Dental Emergencies

Etiology

The etiologies of the various dental emergencies differ depending on the diagnosis, but general themes can be observed within each category.

Traumatic Dental Emergencies

Traumatic dental emergencies are all sustained by the direct or indirect impact on the dentition or surrounding structures.[2] The inciting trauma is most commonly due to falls, sports injuries, traffic accidents, or physical violence.[3] Falls account for most dental trauma, followed by motor vehicle accidents, which most commonly affect primary dentition. Sports-related dental trauma is most prevalent in the teenage population, whereas the incidence of physical violence-related dental trauma increases in young adults aged 21 to 25.[8]

Whether the inciting trauma results in a tooth fracture, luxation, or avulsion depends on multiple factors, including the location of the tooth in the dental arch, the force and direction of the impact, the structure of the impacting object, and the integrity of the tooth and its surrounding structures.[8] Teeth located anteriorly in the maxilla are most likely injured because of their position within the oral cavity. Any patients with previous dental injury, dental caries, or inflammatory changes of the tooth’s surrounding structures are more predisposed to traumatic injuries with even a lower impact than those with healthy tissues.[9]

It takes significant force to avulse a tooth; thus, additional injuries to the surrounding alveolar bony structures and the entire head and neck should be considered in patients with avulsed teeth.[2] 

Infectious Dental Emergencies

Dental caries are the basis for the majority of dental infections. While dental caries are not life-threatening, their presence can predispose patients to oral cavity infections. Other causes of dental infections include trauma or operative manipulation such as root canal treatment and third molar extractions.[10] 

Infections of dental origin prompt patients to seek emergency treatment mainly due to severe pain or swelling. These include irreversible pulpitis, necrosis, periodontitis, and apical and periodontal abscesses (see Image. Dental Abscess). While periodontal disease does not normally induce pain, a severe necrotizing form of the disease exists, which is characterized by an aggressive infection with extreme gingival pain.[11] Pericoronitis, the infection of the gingival tissue overlying an erupting or partially erupted tooth, and typically a 3rd molar, may also cause localized pain and swelling.

The progression of dental infections can lead to deep space infections of the head and neck and osteomyelitis of the facial bones. In 1 study, dental infections were the most common cause of almost 50% of deep neck abscesses.[12] Likewise, dental infections were found to be the etiology for over 90% of patients who presented with Ludwig angina, a rapidly progressive and sometimes fatal infection of the soft tissues of the mouth and neck, which can ultimately cause airway compromise.[13] Thus, early identification and prompt treatment of dental infections are important to prevent more severe, widespread, and life-threatening infections.

Post-procedural Dental Emergencies

Post-procedural Bleeding

Multiple mechanisms may disrupt hemostasis, which can be organized into local and systemic etiologies. Hemostasis can be disrupted locally when the blood clot fails to form or is lost at the site of vessel injury. This depends on intrinsic factors, including the surgical location (whether the site is easily accessible) and wound size, with smaller lesions responding better to local treatment. Extrinsic factors, including accidental disruption of the clot through persistent spitting or rinsing and constant suctioning, can also affect local hemostasis.[14]

A systemic disruption of the hemostasis is seen in congenital and acquired coagulopathies. Congenital coagulopathies are rare, but the most commonly encountered are hemophilia A, hemophilia B, and Von Willebrand Disease, which inhibit stable clot formation.[15] Acquired coagulopathies include patients with systemic diseases that affect either the clotting factors or platelet number and integrity. This commonly involves patients with cirrhosis or end-stage renal disease managed with dialysis.[14] Acquired coagulopathies also include patients on anticoagulant medications such as enoxaparin, warfarin, and direct oral anticoagulants, all of which affect the clotting cascade in unique ways and thus prevent stable clot formation.

Alveolar Osteitis

While the etiology of alveolar osteitis is not fully understood, many hypotheses have been studied to determine why clot formation at the extraction site either doesn’t develop or prematurely breaks down. The etiology is likely multifactorial as many studies have found physiologic and non-physiologic mediators promoting premature clot lysis. Although poorly understood, cytokines (specifically IL-6), biomarkers, local intraoral bacteria, and poor oral hygiene have all been implicated as potential culprits in the pathogenesis of this disease.[7]

Epidemiology

Traumatic Dental Emergencies

Oral trauma accounts for a relatively low percentage of traumatic injuries in all age groups but is responsible for around 17% of total injuries seen in children.[16] Dental trauma is more prevalent in males and is more likely to affect permanent teeth than primary teeth. The peak incidence of dental injuries occurs in children in the 7 to 11 age group.[17] Falls account for the majority of cases of dental trauma, approximately 65%. Sports-related dental trauma is most prevalent in the teenage population, with the incidence of physical violence-related dental trauma increasing in young adults ages 21 to 25.[8]

Infectious Dental Emergencies

The 3 most prevalent orofacial infections in 1 British study were periapical abscesses (14 to 25%), followed by pericoronitis (10 to 11%), with periodontal abscesses being the least common (6 to 7%). See Image. Periapical Abscess.[18] The incidence of periodontitis depends on multiple factors, including ethnicity and geographic location; while periodontitis has many subclassifications, the general prevalence is thought not to exceed 1%.[19]

