Toothache

I am one day post-op from periodontal surgery. The left lower quadrant of my face most resembles a chipmunk toting nuts. The swelling and pain leads me to a discussion of dental issues in the ER.

Toothache is a common presenting complaint, especially on the night shift. The humanitarian in me acknowledges that pain, that keeps a patient from sleeping, is a good reason to visit the ER. The cynicism developed in 30 plus years in the ER recognizes that drug addicts tend to have poor oral hygiene and rarely have dental insurance. Meth mouth (methamphetamine) is a myth, but flossing and brushing is not high on the priority list for drug abusers.

My tooth hurts. Simple enough. The human mouth has 32 teeth: 8 incisors, 4 canines, 8 premolars, and 12 molars. The mouth is also home to gums, the tongue and a cornucopia of bacteria. There is a good reason why human bites are among the most-likely-to-get-infected among all mammalian bites.

Diets high in sugar, acidic drinks (colas), and lack of personal or professional dental care inevitably leads to caries, abscesses and gingivitis. The mouth is well supplied with pain sensing nerve fibers. Add the Saturday night alcohol and testosterone fueled mayhem culminating in oral trauma, and we have lots of ER visits for mouth problems.

I am not a dentist. Some of my best friends are dentists. I have tremendous respect for the dental profession. ER docs do not want to play dentist. We make sure that the problem is not a potentially life threatening infection such as Ludwig's angina (an infection that starts in the mouth but spreads through the neck and into the chest). The immunocompromised patient who has HIV, is undergoing cancer treatment, is taking steroids for a medical condition, or has a congenital defect in immunity, may also have a tooth ache that is a true emergency.

Two severe oral infections may present as mouth pain. NUG (necrotizing ulcerative gingivitis) and herpes gingivastomatitis are true oral emergencies. The treatment of which usually begins in the ER. Manifestations of systemic diseases may also present with mouth pain. Any ulcers, blisters or purpuric lesions should trigger a thorough evaluation of the patient for diseases such a Stevens-Johnson, bullous pemphigous, blood dyscrasias and rheumatological illnesses.

Oral trauma is another source of concern and need for diligence by the ER staff. Unlike our friends, the sharks, humans cannot grow new teeth. Even a child's deciduous (baby) teeth play an important role in oral health and later mouth development. Few ER's have oral surgical back-up on a consistent basis. Prepackaged kits exist that aid the ER staff to provide temporizing measures in managing damaged or avulsed teeth.

Lack of professional dental care is epidemic among adults in the USA. Few people have dental insurance. Emergency medicine training gives very little time to the evaluation and treatment of oral emergencies. I admit that as in most ER's, PA's see the vast majorities of patients with toothache as the presenting complaint. As with so many other problems in the health care system, the ER acts as a safety net.

As my dentist tells me: don't eat sugary treats or foods that stick to your teeth; avoid carbonated beverages; floss once a day; brush after eating; have professional dental cleanings every 6 months. SMILE