agk’s Library of Common Simple Emergencies
The patient develops an acute toothache with sharp and throbbing pain, often worse wth recumbent position. The patient may or may not be aware of having a cavity in that tooth. Initially the pain is decreased by heat and increased by cold, but as the condition progresses, heat makes the pain worse, while ice will dramatically relieve it. (A patient might come in holding a cup of ice and not allow examination unless ice can be kept on the tooth.) Physical exam may reveal dental cavities (caries) or an extensive tooth restoration without facial or gingival swelling.
As a patient’s condition progresses from pulpitis to pulpal necrosis, the patient experiences excruciating pain caused by fluid and gaseous pressure within a closed space. Heat increases the volume and hence the pain, while cold reduces it.
Intractible pain usually responds to nerve block techniques with injection of long-acting local anesthetics. If a patient refuses a nerve block or a nerve block fails to relieve pain, consider the possibility that the patient is drug seeking. At the same time, remember that some people have extreme phobias about dental injections. When in doubt, err on the side of compassion.
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