Dental & facial pain: documentation that holds up
Two dental presentations carry real stakes: the avulsed permanent tooth (a clock — reimplant fast) and the dental infection that becomes an airway emergency. The defensible chart accounts for every tooth, documents the avulsion timing and storage, and shows the airway and cardiac mimics were considered.
01What's at stake
An avulsed permanent tooth has ~90% survival if reimplanted within 5 minutes and almost none after 60 — and a primary tooth must not be reimplanted. A "toothache" can be Ludwig angina or a deep-space neck infection threatening the airway, and lower jaw pain can be an MI. And a missing tooth/fragment can be aspirated.
02Can't-miss diagnoses
- Avulsed permanent tooth — time-critical reimplantation; keep moist (milk/dental media/saliva, not water), handle by the crown.
- Ludwig angina / deep-space infection — floor-of-mouth swelling, trismus, drooling, voice change → airway emergency.
- Cardiac jaw pain — lower jaw/tooth pain as an anginal equivalent.
- Missing tooth/fragment — rule out aspiration / soft-tissue or nasal embedding (facial + chest x-ray).
- Alveolar/mandibular fracture, associated head/neck injury, and non-accidental trauma.
03History & exam
- Floor-of-mouth swelling, trismus, drooling, muffled voice, neck swelling? → Ludwig / deep-space (airway)
- Lower jaw/tooth pain with exertion, diaphoresis, risk factors? → cardiac (get an ECG)
- Avulsed/missing tooth — what time, where is it, primary or permanent? → reimplant timing / find the tooth
- Injury inconsistent with the history/development, torn frenulum in an infant? → non-accidental trauma
- Inspect for fragments in lips/soft tissue; assess tooth mobility/percussion (intrusion can mimic avulsion).
Skip the typing
Work the case in the Dental & Facial Pain Workup — it records the airway assessment and the ECG (for jaw pain), and assembles an MDM that documents the can't-miss airway/cardiac causes and, for trauma, the tooth accounting and follow-up.
04Management
- Avulsed permanent tooth: reimplant ASAP (ideally on scene); store in milk or dental preservation media (saliva or saline if not available, water last); rinse ≤10 s by the crown; reinsert, splint, panorex, tetanus, antibiotics (penicillin/amoxicillin; doxycycline if ≥12 and penicillin-allergic), dental follow-up within 24h. Do not reimplant primary teeth.
- Ludwig/deep-space infection: airway first, IV antibiotics, CT, urgent ENT/OMFS.
- Cardiac jaw pain: ECG ± troponin; treat as ACS if suggestive.
- Missing tooth/fragment: facial + chest radiographs to exclude aspiration/embedded fragment.
- Infections/fractures: analgesia (consider dental blocks), tetanus, antibiotics when indicated, and named dental follow-up timing.
05What to document
06Where charts fail
- Delaying (or storing in water) an avulsed permanent tooth — or reimplanting a primary tooth.
- Assuming a missing tooth was "lost" without imaging for aspiration/embedding.
- Calling Ludwig/deep-space infection a "toothache" and missing the airway threat.
- Not getting an ECG for lower-jaw pain that could be cardiac.
- Missing non-accidental trauma, or not documenting specific dental follow-up timing.
07Sources
- Li J. Emergency department management of dental trauma: recommendations for improved outcomes in pediatric patients. Pediatric Emergency Medicine Practice — Pediatric Trauma EXTRA (EB Medicine). 2024.
- Fouad AF, Abbott PV, Tsilingaridis G, et al. IADT guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol. 2020;36(4):331-342.
- Bourguignon C, Cohenca N, Lauridsen E, et al. IADT guidelines: 1. Fractures and luxations of permanent teeth. Dent Traumatol. 2020;36(4):314-330.
- Day PF, Flores MT, O'Connell AC, et al. IADT guidelines: 3. Injuries in the primary dentition. Dent Traumatol. 2020;36(4):343-359.
© 2026 Kim Trinh, MD. All rights reserved. Educational only — synthesized from EB Medicine and primary literature. Synthetic examples. Not medical advice — apply local protocol and judgment.