Ethics & Law · patient case question
What is the most appropriate next step?
Patient case: After-hours telephone call about a child in severe dental pain
Patient: Child, 6 years old (mother is the patient of record)
Chief Complaint: Mother, by telephone at 11 pm: “My daughter is screaming with pain. Nothing is helping.”
Background: The mother was booked for her own treatment and did not attend. The child was examined three weeks ago: tooth #S had deep caries with a diagnosis of symptomatic irreversible pulpitis and pulp therapy was recommended, but the appointment was not kept.
Vital Signs: Reported by telephone: the child is alert, taking fluids, no fever, no facial swelling, no difficulty breathing or swallowing.
Findings: Not examinable by telephone. The mother reports the pain began this evening and has worsened.
Show answer and explanation
Correct answer: D. Arrange to see the child promptly and provide definitive pulp therapy on tooth #S
- A. The emergency department has a role when there is facial swelling, fever, airway compromise, dehydration or trauma — none of which is reported. Hospital departments cannot generally provide definitive dental treatment, so the child would wait for hours and be sent back with an antibiotic and a referral to you.
- B. Opioids should not be prescribed for paediatric dental pain. CODEINE and TRAMADOL are CONTRAINDICATED in children under 12 — ultra-rapid CYP2D6 metabolisers convert codeine to morphine unpredictably, and deaths have been reported. Prescribing an opioid over the telephone for an unexamined child is indefensible.
- C. Deferring a child in acute pain for two weeks is neglect of an urgent need. The missed appointment explains how she got here; it does not change the obligation now.
- D. CORRECT. SYMPTOMATIC IRREVERSIBLE PULPITIS is not treated by analgesia — it is treated by REMOVING THE INFLAMED PULP. Pulpotomy or pulpectomy on #S is what will abolish the pain, and doing it promptly is both the effective treatment and the ethical obligation for a child in severe pain. Interim analgesia by weight-appropriate ibuprofen with acetaminophen is entirely reasonable to bridge the gap until she is seen, but it is a bridge, not the treatment.
Note: Two rules to carry from this. First, telephone triage sorts by URGENCY: airway, swelling, fever, trauma and bleeding go to hospital; everything else is seen by the dentist. Second, ibuprofen combined with acetaminophen provides analgesia equal or superior to opioid combinations for acute dental pain, with a far better safety profile — and in children it is the only reasonable pharmacological choice. Removing the cause remains the treatment.