Rawnica L. Ruegner
Dental emergencies prompt almost 3 million emergency department (ED) visits nationally, accounting for 0.7% of all ED patients (1). Factors such as poverty, a lack of dental insurance or a primary care dentist, and difficulty finding an “off-hours” dental clinic have contributed to an increasing number of patients with dental-related complaints presenting to emergency physicians (2,3,4). Despite the common nature of dental-related complaints, many physicians receive little training on dental emergencies (5).
This chapter addresses the common nontraumatic dental emergencies. Dental trauma and odontogenic infections of the face are covered elsewhere.
DENTAL ANATOMY
Human teeth are composed of three layers. The outermost layer, enamel, is an extremely hard protective cover that contains no nerve fibers. Enamel covers the visible portion, or crown, of the tooth. The corresponding outer layer in the portion of the tooth embedded in the gum or root is known as cementum and is much softer than enamel. Under the enamel and cementum is dentin, and at the center of the tooth is the pulp chamber through which the nerves and blood vessels connect to the alveolar bone. The tooth sits in a socket with relatively long apices extending into the bone. The tooth is anchored to the bone by the periodontal ligament.
The first set of teeth, known as primary or deciduous dentition, should be completely erupted by 3 years of age. This set consists of 10 maxillary and 10 mandibular teeth. The permanent teeth begin erupting at around 5 years of age. This set consists of 32 teeth divided equally into four quadrants (right upper, right lower, left upper, left lower). In each quadrant, there is a central incisor, a lateral incisor, a canine, two premolars, and three molars. The third molar is called the wisdom tooth and may not be visible if it failed to erupt or has been therapeutically removed. Several numbering systems have been developed to identify a specific tooth. The most commonly used system numbers the permanent teeth consecutively beginning with the upper right third molar (tooth 1), to the upper left third molar (tooth 16), then down to the lower left third molar (tooth 17), and across to the lower right third molar (tooth 32). Other numbering systems exist, and some patients will have teeth missing, which may make numbering difficult. Generally, physicians should simply describe the tooth involved, for example, the left upper second premolar.
The biting area of a tooth is the occlusal surface for molars or incisal surface for the incisors. In the direction of the occlusal or incisal surface is coronal and in the direction of the root is apical. The medial or mesial aspect faces toward the midline of the jaw, and the distal surface faces the ramus of the mandible. The portion of the tooth facing the tongue or palate is the lingual or palatal surface. The portion facing away from the tongue is the labial or buccal surface. The portion of the tooth in contact with an adjacent tooth is the interproximal surface.
The Dental Examination
Patients with dental complaints should first be examined for possible nondental causes of their symptoms. An examination of the external facial structures and neck can detect swelling, cellulitis, or odontogenic fistulae. When performing the intraoral examination, look first for trismus (restricted opening of the mouth) and for swelling of the tongue or lips. Examine the mouth for asymmetry, swelling, or signs of cellulitis. Determine that the uvula is midline and not shifted as a result of abscess formation. Confirm that the tongue is not elevated and that the floor of the mouth is not tender or indurated (signs of Ludwig angina). Examine the teeth looking for signs of caries. Pay particular attention to the junction of the tooth and the socket, where foreign bodies can lodge. The tissue adjacent to the tooth along the alveolar bone should be examined carefully, because odontogenic abscesses typically form in this area. The gum overlying absent molars should be examined for evidence of erupting teeth (usually the wisdom tooth). Each tooth can be gently percussed, preferably with the end of a dental mirror, though a tongue depressor will suffice.
DENTAL ANESTHESIA
Patients with severe dental pain may require anesthesia for either temporary pain relief or for painful procedures such as incision and drainage of a periodontal abscess. Topical anesthesia of the mucosa can be achieved within 2 to 3 minutes by the application of a cotton swab soaked in 20% benzocaine or 10% lidocaine. This anesthesia can lessen the pain of needle injection for further anesthesia and, in some cases, may provide adequate anesthesia for incision and drainage of a superficial abscess. An individual tooth may be anesthetized by infiltration of lidocaine (2% with 1:100,000 epinephrine) or bupivacaine (0.5% with 1:200,000 epinephrine) at the root of the tooth using a supraperiosteal injection. Mandibular teeth may be anesthetized by blocking the inferior alveolar nerve where it enters the lower mandible. Dental blocks generally last between 1 and 7 hours depending on the anesthetic and choice of procedure (6).
