Dental emergency

Dental emergency is a broad, umbrella term used to describe an issue involving the teeth and supporting tissues that is of high importance to be fixed/treated by the relevant professional. Dental emergencies do not always involve pain, although this is a common signal that something needs to be looked at. Pain can originate from the tooth, surrounding tissues or can have the sensation of originating in the teeth but be caused by an independent source (orofacial pain and toothache). Depending on the type of pain experienced an experienced clinician can determine the likely cause and can treat the issue as each tissue type gives different messages in a dental emergency. Many emergencies exist and can range from bacterial/fungal/viral infections to a fractured tooth or dental restoration, each requiring an individual response and treatment that is unique to the situation. Fractures (dental trauma) can occur anywhere on the tooth or to the surrounding bone, depending on the site and extent of fracture the treatment options will vary. Dental restoration falling out or fracturing can also be considered a dental emergency as these can impact on function in regards to aesthetics, eating and pronunciation and as such should be tended to with the same haste as loss of tooth tissue. All dental emergencies should be treated under the supervision or guidance of a dental health professional in order to preserve the teeth for as long as possible.

Definition

There is no widely accepted definition of what constitutes a dental emergency. By contrast, a medical emergency is often more precisely defined as an acute condition which presents an immediate threat to life, limb, vision or long term health. Consequently, dental emergencies rarely can be described as medical emergencies in these terms.

Some define a dental emergency in terms of the individual's willingness to attend for emergency dental treatment at any time at short notice, stating that persons who are fussy about when they are available for treatment are not true emergency cases.^[1]:702

There are often divergent opinions between clinicians and patients as to what constitutes a dental emergency. E.g. a person may suddenly lose a filling, crown, bridge, etc. and although they are completely pain-free, still have great cosmetic concerns about the appearance of their teeth and demand an emergency treatment on the basis of perceived social disability.

Dental Pain

What is pain?

Pain is described as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.^[2] It is one of the most common reasons patients seek dental treatment and many diseases or conditions may be responsible for the cause.^[3]

Odontogenic pain

Odontogenic pain is pain associated with the teeth, originating in the dental pulp and/or the peri-radicular tissues ^[4] The following table shows the different classifications of pulp status.^[4]

Peri-radicular pain

Peri- radicular pain can be of pulpal origin, most commonly due to disease in the pulp extending into the peri-radicular tissues but can also be of periodontal origin due to periodontal disease.^[4] Apical periodontitis is a term used to describe acute inflammation of the periodontal ligament surrounding the tooth. This can be caused by inflammatory mediators from irreversibly inflamed pulp, bacterial toxins from necrotic pulp, restorations that have not been property contoured and in some cases, from treatments such as endodontic treatment.^[4] There is both an acute and chronic form of this condition.^[4] Acute apical periodontitis features include moderate to severe pain, usually stimulated by touch and pressure and may also include spontaneous pain.^[4] The chronic form of the condition can be asymptomatic but may also include pain from surrounding tissues when stimulated.^[4] Apical abscess is a term used to describe an extension of apical periodontitis where the bacteria have infiltrated the peri radicular tissues and are causing a severe inflammatory response; there is also an acute and chronic form of this condition.^[4] An acute apical abscess can cause facial swelling and can cause other systemic consequences such as a high temperature and feelings of malaise.^[4] In some cases this condition can be life-threatening when the inflammation compromises the airway; this is termed Ludwig’s Angina.^[4] A chronic apical abscess can be asymptomatic as the pressure from the inflammation is being drained through a sinus tract; a draining sinus can usually be seen clinically.^[4] A periodontal abscess is a localised inflammation affecting the periodontal tissues.^[4] It is caused by bacteria pre-existing in a periodontal pockets, traumatic insertion of bacteria or foreign body or can occur after periodontal treatment.^[4] This condition has a rapid onset, is stimulated by touch and involves spontaneous pain.^[4] It is important to note that an apical abscess may drain through the periodontal pocket giving a false interpretation of periodontal abscess or a periodontal abscess may appear at the apex of the tooth giving a false interpretation of apical abscess; a tooth may also have both lesions at one point in time.^[4]

