Sunday, 4 June 2017

Top 5 Dental Emergencies

I blogged about my top 5 hidden causes of dental pain; now time for the top 5 most common dental emergencies.



1. Irreversible Pulpitis

The obvious one! I would say the most common dental emergency and cause of toothache. In these cases the patient will report:
  • On/off or constant throbbing/pulsating pain
  • Pain which is worse on hot or relieved by cold
  • Often painkillers are ineffective in managing the symptoms
  • Sleep is often disturbed
  • The patient may report previous pain which was milder and subsided before this acute severe episode of pain
  • The patient often cannot localise the pain e.g. it radiates or feels like coming from both top and bottom teeth
Antibiotics are in most cases ineffective at managing this pain as there is no acute infection but instead the pain is from the inflammation of the pulp. Management in these cases is either extraction or extirpation of the inflamed pulp. 


2. Facial Swellings

One of the true dental emergencies, facial swellings should be treated with urgency. Sometimes swelling can be subtle and present with a mild facial asymmetry that is difficult to distinguish (often you rely on a patient reporting the swelling). In contrast, some patients will walk in with a very obvious facial swelling. Some questions I ask in addition to my usual history if I notice a facial swellling are:
  • How long has it been there?
  • How quickly has it come up? (this will help me determine the severity/progression of the swelling)
  • Is there any difficulty or pain swallowing?
  • Is there difficulty breathing?
  • Is there any fever/temperature?
  • Is there any feeling of unwellness/nausea?
If you notice a swelling, try to take a patient's temperature and check for nodal involvement. Always try to drain the infection (e.g. incise and drain) as well as prescribing antibiotics appropriately according to guidelines

3. Pericoronitis

Pericoronitis is most common with lower third molars; however it can affect other teeth e.g. upper wisdom teeth, second molars etc. The issue is often food and plaque trapping around the operculum as the tooth erupts and from my own experience of this I can vouch it to be quite painful! 

As I mentioned in my previous dental emergency blog, sometimes pericoronitis doesn't present as the obvious case of pain - read here. Management will include:
  • Irrigation underneath the operculum either with saline, peroxide or chlorhexidine digluconate (CHX) mouthwash 
  • Good oral hygiene - I often either give the patient the Monojet syringe I use or advise a single tufted brush in this area
  • Mouthrinses with saline, peroxide or CHX
  • Appropriate analgesic relief - often NSAIDs are the most effective
  • Prescription of antibiotics if appropriate - metronidazole 400mg as per guidelines


4. Trauma

I'm sure many of you know the bible to the management of dental trauma - The Dental Trauma Guide (although now you have to pay for some aspects) which is a great resource of access. I have seen lots of dental trauma, but I must say in most cases it is relatively simple to manage in an acute setting as mostly I see concussion, subluxation or enamel-dentine fractures. 

Of course I do see more extensive traumas from alveolar fractures to avulsions which are more challenging to manage. But in simple cases I will manage as follows:
  • 2 radiographic images at right angles to rule out any fractures e.g. occlusals, PA 
  • Soft diet for 2 weeks
  • Appropriate analgesia
  • Avoid contact sports 
  • Good oral hygiene - use of CHX gel or mouthwash if brushing is difficult
  • Composite or GIC bandage if there is a tooth fracture
  • Follow up with their GDP in 2 weeks
I also warn the patient of possible sequelae e.g. pulpal necrosis, resorption etc. 


5. Periodontally-Involved Teeth

I see this a lot in the area I work in East London. A lot of people have underlying chronic periodontitis and present to me in an emergency with an excessively loose tooth which is now causing them pain. 

Often, a patient will walk into your surgery requesting an extraction straight away but remember to give all the options to the patient is you think that there is a chance of saving a tooth e.g. periodontal therapy In some cases, the prognosis is hopeless and the only option is extraction, especially in patients who are irregular attenders with generalised chronic disease (and in the case of where I am in East London, are paan chewers). 


After a while of working within an acute service, you will be able to diagnose the patient within the first few minutes of history taking. Of course, this isn't always the case so always be mindful and don't fall into traps! If you are unsure, take radiographs to help your diagnosis or refer on. 


Do you work in an acute dental setting? Do you encounter these situations commonly? Leave your comments in the section below!



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