Additionally, some dental infections show a preference for distinct populations. For example, since pericoronitis is most commonly seen with erupting third molars, the condition is prevalent in patients in their twenties.[20] Necrotizing periodontal disease, though rare with a worldwide prevalence of less than 1%, is predominantly seen in immunocompromised and severely malnourished individuals. Furthermore, pulp complications are common amongst those who have cracked teeth or dental fractures that go untreated. Wu S. et al. found in a retrospective cohort study that examined individuals with cracked teeth that 65.5% of patients were later diagnosed with irreversible pulpitis. In comparison, 34.5% were later diagnosed with pulp necrosis.[21]

Dental infections make up the majority of hospital admissions from the emergency department for those presenting with dental-related complaints. Most people who visit the emergency department with a dental complaint are discharged. Of the 5% who require admission, an overwhelming majority (85%) have a diagnosis of dental infection with diseases of the pulp and periapical tissue.[22]

Post-procedural Dental Emergencies

Post-procedural Bleeding

Bleeding is a widely recognized and expected complication encountered in dental practice, and the incidence increases with the presence of congenital or acquired coagulopathies.[5][23][24][25] The incidence of post-extraction bleeding ranges from 0% to 26%, increasing the incidence in patients using anticoagulant medications.[26] With anticoagulant use on the rise in the last decade, these patients are more likely to present to the dental setting than patients with congenital coagulopathies.[27] Bleeding rates are higher in patients using warfarin when compared to patients using direct oral anticoagulants.[26]

While the prevalence of patients with congenital coagulopathies remains low, hemophilia A, hemophilia B, and Von Willebrand disease account for 97% of this population, with Von Willebrand disease being the most common.[15][28] While many patients present with a known congenital coagulopathy diagnosis, up to 14% of patients with hemophilia might not be diagnosed until after sustaining a severe bleeding episode with routine dental treatment.[15]

Prolonged postoperative bleeding most commonly occurs in the mandibular molars compared to the maxillary molars. Dental extractions involving infected supporting structures are also associated with an increased incidence of post-extraction bleeding.[5]

Alveolar Osteitis

While the incidence of alveolar osteitis ranges between 0.5% and 68% in the current literature, studies with larger patient populations suggest that the true incidence is less than 5%.[6][29][30] However, the incidence does appear to be higher in lower third molar extractions, with up to 30% of these patients developing alveolar osteitis.[31] Other risk factors include poor oral hygiene, tobacco use, oral contraceptive use, and difficult extraction.[7]

Pathophysiology

While pertinent pathophysiology differs for each dental emergency, a basic understanding of the anatomy and structure of the teeth and their surrounding structures sets the foundation for understanding the impact of the disturbances of normal physiology for each category of dental emergencies. Each tooth consists of a crown, the visible portion connected to the root or the portion that extends into the gingiva and alveolar bone. The enamel is the outermost layer of the tooth and overlays the dentin layer. Within the dentin layer is the pulp, which houses the neurovascular supply that extends from the alveolar bone through the tooth’s root.[10]

The periodontium consists of 4 main components that comprise the surrounding structures that support dental health: the gingiva, periodontal ligament, alveolar bone, and cementum. The gingiva (ie, the gums) is the specialized mucosa surrounding and protecting the teeth. The periodontal ligament connects the alveolar bone to the cementum tissue, which covers the tooth root.[32] The normal oral cavity flora contains many bacteria, especially gram-negative and facultative anaerobes.[10]

Traumatic Dental Emergencies

In tooth luxations and avulsions, the periodontal ligament can partially or fully tear, allowing for a partial or complete displacement of the tooth from its alveolar socket. As the neurovascular supply for each tooth comes from the alveolar bone, disruption of this periodontal ligament can ultimately lead to pulp necrosis, infection, and tooth loss. The fibers of the periodontal ligament are delicate and may not fully recover even with the replantation of an avulsed tooth. Resorption of the root may occur, further compromising the neurovascular supply and leading to dental fractures and tooth loss.[33][34]

Infectious Dental Emergencies

Pulpitis and Pulp Necrosis

The pulp is the center part of a tooth directly beneath the dentin layer, which contains nerves and blood vessels. Bacterial decay can erode through the enamel and dentin layers and enter the pulp; this causes an infection of this tissue, resulting in pulpitis. The microbes causing pulpitis continue to be an area of study, but it is predominantly thought that anaerobic bacteria are the leading cause of pulp infections.[35] Pulp necrosis results when the pulpitis infection progresses and causes irreversible damage and cell death.

Periapical Abscess

The apex of a tooth is the area where the nerve enters the tooth through the root tip. Bacterial infections of the pulp can progress and collect in the periapical region, creating an abscess. Initially, this abscess is small and focal to the involved tooth. However, local extension of this infection can lead to serious complications.

Periodontitis and Necrotizing Periodontal Disease

Periodontitis is an infection of the pocket surrounding the base of the tooth and gum tissue. It can almost universally be attributed to untreated dental caries spreading to the gingival epithelium. Advanced periodontitis can lead to irreversible loss of tooth attachment and alveolar bone loss.[36]

Periodontal disease progresses from gingivitis and involves transition and accumulation from aerobic to anaerobic bacteria such as Aggregatibacter actinomycemcomitans and Porphyromonas gingivalis. This fosters a host inflammatory response that further contributes to the condition. While periodontal disease is not considered a dental emergency, it becomes emergent when it progresses into a necrotizing infection. While the pathogenesis of necrotizing periodontal disease is not entirely understood, it is largely thought that a reduced host immune response allows commensal oral organisms to become pathogenic. These bacteria produce several metabolites that subsequently cause the rapid destruction of the periodontium.[11]

