I was glad to see the recent article on dental pain in the ED by Shari Welch, MD. (“Dental Pain in the ED: Big Solution in a Small Package,” 2005;27:8.) The management of dental pain is a particular area of interest to me and should be to every emergency physician. While most physicians know nothing about dentistry, emergency physicians, for reasons clearly documented in the article, face the issue on a daily basis, and usually with no training. While I commend Dr. Welch on her treatise, I would like to add what I think are two very important treatment modalities to the approach of the patient with dental pain.
The first, and most important, trick I learned was from the actor Dustin Hoffman in the movie Marathon Man. This movie should be required viewing for every emergency medicine resident. After a maniacal Nazi dentist drills holes in Hoffman's teeth in a quest for information, he completely relieves the pain with a dab of over-the-counter oil of cloves. This miracle medicine works wonders for dental pain from cavities, cracked teeth, or any process that exposes the nerve ending. The active ingredient, eugenol, is still used in modern dentistry, and a bottle of oil of cloves should be part of every emergency physician's tool kit. (Don't forget to take this on the road with you, especially when traveling to distant lands.)
The next tool is the local dental block, a must for the emergency physician. During a rotation at a university ED, I saw that dental pain patients were put in side rooms and the oral surgery intern called to deal with them. I tagged along and soon learned how to do dental blocks and pulled hundreds of teeth, a most satisfying experience. Did you know there is a specific pair of pliers for every tooth?
The emergency physician needs to know only two dental blocks, and when done with Marcaine with epinephrine, these blocks provide total pain relief for up to eight hours. This procedure truly allows the emergency physician to relieve suffering. A further benefit is that if someone allows me to stick a needle in his mouth, I am more inclined to believe he is really hurting, and I will give him Lortab. If he is not willing, he just gets the penicillin and Motrin. Because most drug addicts are afraid of needles, I find this trick helpful, but I have been fooled on occasion when the need to get Lortab simply outweighs the displeasure of getting the block. Anyone with true dental pain will jump at the instant relief this procedure provides.
The bottom jaw can be blocked on either side with the inferior alveolar block, which catches the nerve as it exits the jaw to supply the teeth, tongue, and lip. The upper teeth have to be blocked individually by injecting in the gum above the tooth and the hard palate behind the tooth to block the nerve to the tooth, also very effective.
I feel very strongly that a lecture on management of dental pain should be a mandatory part of every emergency medicine training program and proficiency in dental blocks a required skill. This is an area where we truly can help the patient in pain. You may ask, is it safe? You will have to watch the movie to know why I ask.
Alan J Sorkey, MD