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