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Many types of lesions can cause pain and swelling in the mouth and face.2,3 Table 23-1 provides a brief overview of the presentation, diagnosis, and treatment of various causes of mouth and jaw pain.
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Mucosal Diseases and Facial Swelling
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The most common painful oral lesions are aphthous ulcers (canker sores), traumatic ulcerations, and cold sores (Herpes labialis), and all can be treated with "tincture of time." They may heal faster, and pain may also be reduced, if they are covered. All three can be covered, at least for several hours, with any lip balm or salve, such as petroleum jelly. These usually relieve the pain—until they are licked off. As effective and possibly longer-lasting is cyanoacrylate (e.g., commercial Super Glue and multiple brands for medical wound closure).4
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Multiple intra-oral lesions, including mucositis in immunocompromised (e.g., cancer, AIDS) patients, may be helped by "magic mouthwash." Patients use magic mouthwash by taking a mouthful every 2 to 3 hours, swishing it around in their mouth, and spitting it out. The solution can be made with any of dozens of formulations. The most common basic elements for magic mouthwash are diphenhydramine (e.g., Benadryl) elixir, viscous lidocaine 2%, and a liquid antacid, such as Maalox. Other common ingredients are tetracycline or erythromycin (that may be helpful with bacterial infections in the mouth) or, especially for cancer and immunocompromised patients, a steroid such as dexamethasone or hydrocortisone, or nystatin. One common formula uses 4 parts nystatin suspension 100,000 units/mL, 3.5 parts diphenhydramine elixir, and 1 part lidocaine viscous 2%. If the solution is made with a substance such as Kaopectate or sucralfate (Carafate), the ingredients can adhere to surfaces, and so can be applied directly to the intra-oral lesions.
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A very common oral lesion is candidiasis (thrush). If standard oral agents are not available, treat oral candidiasis by having the patient suck on a vaginal anti-yeast suppository or apply a vaginal anti-yeast cream to the lesion 4 times a day.
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Gum Inflammation and Pain
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Painful gums can result from poor oral hygiene, infections, inflammation over an erupting tooth, or dental appliances such as orthodontics.
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To avoid or treat inflamed gums resulting from poor oral hygiene, patients gently brush their teeth and gums and by floss with dental floss or a substitute. They also can rinse their mouth with warm saltwater (0.5 tsp table salt in 4 oz of warm potable water) or a solution containing 1 part potable water and 1 part 3% hydrogen peroxide (H2O2) several times a day.5
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More serious, and much more painful, is necrotizing ulcerative gingivitis, also known as trench mouth, Vincent's angina or stomatitis, or necrotizing ulcerative periodontitis. This serious but treatable disease of the gums and deeper tissues usually begins abruptly; the patient may be febrile. The gums are very painful and bleeding, with punched-out ulcers covered with a gray pseudo-membrane. Patients have extremely foul breath, pain on talking or swallowing, and may have lymphadenopathy. Treatment consists of gently debriding the area over several days. Wipe the gums with cotton or other absorbent cloth soaked in 3% H2O2. Use 1 part H2O2 to 5 parts water in children. Then scrape off the larger pieces of tartar. Have the patient gently brush their teeth and gums daily with a soft brush and rinse every waking hour with warm saltwater or twice a day with 1.5% H2O2 or 0.12% chlorhexidine. For the pain, use non-steroidal analgesics and, if available, local anesthetic on the gums—after drying them. Encourage patients to avoid spicy foods and to improve their diet. They may need to be on a liquid or soft diet for a while. They should drink lots of liquids, take supplemental vitamin C, and avoid smoking and chewing betel nuts or tobacco. If thorough cleaning and debridement is not available, give oral penicillin VK 500 mg, erythromycin 250 mg, or tetracycline 250 mg q6hr until 72 hours after the symptoms resolve.
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Pericoronitis occurs when inflammation develops around a partially erupted (usually molar) tooth. A flap of gingival tissue remains over the tooth, which traps food particles and is irritated by chewing. Local swelling may cause enough irritation to make it difficult to fully open the jaw. To treat this, gently irrigate the area under the flap. Have the patient rinse his mouth with warm saltwater for 10 minutes every 2 hours while awake. If no dentist will be available within a few days, excise the flap over the tooth.
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If orthodontic appliances are causing pain, use a blunt object, such as a tongue depressor or pencil eraser, to bend the wire away from the gum. If it cannot be bent, cover it with wax (candle or dental) or a tiny piece of cloth or cotton. Paradoxically, chewing (preferably sugarless) gum reduces the general pain caused by orthodontic appliances.
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Most of the cases for which non-dentists will need to provide emergency dental treatment will be for toothaches. While teeth can be transiently painful for a number of reasons, constant, often excruciating pain in a tooth constitutes a toothache. Generally, toothaches are caused by fractures or decay (caries; causes cavities) that extends into the tooth's central area (pulp). A tooth in which the pulp is no longer healthy often has a history of persistent, often severe and throbbing, pain after eating hot or cold food. Cold stimulus causes prolonged pain, but the tooth is generally not sensitive to palpation.
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To locate the painful tooth, have the patient point to it or gently tap on teeth in the affected area with an instrument until the patient experiences discomfort. When a tooth is tender to percussion, it is likely that there is a periapical abscess. The affected tooth can also be located by touching it with the corner of an ice cube. A normal tooth will briefly feel the cold stimulus; a diseased, but salvageable, tooth with some healthy pulp may have slightly more prolonged pain after withdrawal of the ice and is not usually sensitive to percussion. These can be treated as described in the subsequent paragraphs. Be sure to check adjacent teeth for their relative sensitivity to percussion and cold. An unsalvageable tooth generally has no sensation to percussion or a cold stimulus.
