Dental emergency

Pain is described as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It is one of the most common reasons patients seek dental treatment and many diseases or conditions may be responsible for the cause. Odontogenic pain Odontogenic pain is pain associated with the teeth, originating in the dental pulp and/or the peri-radicular tissues. The following table shows the different classifications of pulp status. Peri-radicular pain Peri- radicular pain can be of pulpal origin, most commonly due to disease in the pulp extending into the peri-radicular tissues but can also be of periodontal origin due to periodontal disease. Apical periodontitis is acute inflammation of the periodontal ligament surrounding the tooth. This can be caused by inflammatory mediators from irreversibly inflamed pulp, bacterial toxins from necrotic pulp, restorations that have not been property contoured and in some cases, from treatments such as endodontic treatment. There is both an acute and chronic form of this condition. Acute apical periodontitis features include moderate to severe pain, usually stimulated by touch and pressure and may also include spontaneous pain. The chronic form of the condition can be asymptomatic but may also include pain from surrounding tissues when stimulated. Apical abscess is an extension of apical periodontitis where the bacteria have infiltrated the peri radicular tissues and are causing a severe inflammatory response; there is also an acute and chronic form of this condition. An acute apical abscess can cause facial swelling and can cause other systemic consequences such as a high temperature and feelings of malaise. In some cases this condition can be life-threatening when the inflammation compromises the airway; this is termed Ludwig's Angina. A chronic apical abscess can be asymptomatic as the pressure from the inflammation is being drained through a sinus tract; a draining sinus can usually be seen clinically. A periodontal abscess is a localised inflammation affecting the periodontal tissues. It is caused by bacteria pre-existing in a periodontal pockets, traumatic insertion of bacteria or foreign body or can occur after periodontal treatment. This condition has a rapid onset, is stimulated by touch and involves spontaneous pain. It is important to note that an apical abscess may drain through the periodontal pocket giving a false interpretation of periodontal abscess or a periodontal abscess may appear at the apex of the tooth giving a false interpretation of apical abscess; a tooth may also have both lesions at one point in time. ==Dental Trauma==

Dental trauma refers to an injury on hard and soft tissues of the oral cavity and face. This includes the teeth and surrounding tissues, the periodontium, tongue, lips and cheeks. It is more prevalent with children between 8– 12 years of age but can still happen to anyone. Trauma to primary teeth most commonly occurs at the age of two to three years, during the period of developing motor coordination. When primary teeth are injured, treatment should primarily ensure the safety of the permanent tooth and avoid any risk of damage to the permanent successor teeth. This is because the apex of the root of the injured primary tooth lies close to the developing permanent tooth germ. The prognosis of the tooth is worse the longer it is out of the mouth. The following is a list of dental trauma affecting different surfaces of the teeth and periodontium. Do not touch the root surface. The root is covered with living periodontal ligament cells that are necessary for successful reimplantation. Even light contact can damage these cells and reduce your chances of saving the tooth. Injuries to the hard dental tissues and the pulp Injuries involving periodontal tissues Dental barotrauma and barodontalgia. A sudden incapacitation of diver or aviator due to barometric-induced tooth fracture or toothache, respectively, may be life-threatening to the individual and the airplane passengers. Regular use of a protective mouthguard during sports and other high-risk activities (for example, military training) is the most effective prevention of dental injuries. ==Restorative emergencies==

Lost or broken filling A fractured, ditched or dislodged filling that is broken or lost may cause discomfort or sharp pain due to jagged edges. There can be aesthetical concerns if the filling is in a visible area. Patients need to be aware of the sharp edges and ensure their tongue does not constantly apply pressure around that area, as it can cause cuts to the tongue. However, in some cases the result of the loss of a filling can cause irritation to the side of the cheek and potentially lead to an ulcer. Sharp edges can easily be dealt with by levelling the filling or tooth edges from your local dentist during the emergency appointment. Hypersensitivity issues may also arise, short sharp pain caused by exposed underlying dentine, after the deterioration of the filling material. • Crack, fracture and mobility A crack, fracture and the mobility of a tooth are all interrelated as the pain and symptoms experienced from a tooth that has been cracked are very similar to that of a tooth that has been fractured. The cause of a tooth crack can be by excessive force applied to a healthy tooth or physiologic forces applied to a weakened tooth. The teeth most commonly involved are usually the lower molars, followed by the upper premolars and molars. The condition is extremely common in the age range of 30–60 years. although it is not uncommon for emergency management of a failing implant or one of its components. The failure is most likely due to infection of the implant. It is highly recommended to visit or refer patient to the specialist who provided the implant. Late failures that occur with implants are usually due to moderate to severe bone loss, mostly located in the posterior areas of teeth and involve a multi-unit prosthesis. A fracture or decementation of a post or loosening of the abutment screw of an implant could be the result of dissolved cement, secondary caries, use of a weak post, or excessive occlusal forces. Oral home care needs to remain at a high standard, brushing twice a day for the duration of two minutes with the use of fluoridated tooth paste. Interdental cleaning once a day using either floss, interdental brushes, wood sticks. Regular dental appointments every 6 months to maintain gingival health, professional cleans, radiographs to examine the bone loss and the implant status. All the following is needed to prolong the longevity of the implant and reduce the risk of peri-implantitis. == Acute oral medical and surgical conditions ==

