COVER ARTICLE

Common Dental Emergencies

ALAN B. DOUGLASS, M.D., Middlesex Hospital, Middletown, Connecticut
JOANNA M. DOUGLASS, B.D.S., D.D.S., University of Connecticut School of Dental Medicine,
Farmington, Connecticut

Dental caries, a bacterial disease of teeth characterized by destruction of enamel and den-
tine, is often the underlying cause of dental pain. When a carious lesion impinges on the
dental pulp, pulpitis follows and, ultimately, necrosis of the pulp occurs. Untreated necrosis
may lead to a localized abscess or a spreading infection into the surrounding soft tissue that
results in cellulitis. Immediate treatment involves antibiotic therapy for cellulitis, perhaps
with drainage of abscesses, while definitive treatment requires root canal therapy or extrac-
tion of the involved tooth. Pericoronitis is an inflammation of the soft tissue overlying a par-
tially erupted tooth. Localized cases respond to irrigation. Secondary cellulitis can develop.
Definitive treatment may require surgical extraction of the underlying tooth or excision of
the gum flap. Avulsion of a permanent tooth secondary to trauma is a true dental emer-
gency. The tooth should be reimplanted on the spot, and the patient should be seen imme-
diately by a dentist for splinting and antibiotic prophylaxis. Most dental problems can be
prevented with regular dental care and steps to minimize risks of oral trauma. (Am Fam
Physician 2003;67:511-6. Copyright© 2003 American Academy of Family Physicians.)

D
ental emergencies (Table Dental sources are most common. How-
1) are extremely common ever, pain arising from nondental sources
in America. In one recent such as myofascial inflammation,
survey,1 22 percent of the migraine headache, maxillary sinusitis,
general population had nasal tissues, ears, temporomandibular
experienced orofacial pain in the preced- joints, and neuralgias always must be
ing six months, and 12 percent experi- considered and excluded.4
enced toothache. In 1996, American stu-
dents missed 1,611,000 school days CARIOUS ORIGIN
because of acute dental problems.2 Dental caries is a bacterial disease of
teeth characterized by demineralization
Dental Anatomy of tooth enamel and dentine by acid
All human teeth are composed of three produced during the fermentation of
structural layers3 (Figure 1). The outer layer dietary carbohydrates by oral bacteria,
of enamel is an extremely hard, highly predominately Streptococcus mutans.5,6
mineralized, crystalline structure that cov- Dental decay presents visually as opaque
ers and protects the crown of the tooth. white areas of enamel with grey under-
The core structure of the tooth is com- tones (Figure 2) or, in more advanced
posed of dentine. At the center of the tooth cases, as brownish, discolored cavita-
is the pulp chamber, which contains blood tions (Figure 3). Caries is initially
vessels and nerves that connect to the jaw’s asymptomatic. Pain does not occur until
vascular and nervous supply through the the decay impinges on the pulp, and an
tooth apices. The tooth roots are attached inflammatory process develops.
to the surrounding alveolar bone of the Reversible pulpitis is mild inflamma-
tooth socket via the periodontal ligament. tion of the tooth pulp caused by caries
encroaching on the pulp. Pain is trig-
Dental Pain gered by hot, cold, and sweet stimuli,
The first step in the evaluation of oral lasts for a few seconds, and resolves
pain should be to determine its etiology. spontaneously.7 Treatment involves

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 TABLE 1
Common Dental Emergencies

Diagnosis Definition Presentation Complications Treatment

Reversible Pulpal inflammation Pain with hot, cold, Periapical abscess, Filling
pulpitis or sweet stimuli cellulitis
Irreversible Pulpal inflammation Spontaneous, poorly Periapical abscess, RCT, extraction
pulpitis localized pain cellulitis
Abscess Localized bacterial Localized pain and Cellulitis I & D and RCT or extraction
infection swelling
Cellulitis Diffuse soft tissue Pain, erythema, Regional spread Antibiotics and RCT
bacterial infection and swelling or extraction
Pericoronitis Inflamed gum over Pain, erythema, Cellulitis Irrigation, antibiotics if cellulitis
partially erupted tooth and swelling also present
Tooth fracture Broken tooth Clinical examination Pulpitis and Fillings, with or without RCT,
and radiography sequelae extraction
Tooth luxation Loose tooth Clinical examination Aspiration, pulpitis, Splinting, with or without RCT,
and radiography and sequelae extraction
Tooth avulsion Missing tooth Clinical examination Ankylosis, resorption Reimplantation and splinting

