Emergency Dental Care

Pain may occur following dental treatment. It is not uncommon after a very large and deep filling has been placed or a dental extraction carried out. The degree of pain is related to the damaged dental tissues (i.e. the surgical removal of an impacted wisdom tooth can be associated with several days of pain or discomfort). Patients must therefore expect to be given suitable medication and advised to follow procedures aimed at promoting rapid healing whilst reducing the discomfort to a minimum. It is most unusual for post-operative pain to last for more than ten days, and in the vast majority of cases medication will not be required for more than three days.

There are other causes of dental pain that simulate toothache in people who otherwise may have good oral hygiene and excellent teeth. Sinusitis can cause pain on one or both sides of the face. Trigeminal (facial) neuralgia can bring stabbing pains that will cause serious incapacity. Deep-seated aches in the jaws may also indicate the presence of disease.

Diagnosis may not be easy or certain, and it is imperative to see a dentist who may have to refer to a consultant for further tests.

There are many factors that influence the choice of a successful regime for dental pain control. The young and the old require extra care, together with those who may already be taking medication for other medical or dental conditions, and pregnant or nursing mothers. The assessment of the physical and psychological make-up of the patient, together with their past experiences with various forms of pain control, are key to future choices. Allergies, asthma, other contra-indications and short term personal or business activities may also have to be considered.

In the vast majority of emergencies dental pain can be controlled in the short term by one of three simple medicines: paracetamol, aspirin and ibuprofen. All can be purchased without the need for a prescription and are known as ‘over-the-counter’ (OTC) medicines. Only a minority of dental cases will need access to more powerful ‘prescription-only medicines’ (POM) that can only be supplied by a general medical or dental practitioner.

Proven to help in pain relief in a wide variety of situations that include headaches, muscular pain, neuralgia, influenza and dental pain, paracetamol also reduces raised body temperature. It has remarkably few side effects and is well tolerated in those situations in which aspirin has to be avoided, including in young children.

A useful, trusted, analgesic with blood-thinning properties. The fact that aspirin modifies the blood clotting mechanism has to be recognised as an unwelcome side effect for some patients and particularly those who suffer gastrointestinal problems. Aspirin must be avoided in those with peptic ulcers, pregnant women and also in some post-operative situations as it could delay healing. It should not be given to children under the age of 12, to asthmatics or those with a tendency to allergic reactions. The old fashioned practice of placing an aspirin tablet beside a painful tooth can cause burns and bleeding of the gum and is to be discouraged.

Like aspirin, it has anti-inflammatory properties and works to help lower a fever and relieving pain. It is useful in dental pain control as many dental conditions have an inflammatory element. It should not be used in situations that involve gastrointestinal problems, asthma or after surgery.

The use of paracetamol, aspirin, or ibuprofen may well be sufficient to bring pain relief, but other drugs may be even more appropriate. For example, the addition of opiates such as codeine, either alone or combined with aspirin or paracetamol, will increase significantly the analgesic effects. The same effect occurs when codeine is added to ibuprofen. Caffeine is commonly added and may improve absorption and reduce drowsiness. Research suggests that there may be a benefit to be gained by alternating between aspirin/codeine or paracetamol/codeine combinations and ibuprofen every three hours. Some branded analgesics incorporate antihistamines such as diphenhydramine or doxylamine to improve pain-killing properties.

Manufacturer’s instructions should be read carefully and it should be remembered that medication is only a short-term remedy and not a long-term cure for acute pain.

Accidents (trauma) that involve injury to the teeth, mouth and face are particularly common in childhood. Just over one third of all five-year-olds will have suffered an injury to their first (primary) teeth. By 12 years old, 20-30% of children will have suffered injuries to their teeth. Boys are one third more likely to be affected.

Rapid action by parents, carers and teachers can save a child’s teeth, so it is important to know what to do if an accident should happen. With some injuries there is a much better chance of good recovery if treatment is given immediately, rather than waiting for professional assistance (see below). Any trauma or injury to first teeth (baby teeth) can affect the developing second teeth. Children who have had injuries to first teeth need to be monitored regularly by their dentist.

Injuries to the teeth can include a fracture of the tooth or root. The fracture can go through enamel only, through the enamel into the dentine (sensitive yellow tissue under the enamel), or into the pulp in the middle of a tooth (nerve and blood vessels).

Injury to the tissues that hold the tooth in place (periodontal ligament).

The tooth can be loosened or knocked out of its socket completely.

