Dental Emergencies

Rawnica L. Ruegner

Dental emergencies prompt almost 3 million emergency department (ED) visits nationally, accounting for 0.7% of all ED patients (1). Factors such as poverty, a lack of dental insurance or a primary care dentist, and difficulty finding an “off-hours” dental clinic have contributed to an increasing number of patients with dental-related complaints presenting to emergency physicians (2,3,4). Despite the common nature of dental-related complaints, many physicians receive little training on dental emergencies (5).

This chapter addresses the common nontraumatic dental emergencies. Dental trauma and odontogenic infections of the face are covered elsewhere.

DENTAL ANATOMY

Human teeth are composed of three layers. The outermost layer, enamel, is an extremely hard protective cover that contains no nerve fibers. Enamel covers the visible portion, or crown, of the tooth. The corresponding outer layer in the portion of the tooth embedded in the gum or root is known as cementum and is much softer than enamel. Under the enamel and cementum is dentin, and at the center of the tooth is the pulp chamber through which the nerves and blood vessels connect to the alveolar bone. The tooth sits in a socket with relatively long apices extending into the bone. The tooth is anchored to the bone by the periodontal ligament.

The first set of teeth, known as primary or deciduous dentition, should be completely erupted by 3 years of age. This set consists of 10 maxillary and 10 mandibular teeth. The permanent teeth begin erupting at around 5 years of age. This set consists of 32 teeth divided equally into four quadrants (right upper, right lower, left upper, left lower). In each quadrant, there is a central incisor, a lateral incisor, a canine, two premolars, and three molars. The third molar is called the wisdom tooth and may not be visible if it failed to erupt or has been therapeutically removed. Several numbering systems have been developed to identify a specific tooth. The most commonly used system numbers the permanent teeth consecutively beginning with the upper right third molar (tooth 1), to the upper left third molar (tooth 16), then down to the lower left third molar (tooth 17), and across to the lower right third molar (tooth 32). Other numbering systems exist, and some patients will have teeth missing, which may make numbering difficult. Generally, physicians should simply describe the tooth involved, for example, the left upper second premolar.

The biting area of a tooth is the occlusal surface for molars or incisal surface for the incisors. In the direction of the occlusal or incisal surface is coronal and in the direction of the root is apical. The medial or mesial aspect faces toward the midline of the jaw, and the distal surface faces the ramus of the mandible. The portion of the tooth facing the tongue or palate is the lingual or palatal surface. The portion facing away from the tongue is the labial or buccal surface. The portion of the tooth in contact with an adjacent tooth is the interproximal surface.

The Dental Examination

Patients with dental complaints should first be examined for possible nondental causes of their symptoms. An examination of the external facial structures and neck can detect swelling, cellulitis, or odontogenic fistulae. When performing the intraoral examination, look first for trismus (restricted opening of the mouth) and for swelling of the tongue or lips. Examine the mouth for asymmetry, swelling, or signs of cellulitis. Determine that the uvula is midline and not shifted as a result of abscess formation. Confirm that the tongue is not elevated and that the floor of the mouth is not tender or indurated (signs of Ludwig angina). Examine the teeth looking for signs of caries. Pay particular attention to the junction of the tooth and the socket, where foreign bodies can lodge. The tissue adjacent to the tooth along the alveolar bone should be examined carefully, because odontogenic abscesses typically form in this area. The gum overlying absent molars should be examined for evidence of erupting teeth (usually the wisdom tooth). Each tooth can be gently percussed, preferably with the end of a dental mirror, though a tongue depressor will suffice.

DENTAL ANESTHESIA

Patients with severe dental pain may require anesthesia for either temporary pain relief or for painful procedures such as incision and drainage of a periodontal abscess. Topical anesthesia of the mucosa can be achieved within 2 to 3 minutes by the application of a cotton swab soaked in 20% benzocaine or 10% lidocaine. This anesthesia can lessen the pain of needle injection for further anesthesia and, in some cases, may provide adequate anesthesia for incision and drainage of a superficial abscess. An individual tooth may be anesthetized by infiltration of lidocaine (2% with 1:100,000 epinephrine) or bupivacaine (0.5% with 1:200,000 epinephrine) at the root of the tooth using a supraperiosteal injection. Mandibular teeth may be anesthetized by blocking the inferior alveolar nerve where it enters the lower mandible. Dental blocks generally last between 1 and 7 hours depending on the anesthetic and choice of procedure (6).

CLINICAL PRESENTATION

Caries and Pulpitis

Among the most common dental conditions is dental caries, or “cavities.” As oral bacteria ferment dietary carbohydrates, an acid is formed, which demineralizes the tooth enamel. This demineralization initially is asymptomatic, until the erosion intrudes on the tooth pulp, resulting in inflammation (pulpitis). Caries appear as either a whitish gray discoloration of the enamel or as a brownish visible defect of the enamel surface. Pulpitis, or inflammation of the pulp of the tooth, causes significant pain, which depends upon the extent of inflammation. Early or reversible pulpitis causes relatively well-localized pain that is usually triggered by hot, cold, or sweet stimuli, usually lasts only a few seconds, and resolves spontaneously. Late or irreversible pulpitis results in poorly localized, severe, and persistent pain.

Periodontitis

If the inflammation of the pulp goes unabated, it will extend to the tooth apices, expand outward from the pulp, and cause apical periodontitis. The pain of periodontitis is severe, persistent, and localized to a particular tooth (unlike irreversible pulpitis, which is usually poorly localized). Periodontitis usually results in a tooth sensitive to percussion.

