Triaging Patients with Dental Pain: When Antibiotics are NOT

the Way to go!

Laurence J. Walsh

BDSc, PhD, DDSc, GCEd, FFOP(RCPA),

FAQDI, FICD, FPFA, FIADFE

© 2014

Friday 430 & 530 PM

WS61

Take home messages:When is a dental consult essential?

Diagnostic sieve• Infections

• Dental caries

• Periapical infections

• Periodontal diseases

• Oral fungal infections

• Oral malodour

• Degenerative conditions• Dental erosion

• Accelerated tooth wear

• Cervical dentinal hypersensitivity

• Neoplasia• SCC

• Salivary gland lesions

• Other oral cancers

• Developmental conditions

• Inflammatory conditions• Oral mucosal pathology

• Oral ulcerative diseases

• Auto-immune diseases

• TMJ problems

• Manifestations of systemic diseases

• Medication-induced side effects

Time bombs for medical GPs !

• Endodontic and periodontal abscesses• Sunset rule

• Beta lactamase producing

• Irreversible pulpitis/ pulpal necrosis• Unstimulated toothache which

keeps patient awake

• Root filling or extract

• Endodontic pathology in oncology immune compromised patients• Fevers of unknown origin

• Mucormycosis or sinusitis• Symptom of maxillary toothache

• Untreated periodontitis and recurring fungal infections in diabetics

• Impaired nutrition• Third molars, pericoronitis and

trismus

• TMJ dysfunction

• Primary or reactivated HSV infection intraorally

• Oral cancer• Lip, floor of mouth, tongue

• Maxillary anterior teeth• Dangerous triangle for cavernous

sinus thrombosis

• Mandibular molar teeth• Ludwig’s angina

Common causes of pain in teeth

• Localized to teeth• Dental caries

• Restoration leakage and recurrent caries

• Pulpitis (reversible or irreversible)

• Cervical dentinal hypersensitivity

• Cracked tooth syndrome

• Zingers

• Tooth supporting apparatus “sore to bite on”

• Periapical inflammation from numerous factors• trauma to teeth

• Clenching

• Infection

• orthodontic tooth movement

Other dental causes of pain

• TM joint• Arthritis

• Disc displacement

• Muscle spasm

• Jaws• Trauma, fractures

• Inflammation and infection

• Neoplasia – central lesions of the jaws

• MX sinus pathology

• Maxillary sinusitis

• Mucormycosis

• Cardiac ischaemia –referred pain

Tooth fracture

Heavily restored teeth and fractured cusps

Dental erosion

Dental erosion from subclinical dehydration (e.g. athletes)

Dental erosion from GERD

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Dento-alveolar infections

Endodontic and periodontal abscesses

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Systemic signs and symptoms

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Periapical infections: LPS and cytokines from Porphyromonas gingivalis and P endodontalis : greater fever, swelling, pain (more IL-1 and TNF)

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Fate of localized infections• Local spread through alveolar bone and

soft tissues

• Sinus tract on the skin

• Systemic mediator release

• Total burden of infection

• Osteomyelitis (MX, MD)

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Osteomyelitis

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Spread of infection

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Cellulitis

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Mandibular molars:Dental abscess extending into the submandibular space

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Maxillary tooth infections

• Danger triangle: anterior teeth• Cavernous sinus thrombosis

• Canine teeth• Canine fossa and orbital involvement

• Molars• MX sinus involvement

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Maxillary anterior teeth and the “dangerous triangle”

• Veins of the head do not contain one way valves

• Blood can flow back into the skullto be drained via the internal jugular vein

• Infections can spread to the venous sinuses surrounding the brain.

• Always treat infections promptly and aggressively.

• “Never let the sun set on pus"

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Cavernous sinus

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CS thrombosis symptoms• Rapid onset

• Peri-orbital oedema

• Decrease or loss of vision

• Bulging eye(s) as cranial BP rises

• Headache

• Photophobia

• Paralysis of the cranial nerves which course through the CS.

• Life-threatening

• iv ABT 3-4 wks• Mortality 20% with ABT

Tx, but 80-100% without

• Sometimes surgical drainage in addition

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Drainage of pus

http://www.airahospital.org/?tag=denatal-abscess

3 months

pregnant,

severely

anemic, highly

febrile and

hypoglycemic

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Ludwig’s angina• Serious, potentially life-threatening

cellulitis of the floor of mouth

• Spreads to the sublingual space via the fascial planes, not by the lymphatics

• The tongue is forced upward and backward, causing airway obstruction. • Tracheostomy needed for airway support• High dose iv ABTs and surgical

decompression

• Mortality: No ABT: 50%; ABT and surgical therapies: less than 5%

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Ludwig’s angina

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Keeping infection localized:what can allow “escape” ?

• Depressed CMI or bone marrow activity• Primary and secondary immune

deficiencies• Immunosuppressive drugs• Cytotoxic chemotherapy• Malignancies

• Altered PMN numbers or function response• Trisomy 21, diabetes mellitus• Various syndromes

• Reduced healing capacity• Impaired nutrition• Smoking• Advanced age• Chronic hepatitis

Fistula

Necrotic

pulp

Periapical

infection

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Haematogenous spread of infectionfrom the mouth to distant sites

• Immune compromised patients

• Pyrexias of unknown origin in oncology patients 30% dental origin

• Systemic sepsis and intravascular coagulation

• Orbit

• Brain

• Liver

• Lung

• Spleen

Causes of pain in oral soft tissues

• Trauma

• Ulcerations (31 types)

• Chemical burns

• Infective lesions

• Infection of mucosal breaches

• Acute gingival and periodontal conditions

• Abscesses and suppuration

• Medication side effect

• Lichen planus

• BMMP and other mucosal disorders

• Atypical facial pain

• Psychiatric conditions

• Burning mouth syndrome

• Malignancy with perineural invasion

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Post-surgical wound infections by anaerobes

Pericoronitis

Aphthous ulceration

Aphthous ulceration

Herpetic gingivostomatitis

Kaposi’s sarcoma

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Oral lichen planus

Aspirin chemical burn

Mucositis from chemo/radiotherapy