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How do you treat dental pain?


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We are inundated with toothaches in my ER. Most are just good all fashioned cavities, some are abscesses, and a few are true emergencies (Ludwigs, deep space infx).

For the run of the mill toothaches, how does everyone treat them? There is a running argument in our department of dental block vs no dental block.

I rarely do dental blocks, unless for a specific procedure--ie drain a HUGE gingival abscess etc. I don't feel it's indicated and I'm not a dentist. All risk and no gain, IMHO. I would have a hard time justifying the procedure in light of a bad outcome, like paresthesia, infection, neuritis. It's not like we do a digital block for a finger contusion because it "hurts" or a median nerve block for carpal tunnel syndrome. It wears off in 4-8 hours (depending on what you use), then what? At least once a week, I see a patient in the evening shift for another "numbing shot" he received from the morning shift.

A few colleagues argue that it helps break the pain cycle and allow the pain meds to kick in. Others argue they will only give narcotics to those who allow them to do a dental block, because the others must be drug seeking.

What do you do in your practice?

Sara

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Do the darn block. Give the patient a few hours of pain relief to clean their mouth and get some oral pain meds on board to catch up on the pain! Do an ultimate EM oral exam for infection, abscess, etc. If not contraindicated, topical anesthetic and your preference on mL's of bupivicaine to anesthetize. Do the right thing.

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We are inundated with toothaches in my ER. Most are just good all fashioned cavities, some are abscesses, and a few are true emergencies (Ludwigs, deep space infx).

For the run of the mill toothaches, how does everyone treat them? There is a running argument in our department of dental block vs no dental block.

I rarely do dental blocks, unless for a specific procedure--ie drain a HUGE gingival abscess etc. I don't feel it's indicated and I'm not a dentist. All risk and no gain, IMHO. I would have a hard time justifying the procedure in light of a bad outcome, like paresthesia, infection, neuritis. It's not like we do a digital block for a finger contusion because it "hurts" or a median nerve block for carpal tunnel syndrome. It wears off in 4-8 hours (depending on what you use), then what? At least once a week, I see a patient in the evening shift for another "numbing shot" he received from the morning shift.

A few colleagues argue that it helps break the pain cycle and allow the pain meds to kick in. Others argue they will only give narcotics to those who allow them to do a dental block, because the others must be drug seeking.

What do you do in your practice?

Sara

 

 

Pop Quiz.....What happens when you feed stray cats? BTW the second reply applies, I'm just throwing a bomb into the crowd!

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First thing i always look for is signs of infection.

 

DENTAL INFECTION IS THE #1 COMPLAINT OF DRUG SEEKERS

 

If they have en essentially normal exam (maybe a little gum erythema and nasty teeth are the norm so this is essentially normal) then they get offered toradol, IBU 600 TID and Pen VK 500 QD x 10 days and NOTHING ELSE

 

If they have a lot of swelling but no palpable fluitd pocket I might give them a vocodin

 

If they have a CT confrimed abscess will use just abotu what ever they want.

 

 

Many many times if you look up the history on these patients they are always in ER for some type of pain complaint - - I have also had many discussions with recovered addicts who would say they would commonly use dental pain as a way to get a few narc's to tied them over.......

 

 

It is difficult if you do not have a unified department - if some providers are given the typical Percocet #20 to simple dental pain you are doomed to fight an uphill battle. I have finally gotten my SP's to NOT write narcotics if i have already seen the patient and said no (took some work to get this and i always have to remind them to not give - 50% of the time the patient demands to see a doc and they wait for hours to see them.... but atleast they don't get narc's)

 

remember addicts will do anything to get drugs and sitting in the ER for 4 hours making a stink is safer and cheaper then buying on the street.

 

As for blocks - I will never do them unless there is a confrimed infection with frank swelling or abscess - otherwise you are likely taking on a risk on an addict and they only two outcomes are no relief (never had any pain) or tyou mess up and they come after you.

 

 

 

 

Drug addicts use dental pain to get narcotics and the providers that give drug addicts drugs are not practicing good medicine but instead bring harm to their patients.

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