Management of dental emergencies

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Chapter 38 Management of dental emergencies

There are many kinds of dental emergencies, some of which can be extremely subjective. Whereas a small carious lesion or infected extraction socket may cause excruciating pain for one person, a fractured jaw may be asymptomatic and only discovered as an incidental finding after routine X-rays. Emergency departments in teaching hospitals will nearly always have an accredited on-call dentist or in rural settings may refer all dental emergencies to a local dental emergency service or individual dentist. As dental emergencies are rarely life-threatening, commonsense measures such as antibiotics, sedatives and analgesics where appropriate should get the patient through the night or weekend until an appointment can be arranged for the next working day.

It would be an inappropriate utilisation of resources to ask an on-call dentist to personally attend all cases of dental or oral pain. Many dental problems are the result of dental neglect, which would have initially presented many days or weeks earlier.

If the patient is to be admitted or there is doubt about management, contact the on-call dentist. Always have any relevant medical history at hand and try to establish a history for the dental problem. The dental history should include duration and nature of any pain or swelling and any measures taken to counter the problem by the patient or the patient’s own doctor or dentist.

TOOTHACHE

In the majority of instances toothache can be narrowed down to a specific tooth, which may be tender to touch, and is often a direct result of tooth decay. However, pain can be referred to adjacent teeth, the opposing jaw, facial areas or the neck, but does not generally extend across the midline except when the origin is the anterior teeth. As emergency department imaging may be limited to taking orthopantomogram (OPG) X-rays or standard views of facial bones, the source of the toothache may not be immediately evident. Clinical examination by emergency department staff may prove unrewarding without some training in oral examination. A strong light source, dental mirror and probe, and an air source are required (wall outlet medical air or oxygen or cylinder gases and tubing would normally be available in all emergency departments).

Dental caries

Dental caries may be minor or extensive and may undermine an existing dental restoration or artificial crown.

Response/advice

Provide adequate analgesia until the next working day.

Erosion or abrasion

Erosion or abrasion areas at the tooth/gum junction may produce extreme hypersensitivity.

Response/advice

Provide adequate analgesia until the next working day and suggest an anti-hypersensitivity toothpaste such as Sensodyne or Colgate Gel-Kam.

Dental pulp

Dental pulp (nerve) involvement is often an extension of decay in the body or branches of the dental pulp. Invasion by microorganisms into the dental pulp often leads to an initial acute pulpitis which may settle and return as a chronic, more diffuse pain many weeks or even months or years later. The microorganisms that invaded the dental pulp may now extend beyond the tooth apex and be responsible for dental abscess formation. (See also ‘Facial swellings’.)

Response/advice

Provide adequate analgesia until the next working day; however, antibiotics may also be required if there is established lymphadenopathy, pyrexia or visible dental abscess formation on X-ray. Advise the patient to attend a dentist as a matter of urgency.

Fractured or split teeth

Fractured or split teeth may be the result of trauma or a heavily filled tooth giving way. In some instances intact teeth may fracture as a result of an anatomical irregularity in their formation or as a result of an occlusal or bite discrepancy.

Response/advice

Provide adequate analgesia until the next working day. Advise the patient to attend a dentist as soon as possible.

INFECTED GUMS

Gingivitis/periodontitis

Poor oral health may lead initially to marginal gingivitis, progressing over many years to moderate or severe periodontitis and associated problems with the bone surrounding the teeth. Advanced periodontal disease may lead to tooth mobility, bad breath, oral bleeding, periodontal abscess formation, extrusion, drifting or exfoliation of teeth and generalised mouth pain. Periodontal disease may be an early clinical clue for systemic diseases such as HIV infection and diabetes or follow treatment in the case of graft versus host disease (GVHD) in bone marrow transplantation and radiation therapy of the head and neck.

Response/advice

Provide adequate analgesia until the next working day; however, antibiotics may also be required. A chlorhexidine mouth rinse, preferably alcohol-free (Colgate—Perioguard), will reduce microorganism numbers. Advise the patient to attend a dentist as soon as possible.