Periodontal Abscess

A periodontal abscess occurs when there is an obstruction of the periodontal pocket, causing the accumulation of bacteria. These abscesses involve the supporting structures of the teeth, including the periodontal ligaments and alveolar bone. Blockage can be caused by foreign body impaction, eg, toothpick, dental floss, or calculus accumulation. The local inflammatory response to the abscess formation, such as lysosomal enzyme release from host neutrophils, contributes to tissue damage and bacterial accumulation.[37] Not surprisingly, there is a positive correlation between the development of a periodontal abscess and the depth of the periodontal pocket.[38]

Pericoronitis

Pericoronitis is an infection of the gingival tissue surrounding an erupting or partially erupted tooth. Before the eruption, the tooth's crown exists in a sterile space of the dental follicle. Eruption requires exposure through the gingiva into the oral cavity, which contains a flourishing microbial environment. A small pocket can form between the gingiva and the grooves of the erupting tooth, making it difficult to clean and creating an area where food can easily be impacted. This creates an ideal environment for bacterial overgrowth to progress to an infection of the surrounding soft tissues.

Interestingly, pericoronitis's microbial composition is considered different from that of periodontitis.[39] Although pericoronitis can occur in any tooth, it is most commonly associated with the eruption of wisdom teeth, likely due to the posterior position of this tooth in the mouth and the deep grooves of this particular tooth.[20]

Post-procedural Dental Emergencies

Post-procedural Bleeding

When the vascular endothelium is injured during a routine dental procedure, hemostasis starts by triggering the clotting cascade and forming a platelet plug. While gingival bleeding may occur after dental extractions, the major source of bleeding is the alveolar bone. Local soft tissue bleeding is more likely to occur with a traumatic extraction, which can result in lacerated blood vessels. Osseous bleeding can be from the central vessels or nutrient canals.[5]

Bleeding in hemophilia A and B occurs because of defective fibrin stabilization due to deficiencies in factors VIII and IX, respectively.[40][41] Furthermore, the Von Willebrand factor increases the half-life of factor VII. Thus, patients with Von Willebrand disease also have defective fibrin stabilization due to a mechanism similar to hemophilia A.[42]

Bleeding in patients on anticoagulation therapy occurs because of the inhibition of specific clotting factors, depending on the medication used. Enoxaparin specifically potentiates antithrombin III, which in turn inactivates factor Xa.[43] Warfarin depletes vitamin K-dependent factors and thus reduces the synthesis of factors II, VII, IX, and X.[44] Direct oral anticoagulants are a class of medications that specifically inhibit factor Xa or IIa (thrombin).[45]

Liver and renal pathology can also lead to hematologic consequences. Patients with cirrhosis can experience pancytopenia due to hypersplenism, which can affect platelet plug formation during hemorrhage. Additionally, cirrhosis also leads to impaired coagulation, with the vitamin K-dependent factors being the most affected.[46] Patients with end-stage renal disease also have increased bleeding tendencies because of uremia-induced platelet dysfunction and are more likely to have chronic normocytic anemia at baseline.[47]

Alveolar Osteitis

The pathophysiology is poorly understood, but it is generally accepted that physiologic or non-physiologic mediators trigger premature clot lysis, which ultimately results in alveolar bone exposure after exodontia. Because the literature has shown many factors significantly affect clot formation and lysis, alveolar osteitis is likely a multifactorial phenomenon. Some areas of the previous study include cytokines (specifically IL-6), several biomarkers, local intraoral bacteria, and poor oral hygiene, all of which have been implicated as potential culprits in the pathogenesis of this disease.[7]

History and Physical

Traumatic Dental Emergencies

Tooth Fractures

The classification of dental fractures is dependent upon the tissues involved.[9] Fractures from the most superficial to deepest include enamel infractions, enamel fractures, enamel-dentin fractures, enamel-dentin fractures with pulp exposure, crown-root fractures., and root fractures (See Image. Tooth Fracture).

Enamel infractions are the least worrisome and involve microcracks isolated to the enamel. The tooth structure is preserved, and patients are usually asymptomatic. The enamel abnormalities are visualized by transillumination of the teeth during the physical exam. In contrast, enamel fractures involve more damage to the enamel, yet they still do not involve the dentin or pulp layers.[48]

Both classifications have a normal response to pulp vitality tests and tooth mobility testing; however, radiographs of enamel fractures demonstrate the degree of enamel loss, while enamel infractions have normal imaging.[49] Enamel-dentin fractures extend through the enamel and into the dentin without exposing the pulp layer. Enamel-dentin fractures with pulp exposure are more complex in that the fracture extends to the pulp layer, and the pulp is visible on physical exam.[48]

For enamel-dentin fractures, the physical exam usually demonstrates a vital tooth without sensitivity to percussion and normal mobility testing. In contrast, enamel-dentin fractures extending to the pulp are sensitive to applied pressure and temperature testing. Yet, the pulp is generally viable unless there is a concomitant luxation injury.[49]

Crown-root fractures extend from the tooth’s crown toward its apex and involve the cementoenamel junction overlying the root. The pulp may or may not be involved. The degree of apical involvement is difficult to visualize as the apex of the tooth is below the gingival margin; however, the tooth is likely to be mobile, and the patient also complains of sensitivity to percussion or pressure.[48] Radiographs with multiple views (ie, a parallel periapical view, additional views with vertical and horizontal angles, and an occlusal view) are recommended to reveal the extent and location of the apical fracture.[49]

Root fractures involve the cementum, dentin, and pulp. Again, the fracture is below the gingival margin and can be difficult to visualize during the physical exam. However, there may be clinical gingival bleeding, percussion pain, and crown mobility.[48] Radiographs with multiple views (ie, a parallel periapical view, additional views with vertical and horizontal angles, and an occlusal view) are integral to evaluating the fracture better.

