Dental emergencies cover a wide spectrum of events. Some situations are more urgent than others, and it doesn’t help that it is difficult to see inside the mouth to localize the site of any problem.
Avulsion
One relatively common event is the traumatic loss of a child’s front tooth—avulsion.If it is possible to quickly locate and wash the tooth, it can be reimplanted directly into the socket—being sure to put it the right way around and avoiding touching the root if possible. Following the shock of the injury, this may not be a painful experience. Hold it in place in the socket for some time. Tetanus status and boosters should be checked in these cases. As soon as possible, however, visit the dentist to continue with emergency treatment.
Not everyone will be confident to try to reinsert the tooth. So, the soft tissue surrounding the root of the tooth (periodontal ligament) needs to be kept from drying out while on the way to the dentist. But don’t put the tooth into water or keep it in a tissue as that would definitely kill the delicate fibers remaining on the root surface.
If a baby tooth is knocked out, never try to put it back into the socket as it could interfere with the permanent tooth that is developing underneath the gum.
At a school sporting event, there may be a transport medium available called Hank’s Balanced Salt Solution, which has been formulated for such events, and could be available from the school nurse. However, a sports mouth guard would probably already have been recommended by the school to prevent serious trauma to the teeth during contact and other sports.
Realistically, probably the most readily, or quickly available, transport medium is skim milk. The lost tooth should be completely immersed as soon as possible. Cold milk has the best osmolarity and pH for the delicate periodontal tissue still attached to the root and can help preserve this tissue for up to 8 hours.
Another way is to keep the tooth in the side of the child’s mouth, particularly if the dental office is nearby. In practical terms this may not be advisable for young children, so maybe they can be encouraged to spit into a plastic bag and keep the tooth in that medium.
Unfortunately, a tooth that has not been optimally stored has less than an hour to be reinserted at the dental office to ensure survival without complications.
The avulsed tooth will normally be splinted for 2 to 4 weeks to give it a chance to stabilize – like a plaster cast for a broken limb.
It is still a good idea to retain a tooth that has become contaminated as the dentist can determine if the tooth itself is intact, and if the root has fully developed. Also, pieces of fractured root tips may still be present high up in the bone. This can be checked with X-rays, and through examination of the tooth itself. The adjacent teeth could also be invisibly fractured below the gumline.
If a tooth is broken, but not lost, keep the parts that have fractured off as they may be able to be bonded back onto the broken tooth.
A root filling (endodontics) will normally be required for these avulsed teeth within 7 days, removing all the soft tissue inside the tooth and root. It could be months, or even years, before the tooth actually becomes symptomatic. If the tooth begins to darken, then it definitely needs root filling.
It is worth remembering that the adjacent teeth, or the teeth opposing the lost/injured tooth/teeth, may have received a fatal amount of force at the same time and may also require endodontic treatment. Symptoms in these areas could develop later. The teeth will be checked for vitality (if still alive) by the dentist.
Often there will be damage to the lips and surrounding tissues, and this will also need attention.
The reimplantation can subsequently fail because of internal resorption, even after root filling. So why go to the bother of re-inserting, splinting, root filling etc.? It’s because the area has not fully grown at that stage. The bone remodels after the loss of a tooth and a depression will form in the bone where the tooth used to be, so that the gumline would be at a lower level than the adjacent teeth.
In about 50% of cases of avulsed, replanted teeth, ankylosis can subsequently occur, which is the pathological fusion between the alveolar bone and the cementum of the teeth (outside layer of the root).
For younger children, the root end may still be “open”—that is, not have fully developed. Typically, they will be monitored after replantation. For successful cases, one will see on X-rays the continued development of the root, although usually in a shortened form. Again, the original tooth is the best temporary or permanent measure to allow normal development of the area.
An adult’s avulsed tooth should also be kept for all these reasons. The original crown of such a tooth may be able to be joined to the adjacent tooth as a temporary measure even if it can’t be permanently retained.
Non-traumatic situations
For non-traumatic emergencies with swelling or fever from infections, these should be immediately addressed as they can potentially compromise the patient’s airway, particularly if the person is already suffering from an existing medical condition. A hospital emergency room may be the only solution if there is no dentist available.Severe dental pain can follow from a dental infection or inflammation in a specific tooth, from wisdom teeth, or from a recently removed tooth socket where the blood clot has not formed (dry socket). In a dry socket situation, no healing blood clot has formed or has washed away after extraction, and the bone is exposed at the base of the socket. This is a very painful condition and the socket will need to be cleaned and dressed.
Following an accident, if the teeth don’t seem to fit together the way they used to, the jawbone itself may actually be broken, and this also needs to be addressed quickly. Some teeth may have moved as a result of the accident and thus be “in-the-way” of normal mouth closure, rather than being indicative of a broken jaw.
If the teeth are already loose and compromised from periodontal disease, they are unfortunately not candidates for reinsertion back into their “original home” as that home no longer exists.
Some people have TMJ (Temporomandibular joint) conditions. The TMJ is the lower jaw joint which one can feel in front of the ear. The TMJ can move down and out of its socket, and one will be unable to close it back into the normal biting position. Here, the lower jaw needs to be guided down and back to recapture its socket.
Broken edges of cusps (hills and valleys) of the teeth can feel very sharp to the tongue. Large restorations (fillings) may fracture during normal eating or from biting into a hard object that was hidden in the food. If no decay is present, the edges can be smoothed off to gain immediate relief for the tongue if there is no time for a permanent replacement.
However, a broken tooth may be the first indication that decay was present inside the tooth with the enamel collapsing into the void below. A temporary or permanent filling is required.
Objects can become wedged between the teeth, even interdental cleaning brushes. In the latter case, one can push the broken brush tip with an intact one, keeping the direction parallel to the floor of the mouth.
Orthodontic wires or other dental appliances may become loose, break, or extend beyond their normal placement. The ends of the wires can feel very sharp in these cases. Dental, white-colored wax, or any wax, can be applied in an emergency to the sharp ends, which will provide immediate relief.
Don’t apply aspirin directly to any ulcer that has formed, as this will simply burn that tissue.