RCT = root canal therapy; I & D = incision and drainage.

removal of the carious tissue and placement of a dental severe, spontaneous, and persistent, and is often poorly
restoration, or filling. localized.7 The only way to definitively treat the discomfort
If a carious lesion causing reversible pulpitis is not is root canal treatment (removal of the pulp and filling of
treated, the condition will progress to irreversible pulpitis, the empty pulp chamber and canal) or extraction of the
a severe inflammation of the pulp (Figure 4). Pain becomes tooth. The urgency of referral to a dentist should be deter-
mined by the patient’s level of discomfort, but examination
should not be delayed for more than a few days. The pain
should be managed with appropriate analgesia such as a
Enamel nonsteroidal anti-inflammatory drug (NSAID) or a weak
. opioid combined with an NSAID or acetaminophen in an
appropriate quantity to last until the dental appointment.
Pulp Dentine
. Patients should be warned of the risks of further compli-
. cations if they do not have prompt definitive treatment

Alveolar
bone
. Periodontal
ligament
.
ILLUSTRATIONS BY STACEY OLSON SACHS

. .

Tooth apices
FIGURE 2. Caries presenting as opaque white areas with
FIGURE 1. Normal tooth anatomy. central cavitations.

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 Dental Emergencies

Antibiotics are not necessary to treat apical

abscesses unless concurrent cellulitis is present.

FIGURE 3. Caries in the primary dentition.

Apical abscess is a localized, purulent form of apical
and advised to return to their physician if symptoms periodontitis (Figures 5 and 6). It may present clinically as
change or worsen before they see the dentist. a fluctuant buccal or palatal swelling, with or without a
A severely inflamed pulp will eventually necrose, causing draining fistula. Regional adenopathy is usually present. If
apical periodontitis, which is inflammation around the pus is draining, pain usually is not severe. Antibiotics are
apex of the tooth (Figure 5). Pain is severe, spontaneous, not necessary unless concurrent cellulitis is present. Acute
and persistent, but unlike that of irreversible pulpitis, local- incision and drainage of a fluctuant area by an appropri-
izes to the affected tooth. The tooth is sensitive to percus- ately trained physician would be reasonable. Definitive
sion with a metal object.7 Regional lymphadenopathy can therapy is root canal treatment or extraction. Patients
be present. Management is root canal treatment or extrac- should be seen by a dentist within one to two days and pro-
tion. Referral to a dentist should occur as soon as possible, vided with appropriate pain medication in the meantime.
with provision of appropriate pain medication. Antibiotics Cellulitis may follow apical periodontitis if the infection
are not necessary, but patients should be warned to return spreads into the surrounding tissues (Figure 5). Diffuse,
to the physician immediately if swelling or other evidence tense, painful swelling of the affected tissues occurs.
of spreading infection occurs. Regional lymphadenopathy is common, and fever may be
present. The infection can spread into the major fascial
spaces of the head and neck,8 with the attendant risk of air-
way compromise. Maxillary infection also may spread to
Carious lesion the periorbital area, increasing the risk of serious compli-
encroaching cations that include loss of vision, cavernous sinus throm-
on pulp bosis, and central nervous system involvement.8
. Pulp becoming The examination should focus on determining if the cel-
severely inflamed, lulitis remains localized or has spread regionally. Patients
. causing acute
pain because of
with localized cellulitis that is deemed appropriate for out-
confined space patient therapy should be treated by the physician with
antistreptococcal oral antibiotics, such as oral penicillin in
a dosage of 500 mg three times daily in adults or 50 mg per
kg per day divided into three doses in children.
In the event of true penicillin allergy, erythromycin or
clindamycin (Cleocin) may be substituted. Appropriate
pain medication should be provided. Definitive therapy is
root canal treatment or extraction, which in selected cases
may be delayed until swelling has subsided. Patients should
be evaluated by a dentist within one to two days but
warned to return earlier if swelling or pain worsens.
If infection extends regionally into the deep spaces of the
head and neck as evidenced by severe swelling, the risk of
life-threatening complications such as airway compromise
is substantial. Generally, these patients should be hospital-
ized and provided with surgical and infectious disease con-
FIGURE 4. Irreversible pulpitis. sultation. Imaging, usually with computed tomographic

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 Necrotic pulp
.

