Dental Emergencies

What is Dental Emergencies?

The American Dental Association defines dental emergencies as situations that pose an immediate threat to life and require immediate action to stop bleeding, clear up infections, or relieve severe pain. But not all dental emergencies are life-threatening. Some refer to problems with the teeth or tissues that support them, which need to be addressed immediately to prevent future complications, such as affecting the function or appearance of the teeth.

Pain is usually the primary symptom of a dental emergency. These emergencies can be due to biological factors like bacterial, viral, or fungal infections, or mechanical factors like a broken or dislodged tooth, which can bring about complications and pain in the pulp or gums. If not addressed immediately, the injury site also becomes an avenue for bacteria invasion, potentially leading to infection.

Handling a dental emergency means addressing immediate symptoms, especially pain and bleeding, and then planning the next steps of treatment. To manage dental emergencies more efficiently, they can be categorized into: traumatic, infectious, and post-procedure emergencies.

Traumatic dental emergencies may involve broken, dislodged, or knocked out teeth from falls, sports injuries, car accidents, or physical violence. Each type of injury presents unique symptoms and has different treatment methods. On the other hand, infectious dental emergencies mostly start from dental caries, a common dental disease. If not treated correctly and quickly, it can lead to severe infections, threatening life and compromising airways. Practicing good oral hygiene and early diagnosis and treatment can significantly reduce the risk of these infections.

Post-procedure emergencies commonly involve prolonged bleeding after tooth extraction. This situation is especially seen in patients with inherited bleeding disorders, diseases affecting blood clotting, or those taking blood-thinning medicines. If not properly managed, it can result in dangerous complications like excessive blood loss or blockage of the airway. Another common post-procedure issue is alveolar osteitis, often known as ‘dry socket,’ which is a painful condition that occurs when the blood clot at the extraction site gets lost or does not form, causing the bone to be exposed. It’s not an infection, but slow healing.

Grouping dental emergencies in these categories can help healthcare professionals assess and treat these emergencies more effectively, improving overall patient outcomes.

What Causes Dental Emergencies?

The causes of different dental emergencies can change depending on the specifics of each situation, but there are common patterns we can observe.

In traumatic dental emergencies, the damage is typically caused by a direct or indirect impact on the teeth or the structures around them. This often comes from things like falls, sports injuries, traffic accidents, or physical violence. Injuries from falls and car accidents usually affect the primary teeth. Sports-related dental injuries are most common in teenagers, while injuries from physical violence become more common in young adults aged 21 to 25.

Whether an injury ends up fracturing a tooth, dislodging it, or completely knocking it out depends on several factors. For example, the location of the tooth, the force and direction of the impact, the object that caused the impact, and the condition of the tooth and its surrounding structures can all make a difference. Teeth towards the front of the mouth, for instance, are more likely to get injured because of their position. Patients with prior dental injury, decay, or inflammation are also more likely to sustain injuries, even from small impacts.

If a tooth is knocked out completely, it usually means there was a lot of force involved. Therefore, there might also be injuries to the surrounding bone structures and the overall head and neck area.

Often, infectious dental emergencies are due to dental decay. While decay itself isn’t a threat to life, it can make patients more prone to infections within the mouth. These infections can also stem from trauma, or procedures like root canal treatments or wisdom tooth extractions.

People often seek emergency treatment for dental infections because of severe pain or swelling. Common infections include irreversible pulpitis, pulp necrosis, periodontitis, and apical and periodontal abscesses. While gum disease usually doesn’t cause pain, a severe form of it does cause extreme pain in the gums. Infections can also occur in the gum tissue surrounding a tooth that’s coming in or partially erupted, typically a third molar, causing localized pain and swelling.

If dental infections keep getting worse, they can lead to major infections in the head and neck area, or even infections in the facial bones. Dental infections were found to be the cause for nearly half of major neck abscesses in one study. Even more seriously, in over 90% of patients presenting with Ludwig’s angina – a fast-spreading infection in the mouth and neck region, which can be deadly and lead to breathing issues – the cause was found to be a dental infection. This shows the importance of quickly identifying and treating dental infections.

Then there are post-procedural dental emergencies. One example is post-procedure bleeding, which can happen if the blood clotting process is disrupted. Local disruptions include situations where a blood clot fails to form or is lost at the site of a blood vessel injury. This depends on intrinsic factors like the surgery’s location and wound size, but also on extrinsic factors like accidentally dislodging the clot through repeated spitting or rinsing, or excessive suctioning.

