Perspective Chapter: Dental Emergency and Conditions

Abstract

Dental emergencies are related to dental pain, bleeding and orofacial trauma-like conditions should be attended by dental practitioners. Even the jaw fracture requires the attention of oral and maxillofacial surgeons. Dental pain may be of odontogenic or non-odontogenic in origin, and in some cases, it may be idiopathic in nature. Bleeding in the soft tissues of the oral cavity may occur due to the infection from the microbial flora or inflammation and trauma. The management of these conditions should be based on the cause of the condition that may require the antibiotic prophylaxis along with root canal treatment or extraction of the tooth. Most of the dental conditions can be prevented by visiting to the dentists regularly and minimize the risk of oral trauma.

1. Introduction

Any dental emergency such as an injury to the hard tissue and soft tissues (teeth or gingiva) can be potentially serious and should not be ignored. Ignoring a dental problem may enhance the risk of permanent damage of the hard and soft tissue structures and also more extensive and expensive treatment is required to correct the problem later on.

An acute oral disorder requiring dental and/or medical care, including fractured, loose, or avulsed teeth caused by traumas, any pathology (infections and inflammation) of the soft tissues of the oral cavity; and complications of oral surgery, such as dry tooth socket, fracture jaw and swelling in the jaw.

A dental emergency is basically determined by health care staff which includes any dental condition that require immediate diagnostic evaluation and treatment which is necessary to prevent severe or long-term illness, or to reduce or lessen severe pain. Some of the examples of dental emergencies are acute oral and maxillofacial conditions such as trauma, infection, pain, swelling, or bleeding that are likely to remain acute or will worsen if not provided with immediate intervention and treatment.

Some of the conditions that always require dental emergencies include, but are not limited to like Airway/breathing difficulties occurring mostly from oral infection, A swift spread of oral infection, such as Ludwig’s angina, cellulitis which is characterized by severe swelling on the floor of the mouth, with elevation of the tongue and acute abscess which includes an abscess at root end or a gingival abscess.

Maxillofacial injury or trauma to the jaws or dentition that put on to decrease the loss of airway.

By presuming the shock due to oral infection or trauma, Uncontrolled or spontaneous severe bleeding from the oral cavity, Head injuries (including stabbing or gunshot wounds) that involve maxillary or mandibular jaw along with its dentition, Moderate to severe dehydration associated with altered response in masticatory function due to any infection or trauma, Clear signs of physical distress, (e.g., respiratory distress), related to infection or injury to the jaws or dentition, Suspected or known fractures involving the nasal bones, mandible, zygomatic arch, maxilla and zygoma, Acute Temporomandibular Joint (TMJ) pain, “closed-lock” TMJ, or dislocation of the TMJ, Aspiration or swallowing of a tooth/teeth or foreign object that threatens loss of airway, Acute, severe, debilitating pain due to suspected oral infection, oral trauma, bleeding disorders of oral mucosa, oral ulceration or other dental-related conditions. Infections, including infected third molars, (Pericoronitis) and acute infections with a fever of 101° F or above, infections not responsive to antibiotic therapy, and acute pulpitis. Injuries from trauma, such as an avulsed tooth, or fractured tooth. Postoperative complications including alveolar osteitis, bleeding or infection. Restorative Dental Emergencies include Pain management, Infections and soft tissue problems, Crack, fracture and mobility of teeth and dental restorations, Fractured and loose implants, Fractures and swallowing of removable prostheses.

According to the General Dental Council’s ‘Standards for Dental Professionals’, 2009, registered dentists are expected to:

1. Work within your knowledge, professional competence and physical abilities.

2. Refer patients for a second opinion and for further advice when it is necessary, or if the patient asks.

3. Refer patients for further treatment when it is necessary to do so. As such, the need for referral may be that the situation lies outside: the knowledge the skill the experience the facilities available to the referring dentist.

2. Dental pain (pulpitis)

Dental pain is the commonest dental emergency and it may occur due to various etiological factors. It is delineated as ‘an unpleasant sensory and emotional expertise related to actual or potential tissue damage, or described in terms of such damage. It is one of the most common reasons that why patients seek dental treatment and further to note that various diseases or pathological conditions may be responsible for the initiation of pain. However, pain arising from nondental sources corresponds to myofascial inflammation, cephalalgia headache, maxillary sinusitis, nasal tissues, ears, temporomandibular joints, and neuralgias continually should be thought of and excluded [1].