Severe injuries may include head injury and fractures of the jaw and facial bones. If severe injury is suspected, or there has been any period of loss of consciousness, the patient should be taken to hospital immediately.

Urgent steps to be taken after injury to baby teeth (primary teeth):

1. Calm the child down. Children will usually be very distressed.
2. Wash the blood away with plenty of cold water.
3. Use damp gauze, cotton, clean cloth or tissue to stop the bleeding by pressing on any wound including gums, tongue, lips and cheeks.
4. Try to locate any lost teeth or tooth fragments. It is important to show these to dental/medical staff to eliminate the risk that they have been inhaled.
5. Do not replace primary (first) teeth in the mouth. Infections that may occur after replacement of a primary or baby tooth could affect the development of second teeth.

Urgent steps to be taken after injury to permanent teeth (second teeth):

1. Remain calm and reassure the victim.
2. Wash the areas of injury with plenty of water.
3. Apply a cold compress of damp cotton, gauze, clean cloth or tissue, with pressure, for five minutes to stop the bleeding.
4. Locate any pieces of broken tooth and put the fragments in water. These may be able to be used to repair the broken tooth with special dental adhesive and filling material.
5. If a whole tooth has been knocked out (avulsed) pick up the tooth by the crown (top). Do not touch or scrub the root. If it has been soiled, it can be gently washed for about 10 seconds under a cool tap. Hold the tooth by the crown and gently insert it into its socket then ask the casualty to bite on a damp cloth while they are taken to a dentist.
6. If it is not possible to insert the tooth, put it in some milk, or ask the victim to place the tooth in their mouth between their teeth and cheek. Seek immediate dental assistance.

Patients who have had an accident to either first or second teeth need to be monitored by a dentist. Teeth may appear fine at first, but some teeth can show reaction to damage months, or even years, after the event. A dentist will be able to advise on the necessary follow-up period.

Toddlers and young children, when they begin to explore their surroundings, are often unsteady on their feet. Furniture is used to support awkward first steps, and falling on to a coffee table is common. Making the home as safe as is possible before a child begins to walk (9-12 months) and not allowing children to walk with cups or bottles (or other objects) in their mouths can prevent many injuries.

Sport results in many injuries to the teeth. A thorough check-up at the beginning of each season to identify teeth at risk and the provision of a mouthguard, fitted by a dentist, provide the best protection possible. Anyone involved in contact sports (eg football, rugby, hockey, boxing and wrestling) should have mouthguard protection. Even non-contact sports (eg basketball, squash, skateboarding, and cycling) can cause damage to the teeth and participants would benefit from the use of mouthguards.

Patients with physical disabilities or conditions that may cause them to fall (eg epilepsy) are more prone to accidents that involve the teeth. A dentist can give advice in these cases.

Prominent front teeth (anterior), especially if not covered by the lips, are much more likely to be fractured. Orthodontic treatment (aligning the teeth with braces) reduces this risk.

Seat belts, appropriate child restraints, and car seats all prevent trauma to teeth, mouth and face, as well as the rest of the body in the event of a car accident or sudden stop.

Chipped teeth (or fractures of the crown of the tooth) can be unsightly, sharp, and risk damage to the underlying tooth tissue. Teeth can chip due to trauma, but they can also fracture through underlying tooth decay (cavities). Teeth that are brittle due to root canal treatment, congenital abnormality or tooth grinding (bruxism) may chip more easily.

A tooth may have damage to its hard tissue, a chip or fracture of the crown or crown and root, or it may have damage to the supporting soft tissues and blood vessels. The fracture can go through enamel only, through into the sensitive yellow tissue under the enamel (dentine) or into the nerve and blood vessels (pulp). It is important to have the affected teeth checked to ensure that any injures are treated appropriately and promptly.

The long-term prognosis for any tooth depends on how severe the injury is and how rapidly it is treated. No matter how small an injury seems, if a tooth has been knocked or chipped, dental advice should be sought immediately.

First aid for chipped teeth:

1. Calm the patient down
2. Wash the blood away with plenty of cold water
3. Put a cold compress on bleeding soft tissues, eg lips, gums, or tongue
4. Find all the parts of the chipped tooth and store the fragments in water
5. See a dentist immediately.

The dentist may ask how the accident happened, when it happened, and where the injury occurred. This information is important to establish the exact nature of the blow and whether other treatments such as tetanus booster should be considered. They will also want to know if there have been previous injuries to the affected teeth.

The dentist will usually take an x-ray of the chipped tooth to establish whether there are any injuries to the root or surrounding tissues. The x-ray will show how near the pulp the chip has gone.