Acute necrotising ulcerative gingivitis (ANUG)

ANUG is a severe gingival infection often characterised by severe pain, pyrexia and bad breath with punched out and ulcerated interdental papillae. ANUG can be found in otherwise healthy mouths and is often associated with stress. ANUG is not uncommon around exam time or in times of partnership breakdown.

Response/advice

Provide adequate analgesia until the next working day and prescribe metronidazole or tinidazole. A chlorhexidine mouth rinse, preferably alcohol-free (Colgate—Perioguard) will reduce microorganism numbers. Advise the patient to attend a dentist as soon as possible.

IMPACTED TEETH

The usual age for eruption of wisdom teeth or third molars is 17–22 years, but eruption can occur as early as 15. In the past, when oral health was poor and fluoridation of water supplies had not commenced, it was common for young adults to have had a number of teeth removed due to tooth decay before the end of their teenage years. Today most young adults born and raised in communities with fluoridated water are rarely missing any teeth and also have had a minimal number of teeth restored. A consequence of having good teeth is that for many there is little room for their orderly eruption. This has now led to a significant increase in not only impaction of wisdom teeth but occasionally other teeth as well, especially when there is a discrepancy between tooth and mouth size.

Impacted teeth can cause pain for numerous reasons. In most instances the cause of pain is a result of local infection which often leads to regional lymphadenopathy. Carious breakdown with acute pulpitis and pressure on an adjacent tooth can also cause severe pain.

Response/advice

Provide adequate analgesia until the next working day. Antibiotics may also be required if there is established lymphadenopathy or pyrexia. Advise the patient to attend a dentist or a specialist oral surgeon as soon as possible.

MOUTH SORES AND ULCERATION

Oral ulceration and mouth sores may be the result of a myriad of precipitating factors including stress, acidic foods and even specific foods. Sodium lauryl sulfate (SLS), a detergent commonly found in toothpastes, has also been implicated.

Random aphthous and traumatic ulceration is not uncommon; however, ulceration as an oral manifestation of a systemic disease can also occur. Severe mouth sores also occur in GVHD following bone marrow transplantation and canker sores during head and neck irradiation.

Nutritional deficiencies in the aged and unwell may also lead to oral ulceration. Denture wearers who have lost 5–10 kg or more since the dentures were initially fabricated may have experienced shrinkage of alveolar ridges and other changes within their mouths, altering the once good fit of their dentures. As shrinkage of oral tissues is not uniform, the denture may impinge or dig in at various locations.

Response/advice

Good oral hygiene and reducing stress is a starting point for limiting the recurrence of oral ulceration. Rinsing or topical application of Xylocaine viscous with a cotton bud to a specific ulcer may help. Chlorhexidine mouth rinse and topical steroids, such as Kenalog in orabase, should be prescribed until the patient can get to their dentist. Thalidomide has been shown to reduce pain in large intractable ulcers found in immune compromised patients as has nicotine-containing gum in non-smokers suffering random aphthous ulceration.

NEOPLASIA

The average age of a person with an oral cancer in Australia is 64. However, young people are regularly being diagnosed with oral-based malignancies. An area of induration, leukoplakia or erythroplasia that has progressed in size or has been managed topically or systemically without resolution requires urgent attention.

Long-term immune suppression is closely linked to a higher risk for a neoplasm. Any lumps and bumps in and around the mouth in a person who has been HIV positive for 10 or more years should be carefully assessed. Unusual and aggressive lymphomas are appearing in this cohort. Similarly, any person who has received solid organ transplantation should have any unusual swellings quickly assessed.

Response/advice

As the consequences of delay in providing a definitive diagnosis of an oral cancer may compromise the patient in many ways, biopsy of the suspect lesion should be carried out as soon as possible. Punch biopsy or excisional biopsy can be carried out by a surgical or plastics registrar or on-call dentist.

FACIAL SWELLINGS

The most common cause of facial swellings is dental abscess formation. A dental abscess is an infection around the root of a tooth or in the gum which causes an accumulation of pus. At this stage there is often associated pain but not necessarily swelling. If the infection is left unchecked, the accumulated pus attempts to drain and will track via the path of least resistance, accumulating further as an intra- or extraoral swelling that may not necessarily be overlying the abscessed tooth. Local lymphadenopathy is common, with marked facial swellings caused by dental abscess formation.