Tooth Luxations

In dental trauma, a physical exam demonstrating a tooth with abnormal loosening is consistent with tooth subluxation. If a tooth is found to be displaced out of its alveolar socket in an incisal/axial direction, it is considered to be an extrusive luxation. This is in contrast to an intrusive luxation, which involves the displacement of the tooth apically into the alveolar bone. Lateral luxations consist of a tooth displaced in any lateral direction and are commonly associated with alveolar socket wall fractures.[49]

Tooth subluxations are often tender to light touch and percussion, have increased mobility without displacement, and may have minimal gingival bleeding. Because there can be transient pulp damage, pulp sensitivity testing may initially be negative. If obtained, radiographs are generally normal.[49]

With extrusive luxations, the tooth appears elongated incisally or displaced in the direction of the crown. The tooth has increased mobility and negative pulp sensitivity tests. The tooth has an increased periodontal ligament space apically on radiographs and appears displaced incisally compared to the adjacent non-injured teeth.[49]

With intrusive luxations, the tooth appears to be displaced apically into the alveolar bone. Because the tooth is displaced within the alveolar bone, it is immobile and likely negatively responds to pulp sensitivity testing. On radiographs, the tooth has a partially diminished or completely absent periodontal ligament space and appears displaced apically compared to the adjacent non-injured teeth.[49]

With lateral luxations, the tooth can be displaced in any lateral direction, further described as buccal, lingual, mesial, and distal directions. Lateral luxations are often associated with an alveolar bony fracture, which can entrap the tooth’s root, making mobility testing results variable. Radiographs demonstrate a widened periodontal ligament space, which may only be seen if additional horizontal views are obtained.[49]

As it takes a significant amount of force to cause an extrusive, intrusive, or lateral tooth luxation, a thorough examination of the oral cavity should be performed to evaluate for other traumatic injuries, including lacerations, gingival contusions, and mandibular or midface fractures. Radiographs may be useful for assessing the exact positioning of the tooth and also aid in identifying the extent of the injury.

Tooth Avulsion

In dental trauma, a physical exam demonstrating a missing tooth from its alveolar socket is consistent with a tooth avulsion. It is essential to obtain history regarding the length of time since the tooth was avulsed, whether the involved dentition is a primary or secondary tooth, whether the patient or family has kept the tooth, and what medium (if any) it has been stored in.

A thorough examination of the oral cavity involves assessing for any other traumatic injuries, including lacerations, gingival contusions, and mandibular or midface fractures. The tooth socket should be evaluated for tooth fragments (ie, a sign of dental intrusion) or other foreign bodies that may prevent tooth replantation. If the avulsed tooth is not found, the healthcare provider should consider that the patient may have aspirated or swallowed it and should evaluate for pulmonary versus gastrointestinal foreign body location with radiographs.

Infectious Dental Emergencies

Identifying dental infections is often straightforward and obvious from the history and physical examination—most patients with early dental infections present with complaints of localized pain or swelling.

Patients with reversible pulpitis usually present with a severe toothache exacerbated by temperature changes; as the pulp vitality further deteriorates into irreversible pulpitis and necrosis, dental pain becomes more constant. As pulp necrosis develops, the tooth becomes discolored and can appear yellow, gray, brown, or black.

Those with periodontitis experience gingival pain, bleeding after brushing their teeth, as well as halitosis. Furthermore, gingival inflammation is present during the oral examination. Usually, patients are known to have deep periodontal pockets (4 -12 mm), though these are often not able to be measured during an acute infection.[50]

Patients with necrotizing periodontal disease also present with severe pain and halitosis. However, they often report a rapid onset on systems, and the periodontal attachment can be destroyed in just a few days.[11] The physical exam is notable for “punched-out” ulcerations, necrotic gingiva, and pseudomembrane development consisting of inflammatory cells (see Image. Necrotizing Gingivitis With Pseudomembrane Formation).

Patients often experience spontaneous gingival bleeding or bleeding with minimal manipulation. Unlike periodontitis, deep periodontal pockets are rare, given that the quick progression of the disease does not allow enough time for pocket formation.[11]

Periapical abscesses usually have a palpable swelling at the base of the tooth.[51] Similarly, periodontal abscesses typically present as an intraoral swelling with or without pain. These patients may complain of pain exacerbated by biting or tooth laxity. This is due to the gradual loss of the periodontal ligament. A purulent discharge may be elucidated by biting or probing.[52]

Pericoronitis is often associated with third molar eruptions, and patients complain of the posterior mandible or maxilla pain. Inspection reveals a fully erupted or partially erupted tooth with surrounding gingival tissue that is erythematous and inflamed.[20]

More serious facial and deep neck, mediastinal, or brain infections can arise from untreated dental infections and have more complicated and serious presentations.

Post-procedural Dental Emergencies

Post-procedural Bleeding

Immediately after a tooth extraction, bleeding commonly occurs. Normal postoperative bleeding is often described as a slow ooze; clot formation generally occurs within several minutes, and most bleeding should resolve within 30 minutes. It is common for patients to experience minimal oozing and blood-tinged saliva for up to 8 hours after the extraction.

Post-extraction bleeding can be classified into primary, reactionary, and secondary prolonged bleeding. Primary prolonged bleeding occurs during and immediately after the extraction procedure. In this scenario, the provider notices the patient’s mouth filling with blood after removing a hemostatic dressing. Reactionary prolonged bleeding occurs several hours after the dental extraction.