Odontogenic pain is a pain initiating from the teeth or their supporting structures, the mucosa, gingivae, maxilla, mandible or periodontal membrane.

The major cause of dental pain is inflammation of the dental pulp, most commonly as a result of dental caries (tooth decay), most commonly worldwide, affecting 60–90% of school children. The second most common infection similar to chronic mycobacterial infections is Periodontal disease (gum disease for example Leprosy, is painless. The periodontal pathogens appear to be singularly and odds-on to cause aggressive periodontal disease. Both Porphyromonas gingivalis and A. actinomycetemcomitans, along with multiple deep pockets, severe clinical attachment loss is linked with resistance to standard traditional treatments for soft tissues (gingiva). Other risk factors which include smoking and also there is a genetic predisposition responsible to develop this silent painless disease, which may be the leading cause of tooth loss, and is found in almost 5–400% of middle-aged adults.

Initially, dental caries is asymptomatic. Pain does not occur until the decay caused by bacteria reaches near the pulp, and an inflammatory process starts developing. Reversible pulpitis is defined as mild inflammation of the tooth pulp which is caused by caries encroaching on the pulp. Pain is generally triggered by hot, cold, and sweet stimuli which lasts for a few seconds, and resolves spontaneously. If we talk about the treatment then it includes removal of the caries and placement of a dental restoration, or filling. But if the carious lesion persists, it will progress towards irreversible pulpitis, which is a severe inflammation of the pulp. Pain becomes very severe, spontaneous, and persistent in nature, and is poorly localized. The only way to definitively treat irreversible pulpitis is root canal treatment along with appropriate analgesia such as a nonsteroidal anti-inflammatory drug (NSAID).

A severely inflamed pulp will eventually undergo necrosis which may lead to apical periodontitis, which is inflammation around the apex of the tooth. Pain is severe, spontaneous, and persistent, but unlike that of irreversible pulpitis, localizes to the affected tooth. The tenderness to percussion is positive. Management is root canal treatment or extraction. The patient should be referred to a dentist as soon as possible along with prescription of analgesics (Figure 1).

Figure 1.

The stages and characteristics of pulpal pain.

Apical abscess is a localized and purulent form of apical periodontitis. Clinically it presents as a fluctuating buccal or palatal swelling, with or without a draining fistula. If pus can drain out from the fistula, the pain is usually not severe in nature. Antibiotics are unnecessary unless concomitant cellulitis is present. Incision and drainage of a fluctuating area should be performed by qualified physician. Definitive treatment is root canal treatment or extraction. Patients should be recalled back to dentist within one or two days and also analgesics should be prescribed.

Cellulitis may follow apical periodontitis if the infection spreads to the surrounding tissues and also to the areas of facial space which can lead to facial space infections. Diffuse, tense and painful swelling of the affected tissues may occur. Diagnostic evaluation should focus on determining whether cellulitis remains localized or has spread regionally. Outpatient treatment of patients with localized cellulitis should be treated by the physician with oral antistreptococcal antibiotics, such as oral penicillin 500 mg three times a day in adults or 50 mg/kg/day in children [2].

In case of patient is allergic with penicillin, erythromycin or clindamycin (Cleocin) may be prescribed. In addition, analgesics should be prescribed. Definitive treatment is root canal treatment or extraction, which may be delayed until swelling subsides. Patients should be evaluated by a dentist within one or two days but patient should also advice to return sooner if swelling or pain worsens. If infection spreads into the deep spaces of the head and neck presented with significant swelling, increased risk of life-threatening complications like there is extensive airway involvement. As a general rule, these patients should be hospitalized for a surgical and infectious consultation. Broad-spectrum Intravenous antibiotic therapy should be started immediately and should include coverage for anaerobes.

3. Periodontal origin

Periodontitis can be described as an inflammatory disease of supporting tissues of teeth which is caused by the specific microorganisms or groups of specifics microorganisms which results in progressive destruction of the periodontal ligament and alveolar bone with periodontal pocket formation, gingival recession or both. The main etiological factor is bacterial plaque and calculus. Patients with chronic periodontal disease or patients who have a foreign object impinge in the gingiva may present with an acute periodontal abscess. A gingival abscess is basically a localized, painful and rapidly expanding lesion which involves the marginal gingival or interdental papilla and sometimes in a previously disease-free area. It usually occurs as an acute inflammatory response to foreign substances which has been forced into the gingiva. In its early stage it appears to be a red swelling with a smooth, shiny surface. Within 24 to 48 hours, the lesion is usually fluctuant and pointed, with a surface orifice from which purulent exudates may be seen. If not hindered and allowed to progress, the lesion generally ruptures spontaneously. Acute periodontal abscess presents as a Localized red, ovoid swelling, Periodontal pocket, Mobility, Tooth elevation in socket, Tenderness to percussion or biting, Exudation, Elevated temperature and regional lymphadenopathy.

