Dental emergencies

Anatomy

• 20 primary teeth (labelled A-T from right maxillary back molar clockwise
• 32 permanent teeth (numbered 1-32 from pt’s right maxillary wisdom clockwise)
  • Alternatively quadrant numbering with 1^st quadrant right upper, then 2 is upper left, then 3 lower left then 4 lower right clockwise and each tooth 1-8
• Primary teeth erupt from front to back from 8 – 33months
• Permanent teeth erupt from front to back from 7-13 years

Normal teeth

• Pulp (containing neurovascular supply) surrounded by dentin
• Crown consists of enamel layer overlying dentin
• Root portion extends into alveolar bone and is covered with thin layer of cementum

Normal periodontium

• Gingival and periodontal components
• Gingival component consists of junctional epithelium, gingival tissue and gingival fibres
• Periodontal component consists of periodontal ligament, alveolar bone and cementum of root

Examination

• With tongue depressor look at inner lips, buccal and labial mucosa, hard and soft palate, tongue and floor of mouth
• Palpate floor of mouth with finger on each side for any masses
• Examine teeth visually then gently percuss each one with firm clean object to identify if specific tooth is source of pain
• After trauma assess each tooth for tenderness/mobility
• Assure that no mal-occlusion exists for patient
• Assess degree of opening of mouth
• Palpate for mandibular/maxillae fractures
• Check TMJ by placing finger in each ear and feeling for crepitus or popping while mandible is fully opened and closed +- tenderness anteriorly

Pain of odontogenic origin

• Tooth eruption and pericoronitis
  • Tooth eruption pain must be differentiated from true pericoronitis, which arises from inflammation of the operculum (gingival tissue overlying occlusal surface of erupting tooth secondary to food or debris beneath it)
  • Without intervention, pericoronitis results in localised infection with potential for spread to masseteric space and trismus
  • Treatment of pericoronitis
    • Penicillin V 500mg QID
    • Local irrigation of food or debris from beneath operculum
    • Saline mouth rinses
    • NSAID’s +- opiates
    • More severe cases require IV antibiotics and admissions
    • Refer to dentist

Odontogenic pain

• Dental caries and pulpitis
  • Dental caries is loss of tooth enamel due to prolonged exposure to acidic metabolic by-products of plaque bacteria
  • Most common in pits and fissures of occlusal surface, interproximally, and along gingival margins
  • Once dentin is involved, caries spreads along dentinal microtubules
  • Direct communication between oral environment and vital dental pulp results in cold/sweet sensitivity
  • Reversible pulpitis – Short, sharp pain with stimulation
  • Irreversible pulpitis – Pain lasting minutes to hours with stimulation
  • Pulpal necrosis – Spontaneous dental pain. This requires analgesia, PenV 500mg QID and dental referral
  • Irreversible pulpitis and pulpal necrosis require root canal therapy or dental extraction

Odontogenic pain

• Cracked tooth syndrome
  • Incomplete fracture of tooth that may extend to vital pulp
  • Sharp pain on chewing that resolves once chewing ceases
  • Cold and sweet stimuli may also contribute to pain
  • NSAID’s for relief and dental referral

Odontogenic pain

• Periradicular periodontitis
  • Extension of pulp disease, inflammation or necrosis into tissues around root and apex of tooth
  • OPG – Slight widening of periodontal ligament space around cementum, thinning of lamina dura, radiolucent area near root apex
    • Only shows most extensive lesions but can rule out other painful osseous pathology
  • Pain on percussion helps to identify offending tooth
  • Periapical abscess is indistinguishable clinically or radiologically from periodontitis
  • Parulis – small swelling with draining fistula adjacent to affected tooth
  • If dental abscess erodes through cortical bone but does not drain spontaneously, subperiosteal extension occurs with intra-oral or facial swelling and fluctuance that needs I&D
  • Treat with Pen V 500mg QID or amoxicillin, analgesia and dental referral

Odontogenic pain

Odontogenic pain

• Facial space infections
  • Buccal extension of periapical infection of mandibular teeth will involve the buccinator space
  • Maxillary labial extension will involve the infraorbital space
  • Perforation through the lingual cortical bone of mandibular molars involves the submandibular space
  • Lingual spread of mandibular anterior teeth will affect the lingual space
  • Submandibular space and lingual space communicate directly
  • Cellulitis of bilateral submandibular spaces and lingual space is called Ludwig’s angina and is life-threatening
    • Almost always dental in origin with elevation of floor of mouth and tongue
  • Need CT face/neck and IV antibiotics with admission
  • Infra-orbital space infection can spread via ophthalmic veins to cavernous sinus thrombosis