Patients with reactionary prolonged bleeding are more likely to be on anticoagulation therapy, have a systemic illness, or have a congenital coagulopathy. Secondary prolonged bleeding generally occurs 1 week after the extraction and is rarely encountered in dental practice. Secondary infections are the likely etiology of prolonged secondary bleeding. Primary prolonged bleeding is more likely to respond to local treatment measures such as pressure packs and hemostatic agents, whereas reactionary prolonged bleeding may require a systemic intervention.[5]

Post-extraction bleeding may also result in local oral hematoma development, which would be apparent on the patient’s physical exam. The hematomas may expand over time, resulting in airway compromise, and any hematomas should be monitored frequently for progression. In the event of a traumatic extraction, the provider should perform a thorough physical exam to evaluate for any lacerations or other soft tissue damage that would require repair.[5]

Alveolar Osteitis

Patients with alveolar osteitis generally present 1 to 5 days after a dental extraction with severe pain at the extraction socket. This pain can radiate in the trigeminal nerve distribution and is unrelieved by oral analgesics.[7]

The physical exam demonstrates expected postoperative changes with a partial or complete loss of the blood clot within the alveolar socket. Though it can be difficult to appreciate on visual inspection, exposed alveolar bone is the classic physical exam finding of alveolar osteitis.[53]

Evaluation

Traumatic Dental Emergencies

Both intraoral and extraoral radiographs, in addition to CT scans, can help identify dental and periodontal fractures. The recommended radiographs are 1 parallel periapical view, 2 additional views with a vertical and horizontal angle, and an occlusal view.[49]

They can be useful in discerning between a dental luxation and a dental avulsion and can also better evaluate the extent of fractures below the gingival margin. Depending on the history obtained and the physical exam, radiographs and CT scans may not change the treatment plan. Dentists should consider the risks and benefits of radiation exposure to the patient.[17][9]

Infectious Dental Emergencies

Visual inspection and palpation are the best initial methods to evaluate for infection. Common signs of infection include tissue erythema, swelling, or pus extrusion. Tooth discoloration and gingival necrosis may also be noted. Periodontal probing can aid in the diagnosis of periodontal disease.

Dental radiographs can show the extent of the infection and help evaluate areas that are not obvious to visual evaluation. These include intraoral periapical radiographs, bitewing radiographs, and panoramic radiographs. These radiographs help to identify the extent of dental caries, the presence of a periapical abscess, alveolar bone loss concerning periodontitis, and third molar eruptions. The dental practitioner’s physical examination must confirm all radiographic evidence for a full evaluation and accurate diagnosis.

CT scans and MRIs help assess deep-space infections and osteomyelitis. Cone-beam CT is becoming increasingly common in clinical settings to better visualize areas of oral infections.[54]

Post-procedural Dental Emergencies

Post-procedural Bleeding

Unless in a traumatic oral injury setting, radiographs and CT scans have little utility in managing post-extraction and postoperative bleeding.

Ideally, any history of congenital coagulopathy, systemic illness, or medication use that would predispose a patient to have abnormal bleeding would have been identified by the oral surgeon or dentist before the procedure. It can be useful to ask whether bleeding disorders are present in any members of the patient’s family, as congenital coagulopathies are inherited and may not yet be diagnosed in the patient themselves. Suppose a patient has been diagnosed with congenital coagulopathy. In that case, it is ideal to coordinate their dental care in conjunction with their hematologist and provide factor replacement before any invasive procedures to prevent postoperative bleeding. Similarly, suppose a patient is known to have a systemic illness or uses anticoagulant medications. In that case, it can be beneficial to coordinate their dental care in conjunction with their primary care physicians to minimize the risk of postoperative bleeding.[28]

Some literature reviews suggest patients should discontinue their anticoagulation medications before their dental procedure. Clinical trials suggest that patients on warfarin or direct oral anticoagulants would benefit from starting oral tranexamic acid before their dental procedure. However, these points remain controversial, and other sources suggest that the risk of bleeding is lower than the risk of thromboembolism and recommend patients continue their anticoagulant therapy perioperatively given the high efficacy and availability of local hemostatic therapies.[23][25][55][56][57]

In addition to a thorough physical exam, laboratory studies can be performed preoperative or postoperative if clinically indicated to evaluate hemoglobin and platelet levels, to identify supratherapeutic international normalized ratio (INR) levels with warfarin use and in patients with cirrhosis, and to determine clotting Factor VIII and IX blood levels in patients with Hemophilia A and B, respectively.

Alveolar Osteitis

Alveolar osteitis is a clinical diagnosis and does not require laboratory studies or radiographic examination. A thorough history and physical exam are sufficient to diagnose this postoperative complication. However, panoramic radiographs can be performed if there is a concern for a retained tooth fragment within the alveolar socket.[7]

Treatment / Management

In addition to the treatments described below, all dental emergencies benefit from basic oral hygiene measures to prevent the natural oral cavity flora's overgrowth and opportunistic infections.

