A dental emergency is an issue involving the teeth and supporting tissues that are of high importance to be treated by the relevant professional. Dental emergencies do not always involve pain, although this is a common signal that something needs to be looked at. Pain can originate from the tooth, surrounding tissues or can have the sensation of originating in the teeth but be caused by an independent source (orofacial pain and toothache). Depending on the type of pain experienced, an experienced clinician can determine the likely cause and can treat the issue, as each tissue type gives different messages in a dental emergency.
Many emergencies exist and can range from bacterial, fungal, or viral infections to a fractured tooth or dental restoration, each requiring an individual response and treatment that is unique to the situation. Fractures (dental trauma) can occur anywhere on the tooth or to the surrounding bone; depending on the site and extent of the fracture, the treatment options will vary. Dental restoration falling out or fracturing can also be considered a dental emergency, as these can impact function in regard to aesthetics, eating, and pronunciation and as such should be tended to with the same haste as loss of tooth tissue. All dental emergencies should be treated under the supervision or guidance of a dental health professional in order to preserve the teeth for as long as possible.
By contrast, a medical emergency is often more precisely defined as an acute condition that presents an immediate threat to life, limb, vision, or long-term health. Consequently, dental emergencies can rarely be described as medical emergencies in these terms. Some define a dental emergency in terms of the individual's willingness to attend to emergency dental treatment at any time at short notice, stating that persons who are fussy about when they are available for treatment are not true emergency cases. There are often divergent opinions between clinicians and patients as to what constitutes a dental emergency. E.g., a person may suddenly lose a filling, crown, bridge, etc., and although they are completely pain-free, still have great cosmetic concerns about the appearance of their teeth and demand emergency treatment on the basis of perceived social disability.
Dental Pain Pain is described as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It is one of the most common reasons patients seek dental treatment and many diseases or conditions may be responsible for the cause.
Odontogenic pain Odontogenic pain is pain associated with the teeth, originating in the dental pulp and/or the peri-radicular tissues. The following table shows the different classifications of pulp status.
Classification of pulp status Features Healthy pulp Asymptomatic with mild and transient responses to various stimuli e.g. hot, cold pressure Histologically no inflammation is present Can include dentine hypersenitivity Reversible pulpitis Area of exposed dentine or pathway to exposed dentine Stimulated by hot, cold, sweet, touch, biting Mild sharp pain of short duration “Sharp” “shooting” pain Well-localised No spontaneous or nocturnal pain Histologically the pulp would show a superficial zone of inflammation Irreversible pulpitis Area of exposed dentine Stimulated by hot, cold, sweet, touch, biting Moderate to severe pain that lingers Poorly localised Spontaneous and nocturnal pain Histologically the pulp is vital and exhibits an intense inflammatory response Pulpal necrosis Area of exposed dentine that has resulted in pulp exposure to the oral environment Usually no true symptoms as the pulpal sensory nerves have been destroyed Histologically the pulp is non-vital and usually is heavily infiltrated with bacteria Pulp necrobiosis Phenomenon that occurs in multirooted teeth where one part of the pulp is vital and irreversibly inflamed and the other parts are necrotic
Peri-radicular pain Peri- radicular pain can be of pulpal origin, most commonly due to disease in the pulp extending into the peri-radicular tissues but can also be of periodontal origin due to periodontal disease. Apical periodontitis is acute inflammation of the periodontal ligament surrounding the tooth. This can be caused by inflammatory mediators from irreversibly inflamed pulp, bacterial toxins from necrotic pulp, restorations that have not been property contoured and in some cases, from treatments such as endodontic treatment. There is both an acute and chronic form of this condition. Acute apical periodontitis features include moderate to severe pain, usually stimulated by touch and pressure and may also include spontaneous pain. The chronic form of the condition can be asymptomatic but may also include pain from surrounding tissues when stimulated. Apical abscess is an extension of apical periodontitis where the bacteria have infiltrated the peri radicular tissues and are causing a severe inflammatory response; there is also an acute and chronic form of this condition. An acute apical abscess can cause facial swelling and can cause other systemic consequences such as a high temperature and feelings of malaise. In some cases this condition can be life-threatening when the inflammation compromises the airway; this is termed Ludwig's Angina. A chronic apical abscess can be asymptomatic as the pressure from the inflammation is being drained through a sinus tract; a draining sinus can usually be seen clinically. A periodontal abscess is a localised inflammation affecting the periodontal tissues. It is caused by bacteria pre-existing in a periodontal pockets, traumatic insertion of bacteria or foreign body or can occur after periodontal treatment. This condition has a rapid onset, is stimulated by touch and involves spontaneous pain. An apical abscess may drain through the periodontal pocket giving a false interpretation of periodontal abscess or a periodontal abscess may appear at the apex of the tooth giving a false interpretation of apical abscess; a tooth may also have both lesions at one point in time.