Cellulitis—
spreading of
infection into
.
. surrounding
tissues
FIGURE 6. Abscess adjacent to primary tooth.

Periapical Apical periodontitis WISDOM TOOTH ORIGIN

abscess Pericoronitis is inflammation of the soft tissues surround-
ing the crown of a partially erupted tooth, most commonly
FIGURE 5. Apical periodontitis, periapical abscess, and a wisdom tooth (Figure 7). It occurs when bacterial plaque
cellulitis. and food debris accumulate beneath the flap of gum cover-
ing the partially erupted tooth. Inflammatory edema, often
scanning, is mandatory, as is surgical drainage if abscess complicated by trauma from the opposing tooth, leads to
formation is detected. Intravenous broad-spectrum antibi- swelling of the flap, pain, tenderness, and a bad taste caused
otic treatment should be started immediately and should by pus oozing from beneath the flap.7 Regional lymph-
include coverage for anaerobes.8 adenopathy is common, and cellulitis and trismus (inability
In general, the same principles of initial evaluation and to open the mouth fully) can occur. In severe cases, the oral
management apply to the primary and permanent denti- airway can be compromised.
tion. However, carious lesions of the primary teeth less fre- If pericoronitis is well localized, hot salty mouthwashes
quently cause pain and abscesses and more frequently drain and irrigation under the flap can resolve symptoms in the
cutaneously than lesions of the permanent dentition. The majority of cases.10 Localized cases that do not respond to
systemic effects of infection are more pronounced in chil- mechanical therapy and more severe disseminated cases
dren, with rapid temperature elevations, greater risk of with spreading cellulitis should be treated with penicillin
dehydration, and more rapid spread of infection.8 and appropriate pain medication as described in the sec-
tion on carious origin of pain. Referral to a dentist should
PERIODONTAL ORIGIN
occur as quickly as possible so the patient can be evaluated
Periodontal disease is an inflammatory destruction of the to see if symptomatic treatment can suffice until eruption
periodontal ligament and supporting alveolar bone. The is complete or if surgical therapy to remove the gum flap
main etiologic agent is bacterial plaque. Multiple bacteria or underlying tooth is necessary.
are implicated, but as the disease progresses, gram-negative
anaerobes predominate.5 Patients with chronic periodontal Dental Trauma
disease or patients who have a foreign object lodged in the Dental trauma is extremely common. Children are par-
gingiva may present with an acute periodontal abscess. ticularly affected, with one third of five year olds having suf-
Symptoms include throbbing pain with erythema and fered injury to their primary teeth, and one fourth of
swelling over the affected tissue. The tooth is normally ten- 12 year olds having suffered injury to their permanent
der to percussion and shows increased mobility. teeth.11 Injuries to teeth and their supporting structures can
If left untreated, the abscess may rupture or, less com- be classified as fractures, lateral or extrusive luxation (loosen-
monly, progress to cellulitis. Patients require referral to a ing and displacement of the tooth), intrusion (displacement
dentist within 24 hours for drainage and debridement of of the tooth vertically into the alveolar bone), and avulsion
the infected periodontal area. Antibiotics are not normally (complete displacement of the tooth out of its socket).12
indicated if debridement is successful, but their use The mechanism of injury and timeline are particularly
remains controversial.9 important aspects of the history because they define the

514 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 67, NUMBER 3 / FEBRUARY 1, 2003
 When there is evidence of cellulitis spreading into
Impaction of food the deep spaces of the head and neck, hospital-
Swelling and
and bacteria ization and intravenous antibiotic therapy are
. inflammation
appropriate.