Systemic disruptions to the hemostasis, meanwhile, involve inborn or acquired blood clotting disorders. Congenital disorders are rare but include hemophilia A, hemophilia B, and Von Willebrand Disease, all of which stop stable blood clots from forming. Acquired disorders, on the other hand, can include conditions or medications that affect blood clotting factors or platelets. This includes patients with diseases like cirrhosis or end-stage renal disease who are on dialysis or medications to stop blood clots forming, including enoxaparin, warfarin, and direct oral anticoagulants.

In alveolar osteitis, where the cause isn’t fully understood, the problem seems to be the formation or breakdown of a blood clot at the extraction site. Both physiologic and non-physiologic factors have been studied as ways to promote the premature breakdown of a clot. Poorly understood factors like cytokines, biomarkers, mouth bacteria, and poor oral hygiene have all been suggested as potential contributors to the condition.

Risk Factors and Frequency for Dental Emergencies

Dental trauma is responsible for around 17% of total injuries seen in children and is more common in boys. It tends to affect permanent teeth more and is usually caused by falls. Sports-related dental injuries are most common in teens while dental trauma related to physical violence increases in young adults aged between 21 to 25.

Infections in the mouth are another concern. The three most common types are periapical abscesses (14 to 25%), pericoronitis (10 to 11%), and periodontal abscesses (6 to 7%). The occurrence of these infections can be influenced by ethnicity and location. Some infections target specific groups. For example, pericoronitis often occurs in people in their twenties because it’s associated with the growth of third molars. Necrotizing periodontal disease is more likely in people with compromised immune systems or severe malnutrition. On the other hand, pulp complications are common in people with untreated cracked teeth or dental fractures.

Most people visiting the emergency department with dental issues are discharged. However, about 5% are admitted to the hospital, with 85% of those cases dealing with a dental infection.

Post-procedure bleeding is a known complication, especially in those with coagulation disorders. The incidence of bleeding after tooth extraction varies, but it’s more common in people taking anticoagulant medications. Hemophilia A, Hemophilia B, and Von Willebrand disease are common in patients with blood clotting issues. Note that 14% of patients with hemophilia are not diagnosed until after a severe bleeding episode from routine dental treatment. Prolonged bleeding after a dental operation is more likely to occur in the lower molars and teeth with infected surrounding structures.

Another issue after a dental procedure is alveolar osteitis, which occurs in 0.5% to 68% of cases according to different studies. However, larger studies suggest the real incidence is likely less than 5%. This condition is more often seen in lower third molar extractions (up to 30% of cases) and among people with poor oral hygiene, tobacco use, oral contraceptive use, and difficult tooth extraction.

Signs and Symptoms of Dental Emergencies

For dental emergencies related to physical injury or trauma, such can be classified into different categories based on the parts of the tooth affected. These categories are:

• Enamel infractions and fractures: These involve small cracks or substantial damage mostly to the outer layer of the tooth called the enamel. They do not involve the dentin or pulp layers.
• Enamel-dentin fractures: These extend through the enamel and into the dentin without exposing the pulp layer. On the other hand, enamel-dentin fractures with pulp exposure are more serious because the pulp (contains nerves and blood vessels) is visible.
• Crown-root fractures: These extend from the tooth’s crown (visible part) toward its tip and involve the coating over the root. The pulp may or may not be exposed.
• Root fractures: These involve the base of the tooth, below the gum line, and can be difficult to see during checks.

The damage can also be in the form of tooth displacement or loosening, also known as tooth luxations. Depending on the direction of the tooth’s displacement, this could be subluxation (abnormal loosening), extrusive luxation (tooth displaced out of its socket in a direction away from the root), intrusive luxation (tooth displaced into the jaw bone), or lateral luxations (tooth displaced in any sideways direction).

Another form of damage in dental trauma is tooth avulsion, where a tooth is entirely knocked out of its socket. It is important to check for other oral injuries such as cuts and fractures, and also consider if the tooth might have been swallowed or inhaled.

There are also dental emergencies caused by infections. For instance, pulpitis is an inflammation of the pulp, which can lead to toothache, discoloration and eventually tooth death. Periodontitis involves gum pain, bleeding when brushing, bad breath, and inflamed gums. Another form of gum disease is necrotizing periodontal disease which rapidly destroys gum tissues. Dental abscesses present as swellings, while pericoronitis surrounds partially erupted teeth. Leaving dental infections untreated can result in more serious, life-threatening conditions.