A simple chip may be smoothed and no restorative treatment be required. This treatment is reserved for small chips in enamel only. Chips into dentine usually require treatment, as dentine is porous and, with time, bacteria may find their way through the porous structure and cause decay or an infection of the nerve.

The dentist may temporarily dress the tooth to prevent further damage, and book a longer appointment to complete further work. The fractured piece of tooth may be used to replace the missing fragment using a bonding agent.

Tooth-coloured filling material can be bonded to the tooth to replace the missing portion. It is made of plastic with quartz or glass particles embedded into it. It is shaped by the dentist on to the tooth, and set using a special blue light.

Veneers (porcelain laminates) can also be used to repair broken or chipped teeth. They are as thin as a fingernail and fit over the visible surface of the tooth. Two visits are required; on the first visit a small amount of the tooth is removed, and an impression is taken which is then sent to a laboratory. A technician at the laboratory will make the veneer. The veneer will be bonded to the tooth at the next visit.

Crowns are usually recommended for teeth that have already been treated for decay, or for teeth that have been extensively damaged. They require the removal of 1.0-1.5mm from all around the tooth. An impression is taken from which the laboratory will make the crown. A temporary crown is then fitted. The permanent porcelain one is fitted once it is has been manufactured.

Any damage to the nerve of the tooth may not be apparent immediately, but it can slowly die. The tooth may become discoloured, usually grey. Root treatment may then be required.

Patients who have had injuries to either their first or second teeth need dental follow-up. Injuries to first teeth may affect the underlying second teeth. Both sorts of teeth may appear fine at first, but they may show a reaction months or years after the event. A dentist will be able to advise about the necessary follow-up period, and also discuss treatment alternatives in order to restore the smile.

Participation in sport causes many teeth to be chipped, fractured or knocked out. A thorough check-up at the beginning of each season is desirable as is a mouthguard fitted by a dentist. Even non-contact sports such as skateboarding, squash and cycling can cause chipping to teeth.

Patients with physical disabilities are more likely to have chipped teeth. Dentists can advise on protection for this group of people.

Prominent anterior teeth, especially those not covered by the lips, are vulnerable and are twice as likely to be fractured. Orthodontic treatment (aligning the teeth with braces) reduces this risk.

Seat belts in cars help prevent trauma to teeth, mouth and face, as well as the rest of the body, in the event of an accident.

Tooth sensitivity (also known as dentine hypersensitivity) often appears as a painful reaction to temperature changes, pressure, sweet and acidic food or drink. This reaction may be mild and tingling, or sharp and intense. People whose teeth are sensitive often feel pain when they eat or drink things which are very cold. The classic example is eating ice cream, but simply being out in the cold weather is sometimes enough to set off the problem. Sensitivity to touch may also mean that tooth brushing is uncomfortable.

Research shows that one in three people in Australia suffer from sensitive teeth at any one time. Dentine hypersensitivity can occur from 15 to 70 years of age or more, however the age group when it occurs most is between 20 and 40 years.

Triggers of tooth sensitivity and the severity will vary from person to person, although the most common are:

• Cold food and drinks (e.g. ice cream).
• Over-enthusiastic or incorrect tooth brushing technique.
• Hot food and drinks (e.g. hot tea or coffee).
• Sharp, acidic foods (e.g. apples, oranges).

Any teeth can be affected by sensitivity, but the most likely are those at the front corners of the mouth. This may be because these are the teeth which tend to be brushed more vigorously, causing the wearing of the protective tooth enamel.

A healthy tooth has a chamber inside it for the tooth pulp, which consists of nerves and blood vessels. A young and healthy tooth has a large pulp chamber where the sensitive nerves are more exposed to temperature or pressure changes from the outside. However tooth sensitivity can occur at any age. There are two general ways in which this sensitivity can develop:

1. Wearing or destruction of the hard, protective outer layer of the tooth crown called enamel. This may be related to:

• Biting abnormalities or abnormal tooth grinding.
• Toothbrush abrasion, i.e. the wearing-away of enamel and/or recession of gums caused by over-enthusiastic or incorrect brushing.
• Dietary erosion, which is the destruction of enamel by acidic food and drink or by acid regurgitation from the stomach.
• Nail biting or the placing of metal objects between the teeth
• Grinding of the teeth.

2. Gum recession exposing the softer porous tooth structures called dentine and cementum. This may be related to:

• Chronic gum (periodontal) disease.
• Surgery or difficult tooth extractions.
• Incorrect tooth brushing.