Odontogenic pain

• Post-extraction pain
  • Immediate post-operative pain is usually just surgical trauma related
  • Oedema peaks at 24-48 hours and is best managed with ice packs, head elevation to 30 degrees, analgesia
  • Trismus can be due to TMJ injury, injury to muscles of mastication or normal perioperative inflammation
  • Peaks in first 24 hours and should decrease from then
  • Worsening trismus is concerning for post-operative infection

Odontogenic pain

• Dry socket
  • Post-extraction alveolar osteitis
  • Usually day 2-3 post-operatively
  • Exquisite oral pain
  • Total or partial displacement of clot results in exposure of alveolar bone and localised osteomyelitis
  • Risk factors include smoking, pre-existing pericoronitis or periodontal disease, traumatic extraction, previous dry socket and HRT
  • Incidence 1-5% of all extractions but up to 30% with impacted third molar extractions

Odontogenic pain

• Dry socket
  • Treatment
    • Gentle irrigation with warm saline
    • Local dental anaesthesia is useful
    • Remove all necrotic debris
    • Zinc oxide and eugenol paste to cover socket
    • NSAIDs +- opiates
    • Antibiotics for the most severe cases only
    • Dental follow-up

Odontogenic pain

• Post-extraction bleeding
  • Firm pressure to site is usually sufficient
  • Gauze pad placed over extraction site and then occlude teeth
    • Can add TXA or adrenaline
  • Hold firm for 20 minutes
  • If fails, apply Gelfoam or Surgicel into socket
  • Do not suture gingiva tightly as leads to necrosis of gingival flap but can loosely suture gingiva closed over the top or suture Gelfoam/Surgicel into socket
  • If fails, try injecting lignocaine + Adrenaline into soft tissues around bleeding site

Periodontal pathology

• Periodontal disease
  • Gingivitis through to destruction of periodontal attachment apparatus, deepening of normal gingival sulcus, periodontal pocket formation, bone loss, tooth mobility and ultimately tooth loss
  • Usually progresses painlessly but can present as swollen gingival tissue or gingival bleeding
  • Refer to dentist and advise on oral hygiene
• Gingival abscess
  • Acute painful swelling confined to margin of gingiva that rapidly arises over 24-48 hours
  • Purulent exudate often expressed from orifice
  • Usually entrapped foreign body e.g. popcorn kernel, piece of meat in gingiva
  • Identify and remove FB, irrigate with N/S and continuous home irrigation

Periodontal pathology

• Periodontal abscess
  • Severe pain amenable to warm saline rinses and pen V QID
  • Larger abscess require I&D
  • Chlorhexidine mouth washes twice daily are useful and analgesia while awaiting dental follow-up

Periodontal pathology

• Acute necrotising ulcerative gingitivitis
  • Aka Vincent’s disease or trench mouth
  • Triad of pain, ulcerated/punched out interdental papillae and gingival bleeding
  • Secondary signs include fetid breath, pseudomembrane formation, foul metallic taste, tooth mobility, lymphadenopathy, fever and malaise
  • DDx includes herpes gingivostomatitis with smaller vesicular eruptions, more systemic signs and lack of interdental papillae involvement
  • Thought to be an opportunistic infection in immunocompromised host with Anaerobes (Treponema, Selenomonas, Fusobacterium, Prevotella)
  • Mostly seen in HIV, poor oral hygiene, poor diet, malnutrition, age <21, low SES, recent illness, alcohol/tobacco
  • Chlorhexidine mouthwash BD + metronidazole 400mg TDS with nutrition and hygeine advice

Periodontal pathology

• Peri-implantitis
  • Presents like periodontal disease and require the same treatment

Neurogenic disorders

• Craniofacial neuralgias
  • Trigeminal neuralgia
  • Glossopharyngeal neuralgia
  • Vagal neuralgia
  • Superior laryngeal neuralgia
  • Post-herpes zoster-related neuralgia
• Bell’s palsy can have painful component
• TMJ disorder

Soft tissue lesions of oral cavity

• Aphthous stomatitis
  • 20% of normal population
  • Thought to be cell-mediated immune response to unknown agent
  • Risk factors
    • Local trauma, smoking, stress, poor sleep, chocolate, coffee, peanuts, cereals, almonds, strawberries, cheese, tomatoes and gluten
  • Minor form 2-3mm to several centimetres, painful and often multiple. Heal spontaneously over 10-14 days
  • Major form are larger, deeper and take longer to heal
  • Herpetiform aphthae presents as up to 100 ulcers, each 1-2mm in size that then coalesce to heal over 10-14 days
  • Treatment is symptomatic +- topical corticosteroids