Lastly, dental emergencies could be post-procedural, such as bleeding and pain after tooth extraction. The bleeding might be mild at first but can become more serious, resulting in a local oral blood clot or hematoma. Alveolar osteitis, commonly known as dry socket, is a painful condition that occurs when the blood clot at the extraction site is lost, exposing the underlying bone.

Testing for Dental Emergencies

If you have a dental emergency due to an injury, dentists often use a combination of different types of x-rays and even CT scans to identify any fractures to the teeth and gums. These might include different angles of standard x-rays or even an x-ray of the bite. These can help distinguish between a tooth being knocked out of place and a tooth being knocked out completely, as well as the size of fractures below the gum line. However, depending on the details of your injury and the dentist’s examination, these images might not change the treatment approach. Dentists will always consider the possible risk from radiation exposure for each patient.

When it comes to dental emergencies related to infections, looking at and feeling the area are usually the best initial ways to assess for infection. Some common signs of infection include redness, swelling, or pus. You might also notice a change in tooth color or gum decay. Dentists might also measure the spaces between your teeth and gums to check for gum disease.

Dental x-rays can give a better idea of the extent of an infection, sometimes showing things not visible to the naked eye. Different types of x-rays can be helpful for identifying exactly how far tooth decay has progressed, whether there’s an abscess (a collection of pus), bone loss due to gum disease, or issues with wisdom teeth coming in. The x-rays should correlate with what the dentist sees during the physical examination to ensure the most accurate diagnosis. CT scans and MRIs are helpful to assess deeper infections and bone infections. A specific type of CT scan, known as a cone-beam CT, is becoming increasingly common in clinics to help visualize oral infections better.

After dental procedures, bleeding can occur. Unless you’ve had a traumatic oral injury, x-rays and CT scans usually aren’t very useful in handling bleeding after tooth extractions or operations.

Normally, if a patient is at risk for abnormal bleeding due to a congenital bleeding condition, systemic illness, or medications, the dentist or oral surgeon would identify this before the procedure. If a patient has a bleeding disorder, it’s best to plan their dental care with the assistance of their blood specialist and provide a replacement for the missing clotting factor before any invasive procedures to prevent post-surgery bleeding. Also, for patients with systemic illness or taking anticoagulant medications, coordinating their dental care with their regular doctors can help prevent bleeding after the surgery.

If you take anticoagulation medication, some sources suggest discontinuing it before dental surgery, while others say the risk of a blood clot is higher than the risk of bleeding and recommend you continue it. If you’re taking Warfarin or direct oral anticoagulants, oral tranexamic acid started before the procedure might be beneficial. However, these points are debated, and the effectiveness and availability of local treatments to stop bleeding are high.

Aside from a complete physical examination, labs can be done before or after surgery if they’re needed to check for blood counts and clotting times, especially in patients who are on Warfarin or have liver disease, and in patients with Hemophilia A and B, to ascertain clotting Factor VIII and IX blood levels, respectively.

Alveolar osteitis is a condition that can occur after a tooth extraction. It is diagnosed by examining the patient, and does not require any lab tests or x-rays. However, if there’s a concern about a leftover piece of tooth in the socket after an extraction, a panoramic x-ray can be done.

Treatment Options for Dental Emergencies

Regular oral hygiene can help prevent infections in all types of dental emergencies.

Treating Tooth fractures

Small cracks in the outer layer of your tooth usually need no treatment, but if they get bigger, a dentist might seal them with a special resin to prevent discoloration and infection. If a piece of the tooth has broken off, the dentist may reattach it or smooth the edges if the break isn’t big. In larger breaks, the tooth may need to be rebuilt with a resin composite material. Dentists usually recommend follow-up visits at 2 and 12 months after treatment.

When the inner layer of the tooth is exposed, the dentist applies a calcium compound to protect it from infection and keep the tooth healthy. The calcium compound is a temporary solution and later needs to be covered with a resin composite or a glass-like material. If possible, dentists prefer to reattach the broken part of the tooth.

If tooth pulp (the soft inner part of the tooth containing nerves and blood vessels) is exposed, dentists use calcium to protect it. The best approach depends on the degree and duration of pulp exposure and other injuries. In younger teeth, pulp capping works best. But when the pulp exposure is extensive, a partial pulpotomy (removal of a portion of the pulp) is recommended to keep the tooth alive for a long time. However, root canal treatment and restoration will be necessary later.

A variety of treatments are available for crown-root fractures and root fractures starting from reattaching the tooth fragment, applying resins on exposed parts, splinting the tooth, to root canal therapy, depending on the severity of the fracture and extent of pulp involvement.

