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Dental Emergencies


For paediatric guidelines refer to the Royal Children's Hospital


Tooth anatomy

Teeth have three layers: enamel, dentine and pulp.


Primary teeth

20 small, very white, bulbous crowns, often worn with flat edges. Teeth are identified by two numbers, for example: 52.

The first number indicates the quadrant in the mouth, the second number indicates the tooth number, counting from the midline of the face, towards the back of the mouth:


Mixed dentition

Children will usually present with a mixed dentition between the ages of 6 - 12 years old. It is important to identify if the presentation is associated with a permanent or primary tooth.

Average age when primary teeth are lost:

  • Incisors: 5 – 8 years old
  • Canines and Molars: 9 – 12 years old
  • Usually begin to appear in the mouth from 6 years of age.
  • Teeth are identified by two numbers, for example: 25.

Permanent teeth

(32): larger, creamier colour, jagged edges on newly-erupted teeth.

The first number indicates the quadrant in the mouth, the second number indicates the tooth number, counting from the midline of the face, towards the back of the mouth:

When describing the tooth use the FDI (International Dental Federation) system (above). However, if you are unable to identify the specific tooth number, use a description such as:

  • Upper or lower
  • Left or right
  • Tooth type (if known)

e.g., upper right canine.


Dental conditions - non trauma

Key points

  • Opportunistic education for families on good oral hygiene practices and how to access dental services can prevent dental caries
  • Once a dental abscess or infection has formed, extraction or root canal therapy is usually required to remove the source of the infection
  • Submandibular infection should be considered as differential diagnosis of oral pain

Background

  • Dental caries (tooth decay) occurs in more than 40% of Australian children and can begin as soon as teeth erupt during infancy
  • Routine dental care should be provided in the community rather than by hospitals, except for patients with chronic illness that may be impacted by dental caries (eg cancer, cardiac disease, immunodeficiency, bleeding disorders, special needs) or where general anaesthetic is required

Assessment

Dental History

  • Frequency, duration and who performs tooth brushing
  • Exposure to sugary and high acidity foods and drinks (including processed fruit juice and cordial)
  • Previous dental review and advice given
  • Previous dental trauma
  • Dental or facial pain
  • Chronic conditions which may impact saliva production or swallowing
  • Consider non-dental causes eg cervical lymphadenitis, parotitis, submandibular infections
  • Dental pain is often acute, unliteral, and mostly localised in the mouth. It can be exacerbated by chewing, biting, or thermal stimuli, and can present with swelling.

Examination

  • “Lift the lip” to ensure thorough examination of upper front teeth and gums
    • Look for early signs of decay including white or brown spots/lines along the top of the tooth adjacent to the gum line which don’t brush off
    • Check for loose or tender teeth
  • Abscess may be indicated by:
    • tender gingival swelling or erythema
    • erythema and cellulitis of facial skin overlying tooth, submandibular or periorbital
    • trismus
    • fever and systemic symptoms may be absent

Management

Investigations

  • Blood tests are not required unless systemic symptoms present
  • Consider orthopantogram (OPG) to assess for evidence of abscess

Treatment

General principles

  • Provide adequate analgesia
  • Dental abscess usually involves tooth extraction with incision and drainage
  • Definitive treatment of the carious tooth will still be required after treatment of pain and infection

The table below presents further management principles for common dental conditions.

Condition

Description

Management principles

Abscess

Dental - Most commonly caused by advanced tooth decay

Periodontal – pain caused by an acute infection that originates from a localised area of severe periodontal disease.

May require drainage to relieve the pain.

Antibiotics if systemic infection, immunocompromise, or delay to more definitive treatment.

Post extraction bleed

It is normal for there to be small amounts of ooze for up to 12
hours post extraction

1. Place pressure by using gauze

2. Administer local anesthesia if required and apply pressure to the wound for 5-10 minutes.

3. If bleeding persists, rinse socket with saline, soak gauze with tranexamic acid, place gauze in extraction site and ask the patient to bite firmly on gauze for 30 minutes.

4. If the area is still bleeding, pack the extraction site with absorbable gelatin sponge, and suture into position with 4.0 silk suture.

5. Re-examine after 5 minutes to confirm the haemostasis.

Post extraction pain

This type of pain usually occurs within 24 hours after a tooth extraction

Oral analgesia

Alveolar osteitis

‘Dry socket’ is a condition that may occur post-extraction. It occurs when a blood clot is inadequate, or broken down due to inflammation, or further trauma post extraction.