Non-odontogenic pain

Non-odontogenic pain is pain that is not associated with the teeth but involves other orofacial tissues.^[5] Non-odontogenic pain can be difficult to diagnose and can vary in severity.^[5] The following conditions can mimic pain from a toothache and may be the reason a patient presents to a dental clinic with pain. Pain can originate from the maxillary sinus because there is only a thin plate of bone separating the maxillary teeth from the sinus; inflammation from the sinus lining from infections can lead to facial pain that can be felt in the teeth.^[5] This type of pain is a dull aching pain and may be exacerbated by bending over or lying down.^[5] Temporomandibular joint dysfunction syndrome (TMD) is a term used to describe a number of disorders affecting the temporomandibular joints, masticatory muscles and other structures associated with this region.^[5] Common complaints from patients include pain in the muscles around the mouth, pain in the temporomandibular joint upon use, headache, earache, locking or clicking of the jaw and tinnitus.^[5] Non-odontogenic pain can also be of neuromuscular origin; examples include muscle tension headache, neck pain, whiplash and fibromyalgia.^[5] Pain can be evident in the facial muscles and the neck may be tender, dysfunction of muscles may also be evident.^[5] Neurovascular pain refers to a group of disorders involving the trigeminal neurovascular system.^[5] This condition is most often associated with headaches but can also involve infection or tumors; the pain occurs with the headache and usually subsides when headache ceases.^[5] This type of pain may need a referral to a physician as in some cases can be life-threatening.^[5] Neuropathic pain can mimic toothache when it involves the nerve supply to the teeth.^[5] This can be caused by trauma, inflammation or tumors in the oro-facial region.^[5] Trigeminal neuralgia is the most well known in the dentistry field.^[5] Toothache type pain may also be felt in the presence of oral cancer, squamous cell carcinoma occurring in the oral mucosa may present with pain and sensory problems.^[5]

Dental Trauma

Dental trauma refers to an injury on hard and soft tissues of the oral cavity and face. This includes the teeth and surrounding tissues, the periodontium, tongue, lips and cheeks. It is more prevalent with children between 8– 12 years of age but can still happen to anyone. The prognosis of the tooth is worse the longer it is out of the mouth.^[6]

The following is a list of dental trauma affecting different surfaces of the teeth and periodontium.

Injuries to the hard dental tissues and the pulp^[2]

Injuries involving periodontal tissues ^[2]

Dental barotrauma and barodontalgia.^[7] A sudden incapacitation of diver or aviator due to barometric-induced tooth fracture or toothache, respectively, may be life-threatening to the individual and the airplane passengers.

Restorative emergencies

Lost or broken filling

A fractured, ditched or dislodged filling that is broken or lost may cause discomfort or sharp pain due to jagged edges. There can be aesthetical concerns if the filling is in a visible area. Patients need to be aware of the sharp edges and ensure their tongue does not constantly apply pressure around that area, as it can cause cuts to the tongue. However, in some cases the result of the loss of a filling can cause irritation to the side of the cheek and potentially lead to an ulcer. Sharp edges can easily be dealt with by levelling the filling or tooth edges from your local dentist during the emergency appointment. Hypersensitivity issues may also arise, short sharp pain caused by exposed underlying dentine, after the deterioration of the filling material.^[2]

Reasons for the deterioration of a restoration vary in different cases, the cause may be underlying caries or it could be occlusal trauma, caused from natural dentition during mastication. The longevity of restorative materials could also be a factor; the survival rates of amalgam are usually 10–15 years, composite 7 years, while gold and ceramic fillings have over a 20-year longevity.^[2]

During the emergency appointment the dentist will need to take a set of radiographs to assess for any underlying caries, bone loss or possible abscess. The clinical examination will detect the reasons behind the failure of the restoration. Upon treatment the dentist will provide options on the tooth’s prognosis, these may include a new restoration, extraction, root canal or placement of a crown. The tooth prognosis includes the tooth’s vitality and restorability.

• Crack, fracture and mobility

A crack, fracture and the mobility of a tooth are all interrelated as the pain and symptoms experienced from a tooth that has been cracked are very similar to that of a tooth that has been fractured.^[2] A tooth crack is defined as an incomplete fracture of enamel or dentine and therefore is not usually associated with noticeable mobility.^[8] The cause of a tooth crack can be by excessive force applied to a healthy tooth or physiologic forces applied to a weakened tooth. The teeth most commonly involved are usually the lower molars, followed by the upper premolars and molars. The condition is extremely common in the age range of 30–60 years.^[2]

A diagnosis of a cracked tooth is extremely difficult. Careful history and assessment of the symptoms presented needs to be taken into account; radiographs and certain tests will be conducted in the dental office. Most common symptoms are cold sensitivity, sharp pain when using force to chew, these pain results from the release of pressure and are very important indicators of a cracked tooth. However, the symptoms may differ from various patients, subject to the depth and orientation of the crack.