Soft tissue lesions

• Herpes zoster
  • 1-4 day prodrome of exquisite pain in trigeminal distribution followed by vesicular eruption lasting 7-10 days and not crossing midline
  • Isolated intraoral lesions can occur
• Also consider HSV ½, herpangina, hand/foot/mouth disease, VZV, STI’s
• Traumatic ulcers are common and just need symptomatic treatment and removal of any continued source of irritation

Soft tissue lesions

• Medication-related disorders
  • Gingival hyperplasia – Phenytoin, cyclosporine, CCB (nifedipine)
    • Poor oral hygiene makes this more severe and likelihood
• Lesions of the tongue
  • Benign migratory glossitis – Geographic tongue
    • 1-3% of population. Females 2:1
    • Benign
    • Multiple, well-demarcated zones of erythema on tongue due to atrophy of filiform papillae
    • Concentrated on tip and lateral borders of tongue and heal over days
    • Usually asymptomatic but can cause sensitivity to hot/spicy food
    • Oral topical steroids if particularly distressed

Soft tissue lesions

• Lesions of tongue
  • Strawberry tongue
    • Seen with erythrogenic, toxin-producing S. pyogenes in scarlet fever
    • Prominent red spots on white-coated background
    • Antibiotics against Group A strep
• Leukoplakia
  • White patch or plaque that cannot be scratched off
  • Most common oral precancer but only 2-4% of lesions show dysplastic changes
  • Tobacco, alcohol, UV radiation, candidiasis, HPV, tertiary syphilis and trauma all implicated
  • Mostly buccal mucosa, hard/soft palates, maxillary gingiva and lip mucosa
  • Biopsy mandatory if persistent
  • Those of the floor of mouth, tongue and vermillion border are most likely to be malignant

Soft tissue lesions

• Erythroplakia
  • Red patch without other cause
  • Less common than leukoplakia but much more likely to be dysplastic/malignant
• Oral cancer
  • 90% are squamous cell carcinoma
  • Extrinsic risk factors: Smoking, chewing tobacco, alcohol, UV
  • Intrinsic: Malnutrition, chronic iron-deficiency anaemia
  • Oral candidiasis, immunosuppression and oncogenic HPV, HSV and adenoviruses may all increase risk
  • All ulcers, erythroplakic and leukoplakic lesions that do not respond to supportive measures within 10-14 days warrant biopsy

Dentoalveolar trauma

• If <12yo, pulp in anterior teeth is quite large and dental fractures often involve this
  • In this age group, apex is incompletely formed, so pulpal regenerative capacity is greater
• In older patients, dentin takes up larger portion and pulpal exposure is highly unlikely
• Involvement of the root of the tooth compromises the attachment apparatus and makes it difficult to restore tooth function

Dental fractures

• Ellis Class I – Enamel fracture only
• Ellis Class II – Enamel and dentin fracture
• Ellis Class III – Pulp involvement
• Goal is to maintain pulpal vitality and complete formation of root and apex of the tooth
• Uncomplicated dental fractures that are properly treated have only a 1-3% risk of pulpal necrosis

Dental fractures

• Enamel infraction – No loss of structure. No treatment required
• Enamel fracture
  • Do not extend into dentin
  • Can smooth sharp corners but otherwise no Rx
  • If enamel fracture retained and kept moist, dentist can bond it back in place
  • If fragment not recovered, take X-ray of any soft tissue lacerations to rule out FB retention
  • Referral to dentist for cosmetic repair if desired

Dental fractures

• Enamel-dentin fractures
  • Requires intervention
  • 70% of tooth fractures
  • Sensitivity to hot/cold and air passing over surface
  • Dentin has creamy yellow appearance compared to white enamel
  • Thickness of remaining dentin determines rate of pulpal contamination
    • >2mm remaining dentin offers good protection
  • Delay of >24 hours increases risk of pulpal contamination
  • If definitive treatment not obtainable within 1-2 days, cover exposed dentin with dental cement or if dentin layer <0.5mm thick with pink pulp visible beneath without bleeding, a thin layer of calcium hydroxide (Dycal) first before cement is advised
  • Refer to dentist

Dental fractures

• Enamel-dentin-pulp fractures
  • Exposure of pink pulp with blood after gentle wiping
  • Control bleeding with sterile gauze then cover exposed pulp with calcium hydroxide (Dycal) then cement until urgent dental review obtainable
  • Oral analgesics required

