Dental First Aid
If you are referring a patient/documenting in notes – be CLEAR about which tooth you are talking about!
20 deciduous, 32 permanent teeth
Use International Standards Organisation Designation System (ISO System) e.g. 2,4 when referring
First number = 1 = right maxillary, 2 = left maxillary, 3 = left mandibular 4 = right mandibular
Second number = position from front
E.g. left bottom canine = 3, 3
Image provided courtesy of Productivity Training Corporation (PTC) Dental
Tooth fracture/ trauma
General considerations to remember:
- Adequate, regular multi-modal analgesia – consider systemic and local options
- Tetanus status
- Consider Penicillin prophylaxis
- Liquid diet for few days, then soft diet for at least a week
- Refer on to Dental Service as per local policy
- Do not touch root of tooth
- Replant back in mouth as soon as possible
- Use foil (or specific agent from dental kit) to splint in place
- If primary tooth, do not reimplant. If broken root, do not reimplant
- Place in milk for carrier substance
- Over 6 hours out, will not survive re-implantation (each minute, chance of survival decreases)
Enamel damage only
Not sensitive to temperature/ percussion
Non urgent dental r/v
Damage into dentin
Yellow colour visible
5% risk pulp necrosis
Calcium hydroxide paste and Coloplast (or equivalent)
Referral to dentist within 24 hours
Damage into tooth pulp
Pinkish colour/bleeding visible
Inject local anaesthetic into pulp (symptomatic relief)
Cover with moist cotton gauze then Coloplast
Dental review within 24 hours
There are various different temporary dental pastes. Calcium hydroxide is applied to dry tooth surface and dries within minutes (needs to be mixed together just prior to use as it sets very quickly). GIC (glass ionomer cement) is used for tooth stabilisation and goes on top of calcium hydroxide (not needed if tooth will be reviewed within 48 hours). Zinc oxide eugenol (ZOE) is used to make a putty that is inserted into the socket.
Consider applying topical gel to gums – e.g. jelly/viscous
25g or 27g needle for injection. Maxillary teeth all can be directly numbed by injection into sulcus directly above the tooth to be anaesthetised. Remember you will NOT anaesthetise mandibular molars or the palate by this method.
Bleeding tooth socket
Ooze is normal for 12 hours post tooth extraction:
- Bite down firmly on folded gauze for 5-15 minutes (can happen at triage)
- If bleeding persists, rinse socket with saline, soak gauze with 10% tranexamic acid (1g in 10mLs 0.9% normal saline), place gauze in extraction site and bite firmly on gauze for 30 minutes
- If unsuccessful, infiltrate wound with 1-2% lidocaine and adrenaline
- If still bleeding, pack site with absorbable gelatin sponge, and suture into position with 4.0 silk suture
Remember – check history of anti-platelets/anticoagulants/ alternate medications (e.g. Chinese herbs). Investigate: FBC/coags/x-match if severe. Consider bleeding disorder.
Consider antibiotic cover – infection is the most common cause of delayed bleeding
Become familiar with the following differentials of ‘mouth/tooth pain’:
- Dental abscess – ultimately an abscess will require drainage. Give antibiotics only if suspected systemic infection/immunocompromised or if there will be delay to drainage.
- Periositis – pain within 24 hours of tooth extraction. Treat symptomatically unless high clinical suspicion for complication/ infection.
- Alveolar osteitis (or ‘dry socket’) – 2-3 days post tooth extraction from marginal ischaemia. Pain may radiate to ear. Necrotic debris in cavity. Needs irrigation, antibiotics
- Peridontal abscess
Submandibular infection - aka Ludwig’s angina
Always an important differential of oral pain. Is defined as cellulitis of sublingal/submandibular area – a true emergency as may result in rapid airway obstruction/systemic sepsis.
- submandibular pain.
- dysphonia/dysphnoea are late signs.
A comprehensive, well referenced guide to dental emergencies - how to manage them in the ED, and how/when to refer to specialist treatment..