Loose and Dislocated Teeth

Minor tooth subluxations usually need no treatment unless the tooth is very loose or causing discomfort. Severe tooth dislocations need to be repositioned and stabilised with a splint. Regular follow-ups are recommended for these cases, and root canal treatment may be necessary if the pulp dies.

Teeth that have sunk into the gums on their own may re-emerge without intervention. If not, they need to be helped out orthodontically. If teeth are forced back into the gums, surgical repositioning is desired. Immature teeth are generally safer, but fully formed teeth may always develop pulp necrosis, so early root canal therapy is usually considered.

Knocked-out Teeth

If a tooth gets knocked out, it should be put back in place within 30 minutes for the best chance of survival. The dentist cleans the tooth and the socket, refits the tooth, and stabilises it with a splint. Follow up visits are necessary to monitor the tooth vitality and detect resorption (when the body begins to dissolve the tooth).

Treating Dental Infections

It is essential to treat dental infections promptly to avoid serious complications. If possible, the infected tooth should be preserved. The infected part of the pulp is removed and the tooth is filled in cases of pulpitis. Abscesses can be drained, and antibiotics may be necessary in severe cases. In extreme cases of periodontitis, surgery may be needed to remove the infected gums. Necrotising periodontal disease may need aggressive oral hygiene in addition to antibiotics. For pericoronitis, the soft tissue overlying the erupting tooth is removed or the tooth is extracted.

Post-procedural emergencies

Post-procedure bleeding is usually managed locally with pressure, gauze, suturing or a range of therapies to either absorb or halt the bleeding. In people with blood clotting disorders, fresh blood products, clotting factors or certain medications may be needed. In some cases, securing the airway may be necessary. Dry socket (alveolar osteitis) after a tooth extraction can be treated with irrigation of the socket, pain relief, medicated dressings and chlorhexidine rinses. Low-level laser therapy is a safe, affordable, and effective new treatment that may be used in the future after more research.

What else can Dental Emergencies be?

Dental emergencies can occur as a result of trauma, infections, or even after dental procedures. Here are some simplified explanations of these situations:

Traumatic Dental Emergencies:

When a tooth fracture occurs, doctors diagnose it through an examination, questioning the patient about how it happened, and using X-ray images. However, if there’s significant pain when touching the tooth or the area around it, this could show that the tooth is also dislocated or the root of the tooth is broken.

When diagnosing tooth dislocation, doctors also consider all types of dislocations. This includes total dislocation inside the gum, partial dislocation, and dislocation to the side. Tooth extraction or the complete coming out of a tooth from its socket is also accounted for in such cases.

Infectious Dental Emergencies:

Some dental infections may actually be caused by other conditions. For example, oral cancer can sometimes appear like a dental infection. It can destroy the bone and be mistaken for gum disease. Bleeding gums could happen because of blood cancer, and this could be wrongly identified as an infection. Cysts and tumors can also look like infections. Likewise, side effects from medication could be mistaken for mouth infections. Other conditions that could mimic dental infections include problems with the salivary glands and sinus infections.

If a dental infection is localized or confined to a specific area, it’s essential to make sure it doesn’t develop into a more dangerous issue like a neck infection or a facial abscess.

Post-procedural Dental Emergencies:

Bleeding After a Procedure:

After dental extraction or surgery, bleeding can occur, especially if blood vessels have been affected. In case of excessive bleeding, doctors will consider the possibility of an undiagnosed blood clotting disorder. Other conditions like liver disease or kidney disease, as well as usage of blood-thinning medications, should also be taken into account when dealing with patients whose medical history is not well-known.

Alveolar Osteitis:

Alveolar osteitis, or dry socket, is a condition that is easy to identify based on the patient’s history and a physical examination. However, if the pain is severe or lasts longer than a week after tooth extraction, the doctors would consider other possible causes. In such cases, they look out for signs of infection, particularly in the surrounding tissues. Other conditions that can mimic dry socket include infection of the jawbone, presence of an infection beneath the protective layer of the bone, and a small piece of dead bone separating from the rest of the bone.

What to expect with Dental Emergencies

When it comes to tooth fractures, the severity and treatment received greatly affect the outcome. Minor fractures that only affect the tooth’s outer layer come along with a positive result. However, if larger, deeper fractures are left untreated, they can worsen and may even lead to infections.