Dental fractures

• Crown-root fractures
  • Uncommon
  • Crown segment may be displaced or mobile
  • Tenderness to percussion is usual
  • Need to pay careful attention to root on OPG to identify these fractures
  • May or may not involve pulp
  • Stabilise coronal segment until dental care obtained with flexible splint in anatomical position (confirmed by radiographs)
  • If isolated root fracture, pulp is always involved
  • If highly mobile and unable to splint, remove to prevent aspiration and keep moist until dental follow-up in 24-48 hours
  • If <1/3 of root involved, root canal and salvage may be possible

Luxation injuries

• Account for 50% of injuries to teeth
• Concussion – Injury to supporting structures with tenderness to percussion but no mobility
  • NSAID’s, soft diet, referral to dentist
• Subluxation – Mobility without clinical or radiographic evidence of dislodgement
  • Generally as above with dental follow-up as higher risk of pulpal necrosis. Does not require splinting
• Extrusive luxation – Partial or total disruption of periodontal ligament with partial dislodgement from alveolar bone
  • Requires repositioning (with anaesthesia) and splinting with dental follow-up within 24 hours

Luxation injuries

• Lateral luxation – Displacement towards lip or tongue with concomitant alveolar bone fracture
  • As above if minimal alveolar bone involvement otherwise maxillofacial review in ED warranted for splinting
• Intrusive luxation – Displacement into its socket with associated periodontal ligament damage and alveolar bone contusion/fracture
  • Most significant damage to attachment apparatus
  • Root resorption is common and treatment is allowing tooth to erupt on its own or extrusion if no eruption by 3 weeks

Avulsions

• Total displacement represents 16% of dental injuries and is a true dental emergency
• Ideally reimplant at scene, handling only the crown portion, rinse for maximum 10 seconds then back in socket
• If child or reduced LOC (risk of aspiration), transport tooth with patient in isotonic saline, milk or saliva
• If avulsed tooth not recovered, obtain CXR to ensure not aspirated
• Do not scrub or disrupt periodontal fibres

Avulsions

• Open apex – Gently irrigate tooth root clean with saline
• If closed apex, irrigate to attempt to open apex. If cannot open, viability is not possible but re-implantation keeps alveolar bone contour
  • Moist tooth and/or <60 min extra-oral dry time
    • Soak for 5 min in doxycycline 1mg/20mL solution
    • Administer LA
    • Remove coagulum from socket and reposition any fracture carefully
    • Firmly replant tooth in socket, bite down on gauze, check radiographically and splint for 2 weeks
  • Extra-oral dry time >60 minutes
    • Carefully remove any necrotic tissue with gauze
    • Administer local anaesthesia and re-implant, bite gauze, splint for 4 weeks

Avulsions

• Follow-up for all
  • Doxycycline 100mg BD
  • Tetanus booster if required
  • Soft diet for 2 weeks
  • Brush carefully with soft toothbrush after each meal
  • Chlorhex mouthwash twice daily
  • Dentist

Luxation of primary teeth

• If age 6-12, must identify if primary or permanent tooth injury
• Avulsed primary teeth are never replanted
• Repositioning of replanting primary teeth is avoided as can damage permanent teeth – may in fact need extraction
• Intruded primary teeth are generally left alone to re-erupt in normal position

Oral cavity mucosal lacerations

• Cheek or buccal mucosa must be examined for Stensen’s duct involvement (opens opposite upper second molar)
• Floor of mouth must be examined for Wharton’s duct from submandibular gland involvement

Frenulum lacerations

• Maxillary labial frenulum only needs repair if very large laceration
• Lingual frenulum often does not repair as bleeds a lot – Absorbable suture is appropriate

Tongue lacerations

• Bleeding and delayed swelling can compromise airway
• What to repair
  • Gaping lacerations, flap-shaped lacerations, lacerations at edge and deep lacerations involving muscle
• Linear laceration <1cm involving central dorsal surface that do not gape heal well without repair
• If tongue bisected – needs repair
• All but the largest lacerations heal well without intervention
• Partial amputations can be replanted

Tongue lacerations

• Local anaesthesia
  • Local infiltration or 4% lignocaine-soaked gauze on surface for 5 minutes
  • Bilateral lingual nerve blocks are an option
  • Can place 0-suture through anterior middle of tongue to assist holding in place for repair OR use gauze/surgical towel clamps
• Use absorbable sutures and include muscle and superficial mucosal layers in bites
  • Bury knots if possible and at least 4 square knots per suture
  • Loosely tie to allow for tongue swelling
• Chlorhex mouthwash BD

Last Updated on October 2, 2020 by Andrew Crofton