Dental Emergencies

• Tooth anatomy

• Dental conditions - non trauma

• Dental trauma

• ED Dental Referrals

• References

For paediatric guidelines refer to the Royal Children's Hospital

• Paediatric dental trauma

• Paediatric dental non-trauma

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.

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:

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:

• Mandibular anesthesia
• Maxillary anesthesia
• Inferior alveolar nerve block

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

• Infiltration
• Inferior Alveolar Injection - YouTube
• Mandibular anaesthesia 
• Maxillary anaesthesia
• Inferior alveolar nerve block
• Dental emergency presentation - A comprehensive, well referenced guide to dental emergencies - how to manage them in the ED, and how/when to refer to specialist treatment.
• Emergency Department Dental Referrals - NSW Health Guideline GL2023_005

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.

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

Emergency Department Dental Referrals

It's not shorter, but it is more accurate Some patients presenting to the ED may be eligible for a referral to NSW public dental clinics. Use the statewide form Dental referral for emergency departments to nsw public dental clinics to refer patients. Get copies of this form from TollStream direct using your local process. The form is to be given to the patient on discharge.

Emergency Department dental referrals (GL2023_005) provides direction on making appropriate dental follow-up referrals from NSW hospital emergency departments.

Additional information

• Dental Trauma Guide - Available to LHDs through CIAP
• Maxillofacial Trauma | Therapeutic Guidelines
• Paediatric considerations

References