normal occlusion requires immediate dental evaluation

and treatment to avoid pain and further complications.
Teeth subject to intrusive luxation have been intruded
into the alveolar bone, which may occur to the point that
the teeth are not visible. With regard to injuries to the pri-
mary dentition, dental referral is required for monitoring
to determine if the teeth will re-erupt. For injuries to the
permanent teeth, dental referral is required for monitoring
or treatment to promote re-eruption (surgical or ortho-
dontic), often coupled with root canal therapy.13
Avulsed teeth are a true dental emergency. Primary teeth
are never reimplanted.12 In the case of permanent teeth,
FIGURE 7. Pericoronitis. time is of the essence. Immediate on-scene reimplantation
is the preferred method of treatment. If the tooth is visibly
risk of associated injuries and available treatment options. contaminated, it should be gently rinsed in cold running
Examination should focus on related soft tissue injuries tap water and then reimplanted. Care should be taken not
and the need for suturing, signs of tooth loosening, dis- to touch, rub, or clean the root, which could remove peri-
placement or fracture, and disturbance in the bite or other odontal ligament fibers and reduce the chance of successful
signs of alveolar fracture. Complete diagnosis requires at reimplantation. The patient should then see a dentist
least one dental radiograph in all cases. immediately for splinting and antibiotic prophylaxis.
All patients with traumatized teeth ultimately need fol- If immediate on-scene reimplantation is not possible,
low-up with a dentist for complete diagnosis and long- the tooth should be transported in the patient’s buccal sul-
term care. Long-term sequelae can include pulp death, cus, milk, or a specialized tooth transport container to the
root resorption, and displacement or developmental physician’s or dentist’s office. The tooth should then be
defects of permanent tooth successors. immediately reimplanted. If rinsing is required, normal
Tooth fractures may involve the crown, the root, or both,
with or without exposure of the pulp. Fractures limited to
the enamel and small amounts of dentine that are not sen-
sitive may not require immediate treatment but should be
checked by a dentist. Fractures exposing the pulp are often
painful, and patients with this condition require timely
referral to a dentist. Tooth fragments should be kept
hydrated as they could possibly be reattached. Definitive
treatment may involve root canal therapy or extraction.
Fractures of the root usually require a radiograph for
detection (Figure 8) unless the tooth is particularly loose and
the fracture occurred close to the gingival margin. Treat-
ment may involve root canal therapy, splinting, or extrac-
tion, depending on the exact nature of the root fracture.
Teeth subject to lateral or extrusive luxation have been
displaced and are loose. In the primary dentition, if the
traumatized teeth are so loose that they are in danger of
being aspirated or if they interfere with normal occlusion,
immediate referral to a dentist for extraction is required.12
Luxated permanent teeth require dental referral for reposi-
tioning, splinting, or root canal therapy, along with long-
term follow-up.13 Any luxated tooth that interferes with FIGURE 8. Fractured root shown on radiograph.

FEBRUARY 1, 2003 / VOLUME 67, NUMBER 3 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 515
Dental Emergencies

Permanent teeth that are avulsed should be reim- Dental Referral

planted as soon as possible; primary teeth that Family physicians often ask the question, “What sort of
are avulsed are never reimplanted. dentist should I refer this patient to?” In most cases, a gen-
eral dentist can meet the needs of patients with the prob-
lems described in this article. Children younger than three
years and children who may present a behavior problem in
saline should be used, and any clot present in the socket the dental chair should be referred to a dentist with signif-
should be flushed out before reimplantation. icant experience in managing children. Adults who do not
Antibiotic prophylaxis with penicillin should be pre- wish to attempt to keep their teeth or who have significant
scribed, tetanus vaccine should be administered if the facial swelling should be referred to an oral surgeon.
patient has not received it in the past five years,14 and the
patient should be immediately referred to a dentist for The authors indicate that they do not have any conflicts of inter-
splinting and further therapy. Avulsed teeth that have not est. Sources of funding: none reported.
been managed in an appropriate and timely fashion should
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