What focused questions should I ask a patient presenting to the emergency department with dental pain to identify a true dental emergency versus an urgent medical condition?

Critical Questions to Identify Dental Emergencies in the ED

When evaluating dental pain in the ED, immediately ask about facial swelling, difficulty breathing or swallowing, fever, and trismus to identify life-threatening deep space infections that require urgent intervention.

Life-Threatening Red Flags (Ask First)

• Facial or neck swelling: Indicates potential deep space infection (Ludwig's angina, parapharyngeal abscess) that can compromise the airway 1
• Difficulty breathing or swallowing: Suggests airway compromise requiring immediate intervention 1
• Fever with dental pain: Points to systemic spread of dental infection requiring antibiotics and possible admission 1
• Trismus (inability to open mouth): May indicate masticator space involvement or severe infection 1

Pain Characterization Questions

• Onset and duration: Ask specifically how many days the pain has existed—patients often wait over 7 days before seeking care, and mean duration is approximately 17 days before ED presentation 2, 3
• Pain quality: Sharp, electric shock-like pain triggered by light touch (brushing teeth, talking) suggests trigeminal neuralgia requiring anticonvulsants, not standard analgesics 1, 4
• Continuous vs. intermittent: Persistent, severe pain suggests pulpitis or abscess requiring urgent dental referral 1
• Temperature sensitivity: Sensitivity to hot/cold indicates dentin exposure or pulpal involvement 1

Trauma History

• Recent dental injury: Ask about crown fractures with visible pink/red tissue (pulp exposure)—these require immediate dental referral to prevent pulpal necrosis 5, 1
• Tooth mobility: Severe mobility suggests luxation injury, root fracture, or advanced periodontal abscess requiring urgent evaluation 5, 1
• Missing teeth after trauma: If tooth cannot be found, consider aspiration risk and need for chest radiograph if breathing difficulties present 5

Associated Symptoms

• Visible tooth damage: Fractured teeth with pulp exposure appear as pink/red tissue in the center of the tooth and require immediate referral 1
• Gum swelling or "gum boil": Parulis (gingival abscess) indicates pulpal necrosis and periapical infection 5
• Altered sensation: Numbness or tingling suggests nerve involvement or post-traumatic neuropathic pain 1
• Jaw claudication in patients >50 years: Consider giant cell arteritis—check ESR and temporal artery examination 6

Functional Impact Questions

• Ability to bite teeth together: Luxation injuries may prevent proper occlusion, requiring immediate repositioning 5
• Impact on sleep, mood, and daily activities: Helps assess severity and need for aggressive pain management 1
• Eating difficulties: Determines if soft diet recommendations are needed and assesses severity 1

Common Pitfalls to Avoid

• Failing to recognize airway compromise: Severe dental infections with facial swelling can rapidly progress to airway obstruction 1
• Delaying referral for pulp exposure: Crown fractures exposing pulp tissue lead to pulpal necrosis if not treated urgently 1
• Treating trigeminal neuralgia with opioids: This neuropathic pain requires anticonvulsants (carbamazepine or oxcarbazepine), not standard analgesics 1, 4
• Underestimating pain from dentin exposure: Exposed dentin requires prompt coverage to prevent bacterial contamination and worsening pain 1

Non-Emergency Indicators

• Simple toothache without swelling: Can be managed with NSAIDs (ibuprofen 400mg every 4-6 hours) and routine dental referral 1
• Dental concussion (tender tooth without mobility): Requires observation only, not urgent intervention 1
• Chronic pain >3 months without acute changes: Consider non-odontogenic causes like burning mouth syndrome or atypical facial pain 6