Traumatic Dental Emergencies

Tooth Fractures

Enamel infractions generally do not require treatment. However, if the microcrack starts progressing in size, etching, and sealing with bonding resin is recommended to prevent discoloration and bacterial infection.[49]

If the tooth fragment is available, enamel fractures can be managed by reattaching the enamel fragment. If the tooth fragment is unavailable, the tooth edges can be smoothed if the lesion is small or restored with resin composite if the lesion is more extensive. It is recommended that patients follow up in 2 and 12 months so the dentist can assess the integrity of the restoration clinically and with radiographs.[49]

The focus of initial treatment for enamel-dentin fractures is to protect the exposed dentin. Calcium hydroxide liners are commonly available in urgent care clinics, emergency departments, and primary care offices. These healthcare providers should apply this temporary treatment to prevent infection and protect the tooth’s viability.[58] In dental offices, calcium hydroxide can also be applied initially; however, the material must eventually be covered with a composite resin or glass ionomer. If the fragment is available, a dentist can consider reattaching it. If the fragment is unavailable, the dentist can perform restorative procedures using various materials, including resin direct composites or ceramics.[49]

The focus of initial treatment for enamel-dentin fractures with pulp exposure is to protect the pulp. Calcium hydroxide is 1 method to accomplish this and is often available in non-dentistry practice settings. when initiated early, it can help prevent bacterial infection.[58] For definitive treatment, the dentist has 2 main avenues of managing pulp exposure: pulp capping or partial pulpotomy. The best approach is dependent on the degree and duration of the pulp exposure and the presence of other injuries.

Pulp capping works best in immature teeth with open apices, where the pulp was considered healthy before the trauma. Indications for pulp capping include pulp exposure of a small diameter (less than 1.5 mm) that has only been exposed for a short time, thus minimizing the risk of bacterial invasion.[48]

Partial pulpotomy is indicated when the duration of pulp exposure has been extensive, or the diameter of exposure exceeds 1.5 mm. In these cases, a partial pulpotomy can be performed, ultimately allowing the tooth to remain vital for an extended time. However, the tooth eventually requires root canal therapy and restoration.[9]

Crown-root fractures are initially managed by identifying the extent of the fracture and exposing its margins. If still attached, the tooth fragment is removed by the dentist to evaluate for pulp involvement. If the pulp is not involved, the fragment can be reattached, or the exposed dentin can be covered with resin composite or glass ionomer.

If the pulp is exposed or the fracture extends far past the cementoenamel junction, definitive management becomes more complex and interdisciplinary, involving the dentist, endodontist, and oral surgeon.[9][49]

The initial focus for treating root fractures involves ensuring appropriate crown fragment placement on physical exams and radiography. The crown is often mobile and thus needs to be stabilized with a dental splint for weeks to months, with cervically-located fractures requiring a longer duration of immobilization when compared to apically located fractures.[49]

It is recommended that patients who have undergone treatment for enamel-dentin fractures with pulp exposure, crown-root fractures, and root fractures should have regular follow up with their dentist or oral surgeon at 2 months, 3 months, 6 months, and 12 months duration.[49]

Tooth Luxations

Tooth subluxations generally do not require treatment; however, a passive and flexible splint can stabilize the tooth if there is marked mobility or tenderness when the patient bites down. If a splint is applied, it is recommended that the patient follow up with a dentist after 2 weeks to remove the splint. If a splint is not utilized, the patient should be reevaluated by a dentist clinically and radiographically after 2 weeks, 12 weeks, 6 months, and 12 months.[49]

Extrusive luxations require that the tooth be gently pushed back into its alveolar socket under local anesthesia. The tooth must be stabilized with a passive, flexible splint for 2 to 4 weeks. The patient is recommended to follow up with a dentist after 2 weeks, 4 weeks, 8 weeks, 12 weeks, 6 months, and 12 months. The patient requires endodontic treatment if subsequent radiographs or pulp sensitivity testing indicate pulp necrosis.[49]

Intrusive luxations in teeth with incomplete root formation may spontaneously re-erupt without intervention. If spontaneous repositioning does not occur within 4 weeks, orthodontic repositioning becomes necessary. Teeth with complete root formation may spontaneously re-erupt if there is less than 3 mm of intrusion; however, surgical repositioning should be initiated if there is no spontaneous eruption within 8 weeks. If there is more than 3 mm of intrusion, the tooth should be repositioned surgically. The tooth should be stabilized in a passive, flexible splint for 4 weeks. While teeth with incomplete root formation are unlikely to develop pulp necrosis, mature teeth almost always experience pulp necrosis, and the health of the pulp should be monitored at subsequent follow-up appointments. Root canal therapy should be considered early.[49]

Lateral luxations require that the tooth be gently relocated back to this alveolar socket under local anesthesia. This can be difficult when the root is “locked” into position by a concomitant alveolar fracture and may require the dentist to disengage the tooth apex before repositioning it. The tooth requires stabilization with a passive and flexible splint for at least 4 weeks, perhaps longer if there are concomitant alveolar fractures. The pulp should be evaluated for necrosis 2 weeks after the injury with sensitivity testing. Teeth with incomplete root formation may experience spontaneous revascularization. However, teeth with complete root formation likely experience pulp necrosis, and root canal therapy is often indicated. The patient is recommended to follow up with a dentist after 2 weeks, 4 weeks, 8 weeks, 12 weeks, 6 months, and 12 months.[49]

Tooth Avulsions

If possible, replantation is the preferred treatment modality.[59] This must occur quickly, with the highest tooth survival seen with tooth replantation within the first 30 minutes. Early treatment focuses on preserving both tooth viability and a functioning alveolar socket.[17] Primary teeth are never replanted, as this can affect the normal eruption of underlying permanent teeth.

