434 Maxillofacial and Dental Emergencies
Non-traumatic Conditions of the Mouth
Toothache
DIAGNOSIS AND MANAGEMENT
1 Toothache is usually due to inf lammation of the pulp space in a carious tooth.
2 Exclude a dental abscess (see below) and give the patient an analgesic such as
paracetamol 500 mg and codeine phosphate 8 mg two tablets orally q.d.s.
3 Return the patient to his or her own dentist.Dental abscess
DIAGNOSIS AND MANAGEMENT
1 An apica l or periapica l abscess is an extension of a pulp space infection.
(i) The tooth is tender on tapping, with associated soft-tissue
swelling and continuous pain.
(ii) There may be systemic malaise and fever.
2 Refer the patient to the oral surgery team if severely ill, or the abscess is
pointing extraorally.
3 Otherwise, commence an antibiotic such as amoxycillin 500 mg orally t.d.s.
then give an analgesic (e.g. codeine phosphate 30–60 mg orally q.d.s.) and
return the patient to his or her own dentist.Ludwig’s angina
DIAGNOSIS AND MANAGEMENT
1 This condition is a bilateral, fulminant, brawny cellulitis of the sublingual
and submandibular areas, associated with poor dental hygiene or dental
instrumentation. It is uncommon, and may spread into the retropharyngeal
and superior mediastinal spaces.
2 There is trismus with reduced mouth opening, dysphagia, with elevation and
f irmness of t he tongue associated wit h submandibular pain and swelling.
(i) The main risk is sudden respiratory obstruction from
displacement of the tongue and submandibular tissues.
(ii) Do not send for an x-ray without expert airway supervision.
3 Call immediately for senior ED doctor help, and prepare for orotracheal
intubation or even a cricot hy rotomy.
4 Give benzylpenicillin 1.8 g i.v. and metronidazole 500 mg i.v. and admit the
patient immediately under the ENT team for careful observation of the
airway.
5 Request a CT scan only if t he air way is protected, or not considered at risk.