Broken crown

Crowns can become broken by a fracture, non-retentive preparation, secondary caries, weak cement, excessive occlusal forces, decementation or loosening of the crown.^[8] The consequences of a crown becoming loose include the risk of ingestion and less likely, inhalation. The management of the loose crown includes immediate recementation or a replacement crown, depending on the assessment conducted by the dentist.

The factors that are taken into consideration in making this decision include the strength of the temporary crown to be placed and occlusal forces. Thus, a thorough occlusal examination is of paramount importance, strength of the cement, a strong alternative of cement should be considered. The occlusion assessment should also include the static and functional occlusion as well as the possible presence of Para functional habits, such as clenching or bruxism.

Management includes cleaning all the cement and residues, to carefully inspect for any underlying caries or fractures. Details that need to be assessed include margins, gingivae and contact points; occlusion needs to be checked in both ICP and in lateral and protrusive excursions, before the crown can be re-cemented. Stronger cement should be used than the original such as resin cements, especially in cases of heavy occlusal forces.

In some cases, immediate reconstruction of the abutment may be deemed inappropriate, if the underlying structure is deemed deficient due to caries or a fracture then this issue needs to be addressed. The treatment plan may vary with the addition of a root canal treatment or a temporary crown for the reconstruction of a new crown.

• Fracture of a porcelain veneer or a porcelain-fused-to-metal crown

Immediate management includes a chair side repair of the fractured veneer with composite material. Bonding composite to the exposed metal will involve achieving macro mechanical retention by making grooves and notches or abrading the surface. Bonding material back onto exposed porcelain involves abrading, hydrofluoric acid etching and silanating then followed by a conventional bonding procedure. Composite patch will remain a temporary solution as the longevity of composite restorations is not predictable as well as the colour of composite is not as stable as porcelain for aesthetical reasons.^[2]

Broken denture

A fracture can involve any damage to the denture. Any type of repair to the denture is much less ideal then making a new one. The ratio of fracture to a denture is a 1:3 ratio of the upper to lower.^[8]

The most common reason for fracture in a denture; is accidental dropping of the denture in the case of the lower denture, and improper fitting and stability of the denture in the upper denture.

• Techniques to prevent denture from being broken:

1. Use a basin of water in the sink, to help prevent the denture from breaking if happens to fall on a hard surface.
2. Hold the denture in non-dominant hand with a firm, but gentle grasp.
3. Do not use any powdered or abrasive cleaners, including most regular toothpastes, they are too abrasive and produce scratches on the denture surface.
4. Avoid excessive scrubbing as this can damage the denture.
5. Dry denture and place in a plastic container stored some where safe over night.

Broken or loose implants

Implant success is relatively high, the rate of implant survival is between 85-95%,^[9] although it is not uncommon for emergency management of a failing implant or one of its components. The failure is most likely due to infection of the implant. It is highly recommended to visit or refer patient to the specialist who provided the implant.

Late failures that occur with implants are usually due to moderate to severe bone loss, mostly located in the posterior areas of teeth and involve a multi-unit prosthesis. A fracture or decementation of a post or loosening of the abutment screw of an implant could be the result of dissolved cement, secondary caries, use of a weak post, or excessive occlusal forces.^[8] Oral home care needs to remain at a high standard, brushing twice a day for the duration of two minutes with the use of fluoridated tooth paste. Interdental cleaning once a day using either floss, interdental brushes, wood sticks. Regular dental appointments every 6 months to maintain gingival health, professional cleans, radiographs to examine the bone loss and the implant status. All the following is needed to prolong the longevity of the implant and reduce the risk of peri-implantitis.

Acute oral medical and surgical conditions

An abscess originating from a tooth which has spread to involve the buccal space. Above, deformation of the cheek on the second day. Below, deformation on the third day.

An acute condition may be defined as a suddenly presenting disorder, usually with only a short history of symptoms, but with a degree of severity that causes significant disruption to the patient.^[2]

Types of acute conditions

Orofacial swelling

A swelling is a transient abnormal enlargement of a body part or area not caused by proliferation of cells but by accumulation of fluid in tissues. It can occur throughout the body (generalized), or a specific part or organ can be affected (localized). A swelling may arise intra-orally or externally around the face, jaws and neck and can be caused by trauma (hematoma, swelling due to fracture, TMJ dislocation), infection or inflammation. Swelling can occur in the gums, palate, lips, buccal space, etc. It can happen due to periodontal problems, infection, abscess, cysts, allergic reaction (anaphylactic shock), salivary gland tumour, inflammation or obstruction of salivary gland.