. Above, deformation of the cheek on the second day. Below, deformation on the third day. An acute condition may be defined as a suddenly presenting disorder, usually with only a short history of symptoms, but with a degree of severity that causes significant disruption to the patient. Such presentations require immediate attention. Localised dental abscesses may be appropriately treated by intra-oral drainage via tooth extraction, opening of root canals and/or intra-oral incision and drainage. Wherever there are signs of spreading cervico-facial infection or significant systemic disturbance, however, patients should be referred urgently further management. Pericoronitis Pericoronitis is defined as inflammation in the soft tissues surrounding the crown of a partially erupted tooth. The acute form is characterised by severe pain, often referred to adjacent areas, causing loss of sleep, swelling of the pericoronal tissues, discharge of pus, trismus, regional lymphadenopathy, pain on swallowing, pyrexia, and in some cases spread of the infection to adjacent tissue spaces. • Blistering disorders of oral mucosa (see vesiculobullous disease) • oral ulceration • Disturbed orofacial sensory or motor function Trismus Trismus may be defined as inability to open the mouth due to muscle spasm, but the term is frequently used for limited movement of the jaw from any cause and usually refers to temporary limitation of movement. Hemorrhage Whilst haemorrhage from the oro-facial region may present spontaneously, particularly from gingival tissue as a result of a bleeding diathesis or a haematological abnormality such as leukaemia, the most common cause is in response to trauma or a post-operative haemorrhage following dental extraction. They are not to be confused with abscesses, which are cavities filled with pus. Cysts can cause root resorption of adjacent teeth, tooth mobility and can be associated with mandibular fracture. Cyst would usually require surgical management if indicated. Post-extraction pain and infection, or dry socket Following a tooth extraction, if a blood clot forms inadequately in the socket or it is broken down, a painful infection may develop which is often referred to as a ‘dry socket’. It is clinically characterized by a putrid odor and intense pain that radiates to the ear and neck. Pain is considered the most important symptom of dry socket. It can vary in frequency and intensity, and other symptoms, such as headache, insomnia, and dizziness, can be present. Pre-disposing factors to dry socket include smoking, traumatic extraction, history of radiotherapy and bisphosphonate medication. A dry socket can be managed by irrigating the socket with chlorhexidine or warmed saline to remove debris followed by dressing of the socket with bismuth iodoform paraffin paste and lidocaine gel on ribbon gauze to protect the socket from painful stimuli. If pus is seen in the socket and there is localised swelling and possibly lymphadenopathy, it has become infected and can often be managed as in dry socket, but usually antibiotics should be prescribed. A radiograph is useful to see if there is a retained root or bony sequestrum, which could be the cause of the infection. Clearly, if one or both is present, further treatment is indicated. Postoperative swelling Mild inflammatory swelling may follow dental extractions but is unusual unless the procedure was difficult and significant surgical trauma occurred. More significant swelling usually indicates postoperative infection or presence of a haematoma. Management of infection may require systemic antibiotics or drainage. A large haematoma may need to be drained. == Orthodontic emergencies ==

