ESSENTIAL WORKUP
- Obtain appropriate medical and dental history
- Ask about drug allergies, especially antibiotics and analgesics, and current medications
- Assess need for predental procedure antibiotic prophylaxis:
- Rheumatic fever
- Cardiac valve replacements
- Orthopedic joint replacements
- Mitral valve prolapse or valvular heart disease
- If physical exam conflicts with patient’s history and intraoral source of pain is not apparent consider other sources of pain:
- Nonodontogenic etiologies of pain
- Factitious pain/drug-seeking behavior
DIAGNOSIS TESTS & NTERPRETATION
Lab
- No lab tests needed except in patients with signs of systemic toxicity and those patients with perceptible deep-space infection
- As with any other infection with symptoms of systemic toxicity, consider CBC, blood cultures, markers of inflammation like ESR or CRP
Imaging
- Panoramic and periapical radiograph views if suspicion exists about dental infection or fracture
- CT or MRI to evaluate deeper infections
Diagnostic Procedures/Surgery
A local or regional dental nerve block may sometimes offer both therapeutic and diagnostic benefit
DIFFERENTIAL DIAGNOSIS
- Sinusitis
- Otitis media
- Pharyngitis
- Peritonsillar abscess
- Temporomandibular joint syndrome:
- Usually presents with pain around the ear
- Trigeminal neuralgia
- Vascular headache
- Herpes zoster
- Cardiac ischemia
Pediatric Considerations
- Tooth eruption in a child or infant may cause oral pain, irritability, low-grade fever, diarrhea, and decreased food intake
- Facial swelling with fever and leukocytes >15,000/mm
3
suggests a nonodontogenic source
- Children have a maximum of 20 deciduous teeth, 10 upper and 10 lower
TREATMENT
PRE HOSPITAL
- Maintain patent airway in patients with severe facial swelling or trismus
- The patient should be kept in a sitting position if possible
INITIAL STABILIZATION/THERAPY
- Airway management for deep-space infection and airway compromise
- Early pain management as indicated
ED TREATMENT/PROCEDURES
- Appropriate analgesia
- NSAIDs are
1st-line
therapy for uncomplicated dental pain
- Opiate analgesics are an alternative therapy
- Dental anesthetic field block:
- Injected along the buccal surface of the affected tooth
- Specific nerve block for multiple teeth
- Long-acting anesthetic (e.g., bupivacaine)
- Antibiotics if dental infection is present:
- Penicillin is the antibiotic of choice
if patient is not allergic
- Clindamycin for patients with penicillin allergy or for predominance of anaerobes
- Localized periapical and periodontal abscesses should be incised, drained, and irrigated:
- Drain may be placed for 24 hr
- Saline rinses at home 4 times a day and dental referral in 24 hr
MEDICATION
- Antibiotics:
- Ampicillin/sulbactam 1.5–3 g IM/IV q6h (peds: 300–600 mg/kg/d [max. 3 g] IV div. q6h)
- Clindamycin: 150–450 mg PO q6h (peds: 15–30 mg/kg/24 h [max. 2 g] q6h):
- IV dose 300–900 mg (peds: 25–40 mg/kg/24 h div. q8h)
- Penicillin VK: 500 mg PO q6h (peds: 25–50 mg/kg/24 h [max. 3 g] q6h)
- Penicillin G potassium aqueous: 4 mU IM/IV q4h (peds: 250,000–400,000 U/kg/d IM/IV div. q4–6h, max. 24 mU/d)
- Analgesics:
- Acetaminophen: 500 mg PO/PR q4–6h (peds: 10–15 mg/kg/dose; do not exceed 5 doses/24 h); do not exceed 4 g/24 h
- Acetaminophen and codeine no. 3: 1–2 tablets PO q4–6h (peds: elixir–codeine 12 mg/5 mL)
- Oxycodone 5 mg ± with acetaminophen 325 mg: 1 or 2 tablets PO q6h (peds: 0.05–0.15 mg/kg (oxycodone) per dose [max. 5 mg]); not available in liquid preparation
- Ibuprofen: 400–800 mg PO q8h (peds: 10 mg/kg PO q6h)
- Ketorolac: 30 mg IV, 30–60 mg IM q6h (peds: 1 mg/kg/dose IM/IV)
- Morphine sulfate: 2–8 mg SC or IM/IV q2h (peds: 0.1 mg/kg/dose SC or IM/V q2h)
Pediatric Considerations
Teething infants may be helped by over-the-counter topical anesthetics and oral analgesics
FOLLOW-UP
DISPOSITION
Admission Criteria
- Suspicion of deep-space infections (e.g., Ludwig angina, retropharyngeal abscess)
- Facial cellulitis proximal to the eye
- Extensive trismus
- Inability to maintain nutrition and hydration
- Evidence of systemic toxicity
Discharge Criteria
Patients with toothache and localized dental infections can be discharged from the ED
Issues for Referral
Patients treated in the ED should be referred to a dentist or dental surgeon promptly
FOLLOW-UP RECOMMENDATIONS
Regular and routine dental evaluations
PEARLS AND PITFALLS
- Mistaking a deep infection for local infection
- Failing to identify source of referred pain to the mouth
ADDITIONAL READING
- Annino DJ Jr, Goguen LA. Pain from the oral cavity.
Otolaryngol Clin North Am
. 2003;6:1127–1135.
- Lockhart PB, Hong CH, van Diermen DE. The influence of systemic diseases on the diagnosis of oral diseases: A problem-based approach.
Dent Clin North Am
. 2011;55:15–28.
- Rodriguez DS, Sarlani E. Decision making for the patient who presents with acute dental pain.
AACN Clin Issues
. 2005;16:359–372.
- Van Meter MW, Dave AK. Oral Nerve Block.
Emedicine.
Available at
http://emedicine.medscape.com/article/82850-overview
. Accessed on February 3, 2013.
See Also (Topic, Algorithm, Electronic Media Element)
- Aphthous Ulcer
- Facial Fracture
- Periodontal Abscess
- Peritonsillar Abscess
- Retropharyngeal Abscess
- Temporal–Mandibular Joint Injury/Syndrome
CODES
ICD9
- 521.00 Dental caries, unspecified
- 522.0 Pulpitis
- 525.9 Unspecified disorder of the teeth and supporting structures
ICD10
- K02.9 Dental caries, unspecified
- K04.0 Pulpitis
- K08.8 Other specified disorders of teeth and supporting structures
TORTICOLLIS
Andrew K. Chang
•
Robert Meyer
BASICS
DESCRIPTION
- Torticollis is a symptom, not a disease
- “Twisted neck” (L.
tortus
, twisted +
collum
, neck)
- A fixed or dynamic posturing of the head and neck
- Synonym(s): Cervical dystonia, wry neck
ETIOLOGY
Local
- Acute wry neck:
- Develops overnight without provocation
- Most prevalent
- Self-limited, symptoms resolve in 1 to 2 wk
- Cervical spine disease
- Fracture
- Dislocation, subluxation
- Infections
- Spondylosis
- Tumor
- Scar tissue–producing injuries
- Ligamentous laxity in atlantoaxial region
- Inflammatory disease causing muscular damage:
- Myositis
- Lymphadenitis
- Tuberculosis
- Myasthenia gravis
- Neuritis of the auriculotemporal branch of the trigeminal nerve
- Infections of surrounding soft tissues:
- Nasopharyngeal abscess
- Retropharyngeal abscess
- Cervical adenitis
- Tonsillitis
- Meningitis
- Mastoiditis
- Sinusitis