CLINICAL PRESENTATION
Caries and Pulpitis
Among the most common dental conditions is dental caries, or “cavities.” As oral bacteria ferment dietary carbohydrates, an acid is formed, which demineralizes the tooth enamel. This demineralization initially is asymptomatic, until the erosion intrudes on the tooth pulp, resulting in inflammation (pulpitis). Caries appear as either a whitish gray discoloration of the enamel or as a brownish visible defect of the enamel surface. Pulpitis, or inflammation of the pulp of the tooth, causes significant pain, which depends upon the extent of inflammation. Early or reversible pulpitis causes relatively well-localized pain that is usually triggered by hot, cold, or sweet stimuli, usually lasts only a few seconds, and resolves spontaneously. Late or irreversible pulpitis results in poorly localized, severe, and persistent pain.
Periodontitis
If the inflammation of the pulp goes unabated, it will extend to the tooth apices, expand outward from the pulp, and cause apical periodontitis. The pain of periodontitis is severe, persistent, and localized to a particular tooth (unlike irreversible pulpitis, which is usually poorly localized). Periodontitis usually results in a tooth sensitive to percussion.
Peri-Implantitis
Recent advances in reconstructive dentistry may cause patients to visit the ED with problems relating to their dental implants. These patients present similarly to those with periodontitis.
Abscess and Cellulitis
Should periodontitis progress unchecked, the inflammation may extend laterally from the tooth apex to cause an apical abscess. Alternatively, an abscess can form in the absence of dental caries when inflammation begins at the junction of the tooth and gum line, extends down the tooth apices, and involves the periodontal ligament and adjacent alveolar bone. This is termed a periodontal abscess and results from either chronic bacterial plaque (periodontal disease) or a foreign body lodged between the tooth and gum. Clinically, both abscesses appear as a small fluctuant swelling located adjacent to the involved tooth. The swelling may appear tense and painful or it may be draining pus. Periodontal abscesses may result in teeth that are somewhat mobile due to bone destruction. The area surrounding the abscess should be examined for evidence of cellulitis.
Pericoronitis
A partially erupted molar creates a potential space between the occlusal surface of the tooth and the gingiva through which the tooth protrudes. If plaque or food particles become lodged in this space, the overlying mucosal flap will become inflamed. Pericoronitis presents as a painful, tender area over a partially erupted tooth often accompanied by a foul taste or odor due to extruded pus.
Gingivitis
Gingivitis is inflammation of the gingiva usually caused by bacterial plaque on the tooth. Simple gingivitis does not typically prompt an ED visit, as it is painless. Gingivitis appears as redness, swelling, and pocket formation of the gingiva. If the inflammation is significant, it can produce some bleeding from the gums after brushing the teeth.
Acute Necrotizing Ulcerative Gingivitis
If bacteria actively invade the gingiva, the inflammation may produce painful, swollen gums often accompanied by fever, malaise, grayish pseudomembranes, lymphadenopathy, a foul odor, and a metallic taste. This disorder is commonly called trench mouth and may be facilitated by immunocompromise or physiologic stressors.
Gum Hyperplasia
Unusual gum swelling may rarely prompt an ED visit. In addition to gingivitis and acute necrotizing ulcerative gingivitis (ANUG), other conditions that may cause generalized gingival hyperplasia or swelling include acute leukemic infiltration and drug-induced hyperplasia (most commonly phenytoin and nifedipine).
Postextraction Bleeding
Teeth are commonly removed for therapeutic reasons, and postextraction bleeding is a frequent complication. Although life-threatening hemorrhage may occur, most patients present with persistent oozing from the extraction site. In patients with acquired or congenital bleeding disorders, bleeding may be persistent and difficult to stop.
Alveolar Osteitis (“Dry Socket”)
Following a tooth extraction, some sockets may lose the protective clot prematurely, exposing the socket down to the bone. Typically, patients present 3 to 5 days following the extraction with severe localized pain. Some patients complain of a foul odor or taste. Physical examination shows a nontoxic-appearing patient without signs of infection. The extraction site usually is unimpressive. In contrast, postextraction osteomyelitis often is associated with fever, malaise, leukocytosis, and the surrounding teeth and bone may be sensitive to palpation. A radiograph is usually indicated to rule out retained roots or foreign bodies.
Oral Candidiasis
Candidal infections of the mouth are relatively common, especially among children and the immunocompromised. Painful white plaques are present that typically can be easily scraped off to show an erythematous underlying mucosa.
Aphthous Stomatitis
Many individuals will experience painful recurrent oral ulcers. Aphthous stomatitis is a common cause, though ulcers from hand-foot-and-mouth disease, herpangina, and herpetic gingivostomatitis may appear similar. While most aphthous ulcers are <5 mm, they may coalesce to form large lesions. These ulcers are self-limited and rarely are complicated by a localized cellulitis requiring antibiotic therapy.
Herpetic Gingivostomatitis
In children younger than 5 years old, a primary herpes virus infection (herpes simplex type 1) may present with multiple painful, ulcerated vesicles in the oropharynx. Often there is accompanying fever, lymphadenopathy, erythema, and edema. Although the primary infection lasts about 2 weeks, recurrences are common, though these usually present with a lesion at the border of the lip. Eruptions are generally self-limited.
