How to evaluate tooth pain after trauma?

Evaluation of Tooth Pain After Trauma

A systematic approach to evaluating tooth pain after trauma requires a thorough assessment of the injury mechanism, neurological status, and specific dental examination, with periapical intraoral radiography as the primary imaging modality for diagnosis. 1

Initial Assessment

• Begin by determining when and how the dental injury occurred, which is crucial for assessing the need for tetanus booster, possibility of child abuse, and potential head injury 1
• Complete an age-appropriate neurological assessment if cranial injury is suspected, including questions about loss of consciousness, dizziness, headache, nausea, and vomiting 1
• If concussion or more severe intracranial injury is suspected, prioritize protection of the cervical spine and immediate medical evaluation 1
• Assess for disturbances in occlusion (bite), which may indicate a displaced tooth or alveolar/jaw fracture 1
• Evaluate tooth sensitivity or pain to hot/cold exposures, which may indicate exposed dentin and/or pulp tissue requiring immediate dental referral 1

Clinical Examination

• Cleanse the face and oral cavity with water or saline to facilitate accurate examination 1
• Palpate the facial skeleton for signs of fractures 1
• Inspect the dental trauma region for:
  • Fractures (tooth or bone) 1
  • Abnormal tooth position 1
  • Tooth mobility 1
• Identify whether the injured tooth is primary or permanent, as management differs significantly 1
  • Children under 5 years typically have primary dentition 1
  • Children 6-12 years have mixed dentition 1
  • By age 13, most children have all permanent teeth 1

Pain Assessment by Injury Type

• Concussion: Tooth is tender to touch but without increased mobility or displacement; no sulcular bleeding present 1
• Subluxation: Tooth presents with abnormal mobility but no displacement; sulcular bleeding is present 1
• Lateral luxation: Tooth is displaced laterally (often in palatal/lingual direction); may be mobile or firmly locked in displaced position 1
• Extrusive luxation: Partial vertical displacement of tooth from socket; often causes significant pain 1
• Intrusive luxation: Tooth is forced into the alveolus; pain may be severe 1
• Crown fractures: Pain severity depends on whether pulp is exposed 1
  • Enamel-only fractures generally cause minimal sensitivity 2
  • Enamel and dentin fractures without pulp exposure often cause moderate sensitivity 2
  • Crown fractures with exposed pulp cause significant pain requiring immediate intervention 2

Radiographic Assessment

• Periapical intraoral x-ray is the imaging technique of choice for evaluating dental trauma 1
• Use an adequate paralleling system for optimal visualization 1
• Conventional intraoral dental radiographs provide the best assessment of an injured tooth 1
• Ortopantomography (OPT) is NOT recommended for localized dental trauma due to lower spatial resolution and longer exposure time 1
• CBCT is indicated only when clinical evaluation and primary radiographic investigations are not sufficient for treatment planning 1
• Follow the ALARA principle (as low as reasonably achievable) to minimize radiation exposure 1

Pain Management

• NSAIDs (such as ibuprofen) are recommended as first-line treatment for acute dental pain following tooth fracture, with acetaminophen as an alternative when NSAIDs are contraindicated 2
• Apply cold compresses to reduce swelling and discomfort 2
• Maintain a soft diet for the first 10 days after injury 2
• Avoid extremes of temperature with food and drink to prevent sensitivity 2

Common Pitfalls to Avoid

• Failing to consider referred pain from other structures (muscles, temporomandibular joint) when dental origin isn't obvious 3, 4
• Delaying referral for crown fractures with pulp exposure, which can lead to pulpal necrosis 2
• Underestimating pain from dentin exposure, which requires prompt coverage to prevent bacterial contamination 2
• Misdiagnosing chronic pain conditions, which may lead to unnecessary dental treatment 3
• Using water to store avulsed teeth or tooth fragments, which can damage cells (use milk or saline instead) 2, 5

Timing of Dental Referral

• Immediate referral (same day) for:
  • Crown fractures with pulp exposure 2
  • Severe tooth mobility 2
  • Significant pain unresponsive to analgesics 2
  • Lateral luxation affecting occlusion 1
• Referral within a few days for:
  • Enamel and dentin fractures with sensitivity 2
  • Subluxated teeth with developing pulpal necrosis signs 1
• Less urgent (within a week) referral for enamel-only fractures with minimal symptoms 2