Orthodontic emergencies can be classified as urgent problems relating to the maintenance of orthodontic appliances, or excessive pain caused by orthodontic appliances. General dental practitioners should be able to manage orthodontic emergencies, including referral to an orthodontist when necessary. Loose removable appliance Removable active appliance are used by dentist to tip teeth using screws, springs and bows of various types to correct malocclusion. The appliance can be taken out for cleaning and for adjustments made by orthodontists. If the appliance is loose in an emergency situation, the dentist can adjust the retentive component of the appliance to increase the retention of the appliance by using Adams pliers. Fractured removable appliance Suppose the appliance breaks, the orthodontist should be alerted as soon as possible. The wearer should not use the appliance as it could cause trauma and could pose a significant risk of airway obstruction if the wearer accidentally inhales. Loose or fractured fixed appliance (wire or band) There are many components to the fixed appliance which have a potential to break off if the patient chews on hard or crunchy food. Wearers should wear a mouth guard over the appliance if when playing contact sports. If one of the components is loose or comes off, the user must call the orthodontist right away. Lost separator/spacer Separators, also known as orthodontic spacers, are usually placed between posterior teeth to open up contact point prior to placing metal orthodontic bands. The separators should ideally be kept in place until the patient's next appointment in order for the orthodontic band to fit. If the separator is lost, the orthodontist should be informed and he/she can advise for a next appointment for the patient. Protruding archwires The archwire in fixed orthodontic appliances should be flat against the tooth, however if the wire is protruding it can cause irritation to the surrounding soft tissues. Wire benders or a dental flat plastic can be used to bend the wire into place, or if this is not possible, the protruding wire can be covered with wax. If there are significant problems, the wire can be clipped using distal end cutters, being careful to avoid inhaling or ingesting wire fragments. As a last resort measure, the whole wire and ligatures can be removed. De-bonded bracket De-bonded brackets, if left untreated, can result in irritation of lip and cheek in short term. If a bracket de-bonds from the tooth, the de-bonded bracket can be removed from the archwire by initially removing the ligature holding it in place. Alternatively, orthodontic wax relief can be used to secure the de-bonded bracket to the adjacent bracket as a temporary measure to prevent irritation of lip and cheek. However, it is essential to inform the orthodontist as soon as possible so that appropriate actions are taken to address the de-bonded brackets immediately. Allergic/hypersensitivity reactions The most common allergy in orthodontics is to nickel. Nickel is found in multiple orthodontic components, such as nickel-titanium (NiTi) archwires and stainless steel brackets. If patients are previously exposed to nickel, for example with nickel-containing jewellery, the re-exposure with orthodontic components are more likely to lead to a Type IV delayed hypersensitivity immune response. This response is usually delayed for a few days or weeks. In this case, the orthodontist must be informed immediately to make arrangements for patient to receive nickel-free components. However, such immune response to nickel is rare, as it is believed that the oral mucosa requires a much higher concentration to illicit a response compared to the skin. Airway obstruction When a small removable appliance or a loose component obstructs a patient's airway a true medical emergency arises. If the object is visible, recline the patient and attempt to remove it while otherwise encouraging the patient to cough the object out. If this is not immediately successful call for help and an ambulance. Follow the guidelines for 'choking/aspiration' in the 'Medical Emergencies and Resuscitation' document provided by the Resuscitation Council UK. Ingested or aspirated component It is not unheard of to ingest an orthodontic component or appliance, usually being asymptomatic causing no harm to the patient. No treatment is required except for monitoring stools to ensure the component has passed safely. If however the patient is having symptoms of pain or vomiting, the component may be lodged in the oesophagus or oropharynx. In such situations the patient must be sent to hospital. If the component is more than 5 cm long the patient should always be sent to A&E as there is a higher risk of obstruction or perforation of the gastrointestinal tract so removal may be advised instead of allowing the component to pass naturally. When sending a patient to hospital the referral letter must contain details regarding the components size, shape, flexibility, radio-opacity as well as information about the incident for example when it was swallowed. Aspiration of an orthodontic component which was unable to be removed must be referred to A&E for chest radiographs and subsequent removal of the component. The referral letter again must include details as described above. ==Treatments==

The treatment is cause-related. For example, oil of cloves, which contains eugenol, can be used to treat dental pain; a drop can be applied with a cotton swab as a palliative . After wisdom tooth extraction, for example, a condition known as dry socket can develop where nerve endings are exposed to air. A piece of sterile gauze or cotton soaked in oil of cloves may be placed in the socket after careful cleaning with saline to relieve this form of pain . Over-the-counter topical anesthetics containing active ingredients such as benzocaine or choline salicylate may be applied directly to the gum in order to deaden sensation. Analgesics such as aspirin, paracetamol (acetaminophen) and ibuprofen are also commonly used; aspirin and ibuprofen have the additional benefits of being anti-inflammatories. Ice and/or heat are also frequently applied . A dentist may prescribe an anti-inflammatory corticosteroid such as Dexameth for pain relief prior to treatment. == References ==