Other Systemic Diseases
Several systemic diseases can present with oral lesions, though most are nonspecific. Systemic lupus erythematosus, scleroderma, Wegener granulomatosis, pemphigus vulgaris, Stevens–Johnson syndrome, Behçet syndrome, varicella zoster, and several neoplasms all can present with oral manifestations.
DIFFERENTIAL DIAGNOSIS
Although most patients with apparent dental complaints ultimately are diagnosed with relatively minor conditions, a few will have a serious illness. Perceived dental pain can result from sinus infections, temporomandibular joint dysfunction, otitis media, migraine headaches, neuritis, or myocardial ischemia. A dental infection can occasionally spread to the cavernous sinus, face, mouth, or throat, causing a potentially life-threatening complication.
ED EVALUATION
The evaluation of the patient with dental pain begins with a relevant history and physical examination to determine if the complaint is truly odontogenic in nature. A history of recent dental procedures, medication allergies, and anticoagulant medications is particularly important. Radiographs may be helpful in the evaluation of some patients in a search for retained roots or foreign body after a dental procedure. Computed tomography (CT) scanning is indicated if one suspects the extension of an infection to the cavernous sinus, neck, or deep spaces.
KEY TESTING
• Consider radiographs for suspected foreign body, or CT scan for deep space infection.
ED MANAGEMENT
The treatment of asymptomatic dental caries and reversible pulpitis is a dental filling, and irreversible pulpitis requires root canal therapy. In the ED, patients with dental pain caused by pulpitis or periodontitis should receive pain medications and a referral to a dentist. Pain medications may include a nonsteroidal anti-inflammatory drug (NSAID), acetaminophen, or a mild narcotic. Antibiotics are not necessary for simple caries, but there are diverging opinions on their role in periodontitis. Treatment of peri-implantitis consists of irrigation with saline or 0.12% chlorhexidine, antibiotic therapy for 10 days, pain medication, and referral to a dentist (7).
A large apical abscess may be incised and drained following appropriate anesthesia of the area, usually accomplished with a dental block or topical anesthesia. Smaller abscesses, especially in children, may respond to antibiotics alone. The use of antibiotics for drained abscesses without accompanying cellulitis is controversial. Some authorities recommend antibiotics (4,8), and others do not (9). As many as two-thirds of dentists in one study prescribed antibiotics liberally (10). If the cellulitis is relatively minor and localized, oral medications are appropriate, typically penicillin V potassium 500 mg/qid (or erythromycin 500 mg/qid for patients with penicillin allergy). Patients who do not respond to initial treatment within 3 days should be switched to clindamycin 300 mg/qid.
Patients with apical abscesses or cellulitis treated as an outpatient should be referred to a dentist within 1 to 2 days. For cellulitis that is severe, has spread into the deep spaces of the face or neck, or is associated with a toxic appearance or an immunocompromised patient, hospital admission and parenteral antibiotics are recommended. These antibiotics are typically clindamycin 600 to 900 mg intravenously (IV) every 6 hours or ampicillin/sulbactam 1.5 to 3 g IV every 6 hours. If significant cellulitis is present, CT scanning of the involved areas should be performed to rule out deep space infection. Remember that incision and drainage of a dental abscess may lead to transient bacteremia, so antibiotics should be given for prophylaxis against endocarditis for individuals at risk.
Pericoronitis should be treated with mechanical irrigation under the flap following appropriate anesthesia. Some sources recommend antibiotic treatment with penicillin, erythromycin, or clindamycin in the same dosing regimens as noted previously. Patients should receive pain medications and follow up with a dentist within 48 hours. Cellulitis or abscess-accompanying pericoronitis should be evaluated and treated as discussed previously.
ANUG may be treated with systemic antibiotics and rinses with warm saline or 3% hydrogen peroxide. Improved oral hygiene is mandatory and may require prescription analgesics to alleviate the pain. Viscous lidocaine may also assist with pain relief and improve oral hygiene. ANUG requires referral to a dentist.
Postextraction bleeding can usually be stopped by having the patient bite down for 10 to 15 minutes on gauze placed over the site. Arterial bleeding may require ligation of the artery, a procedure that can be difficult without proper dental equipment. Patients taking anticoagulants or with bleeding disorders may require reversal, depending on the initial indication for anticoagulation and the extent of bleeding. Oozing that does not stop with direct pressure may require the topical application of procoagulant agents including Gelfoam, Oxycel, Surgicel, or Thrombogen (11).
For alveolar osteitis, the socket should be irrigated with chlorhexidine or warmed saline (12), dried thoroughly, and packed with eugenol-soaked Gelfoam. Analgesics should be prescribed, and the patient should be referred promptly because the packing will usually need to be replaced within 24 hours.