Response/advice

Provide adequate analgesia until the next working day together with antibiotics if the swelling is slight and there is no concern about airway obstruction or progression to cellulitis. Tell the patient to rinse out the mouth with warm salty water every hour or as needed to ease the pain. If able, the patient can cover the handle of a teaspoon with cotton wool, immerse it in hot salty water and press it on the swelling. This may help to establish drainage. Using ice packs or frozen peas, 20 minutes on and 10 off, over the affected area may also help to relieve the pain. Advise the patient to return to the emergency department if:

• swelling in the face, jaw, cheek or eye increases

• swelling spreads to the neck or chest

• there are any symptoms of airway obstruction

• the pain becomes worse

• the patient develops pyrexia.

If the swelling is significant or has spread to the eye, neck or chest, or there is concern for potential airway obstruction (Ludwig’s angina), the patient should be admitted and IV antibiotics commenced immediately (benzylpenicillin 1.2 g 6-hourly). In the more severe or unresponsive cases, add metronidazole. For patients hypersensitive to penicillin, administer clindamycin 300 mg 8-hourly or lincomycin 600 mg 8-hourly. IV fluids should also be considered. Contact the on-call dentist; however, if the swelling is significant and CT X-rays are available, fine cut views in the area of the swelling will help determine if there is an accumulation of pus and if incision and drainage is required.

HEART DISEASE AND DENTAL CARE

The following recommendations from the St Vincent’s Hospital Dental Department are based on guidelines and antibiotic regimens that have been endorsed by all Australian State and Commonwealth Health Departments, the Cardiac Society of Australia and New Zealand and the Australian Dental Association Inc.

Several heart conditions require the patient and dentist to take special precautions. These recommendations are especially important for:

• people with artificial heart valves (aortic, mitral)

• people with a previous history of heart valve infection

• people born with or who acquire heart problems such as—

• most at-birth heart malformations

• damaged heart valves

• thickened heart muscle

• cardiac transplantation recipients with cardiac valvular disease.

People with heart problems have three responsibilities:

1. They need to establish and maintain a clean and healthy mouth. That means practising good oral hygiene and visiting their dentist regularly.

2. They need to make sure that their dentist knows they have a heart problem.

3. They must carefully follow both their doctor’s and dentist’s instructions when prescribed any medications and in particular antibiotics.

ANTIBIOTIC GUIDELINES FOR DENTAL PROCEDURES IN HIGH-RISK PATIENTS ¹

Amoxycillin 2 g (children: 50 mg/kg up to 2 g) orally as a single dose 1 hour before the procedure. (Note: the Australian guidelines are now 2 g, not 3 g.)

For patients hypersensitive to penicillin, on long-term penicillin therapy or having taken penicillin or a related beta-lactam antibiotic more than once in the previous month, use: clindamycin 600 mg (children: 10 mg/kg up to 600 mg), not erythromycin or tetracycline, orally as a single dose 1 hour before the procedure commences.

POST-EXTRACTION INSTRUCTIONS

Often teeth need to be removed due to excessive dental decay or formation of a dental abscess. Immediately following a tooth extraction, the patient should be advised to keep biting on the rolled gauze that has been placed in their mouth for at least 20–30 minutes. If the patient is still bleeding provide extra gauze.

General advice to the patient

1. Do not smoke or rinse the mouth vigorously.

2. Do not spit or continually wipe away blood.

3. Do not drink through a straw for 24 hours.

4. Do not suck on the extraction site.

These activities may disturb the healing blood clot.

Immediately after a tooth is extracted, the patient may experience discomfort and notice some swelling. This is normal. The initial healing period typically takes 1–2 weeks, and some swelling and residual bleeding should be expected in the 24 hours following an extraction. It is important not to dislodge the blood clot that forms on the wound. Occasionally, this clot can break down, leaving what is known as a dry socket. This can cause temporary pain and discomfort that will subside as the socket heals through a secondary healing process.