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Table 23-2 provides a method of diagnosing about 90% of non-trauma-related toothaches. However, for the clinician faced with a patient's sore tooth, this table may not help in differentiating between an abscess and pulpitis. (Pulpitis is inflammation of the pulp, or center, of the tooth that contains vessels and nerves). To make this differentiation easier, remember the mnemonic PAIN to indicate that pain on Percussion (the tap test on the tooth) = Abscess (periodontal or periapical) and pain with Ice (test the tooth by touching ice to it) = Nerve pain (pulpitis).
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First try to treat a toothache conservatively. Have the patient rinse vigorously with warm water. Then clean out the tooth defect and insert an analgesic gauze or filling. (See "Filling Cavities" in Chapter 24, Dental: Fillings, Extractions, and Trauma.) The cleaning can be done using dental floss, a toothbrush, a toothpick, or a similar narrow and relatively blunt tool. If an abscess is present, treat accordingly.6 (See "Dental Abscesses," below.)
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Using small tweezers, a hemostat, or a similar instrument, put a very small piece of cotton or other cloth soaked in local anesthetic, such as oil of cloves (long-acting) or benzocaine, into the cavity or over the fracture site. A paste of oil of cloves and zinc oxide can also be used effectively, if available. When using oil of cloves rather than the less-potent commercial products containing eugenol, avoid using too much or letting it drip onto the gums or mouth tissues, since it causes mucosal burns. This provides immediate, but temporary, pain relief.
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Cover this anesthetic dressing with a temporary soft putty-like filling material that can be molded to the cavity. Wax from a candle can be used: melt some wax, let it cool until it is pliable, and then place it over the affected area. An alternative is to use cyanoacrylate glue.
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If this doesn't work, open the pulp chamber (center of tooth) to drain the tooth. As a last resort, extraction may be necessary (see "Extractions" in Chapter 24, Dental: Fillings, Extractions, and Trauma).
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Dental (periapical and periodontal) abscesses are adjacent to the affected teeth. The presence of abscesses can often be recognized by swelling of the cheek, the mouth, or the neck. The adjacent tooth will generally be very tender to gentle percussion. The patient with a periapical abscess may also have increased pain when recumbent, have a bad taste in his mouth, or say that the tooth feels "longer" than adjacent teeth. In addition, he may have a gumboil (an abscess under the gum at the end of a sinus tract extending from the periapical abscess). The abscess may also develop into facial cellulitis with significant swelling. Periodontal abscesses may be more localized than periapical abscesses and usually result from chronic gingival disease, rather than caries.
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Treat these by having the patient rinse the abscessed area with warm saltwater for 10 minutes every 2 hours while awake. This may provide some immediate relief and can help the abscess drain spontaneously. Apply ice to the face. Nonsteroidal analgesics may decrease the pain; opioids may be required.
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If no dental care will be readily available and the abscess is pointing, drain it using a scalpel, needle, or fishhook that has been thoroughly cleaned. Be sure to remove the barb before using a fishhook. Subsequent warm saltwater rinsing, although initially painful, will help the drained abscess resolve more quickly.
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If the tooth is loose due to the abscess or, if not, as a last resort after more conservative treatment has failed, extract the tooth (see "Extractions" in Chapter 24, Dental: Fillings, Extractions, and Trauma). Since the tooth acts similar to any infected foreign body (such as a splinter), the infection is best treated by removing the tooth as soon as possible once it is determined that the tooth cannot be salvaged. (Daniel Kemmedson, DMD, personal written communication received June 5, 2008.) If extraction is not possible, treat the patient with antibiotics, if available, to cover mouth flora (usually penicillin); have the patient use warm moist soaks over the affected area and warm water rinses in the mouth.
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Since antibiotics may be scarce, it is worthwhile to consider whether they are necessary for dental lesions.7 While antibiotics may not make a difference in most outcomes, "without good radiographic and pulpal evaluation or good follow-up, and [given] the potential of serious deep-space infection risk, antibiotics should probably be prescribed for at-risk patients."8 So, prescribing antibiotics will depend on both the specific circumstances and the availability of the medication. If used, antibiotics for dental infections include penicillin VK 500 mg po qid, erythromycin 500 mg po qid, and clindamycin 300 mg po tid.
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Lost Filling or Lost Crown (Cap)
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If a dentist-formed crown, otherwise known as a "cap," is lost, gently clean out the hole where the filling resided. Do not try to replace the cap unless the patient is in so much pain that there is no other choice or if dental care will not be available in a timely manner. Save the cap for a dentist to use at a later time. The danger in replacing the cap is that it could come off again and the patient might aspirate it. In the meantime, the exposed pulp can be covered with softened candle wax, cyanoacrylate, or a commercial temporary tooth filling material.
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If a cap must be replaced by a non-dentist, gently clean out any residual cement from the inside of the cap with a very small knife, paperclip, the filament from a lightbulb, or similar tool. Then place a thin layer of dental filling, denture adhesive, cyanoacrylate, or a thick mixture of flour and water inside the crown. Having the patient gently bite down on the replaced cap helps position it correctly. Remove any excess material. Advise the patient not to use that tooth when eating; the cap will most likely come off.
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If a tooth has a cavity but is not abscessed, try to put in a temporary filling. (A permanent filling requires the skill and equipment that only a dentist can provide.) This decreases the chance of further tooth decay, prevents an abscess from forming, decreases the patient's pain, and may ultimately save the tooth.9
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Do not put a filling in an abscessed tooth! It will only make the pain and swelling worse. If the tooth has an abscess and you are in a situation with few resources and no dentist, pull the tooth. (Even if you break the tooth, it will allow the abscess to drain, improving the patient's condition.9)
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Chapter 24, Dental: Fillings, Extractions, and Trauma, provides detailed information on how to do fillings and extractions.