Cellulitis

Bacterial infection in the oro-facial region can lead to abscess and swelling. The rapid spread of this infection through connective tissue spaces, is often referred to as cellulitis. The clinical features of cellulitis are a painful, diffuse, brawny swelling. The overlying skin is red, tense and shiny. There is usually an associated trismus, cervical lymphadenopathy, malaise and pyrexia. Cellulitis usually develops quickly, over the course of hours, and may follow an inadequately managed or ignored local dental infection. If the infection spreads to involve the floor of mouth and pharyngeal spaces, then the airway can be compromised. Initially, the floor of the mouth will be raised and the patient will have difficulty in swallowing saliva; this pools and may be observed running from the patient’s mouth. This sign indicates the need for urgent management. Cellulitis involving the tissue spaces on both sides of the floor of mouth is described as Ludwig’s angina ^[10] Such presentations require immediate attention.

Localised dental abscesses may be appropriately treated by intra-oral drainage via tooth extraction, opening of root canals and/or intra-oral incision and drainage. Wherever there are signs of spreading cervico-facial infection or significant systemic disturbance, however, patients should be referred urgently further management.

Pericoronitis

Pericoronitis is defined as inflammation in the soft tissues surrounding the crown of a partially erupted tooth. The acute form is characterised by severe pain, often referred to adjacent areas, causing loss of sleep, swelling of the pericoronal tissues, discharge of pus, trismus, regional lymphadenopathy, pain on swallowing, pyrexia, and in some cases spread of the infection to adjacent tissue spaces.^[11]

• Blistering disorders of oral mucosa (see vesiculobullous disease)
• oral ulceration
• Disturbed orofacial sensory or motor function

Trismus

Trismus may be defined as inability to open the mouth due to muscle spasm, but the term is frequently used for limited movement of the jaw from any cause and usually refers to temporary limitation of movement.^[8] Trismus can occur as a result of temporomandibular joint disorder, infection, cancer therapy, complicated extraction, arthritis, complication from a mandibular block and fractures.^[12]

Hemorrhage

Whilst haemorrhage from the oro-facial region may present spontaneously, particularly from gingival tissue as a result of a bleeding diathesis or a haematological abnormality such as leukaemia, the most common cause is in response to trauma or a post-operative haemorrhage following dental extraction.^[2]

Post-extraction pain and infection, or dry socket

Following a tooth extraction, if a blood clot forms inadequately in the socket or it is broken down, a painful infection may develop which is often referred to as a ‘dry socket’. It is clinically characterized by a putrid odor and intense pain that radiates to the ear and neck. Pain is considered the most important symptom of dry socket. It can vary in frequency and intensity, and other symptoms, such as headache, insomnia, and dizziness, can be present.^[13] Pre-disposing factors to dry socket include smoking, traumatic extraction, history of radiotherapy and bisphosphonate medication. A dry socket can be managed by irrigating the socket with chlorhexidine or warmed saline to remove debris followed by dressing of the socket with bismuth iodoform paraffin paste and lidocaine gel on ribbon gauze to protect the socket from painful stimuli.^[14] If pus is seen in the socket and there is localised swelling and possibly lymphadenopathy, it has become infected and can often be managed as in dry socket, but usually antibiotics should be prescribed. A radiograph is useful to see if there is a retained root or bony sequestrum, which could be the cause of the infection. Clearly, if one or both is present, further treatment is indicated.^[14]

Postoperative swelling

Mild inflammatory swelling may follow dental extractions but is unusual unless the procedure was difficult and significant surgical trauma occurred. More significant swelling usually indicates postoperative infection or presence of a haematoma. Management of infection may require systemic antibiotics or drainage. A large haematoma may need to be drained.

Treatments

The treatment is cause-related. For example, oil of cloves, which contains eugenol, can be used to treat dental pain; a drop can be applied with a cotton swab as a palliative . After wisdom tooth extraction, for example, a condition known as dry socket can develop where nerve endings are exposed to air. A piece of sterile gauze or cotton soaked in oil of cloves may be placed in the socket after careful cleaning with saline to relieve this form of pain .

Over-the-counter topical anesthetics containing active ingredients such as benzocaine or choline salicylate may be applied directly to the gum in order to deaden sensation.

Analgesics such as aspirin, paracetamol (acetaminophen) and ibuprofen are also commonly used; aspirin and ibuprofen have the additional benefits of being anti-inflammatories. Ice and/or heat are also frequently applied . A dentist may prescribe an anti-inflammatory corticosteroid such as Dexameth for pain relief prior to treatment.

References

External links

• Colgate on dental emergencies