DRY SOCKET

Alveolar osteitis, or dry socket, is a severe pain that often follows a recent extraction. It is the result of disintegration of the blood clot formed in the socket after the extraction and may not be relieved by over-the-counter analgesics. The pain may radiate to the ear and is often accompanied by fetor oris, or bad breath. When the usual process of healing is disturbed, the blood clot may be dislodged leaving bone within the socket exposed to saliva, food and other mouth debris rather than surrounded by an organising blood clot. If a dry socket occurs, it usually does so immediately following the extraction, although breakdown of the blood clot occasionally occurs after several days of uneventful healing.

Response/advice

Provide adequate analgesia, which may include the addition of a non-steroidal anti-inflammatory drug (NSAID), until the next working day. However, antibiotics may also be required if there is established lymphadenopathy or pyrexia. Advise the patient to attend a dentist as soon as possible to have the dry socket irrigated and dressed.

ORAL BLEEDING

Generally warfarin or antiplatelet medications need not be stopped prior to dental extractions or deep cleaning. However, appropriate local measures should be adopted in addition to checking with the patient’s cardiologist, in the case of an underlying cardiovascular disease, or haematologist if the concern is due to a blood dyscrasia. Most patients can be managed in a general dental practice setting and do not need to be admitted to hospital. St Vincent’s Hospital has adopted dental recommendations from the United Kingdom as the basis for new prescribing and formulary guidelines.²

Patients being treated with oral anticoagulant medication who have an international normalisation ratio (INR) below 4.0 may have dental extractions without interruption to their treatment. Local measures, which include suturing and packing the extraction site with absorbable gelatine sponge, are generally sufficient to prevent post-extraction bleeding. However, excessive post-extraction or oral bleeding for other reasons may still occur. The most common cause of post-extraction bleeding for the patient with no known systemic problems is failure to follow instructions from the dentist.

Response/advice

If bleeding persists in spite of repeating local measures as described in the above section, or if a bleeding disorder or dyscrasia is suspected, follow the St Vincent’s Hospital Dental Department Protocol for local anti-fibrinolytic treatment, as follows:

1. Dilute IV aminocaproic acid 5 mL in 10 mL sterile water and ask patient to rinse.

2. Wet but not do not saturate a sterile gauze square in undiluted aminocaproic acid.

3. Fold or roll the gauze so that it can be placed on the extraction site and ensure that the gauze is exerting pressure on the site.

4. Repeat after half an hour or as required.

5. If the patient is being discharged, provide the remaining aminocaproic acid and additional bite pads to repeat at home if required.

6. Tell the patient to use an alcohol/phenol-free mouth wash twice daily, commencing after 24 hours.

TRAUMATIC INJURIES TO TEETH

Traumatic injuries to teeth can be divided into five categories.

Fracture

• Grade 1—involves minor chipping of the incisal edge limited to enamel

• Grade 2—involves fracture through to dentine without pulpal or nerve exposure

• Grade 3—fracture with pulpal or nerve exposure

• Grade 4—root fracture

• Grade 5—complex

Response/advice

If the traumatic injury is the result of a minor accident, provide analgesia if required until the next working day. If, however, the injury is the result of a motor vehicle accident, assault or other significant incident, an OPG X-ray should be taken, if available. Often, undisplaced and asymptomatic fractures of the body of the mandible, ramus, condylar head or coranoid process may be detected with an OPG. With grade 3–5 fractures where there are no other bodily injuries present other than minor local lacerations, provide analgesia until the next working day. Should the patient be admitted or require observation in the emergency department for any length of time, contact the on-call dentist.

Luxation

A tooth is considered luxated when it has been moved, often occupying a position other than its original one. Luxated teeth can teeth can be divided into five categories:

• Grade 1—tooth loosened but still in its original position (subluxation)

• Grade 2—loosened and out of position

• Grade 3—significantly out of position

• Grade 4—pushed into upper or lower jaw

• Grade 5—complex (out of its original position with a grade 2–5 tooth fracture).

Response/advice

Except for a grade 1 luxation, always contact the on-call dentist as soon as possible. If there are no other bodily injuries precluding dental management, repositioning and splinting of the loosened teeth will generally be required.