Tooth subluxations, which are partial dislocations of the tooth, typically have a good recovery rate, especially if the symptom is minimal, and there’s a positive response to pulp sensitivity tests. However, other types of tooth dislocations like extrusive, intrusive, and lateral luxations might have less favorable results, particularly for very symptomatic cases.

If a tooth is knocked out completely, the success of replanting it largely depends on how quickly it’s replanted, ideally within 30 minutes. Extended periods outside of the mouth tend to lessen the success of replantation.

Dental infections, which once had deadly consequences, now have a good recovery rate if caught and treated early. If ignored, these infections can spread and lead to severe complications. The teeth and the surrounding tissues that have a history of repeated infections or pre-existing disease also have a poorer recovery rate.

On the other hand, most patients undergoing dental procedures deal well with post-surgery bleeding through local interventions. Patients with blood clotting disorders can fair out well if they received clotting factor replacements beforehand. Further research, however, suggests it’s best for some people to continue their blood thinning medication during procedures to effectively control bleeding.

Finally, alveolar osteitis, a painful condition after tooth removal, generally goes away on its own after a few days of treatment, but even without treatment, the symptoms usually resolve in a timely manner.

Possible Complications When Diagnosed with Dental Emergencies

Different types of dental emergencies may lead to various complications based on their specific diagnosis and category.

For Traumatic Dental Emergencies, the complications include necrosis (death of the inner tissue of the tooth), disappearance of inner tooth tissue, tooth discoloration, and other issues like:

• Dental or gum abscesses
• Fistula formation (abnormal passageway)
• Root resorption (breakdown of the tooth root)

Particularly, tooth avulsions (knocked-out teeth) have a high risk of inner tooth tissue death. This risk increases each minute that a knocked-out tooth remains outside its socket.

The Infectious Dental Emergencies most commonly result in tooth loss. If not treated promptly, dental infections can spread in the body and lead to several issues:

• Infection of the jawbone
• Deep neck space infections, including Ludwig’s angina, retropharyngeal abscesses, and mediastinitis
• Intracranial infections
• Endocarditis, inflammation of the inner layer of the heart

Conditions like Ludwig’s angina and retropharyngeal abscesses can lead to airway obstruction. Patients with Ludwig’s angina might have swelling of the face, mouth, and neck, leading to respiratory distress, voice changes, jaw movement restriction, and trouble with oral secretions. Any sign of stridor, a harsh, vibrating noise when breathing, is serious, and immediate intubation might be necessary. Patients with retropharyngeal abscesses typically appear ill and may report neck stiffness and discomfort when extending their neck. These typical presentations can vary, which is why healthcare providers should always consider them when treating patients with severe dental infections.

For Post-procedural Dental Emergencies, the most common complication is recurrent visits to the dentist or emergency department.

• They could also develop large hematomas (blood collection) inside the mouth that could threaten their airway.
• In cases where it’s challenging to control bleeding, patients might need blood transfusions or hospitalization.

However, alveolar osteitis (dry socket) is self-limiting and does not lead to further dental complications.

Preventing Dental Emergencies

Education about dental emergencies is tailored to the particular situation at hand.

For dental emergencies caused by trauma, it’s hard to predict when they will occur due to things like accidents, falls or physical violence. However, wearing custom-fit mouthguards during contact sports can help to prevent such injuries. It’s very important for not just patients, but also parents, school teachers, sports coaches, and first responders to know what to do when dental trauma occurs. Getting medical help quickly is key for successful treatment.

When it comes to infectious dental emergencies, patients must understand how serious dental infections can be and how they can be prevented. Good oral hygiene practices like brushing and flossing every day alongside regular visits to the dentist can help stop infections. It’s also crucial to understand how to reduce risk factors, like quitting smoking and managing diabetes well, to avoid dental emergencies related to infections.

After dental procedures, patients should be aware that they might experience bleeding and should know how to respond, for example by applying pressure to the area. People who have disorders that affect blood clotting, are suffering from illnesses that can cause excessive bleeding or are taking blood thinners should be informed of their higher bleeding risk, even after minor dental treatments. Their dental care should also be coordinated with a hematologist (for patients with blood clotting disorders) or a primary care physician (for patients with liver disease, end-stage kidney disease or those taking blood thinners).

Patients who have had a tooth pulled should be aware of the risk of socket inflammation, especially if they use tobacco or oral contraceptives which can increase this risk. For high risk patients, preventive measures like mouth rinses with an antibacterial agent can be used. If patients experience symptoms of socket inflammation, they should immediately contact their dentist, who should arrange for prompt follow-up appointments in such cases.