Sensitivity and dental pain can also be experienced for several other reasons:

• Chipped teeth.
• Fractured or cracked fillings.
• Dental decay (caries).
• Deep fillings.
• Cracked teeth.

Avoidance of tooth sensitivity is possible if the teeth are cleaned thoroughly, but carefully, twice a day. Chewing a disclosing tablet (obtainable from chemists) after brushing will show if any plaque is left behind. Using the correct brushing technique is essential, as is the use of a specialist toothpaste formulated for sensitive teeth. If you need advice as to the best technique to use, ask a dentist or hygienist.

Care should be taken with diet. A high intake of acid-containing food and drink such as citrus fruits and fizzy drinks will make teeth more sensitive and can lead to destruction of the tooth enamel. A dental professional can help by:

• Applying fluoride varnish to exposed sensitive dentine or cementum.
• Applying a sealer to exposed root surfaces to block the tiny tubes which are exposed or offer treatment that will desensitise the dental nerves (no drilling is required).
• Correcting any bite abnormalities to help reduce the wearing of enamel.
• Placing fillings to cover exposed dentine or cementum on root surfaces.

An ulcer is any breakdown of the lining of the mouth, which includes the cheeks, tongue, gums, lips and roof of the mouth. The raw area of an ulcer is often very sensitive and painful.

Some ulcers appear as single ulcers, other ulcers arrive in groups. Some heal quickly leaving no mark behind, and some heal leaving a scar that may be noticeable for some time. Some ulcers appear and then disappear never to return, others may keep coming back again and again.

A single ulcer which is not healing, and which has been present for more than ten days, should be looked at by your dentist. If there is no good reason for the ulcer not healing, it should be investigated further to exclude a possible cancer. Most ulcers are not malignant and can be explained after the dentist has asked about different features of the ulcer.

Single ulcers that heal are often caused by some minor damage to the lining of the mouth, such as a scratch from sharp food, or damage from a broken tooth or filling. Alternatively, a burn from hot food could cause a blister that breaks down to leave an ulcer. Occasionally, an ulcer may arise from a chemical burn such as when aspirin is left to dissolve on the gum next to a painful tooth (this will not stop the toothache). Also, the frequent and prolonged use of some toothache or teething gels can result in an ulcer in the area to which they are applied.

Other single ulcers may result from a cold sore, or much less often, a recurrence of chicken pox (shingles) affecting the mouth. More rarely, there are some conditions that can affect the mouth and cause ulceration (e.g. lichen planus, gluten sensitivity and other rare conditions).

Recurring ulcers are known by different names: recurrent oral ulceration, recurrent aphthous (pronounced ‘af-thus’) ulceration and sometimes recurrent aphthous stomatitis. These recurrent ulcers can be divided into three groups depending on their appearance and duration.

The most common type of recurrent ulcers is minor recurrent oral ulceration. The name is given because the ulcers are small, about 3-5mm in diameter. These ulcers often come in groups of half-a-dozen or so. They appear in the mouth over two or three days, last about five to seven days, and then heal over the next couple of days. They most commonly affect areas towards the front of the mouth; the lips, tongue and gums, and when they heal there is no sign of where they have been.

Much less common are major recurrent oral ulcers. These ulcers tend to occur towards the back of the mouth, the back and sides of the tongue, roof of the mouth and near the tonsils. These ulcers are usually single and large (about 1cm in diameter), and may last for many weeks. They heal slowly and leave a scar where the ulcer was.

Also very uncommon are herpetiform ulcers. These ulcers are tiny (1mm in diameter) and may appear in all areas of the mouth. There are often many tiny ulcers (dozens) appearing together. These will heal in a few days, do not leave a scar, and recur infrequently. The name, herpetiform, is because of the appearance of the ulcers. They do not have anything to do with the virus of a similar name that can cause cold sores.

No treatments are available which will cure the ulcers. Medications can be bought over the counter in a pharmacy that can help to lessen the discomfort, and include:

• Chlorhexidine mouthwash (eg Corsodyl): an antiseptic mouthwash that helps to keep the mouth clean.
• Difflam: a mouthwash or spray that can temporarily numb the lining of the mouth and reduce the soreness.
• Adcortyl in Orabase: a paste application of a mild steroid. The paste acts as a protective covering over the ulcer and the steroid part helps to reduce the inflammation and discomfort.

A dentist can look at ulcers and, if appropriate, they may refer to a hospital specialist, such as a consultant in Oral Medicine, for further investigation and/or treatment.