure. The tooth may respond to antibiotics, but they are not essential. Dental intervention is still required.
4. An acute apical abscess is a common manifestation of untreated apical periodontitis and is associated with a swelling, tooth mobility, and severe tenderness to touch. Conversely, a chronic apical abscess may be present without pain or obvious swelling if the infection is draining.1 Chronic abscesses usually drain intra-orally but occasionally can appear as a skin “pimple” extra-orally. Acute apical abscesses will require drainage by a dentist but will be relieved in the short term by antibiotics.
5. Acute abscesses may spread as a cellulitis within soft tissue spaces to the floor of the mouth (Ludwig’s angina), leading to neck and mediastinal abscesses; this can compromise the patient’s airway. The patient’s general health affects the spread of infection. Spreading infection, pyrexia, and affected breathing will require referral and hospital admission.
Take a pain history—This is necessary to identify the stage and severity of the infection (see above).
Ascertain pattern of swelling—How long has the swelling been present and is it worsening? If the swelling is rapidly progressing and affecting swallowing, breathing, speech, or ability to open the eye, hospital referral is required. If there are signs and symptoms of systemic infection, including nausea, malaise, pyrexia, or rigors,2 prescribe antibiotics and consider hospital referral.
Ask about recent or planned dental treatment—A history of recent dental treatment is more likely to indicate a dental aetiology, which has resulted in an inflammatory or infective complication. Returning to the dentist should be priority for the patient.
Check medication—Ask the patient if he or she is already taking medication for the problem, such as antibiotics or analgesics, as this will affect your assessment of how the condition is responding, as well as your treatment.
Remember the relevance of medical history—Patients who are immunosuppressed or have unstable diabetes are more susceptible to infection. Ask about allergies to antibiotics and latex, which is present in the gloves used for examination.
What you should do
Check for swelling—Is swelling evident around the mandible, submandibularly (usually associated with a lower tooth), or in the infraorbital region (usually associated with an upper tooth)? Is the eye opening limited? These indicate spreading infection, which will require referral to a hospital.
Assess trismus—Normal mouth opening is 40-60 mm (between two and three finger breadths). If mouth opening is less than two finger breadths, hospital referral is advised, as this implies that the infection is spreading to the tissue planes around the muscles of mastication.
Check vital signs—Check temperature, pulse, blood pressure, and oxygen saturation if the airway is compromised. These are signs of systemic infection, which warrants antibiotic treatment and hospital referral if the airway is compromised.
Palpate the lymph nodes—If there is regional lymphadenopathy, antibiotic treatment is required.
Look for extra-oral drainage—Draining dental infection can present as a large red spot on the skin.
Examine intra-orally—Look inside the mouth with good light and a tongue spatula if no dental mirror is available.
Check for swelling—If a swelling is present, is it raising the tongue? A raised tongue should flag concern as it indicates infection that has spread to the floor of the mouth. If this is not treated, the airway may become compromised; therefore, it warrants hospital referral.
Look at the teeth—Is gross decay or a badly broken down tooth evident? These may indicate likely sources of infection. Remember, a denture can conceal an offending tooth and needs to be removed. A chronic abscess may present as a sinus tract (appearing as a “bubble” on the gum).
Examine the back of the mouth—Lower wisdom teeth often give rise to dental pain because of caries or inflammation of the surrounding gum tissue (pericoronitis).
After examination, decide if any treatment, prescription, or immediate hospital referral is required. If red flags (see box) are not present, the patient should be reassured.
In general, the importance of attending a dentist should be emphasised to the patient. It should be stressed that the prescription of medication will not eliminate the source of infection.
Red flags (warranting hospital referral and assessment)
Difficulty swallowing, breathing, or speaking
Difficulty opening the eye
Mouth opening of less than 2 finger breadths
Infection spreading to the neck
Swelling in the floor of the mouth, leading to a raised tongue
Rapid progression of infection despite adequate oral antibiotics
Signs and symptoms of systemic infection—such as pyrexia, tachycardia, and altered blood pressure—may also be recorded
Often, the prescription of analgesia and advice that the patient should see his or her dentist are all that is required. Appropriate pain relief would ideally be a non-steroidal anti-inflammatory drug such as ibuprofen, which can be taken with paracetamol. Codeine phosphate can also be prescribed for adult patients.3 Prolonged use of opiates can lead to dependence. The prescriber should regularly evaluate the risks and benefits of taking these drugs. It is of utmost importance that patients are advised to see their dentist even if symptoms are subsiding.
Antibiotics should be prescribed if there are systemic symptoms (as described above). When bacteria from acute dental abscesses have been cultured, there are many combinations, including strict anaerobic infections (20%), mixed aerobic infections (6%), and both facultative and strict anaerobic infections (59-75%). The common bacteria from acute dental abscesses include streptococci species and Fusobacterium.4 The appropriate antibiotics are a combination of amoxicillin (250 mg every 8 hours for 5 days) and metronidazole (200 mg every 8 hours for 5 days).5 6 Both antibiotics can be doubled in severe infections. Another suggested option is amoxicillin 3 g dose, repeated once after 8 hours.3 6 There is little evidence to support a specific antibiotic regimen for the treatment of dental abscesses. Patients should be reviewed by their dentist within three days to ensure systemic signs of infection are resolving2 and to allow necessary dental treatment to be carried out.
Subsequent dental treatment may include a filling or restoration, root canal treatment, tooth extraction, incision and drainage of a swelling, or a combination of these.
Cite this as: BMJ 2013;347:f6539
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
Contributors: YM conceived of the article. PO’D advised on the information required and helped edit the piece. HFD provided expert opinion. All authors participated in final editing of the manuscrip.
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Not commissioned, externally peer reviewed.
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