Peri-Implantitis

Recent advances in reconstructive dentistry may cause patients to visit the ED with problems relating to their dental implants. These patients present similarly to those with periodontitis.

Abscess and Cellulitis

Should periodontitis progress unchecked, the inflammation may extend laterally from the tooth apex to cause an apical abscess. Alternatively, an abscess can form in the absence of dental caries when inflammation begins at the junction of the tooth and gum line, extends down the tooth apices, and involves the periodontal ligament and adjacent alveolar bone. This is termed a periodontal abscess and results from either chronic bacterial plaque (periodontal disease) or a foreign body lodged between the tooth and gum. Clinically, both abscesses appear as a small fluctuant swelling located adjacent to the involved tooth. The swelling may appear tense and painful or it may be draining pus. Periodontal abscesses may result in teeth that are somewhat mobile due to bone destruction. The area surrounding the abscess should be examined for evidence of cellulitis.

Pericoronitis

A partially erupted molar creates a potential space between the occlusal surface of the tooth and the gingiva through which the tooth protrudes. If plaque or food particles become lodged in this space, the overlying mucosal flap will become inflamed. Pericoronitis presents as a painful, tender area over a partially erupted tooth often accompanied by a foul taste or odor due to extruded pus.

Gingivitis

Gingivitis is inflammation of the gingiva usually caused by bacterial plaque on the tooth. Simple gingivitis does not typically prompt an ED visit, as it is painless. Gingivitis appears as redness, swelling, and pocket formation of the gingiva. If the inflammation is significant, it can produce some bleeding from the gums after brushing the teeth.

Acute Necrotizing Ulcerative Gingivitis

If bacteria actively invade the gingiva, the inflammation may produce painful, swollen gums often accompanied by fever, malaise, grayish pseudomembranes, lymphadenopathy, a foul odor, and a metallic taste. This disorder is commonly called trench mouth and may be facilitated by immunocompromise or physiologic stressors.

Gum Hyperplasia

Unusual gum swelling may rarely prompt an ED visit. In addition to gingivitis and acute necrotizing ulcerative gingivitis (ANUG), other conditions that may cause generalized gingival hyperplasia or swelling include acute leukemic infiltration and drug-induced hyperplasia (most commonly phenytoin and nifedipine).

Postextraction Bleeding

Teeth are commonly removed for therapeutic reasons, and postextraction bleeding is a frequent complication. Although life-threatening hemorrhage may occur, most patients present with persistent oozing from the extraction site. In patients with acquired or congenital bleeding disorders, bleeding may be persistent and difficult to stop.

Alveolar Osteitis (“Dry Socket”)

Following a tooth extraction, some sockets may lose the protective clot prematurely, exposing the socket down to the bone. Typically, patients present 3 to 5 days following the extraction with severe localized pain. Some patients complain of a foul odor or taste. Physical examination shows a nontoxic-appearing patient without signs of infection. The extraction site usually is unimpressive. In contrast, postextraction osteomyelitis often is associated with fever, malaise, leukocytosis, and the surrounding teeth and bone may be sensitive to palpation. A radiograph is usually indicated to rule out retained roots or foreign bodies.

Oral Candidiasis

Candidal infections of the mouth are relatively common, especially among children and the immunocompromised. Painful white plaques are present that typically can be easily scraped off to show an erythematous underlying mucosa.

Aphthous Stomatitis

Many individuals will experience painful recurrent oral ulcers. Aphthous stomatitis is a common cause, though ulcers from hand-foot-and-mouth disease, herpangina, and herpetic gingivostomatitis may appear similar. While most aphthous ulcers are <5 mm, they may coalesce to form large lesions. These ulcers are self-limited and rarely are complicated by a localized cellulitis requiring antibiotic therapy.

Herpetic Gingivostomatitis

In children younger than 5 years old, a primary herpes virus infection (herpes simplex type 1) may present with multiple painful, ulcerated vesicles in the oropharynx. Often there is accompanying fever, lymphadenopathy, erythema, and edema. Although the primary infection lasts about 2 weeks, recurrences are common, though these usually present with a lesion at the border of the lip. Eruptions are generally self-limited.

Other Systemic Diseases

Several systemic diseases can present with oral lesions, though most are nonspecific. Systemic lupus erythematosus, scleroderma, Wegener granulomatosis, pemphigus vulgaris, Stevens–Johnson syndrome, Behçet syndrome, varicella zoster, and several neoplasms all can present with oral manifestations.

DIFFERENTIAL DIAGNOSIS

Although most patients with apparent dental complaints ultimately are diagnosed with relatively minor conditions, a few will have a serious illness. Perceived dental pain can result from sinus infections, temporomandibular joint dysfunction, otitis media, migraine headaches, neuritis, or myocardial ischemia. A dental infection can occasionally spread to the cavernous sinus, face, mouth, or throat, causing a potentially life-threatening complication.

ED EVALUATION

The evaluation of the patient with dental pain begins with a relevant history and physical examination to determine if the complaint is truly odontogenic in nature. A history of recent dental procedures, medication allergies, and anticoagulant medications is particularly important. Radiographs may be helpful in the evaluation of some patients in a search for retained roots or foreign body after a dental procedure. Computed tomography (CT) scanning is indicated if one suspects the extension of an infection to the cavernous sinus, neck, or deep spaces.