Oral candidiasis may be treated with an oral antifungal agent such as nystatin suspension (100,000 units/mL) (13). Five milliliters is rinsed in the mouth and held as long as possible before swallowing or spitting. Aphthous stomatitis should be treated symptomatically with hydrogen peroxide rinses or diphenhydramine syrup mixed half and half with bismuth subsalicylate (Kaopectate, 2 teaspoons as a rinse as needed). Oral corticosteroids such as triamcinolone may speed healing (Kenalog in Orabase: Dispense 5 mg and apply in a thin layer to the ulcer three times a day), and topical analgesics such as 2% viscous lidocaine or amlexanox (Aphthasol) 5% paste (apply to the lesion up to four times daily) may help with pain (14). Herpes gingivostomatitis may also be treated with analgesics such as acetaminophen or ibuprofen, adequate hydration, and oral application of agents such as “magic mouthwash,” variably described as a mixture of equal portions of diphenhydramine elixir (12.5 mg/5 mL), 2% lidocaine, and Maalox or bismuth subsalicylate (Kaopectate). For adults with a herpetic prodrome of burning or tingling, antiviral therapy with acyclovir or valacyclovir may reduce the duration or severity of the eruption. Administer acyclovir 200 mg five times a day, valacyclovir 500 to 1,000 mg bid for 5 days, or valacyclovir 2,000 mg bid for 1 day (15).
CRITICAL INTERVENTIONS
• Treat dental infections and abscesses with incision and drainage as needed and antibiotics when appropriate.
• Provide adequate analgesia by using medications and/or dental blocks.
DISPOSITION
Most patients with dental disorders may be successfully treated and discharged from the ED with appropriate dental follow-up. However, as discussed previously, some disorders may necessitate emergent dental consultation or hospital admission, such as abscesses that are large or extending over the face and neck or postextraction bleeding that cannot be controlled by simple measures.
Common Pitfalls
• Failing to identify a systemic cause, such as myocardial infarction, for face or jaw pain.
• Failing to recognize the spread of an odontogenic infection to the face or neck.
• Failing to ascertain antibiotic allergies before prescribing penicillin or other common dental antibiotics.
• Performing dental procedures prior to antibiotic prophylaxis in a patient at risk for endocarditis.
ACKNOWLEDGMENTS
The author gratefully acknowledge the contributions of Gregory T. Guldner and Thomas Forney to the content of this chapter.
REFERENCES
1. Lewis C, Lynch H, Johnston B. Dental complaints in emergency departments: A national perspective. Ann Emerg Med. 2003;42:93–99.
2. Dorfman DH, Kastner B, Vinci RJ. Dental concerns unrelated to trauma in the pediatric emergency department: Barriers to care. Arch Pediatr Adolesc Med. 2001;155:699–703.
3. Graham DB, Webb MD, Seale NS. Pediatric emergency room visits for nontraumatic dental disease. Pediatr Dent. 2000;22:134–140.
4. Von Kaenel D. Social factors associated with pediatric emergency department visits for caries-related dental pain. Pediatr Dent. 2001;23:56–60.
5. Patel KK, Driscoll P. Dental knowledge of accident and emergency senior house officers. Merg Med J. 2002;19:539–541.
6. Arizona Department of Health Services. Physician’s Guide to Dental Emergencies. Phoenix, AZ: Arizona Department of Health Services; 1998.
7. Rodriguez DS, Sarlani E. Decision making for the patient who presents with acute dental pain. AACN Clin Issues. 2005;16(3):359–372.
8. Beaudreau RW. Acute nontraumatic dental emergencies. In: Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill; 2004:1482–1493.
9. Douglass AB, Douglass JM. Common dental emergencies. Am Fam Phys. 2003; 67:511–516.
10. Dailey YM, Martin MV. Are antibiotics being used appropriately for emergency dental treatment? Br Dental J. 2001;191:391–393.
11. Matocha DL. Postsurgical complications. Emerg Med Clin North Am. 2000;18:
549–564.
12. Bowe DC, Rogers S, Stassen LF. The management of dry socket/alveolar osteitis. J Ir Dent Assoc. 2011;57(6):305–310.
13. Weinberg MA, Maloney WJ. Treatment of common oral lesions. US Pharm. 2007;32:82–88.
14. Gonsalves WC, Chi AC, Neville BW. Common oral lesions: Part I: Superficial mucosal lesions. Am Fam Physician. 2007;75:501–508.
15. Spuance SL, Jones TM, Blatter MM, et al. High-dose, short-duration, early valacyclovir therapy for episodic treatment of cold sores: Results of two randomized, placedo-controlled, multicenter studies. Antimicrob Agents Chemother. 2003;47(3):1072–1080.