If it is not treated on time, the abscess may rupture or progress to cellulitis. Oral intervention is incision and drainage within 24 hours of patient referral and debridement of the infected periodontal area. Antibiotics are not prescribed if debridement is successful, because their use remains controversial in these cases.

However, Penicillin is the first drug of choice in the treatment of periodontal abscesses in the UK, being used by 57% of surveyed dentists, followed by amoxicillin (21%) and metronidazole (14%). Amoxicillin, 500 mg (because amoxicillin exhibits an excellent ability to penetrate into both normal and pathologic periodontal tissues and is highly active against many periodontal pathogens) 1.0-g loading dose, then 500 mg three times a day for 3 days. Re-evaluation after 3 days to determine if there is any need for continued or adjusted antibiotic therapy.

4. Pericoronitis

Pericoronitis is inflammation of the soft tissues surrounding the crown of a partially erupted third molar. It occurs when bacterial plaque and food debris accumulate beneath the flap of soft tissue covering the partially erupted third molar. Inflammatory edema, most commonly complicated by trauma from the opposing tooth, which may result in swelling of the flap, pain, tenderness, and a bad taste caused by pus oozing from beneath the flap. Lymphadenopathy is common, and cellulitis and trismus may occur. In severe cases, the oral airway can be compromised. If pericoronitis is well localized, chlorhexidine mouthwashes and irrigation with normal saline and povidone iodine can resolve symptoms in the majority of cases. Localized cases that do not respond to mechanical therapy and more severe untreated cases with spreading cellulitis should be treated with prescribing antibiotic like penicillin and analgesics like NSAIDs prescribed as medication. Patient can be diagnosed in case of symptomatic treatment and refer to the dentists as soon as possible. The intervention of pericoronitis is surgical removal of soft tissue called as operculectomy. If the tooth is impacted, in that case surgical extraction is recommended.

5. Exposed cementum and dentin

Dentinal sensitivity is one of the most common dental emergency conditions. It is characterized by short, sharp pain arising from exposed dentine in response to stimuli, typically thermal, tactile, osmotic or chemical and which cannot be attributed to any other dental defects or pathological conditions. The tooth is having sensitivity from cold fluids or from air which directly affects the pulp of the tooth. The etiological factors are gingival recession, scaling and root planning or wasting disease such as erosion (tooth wear) due to a high acid diet or gastric reflux, the patient may experience generalized dentinal hypersensitivity. The root surface comprised of a thin layer of cementum overlying dentine which may be exposed to oral environment due to aggressive or using wrong tooth brushing technique. Dentine underlying the enamel layer comprised of minute tubules which are fluid filled and connects to the nerve ending in the dental pulp directly. The recent postulate for dental pain includes the osmolality theory, whereby the dentine fluids initiates an action potential within the A delta and C fibers in the pulp when stimulated by mechanical stimulation.

The use of a desensitizing toothpaste and a reduction in acid in the diet will help resolve the symptoms of root sensitivity. Modification and accurate tooth brushing habits along with use of fluoride toothpaste may also reduce the tooth sensitivity symptoms is also recommended. In the case of dental caries, a lost filling or fractured tooth, coverage of the exposed dentine with a temporary restoration will usually relieve the symptoms.

6. Fractured tooth/dental trauma

Dental trauma is most commonly seen in children with a peak age of 12 years old and having a primary tooth. Injury to the teeth and their supporting structure may lead to fractures, lateral or extrusive luxation in which loosening and displacement of the tooth, intrusion where displacement of the tooth vertically into the alveolar bone), and avulsion is a complete displacement of the tooth out of its socket [3]. Tooth fracture may occur on the crown, root or both and in some cases, it may cause exposure to the pulp. Fractures exposing the pulp are often painful, and patients with this condition require timely referral to a dentist. If the crown of a tooth is fractured by trauma and the broken fragment is available, it should be stored in a physiological medium (milk) until a dentist can assess the patient. Definitive treatment may involve root canal therapy or extraction. Coverage of exposed dentine on the fractured crown with a temporary restoration is desirable to protect the underlying pulp tissue [4].