Avulsion

Evidence suggests that avulsed or knocked out teeth, which have been reimplanted within 30–45 minutes, have a reasonable chance of long-term retention. However, after 2 hours out of the mouth, the prospects are diminished. Correct handling, transportation and storage of the knocked-out tooth is critical.

Response/advice

Ideally the patient should be encouraged to push the tooth back into the socket, even if it is out of alignment and loose. If this is too painful or not possible, holding the tooth in the floor of the mouth will keep the root bathed in the patient’s own saliva. Should other injuries or the patient’s mental state preclude the above, immediate storage in UHT milk is preferred to whole milk or water. Handle avulsed teeth only by the enamel and do not rinse in any disinfectant solution. Always contact the on-call dentist as soon as possible as implantation, repositioning and splinting of an avulsed tooth will be required.

Should the dentist be unavailable immediately, small rectangular strips of ConvaTec Stomahesive® wafer can be used to provisionally hold the tooth.

This will provide additional working time for the dentist and could save the patient many thousands of dollars.

1. Hold the tooth only by the crown.

2. Try not to touch the root.

3. Remove visible debris by gently washing with saline.

4. Replace back in dental socket ASAP.

5. Use a single rectangular piece of ConvaTec Stomahesive® wafer.

6. Wetting the wafer first can help. It may take 10–15 minutes for the wafer to feel secure. When in place, the wafer can last several hours.

TRISMUS AND TEMPEROMANDIBULAR JOINT (TMJ) DYSFUNCTION

Many people have pain or discomfort in and around the TMJ at some time during their lives. The symptoms may include pain, tenderness, spasm, clicking or crepitus as well as direct or referred pain in the muscles of the face, neck, shoulder and ears. TMJ dysfunction may lead to loss of jaw function, with the pain ranging from a mild discomfort in the morning to a chronic debilitating pain rendering the patient unable to open their mouth by the afternoon.

Conservative treatment (NSAIDs plus alternating hot and cold packs or compresses and rest) may prove effective following acute trauma to the jaw during a motor vehicle accident, fall or bashing. Direct trauma to the TMJ area or either jaw may also cause chronic or latent damage which may eventually contribute to a TMJ problem, often years later.

Bruxism is a non-functional clenching or grinding of the teeth. Some people will brux during waking hours, but bruxing is generally carried out subconsciously while asleep. Although bruxing while asleep is extremely common and can lead to enamel wear, pathological bruxing can lead to significant TMJ damage over time, especially when the dentition is less than optimal in the first place. Dentists can fabricate a variety of splints, which the patient will generally wear at night, to help either in alleviating the symptoms of TMJ dysfunction or in the retraining of the facial musculature.

DENTAL NOMENCLATURE

The international numbering system of teeth (Federation Dentaire Internationale—FDI) should be used in any written or verbal communication. The mouth can be divided into four quadrants. In the adult dentition (Figure 38.1) the maxillary right is quadrant 1; the maxillary left, quadrant 2; the mandibular left, quadrant 3; and the mandibular right, quadrant 4. The individual teeth are numbered from the central incisor outwards to the third molar. This provides an easy-to-use two-digit code to indicate the tooth or region of concern. Deciduous or baby teeth follow a similar pattern. The maxillary right is quadrant 5; the maxillary left, quadrant 6; the mandibular left, quadrant 7; and the mandibular right, quadrant 8. The complete deciduous dentition has only five teeth in each quadrant as opposed to eight teeth in each quadrant in the adult dentition.

Figure 38.1 International numbering system of teeth (FDI)

REFERENCES

1 Therapeutic guideline: oral and dental. Version 1. Therapeutic Guidelines Limited; 2007. Also online. Available: http://www.tg.com.au.

2 Online. Available: http://www.ukmi.nhs.uk/med_info/documents/Dental_Patient_on_Warfarin.pdf; http://www.ukmi.nhs.uk/med_info/documents/Dental_Patient_on_Antiplatelet_Medication.pdf.

Copies of information sheets referred to in this chapter are available from mailto:pfoltyn@stvincents.com.au

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