Diagnosis and management of toothache

Question 1

How would you take a pain history for a child?

Answer 1

Site - where is the pain coming from? You can ask the child to point to where the pain is coming from and which tooth is causing the pain.
Onset - Ask the child when the pain started or if anything caused the pain to start?
Character - Ask the child what the pain feels like? For example, a sharp pain is like a scratch, dull pain is like stomach ache
Radiating - Ask the child if they pain anywhere else?
Associated symptoms - Are there any other problems other than the pain? For example, child might have pyrexia due to a dental abscess causing systemic infection or it could be a systemic condition causing a dental problem e.g. primary hepatic gingivostomatitis, lymph node involvement, can’t eat or drink, nausea
Time/duration - Ask how long the pain lasts? (Child is a poor judge of time so can relate to time concept which they would be familiar with e.g. as long as school break lasts) and whether the pain wakes up at night?
Exacerbating/relieving factors - Does something make the pain feel better or worse? Does the pain feel worse with hot foods, cold foods or pressure e.g. when they bite on something? Does the pain start happening for no reason? Do they need calpol to relieve it?
Severity - How bad is the pain on a scale of 1-10 (older children)? And for younger children, there is the Wong Baker Pain scale (uses series of faces ranging from happy to crying face). Does the pain stop them from playing or eating their favourite foods?

Question 2

Reversible pulpitis - what is it and management?

Answer 2

The pain will be intermittent in nature, it will be a pain with a stimulus (hot, cold or sweet). It is not spontaneous pain. The pain will last as long as the stimulus. There will be no history of dental swelling. The child can’t normally point out the tooth.

Emergency management: LA, excavate soft caries, restore temporarily with zinc oxide/eugenol cement. If exposed and vital dress polyantibiotic paste (ledermix)
Definitive management: pulpotomy or extraction

Question 3

Irreversible pulpitis - what is it and management? - what

Answer 3

This causes spontaneous pain. The child could also be experiencing pain with a stimulus but the pain will last longer than the stimulus. It can wake the pt up at night. A painkiller will be required. There will be no history of dental swelling.

Emergency management: LA, excavate soft caries, dress with polyantibiotic paste, restore temporarily with zinc oxide/eugenol or GI cement

Definitive management: pulpotomy/pulpectomy or extraction

Question 4

Periradicular/periapical periodontitis - what is it and management?

Answer 4

The periodontal ligament is now inflamed and so the child will be able to point to the tooth. The tooth will be painful to bite on.

Acute periradicular periodontitis emergency management: LA (may not be necessary if loss of vitality is certain), excavate soft caries until pulp chamber accessed - dress pulp chamber with polyantibiotic paste on cotton wool, seal with temporary dressing.

Question 5

Dental Abscess

Answer 5

If it is acute in nature the tooth will be tender to bite on. A swelling will be present. Chronic abscesses can sometimes be asymptomatic.

Question 6

Tooth Surface Loss

Answer 6

Dentine hypersensitivity can cause pain

Question 7

Teething

Answer 7

This can cause pain

Question 8

Ulcers

Answer 8

Sign of underlying health problem like bowel problems and can cause pain

Question 9

Acute Periodontitis with facial swelling if no/mild pyrexia (<38 degrees), localised acute erythematous tender soft tissue swelling, no significant involvement of ‘danger area’, not otherwise systemically unwell

Answer 9

Emergency treatment:
Antibiotics and analgesics, ensure adequate fluid intake, establish drainage via tooth (and dress) if possible, review every 24h to ensure resolution
Definitive management:
extraction of a tooth (or pulpectomy in selected case) once acute phase has resolved.

Question 10

Acute periodontitis with facial swelling, if significant pyrexia >38 degrees, poorly localised, spreading infection, systemically unwell: dehydration, lethargy, nausea and vomiting and swelling involving a ‘danger area’ e.g. floor of mouth

Answer 10

Emergency management
Aggressive antibiotic Rx (e.g. amoxicillin and metronidazole), immediate referral to specialist centre.

Definitive management:
Extraction of tooth and/or intra/extra-oral drainage