Fracture of the root usually require radiograph and treatment may involve root canal therapy, splinting, or extraction, depending on the exact nature of the root fracture. In case of luxation of tooth if the primary dentition is traumatized and teeth are so loose and are in danger of being aspirated then immediate referral to a dentist for extraction is required [3]. If permanent teeth are involved the dental referral is required for repositioning, splinting, or root canal therapy, along with long term follow-up.

Avulsed teeth are one of the true dental emergency conditions. Primary teeth are never reimplanted [3]. In case of permanent teeth involvement, Immediate on-scene reimplantation is the preferred method of treatment. If the tooth is contaminated, it should be gently rinsed in cold running tap water and then reimplanted. Care should be taken not to touch, rub, or clean the root because it may remove the periodontal ligament fibers and reduce the chance of successful reimplantation. The patient should immediately report to dentist for splinting and antibiotic prophylaxis [5].

7. Placement of temporary restorations

Although it is dubious that general medical practitioners will have temporary filling materials available in their surgeries. Dentine that has been exposed due to caries, a lost filling or tooth fracture can be treated relatively easily by using glass ionomer cement (GIC) or zinc oxide eugenol (ZOE) materials. Mostly GIC materials are available in capsules but a hand-mixed material is also available which consists of a powder, liquid and conditioner. Firstly, the surface of the cavity is painted with the conditioner followed by rinsing and drying and then finally placement of the filling is done. Zinc oxide eugenol materials consist of a powder and liquid (oil of cloves) that are mixed to a putty-like consistency before placement in the tooth.

8. Alveolar osteitis

After extraction, the most common complication is a ‘dry socket’ in which the clot formation within the socket fails at 3–5 days. It occurs due to the disruption of the clot within the socket. The socket may be filled with food debris along with saliva. Pain usually initiates within 24–72 hours after the extraction of tooth. Pain may vary in frequency and intensity and radiates to the ear and neck which may cause headache, insomnia and dizziness may be present. Redness, swelling, fever or pus formation is uncommon but edema of the surrounding gingiva and regional lymphadenitis is usually present. There is marked halitosis and foul taste. Smoking is a major predisposing environmental factor as it reduces the blood supply. The tissue around the socket appears to be tender and white necrotic bone is exposed in the socket. The incidence of dry socket may vary from 1 to 9%.

Irrigation of the socket using saline or chlorhexidine or powdered sodium perborate and then placement of medicated dressing soaked in bacteriostatic solution (alvogyl paste, bismuth iodoform paraffin paste (BIPP), cotton wool or gauze soaked in iodoform) on ribbon gauze and metronidazole and lidocaine ointment. Analgesics should be prescribed as a short course of non-steroidal anti-inflammatory drug to narcotic based like codeine. Immediate pain relief is usually attained and patients rarely re-present for additional treatment. Patients should be instructed to irrigate the area regularly. If the patient returns with ongoing pain, then osteomyelitis should be excluded and localized bony sequestrate should be excluded.

However, the rate of occurrence is unavoidable. Dry socket condition can only be prevented by copious use of irrigation, antibiotic medicated dressings and maintenance of oral hygiene.

9. Maxillary sinusitis ‘mimicking’ toothache

Recurrent maxillary sinusitis can result in extensive maxillary tooth pain. When lying down or bending over, the discomfort tends to get worse. On the affected side, there is frequently a sensation of ‘fullness.’ The discomfort is usually one-sided, dull, throbbing, and constant. Frequently, the patient is sick in general and has a temperature. In temporomandibular disorders (TMD) or neuropathic pain, it might mimic the symptoms of maxillary sinusitis. Unless misdiagnosed, many dental disorders rarely cause chronic discomfort.

Inflammation of the maxillary sinuses is best treated with local and systemic decongestants, and antibiotics may be administered if the condition persists10. Sinus pain is caused by a build-up of pressure in the sinuses. Sinus drainage can be aided by decongestants. In moderate situations, antibiotics are likely to play only a minimal influence. The patient is sent to an otorhinolaryngologist.