  • Occurs 2-3 days post tooth extraction
  • Pain may radiate to the ear
  • Necrotic debris may be present in socket
  • Malodorous breath

The condition is usually self-limiting within 2-3 weeks and is more commonly seen in the lower jaw and among patients who smoke.

1.Irrigation of the socket (chlorhexidine or warm saline to remove the debris).

2. Dress the socket with bismuth iodoform paraffin paste, lidocaine gel on ribbon gauze to protect the stimuli.

3. Oral analgesia

4. Antibiotics – if pus in the socket or swelling in the area.

*note that dry sockets are not a bacterial infection, thus antibiotics are not usually required in the absence of pus or swelling.

Other Dental conditions

Tooth decay (dental caries)

Tooth decay is a preventable disease caused by increased acid in the oral environment which attacks the tooth surface causing cavitation. Left untreated, tooth decay can cause pain, infection, and tooth loss.

Gum disease

Gingivitis is a preventable, reversible inflammation of the gingivae (gums) caused by poor oral hygiene. It results in gingival tissues that bleed very easily when brushed. Periodontal disease occurs when gingivitis has progressed to involve the deeper soft tissues and supporting alveolar bone. Periodontitis is progressive and can lead to localised infection and eventual tooth loss. This disease usually progresses without symptoms, however there may be localised acute infections that may cause acute pain resulting in presentations to emergency departments.

Submandibular infections

Submandibular infection should be considered as differential diagnosis of oral pain. It is defined as cellulitis of sublingual/submandibular area and may be either unilateral or bilateral. This cellulitis may cause an obstruction to the airway (Ludwig’s angina) or systemic sepsis.

Symptoms associated with submandibular infection can include:

  • submandibular pain
  • swelling
  • trismus
  • inability to protrude tongue
  • drooling
  • dysphagia
  • dysphonia/dyspnoea are late signs

If the patient presents with a dental infection that poses a risk of airway obstruction, they may need IV antibiotics and/or surgical drainage.


Antibiotics

Indications:

  • Adult teeth that have been re-implanted.
  • Where the patient has systematic signs of infection (fever, malaise, lymphadenopathy, trismus), has compromised immunity, or is at risk of the progressive and rapid spread of infection (cellulitis or Ludwig’s angina).

Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to local guidelines. Common antibiotics for odontogenic infections include:

INFECTION 

SYSTEMIC

SYMPTOMS 

NO ALLERGY 

PENICILLIN

ALLERGY 

SPREADING ONDONTOGENIC

NO

Amoxicillin + clavulanate 875+125 mg PO, BD, 5/7

Clindamycin 300mg, PO, TDS, 5/7

YES

(incld Ludwig angina)

Amoxicillin + clavulanate 1 + 0.2g IV, QID

Clindamycin 600 mg, IV, TDS

POST DENTOALVEOLAR SURGERY

YES

Amoxicillin + clavulanate 875+125 mg PO, BD, 5/7

Clindamycin 300mg, PO, TDS, 5/7

Refer to Therapeutic Guidelines (login required) or local policy for more information


Anaesthetic

Administration of local anaesthetic is effective for the initial management of severe pain, alongside oral analgesics.

Topical local anesthetics (2% lignocaine gel) can also be effective for temporary pain relief for oral ulcerations. It can also be applied prior to the provision of anaesthetic.

After the administration of local anesthesia patients should be told to be careful about biting the numb areas of their mouth and lip.

The following provide links to a demonstration of achieving anesthesia to the areas of the dentition:

Please note adequate training should be completed before administering anaesthesia.


Consider consultation with dentist when

Fever in setting of suspected dental abscess

Facial cellulitis or swelling

Consider transfer when

Specialist dental or maxillofacial assessment and management is required and is not locally available

Additional information


Dental trauma

See also

    Key points

    • Management of dental trauma depends on whether primary or permanent teeth are impacted. Primary teeth should not be reimplanted, adult teeth can be reimplanted
    • Successful replantation of permanent teeth or teeth fragments requires urgent management to improve long term tooth viability
    • Please refer to the RCH guidelines on managing paediatric dental trauma

    Background

    • Dental trauma is very common, and often occurs alongside other injuries, especially facial and head injuries. Where required perform a primary and secondary survey prior to instituting dental management
    • Healing after a dental injury requires good oral hygiene. Swabbing the area with 0.1% chlorhexidine twice a day for 10–14 days reduces the infection risk. A soft diet will also allow loose teeth to become firmer

    Assessment

    History

    • Mechanism of injury and associated injuries
    • Time since injury – avulsion of a permanent tooth is a dental emergency (prognosis dependent on how swiftly the tooth is replanted into socket)
    • Encourage recovery of avulsed tooth or tooth fragments
    • First aid rendered (tooth rinsing, wet or dry storage)
    • Sensitivity to hot and/or cold
    • Previous dental history including injuries, crowns or prostheses
    • Tetanus immunisation status

    Examination

    Examine the head, neck and inside the mouth for hard and soft tissue injuries.

