Dental emergencies

Anatomy

The tooth consists of the crown, which is exposed, and the root, which lies within the socket covered by the gum; the latter serves to anchor the tooth. The gingival pulp carries the neurovascular structures via the root canal and is covered by dentine which, in turn, is covered by enamel, the hardest substance in the body ( Fig. 17.1.1 ).

The deciduous teeth are 20 in number and erupt between the ages of 6 months and 2 years. The permanent dentition begins to erupt at around age 6 and, in the adult, consists of 32 teeth.

Dental caries

The most common cause of toothache or odontalgia is caries. Dental caries-related emergencies account for up to 52% of first contact with a dentist for children below the age of 3 years. Dental caries is the cause of emergency visits to a dentist in 73% of paediatric patients. Pain associated with dental caries is of a dull, throbbing nature, localized to a specific area and aggravated by changes in temperature in the oral cavity (hypersensitivity to hot and cold food or fluids).

Examination reveals tenderness of the offending tooth when tapped with a tongue depressor or mirror. Management includes symptomatic pain relief using analgesics, such as paracetamol with or without codeine, non-steroidal anti-inflammatory drugs (NSAIDs) and urgent referral to the dentist.

Periodontal emergencies

Pain is the most common cause of self-referral to the emergency department for dental problems. The common conditions causing dental pain are acute apical periodontitis and reversible and irreversible pulpitis resulting from dental caries. Symptoms include painful, swollen gums with or without halitosis. On occasion, frank pus or bleeding from the gums may be the presenting symptom. At all stages, varying degrees of pain associated with inflammation are present.

Infected gums can be an early clinical sign of undiagnosed diabetes, acute myeloid leukaemia (AML), HIV and graft-versus-host disease in bone marrow transplantation.

Management includes diagnosis of the periodontal disease and the offending tooth. Symptomatic pain relief can be achieved with analgesics, NSAIDs and warm saline rinses. Routine antibiotic therapy is not required unless there is evidence of gross infection locally, regional lymphadenopathy or fever. In all cases, urgent review by the dentist is mandatory.

Acute necrotizing ulcerative gingivitis (ANUG) is a severe form of gingivitis that could be related to stress and needs antibiotic cover and urgent referral to the dentist.

Alveolar osteitis (dry socket)

Dry socket occurs between 2 and 5 days following dental extraction. The dull throbbing pain is due to the collection of necrotic clot and debris in the socket. The condition is diagnosed on the history and examination, which confirms the acutely tender extraction site.

Treatment consists of irrigation (2% chlorhexidine) of the extraction site to remove the necrotic material and packing the socket with sterile gauze soaked in local anaesthetic, such as cophenylcaine, or placing alvogyl into the socket (butamben, iodoform and eugenol) followed by urgent dental review.

Post–dental extraction bleeding

Bleeding from the socket within 48 hours after extraction results from reactionary haemorrhage due to opening up of the small divided blood vessels. Bleeding after 5 days is secondary haemorrhage due to infection that has destroyed the organizing blood clot.

General causes, such as hypertension and warfarin therapy, must be addressed to control the bleeding.

Management is essentially reassurance and careful suctioning to clear the debris and clot in the socket; this is followed by packing with gauze soaked in lignocaine with adrenaline or cophenylcaine and pressure. Or Surgicel may be placed into the socket.

Dilute aminocaproic acid (IV Amicar) 5 mL in 10 mL of normal saline may be used to rinse the mouth. Use Amicar or tranexamic acid–soaked gauze to bite on, applying direct pressure for about 30 minutes and repeat as required to control the bleeding. Occasionally the gingival flaps may have to be sutured under local anaesthetic.

Traumatic dental emergencies

Tooth avulsion is probably the most serious tooth injury. An avulsed tooth, if reimplanted in the socket within 30 minutes, has a 90% chance of survival. The mechanism of injury in such cases is usually either an accidental sports-related facial injury or an assault.