Acute necrotizing ulcerative gingivitis is a type of gingival infection that produces ulceration of the interdental gingival papillae. It has the potential to cause widespread devastation. Typically, young to middle-aged adults with low infection resistance are afflicted (diabetes, HIV infection, chemotherapy). Males are more likely to be impacted than females, with predisposing factors including stress, smoking, and poor oral hygiene. Important indications include halitosis, spontaneous gingival bleeding, and a ‘punched-out’ appearance of the interdental papillae. Patients frequently complain of significant gingival tenderness, which causes pain when eating and brushing their teeth. The ache is dull, profound, and unrelenting. Gums can bleed on their own, and there’s an awful taste in the mouth as well as visible halitosis.

Because the infection is anaerobic, treatment is based on surgical principles and comprises superficial debridement, chlorhexidine mouthwashes, and a course of metronidazole pills. A recurrence should be avoided if the causative causes are addressed.

Which tests can assist in diagnosis?

There are several simple tests that may assist in diagnosis of dental pain.

1. Pulp sensitivity test: On the cervical third (neck region) of the tooth crown, dry ice on a cotton bud or an ordinary ice stick (made in a plastic or glass tube) is placed. The pulpal tissue is capable of sending nerve impulses and is vital if it responds to the stimuli (pain is the only sensory response from the dental pulp). The absence of a response could imply pulp necrosis.

2. Percussion test: A percussion test is performed. The tooth is tapped in the longitudinal axis with an instrument handle. Pain indicates periapical inflammation caused by inflammatory sensitivity of the mechanosensory receptors in the periodontal membrane around the tooth.

3. Probing: The health of the gingival tissues can be checked by gently inserting a fine, blunt probe into the gingival sulcus surrounding the tooth. Gum disease caused by inflammation is indicated by bleeding and/or sulcus depths more than 3–4 mm.

4. Mobility test: The mobility of a tooth can be tested by holding it firmly between the fingers on the buccal (cheek) and lingual surfaces. Although all teeth have a little amount of mobility (0.5 mm), noticeable movement indicates that the tooth’s root has lost bone support.

5. Palpation: Tenderness, as well as the type and extent of swelling, may be revealed by careful palpation around the area of concern.

6. Sinus formation: Chronic dental abscesses tend to empty the mucosa though buccal aspect causing mucosal sinuses. Rarely lower mandibular teeth with chronic abscesses may drain buccally (below the cheek muscle attachment) or inferiorly below the mylohyoid muscle leading to dermal sinuses that are often mistaken for skin lesions remaining immune to routine dermatological remedies

7. Radiographic examination: If it’s possible to get a screening radiograph, like an orthopantomography, this could help in diagnosis and pinpointing the explanation for the pain. The radiograph shows clearly the apical, periapical and associated structures and tissues. The connection of the maxillary molars and premolars to the ground of the sinus are often examined, and radiographs may reveal recurrent caries or periapical radiolucency’s related to a long-time infection (Table 1).

Diagnosis	Characteristic features	Clinical presentation	complications	Treatment
Reversible pulpitis	Pulpal inflammation	Pain with hot cold and sweet stimuli	Periapical abscess, cellulitis	Restoration
Irreversible pulpitis	Pulpal inflammation	Spontaneous, poorly localized pain	Periapical abscess, cellulitis	RCT, Extraction
Abscess	Localized bacterial infection	Localized pain and swelling	cellulitis	Incision and Drainage, RCT or Extraction
Cellulitis	Diffuse soft tissue bacterial infection	Pain, erythema and swelling	Regional spread	Antibiotics and RCT or Extraction
Pericoronitis	Inflamed gum over partially erupted teeth	Pain, erythema and swelling	Cellulitis	Irrigation, antibiotics if cellulitis is also present
Tooth Fracture	Broken tooth	Clinical examination and Radiography	Pulpitis and sequelae	Restoration with or without RCT, Extraction
Tooth Luxation	Loose tooth	Clinical examination and Radiography	Aspiration, Pulpitis and sequelae	Splinting, with or without RCT, Extraction
Tooth avulsion	Missing tooth	Clinical examination	Ankylosis, Resorption	Reimplantation, splinting

Table 1.

Most common dental emergencies.

10. Conclusion

It has been estimated that one or two life threatening emergencies will occur in the lifetime practice of a general dentist so prompt recognition and efficient management of dental emergencies by a well-prepared dental team can increase the likelihood of a satisfactory outcome. With proper training, thorough preparation, and regular practice, the staff of the dental office will be able to provide appropriate dental care whenever the need arises. To improve access and the quality-of-life care indeed it is essential to identify the need of the use of emergency dental services.