    • Symmetry in the mouth and teeth
    • Lift the lips to look for gingival or oral mucosal injury
    • Type of dental injury: loose or displaced tooth, fractured tooth, injury to supporting bone, injury to oral mucosa or gingivae
    • Bite for even occlusion, subjective or objective; steps in bite or bone border
    • Temporomandibular joint movement and tenderness
    • Numbness, intra or extra-oral bruising
    • Account for all lost teeth and fragments, examine chest and soft tissues of the mouth if any missing as they may have been aspirated or embedded
    • Be aware of concomitant injuries including head injuries (e.g. concussion), facial fractures

    Management

    Investigations

    • Orthopantogram (OPG) if considering fractured mandible, TMJ injury or concern for fully intruded tooth
    • Chest x-ray if suspicious tooth has been aspirated

    Treatment

    • Prophylactic antibiotics are not recommended if operative management is not required
    • Provide tetanus booster if required

    The table below presents further management principles for common injuries.

    Type of Injury

    Description

    Management Principles

    Fracture

    Uncomplicated fracture – fracture with no pulpal exposure

    1. Store the broken piece of tooth in water.
    2. If the tooth remaining in the mouth is sensitive, cover with a temporary filling material available in your department e.g., Cavit or GIC.
    3. Refer to a local dentist for further management.

    Complicated fracture – fracture with pulpal exposure

    1. Consider the use of local anaesthetic for symptomatic relief.
    2. Cover the exposed pulp with a small moist cotton gauze then cover with a temporary filling material e.g., Coloplast.
    3. Refer to local dentist for further management.

    Luxation

    Luxation injuries – teeth which are loosened, pushed in, and moved

    Initial considerations:

    • Do not handle the tooth by the root surface.
    • Consider antibiotic prophylaxis, and a tetanus booster if the tooth has come into contact with soil.
    • Notify the patient that a delayed replantation has a poor longā€term prognosis.

    Management principles

    1. Move teeth gently back into their original position.
    2. Place gauze between upper and lower teeth.
    3. Refer to a local dentist for further management.

    Avulsion

    Avulsion injuries where the tooth is knocked out

    Initial considerations:

    • DO NOT replant primary (baby) tooth

    To replant permanent (adult) teeth:

    1. Rinse the tooth with saline.
    2. Administer local anaesthetic.
    3. Replant tooth into socket gently.
    4. Apply a splint if comfortable doing so.
    5. Advise good oral hygiene, gentle brushing, and a soft diet for 2 weeks.
    6. Refer to local dentist for further management

    Consider consultation with dentist when

    Trauma requiring surgical input and assessment

    Consider transfer when

    Specialist dental or maxillofacial assessment and management is required and is not locally available


    Additional information


    References

    Bourguignon, C., Cohenca, N., Lauridsen, E., Flores, M. T., O'Connell, A. C., Day, P. F., . . . Levin, L. (2020). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations. 36(4), 314-330. doi:https://doi.org/10.1111/edt.12578

    Day, P. F., Flores, M. T., O'Connell, A. C., Abbott, P. V., Tsilingaridis, G., Fouad, A. F., . . . Levin, L. (2020). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. 36(4), 343-359. doi:https://doi.org/10.1111/edt.12576

    Fouad, A. F., Abbott, P. V., Tsilingaridis, G., Cohenca, N., Lauridsen, E., Bourguignon, C., . . . Levin, L. (2020). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. 36(4), 331-342. doi:https://doi.org/10.1111/edt.12573

    Levin, L., Day, P. F., Hicks, L., O'Connell, A., Fouad, A. F., Bourguignon, C., & Abbott, P. V. (2020). International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: General introduction. 36(4), 309-313. doi:https://doi.org/10.1111/edt.12574

    Acute odontogenic infections [published 2019 Dec]. In: Therapeutic Guidelines [digital]. Melbourne: Therapeutic Guidelines Limited; 2021 Mar. <https://www.tg.org.au>

    Complications after oral surgery [published 2019 Dec]. In: Therapeutic Guidelines [digital]. Melbourne: Therapeutic Guidelines Limited; 2021 Mar. <https://www.tg.org.au>

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