Dental Trauma
Dental trauma refers to an injury to the hard and soft tissues of the oral cavity and face. This includes the teeth and surrounding tissues, the periodontium, the tongue, the lips, and the cheeks. It is more prevalent with children between 8–12 years of age but can still happen to anyone. Trauma to primary teeth most commonly occurs at the age of two to three years, during the period of developing motor coordination. When primary teeth are injured, treatment should primarily ensure the safety of the permanent tooth and avoid any risk of damage to the permanent successor teeth. This is because the apex of the root of the injured primary tooth lies close to the developing permanent tooth germ. The prognosis of the tooth is worse the longer it is out of the mouth.
The following is a list of dental trauma affecting different surfaces of the teeth and periodontium.
Do not touch the root surface. The root is covered with living periodontal ligament cells that are necessary for successful reimplantation. Even light contact can damage these cells and reduce your chances of saving the tooth.
Injuries to the hard dental tissues and the pulp
Description Clinical status Treatment Deciduous tooth Enamel/ crown infraction Incomplete crack limited to the enamel with no loss of tooth structure Visible fracture or craze line/s, no tender to percussion, no mobility, positive to vitality testing, no radiographic abnormalities No immediate treatment required and no follow-up needed if no associated dental injuries No treatment required Enamel fracture Loss of tooth surface confined at the enamel Loss of enamel, not TTP, no mobility, positive vitality testing Smooth edges, restore tooth or attach tooth fragment if available. Dependent on the size of the fracture. Follow up radiograph in a year Restore or smoothen tooth. Review 4–6 months until exfoliation Crown and root fracture Involves dentin and cementum but not necessarily pulp TTP, mobile, positive vitality testing, pain on biting and sensitivity to air temperature. Apical extension of fracture is visible radiographically There are a number of treatment options for crown and root fracture depending on the clinical findings. Initial treatment is to stabilise loose segments by cementing into place if fragment is still available. If it has been lost then a supragingival restoration is done. Monitor tooth 3, 6, 12 months to 2 years with radiographs Extract tooth and monitor potential damage to permanent successor tooth Root fracture Fracture involving the cementum, dentin and pulp, with coronal portion of root displaced and apical portion of pulp remains vital Coronal segment may be mobile and sometimes displaced, tender, vitality testing usually negative. Root fracture is visible radiographically appearing horizontally or diagonally planed Splint to stabilise loose fragment for 4– 4 months depending location of fracture and then root canal treatment. Clinical and radiographic analysis after 8 weeks, 4, 6, 12 months and yearly for 5 years Extract tooth and monitor for potential damage to permanent successor Uncomplicated crown fracture Fracture of the enamel with/ without dentin involvement, with no disturbance to the pulp Visible loss of enamel and dentine, not TTP, normal mobility, positive to vitality testing Tooth fragment is bonded on or restoration. Follow-up 6–8 weeks and 1 year Smoothen sharp edges and/ or restore tooth. Review with radiographs after 6– 8 weeks. Monitor until exfoliation Complicated crown fracture Involves the enamel, dentin and pulp Loss of enamel and dentine with exposure of pulp, no TTP, normal mobility, pulp sensitive to touch Pulp capping, partial pulpotomy or coronal pulpotomy if root of tooth still forming or root canal treatment. Review and monitor every 3 months and then yearly Extract tooth or pulp treatment if patient is cooperative. Monitor signs for symptoms and pathology
Injuries involving periodontal tissues