Before replantation, it is recommended that the avulsed tooth be stored in an isotonic solution to prevent apoptosis of the periodontal ligament. Such acceptable solutions include milk, normal saline, or the patient’s saliva. Cell death of the periodontal ligament is inevitable and can only be temporarily delayed with a proper storage medium.[60] The alveolar bone should be gently irrigated with normal saline, and any obstructing blood clot should be aspirated before replantation.(B3)

The tooth should be replanted in the correct anatomic alignment with firm pressure into the alveolar socket. It should then be stabilized with a passive and flexible splint.[9] Immobilization with a splint allows the periodontal ligament fibers to reform connections between the alveolus and the cementum. It is recommended that patients follow up to have their splint rechecked or removed at 2 weeks. If, at this time, the tooth is not viable, root canal therapy is indicated. If the tooth is viable, radiographs should be obtained at the 2-week, 1-month, 3-month, and 6-month follow-up appointments to evaluate for resorption of the tooth. Root canal therapy or even tooth extraction may be indicated if resorption develops.[49]

Infectious Dental Emergencies

Dental infections should be promptly identified and treated immediately to avoid contiguous or hematogenous spread and subsequent life-threatening complications.

As with any infection, complete removal of the source is always ideal but not practical in the case of dental infections. Tooth extraction is an option for certain patients but is usually the last resort. Often, other techniques are recommended so patients can maintain their dentition.

Pulpitis requires treatment for pulp protection and insertion of restorative materials if considered reversible. Either root canal therapy or tooth extraction treats irreversible pulpitis and necrosis. 

Periapical and periodontal abscesses require incision and drainage if a tooth extraction is not the desired option. Oral antibiotics should also be given if there is surrounding cellulitis or the patient is immunocompromised. Antibiotics should include gram-negative bacteria and anaerobic coverage. Common antibiotic choices include amoxicillin, amoxicillin-clavulanate, or clindamycin.[61] Large abscesses and deep space infections require hospital admission, parenteral antibiotics, and sometimes operative intervention.(B3)

Treatment for periodontitis is almost universally non-surgical. Mitigation of risk factors such as tobacco cessation and diabetes control is essential for treatment. Professional dental cleanings can be a first step to reversing the disease as it removes the gross buildup of plaque and calculus. Proper home oral hygiene and antimicrobial mouth rinses such as chlorhexidine gluconate are recommended. Rarely systemic oral antibiotics are needed. In extreme cases, surgery to remove the infected gums can be done to maintain dentition.[36]

Treatment for necrotizing periodontal disease is dependent on the severity of the disease. However, the initial management generally involves mechanical debridement of necrotic tissue under local anesthesia, removal of any pseudomembrane, and aggressive oral hygiene incorporating an antiseptic mouthwash. In addition to these local measures, oral antibiotics are indicated if systemic symptoms (such as fever or lymphadenopathy) are present. Mitigating risk factors such as tobacco use or any underlying immunologic condition is also important in managing necrotizing periodontal disease.[11]

Treatment for pericoronitis includes non-surgical and surgical treatment options. Aggressive oral hygiene with irrigation of the pericoronal space is recommended to dislodge any impacted debris.[62] Often, oral antibiotics help decrease the bacterial load in that area.[63] Surgical treatment involves removing the soft tissue layer overlying the erupting third molar called the operculum. This procedure is beneficial as it removes the deep pocket within the gingiva and makes it easier for the tooth to erupt.[64] Extraction of the involved tooth is often an acceptable treatment for pericoronitis involving third molar eruptions.(A1)

Post-procedural Dental Emergencies

Post-procedural Bleeding

The initial treatment of post-extraction and postoperative bleeding is to augment hemostasis while maintaining airway patency. The interventions available for post-extraction and postoperative bleeding can be categorized into local or systemic treatments.[5](A1)

Local interventions consist of both surgical and non-surgical hemostatic measures. Basic non-surgical hemostatic measures include manual pressure or pressure packing with gauze. However, various therapies can be applied locally to absorb or halt bleeding. These therapies typically involve hemostatic pharmacologic or biologic agents impregnated into packing material, sponge, gel foam, adhesive, or solution applied locally to the bleeding site. These therapies have been well documented in the literature and are considered effective in common practice.[5][55] Below is a list of common locally acting hemostatic agents organized by category:(A1)

• Adhesive agents: cyanoacrylate glue, fibrin glue, and chlorhexidine bio-adhesive gel
• Absorbable agents: oxidized cellulose, gel foam, collagen fleeces or sponges, and gelatin sponge
• Biologic agents: topical thrombin, green tea extract, Haemocoagulase, and Ankaferd Blood Stopper
• Sealant agents: acrylic or surgical splints and calcium alginate 
• Pharmacotherapies: local antifibrinolytic solutions (ie, tranexamic acid mouthwash) and gauze soaked in the tranexamic acid

Surgical measures can also be used in isolation or non-surgical methods to obtain hemostasis. This involves the oral surgeon cauterizing or suturing the site of bleeding. The exact surgical approach depends on the source of the bleeding.[5](A1)

Systemic interventions should be considered when a patient has a known congenital coagulopathy, a systemic illness that makes them prone to bleeding, or using anticoagulant therapies. The role of local hemostatic agents can be limited in these scenarios as they do not address the underlying etiology of the bleeding. Systemic interventions include the administration of:

• Blood products such as fresh frozen plasma (FFP), platelets, or packed red blood cells (pRBCs) in the setting of warfarin use or cirrhosis
• Specific factor replacement therapy in the setting of congenital coagulopathies
• Anti-hemophilic factor A or anti-hemophilic factor B for Hemophilia A and B, respectively
• Von Willebrand factor concentrates on the setting of Von Willebrand disease
• Prothrombin complex concentrate (PCC) in the setting of cirrhosis, warfarin use, or direct oral anticoagulant use
• Epsilon amino-d-caproic acid in the setting of enoxaparin use
• Desmopressin in the setting of damaged platelets
• Tranexamic acid

Systemic agents should be used cautiously in the anticoagulated patient as there is a risk of thrombotic events with anticoagulation reversal. The risks and benefits of anticoagulation reversal must be considered individually, discussed with the patient, and using the clinician’s best judgment.[5][25](A1)

The general approach to the patient experiencing postoperative bleeding should be for the dentist or oral surgeon to first clearly visualize the source of bleeding by removing all saliva and residual clots from the surgical site with suction. Manual pressure should be applied firmly with a damp gauze for at least 5 minutes. If the bleeding has not resolved with this measure, local anesthesia should be administered so the patient can be treated with more aggressive therapy. The oral surgeon or dentist should utilize an appropriate local non-surgical hemostatic agent with or without sutures. If the bleeding is not controlled with these methods, systemic treatment should be considered with a hematologist.[5](A1)

If the bleeding is brisk and hemostasis is not obtained such that the patient cannot adequately tolerate their secretions, or if there is an expanding hematoma, the healthcare provider should have a low threshold to secure the patient’s airway in conjunction with definitive hemostasis.

Alveolar Osteitis

Not surprisingly, as the pathophysiology of alveolar osteitis is poorly understood, there is no consensus on protocols for its treatment or management. Despite this, treatment approaches focus on symptomatic relief rather than addressing any underlying disease process.

While it does little to relieve pain, initial management involves intra-alveolar irrigation, which assists in removing clot debris and necrotic tissue. Local analgesia can be obtained with topical anesthetics gels, which can be applied after irrigation. Local analgesia can also be augmented with oral non-steroidal anti-inflammatory drugs (NSAIDs). Although they may impair healing and cause local inflammatory reactions, they appear to have a role in temporarily applying medicated dressings (impregnated with analgesic or antibacterial compounds) post-operatively. Additionally, chlorhexidine oral rinses after exodontia have been shown to help prevent alveolar osteitis, while its use as a primary treatment is still being investigated.[7]

More recently, low-level laser therapy (LLLT) has been suggested to be an effective alternative treatment with comparable results to other known treatments with the benefit of being both safe and inexpensive.[7] With some studies showing this newer technology to be both effective and advantageous, with further study, it could become a protocolized consensus treatment in the future.

Differential Diagnosis

Traumatic Dental Emergencies

Generally, tooth fractures are accurately diagnosed with a detailed clinical history, physical exam, and radiographic evaluation. However, marked tenderness with manipulation of the tooth or the surrounding structures may indicate the presence of a simultaneous tooth luxation or root fracture.[9]

The differential diagnosis of tooth luxations includes all categories of luxations (ie, complete tooth intrusion, subluxation, and lateral luxation) and tooth avulsion. Similarly, all tooth luxations should be considered when diagnosing a tooth avulsion.[17]

Infectious Dental Emergencies

Oncologic etiology can sometimes mimic the appearance of dental infections. Squamous cell carcinoma can contribute to bone loss and be misdiagnosed as periodontal disease.[65] Gingival bleeding can occur from leukemia and can also be misdiagnosed as an infectious process.[66] Cysts, tumors, and granulomas can likewise have an infectious appearance.[67] Oral side effects from drug therapy can also be misdiagnosed as an oral infection. Other differentials for dental infection include salivary gland pathology as well as sinusitis.[51] The limited extent of a localized dental infection must be ensured so as not to miss a more life-threatening related complication such as a deep space neck infection or facial abscess.

Post-procedural Dental Emergencies

Post-operative Bleeding

Traumatic extractions with or without oral lacerations affecting vessels should be considered in the differential diagnosis of post-extraction bleeding and post-operative bleeding. Congenital coagulopathies should be considered in the profusely bleeding dental patient as they may not have been previously diagnosed. Systemic illnesses, such as cirrhosis or end-stage renal disease, or the use of anticoagulants should be considered in bleeding patients when little is known about their medical history. 

Alveolar Osteitis

While the diagnosis of alveolar osteitis is straightforward in the setting of an appropriate history and physical exam if the pain is severe or occurring for longer than 1-week post exodontia, a broader differential diagnosis should be considered.[29] In these situations, infectious etiology should be considered, especially if there are signs of tissue abnormalities extending beyond the extraction soc et. Differential diagnoses that should be considered are mandibular or maxilla osteomyelitis, subperiosteal infection, and bony sequestrum.[7] 

Prognosis

Traumatic Dental Emergencies

Tooth Fractures

The outcome of a given dental fracture depends on the fracture category, the quality of the treatment received, and whether there was a delay in treatment. The prognosis is favorable for minor fractures involving only the enamel. The prognosis worsens for fractures left untreated or involving deeper structures of the tooth and surrounding tissues; these dental fractures are more likely to develop infections.[68]

Tooth Luxations

Tooth subluxations generally have a good prognosis with patients with minimal symptoms, a positive response to pulp sensitivity testing, and immature teeth having the best outcomes. Extrusive luxations, intrusive luxations, and lateral luxations are prone to worse outcomes than tooth subluxations. The best outcomes are seen in patients with minimal symptoms, a positive response to pulp sensitivity testing, no marginal bone loss, signs of healing periodontium on radiographs, and skeletally immature teeth. Very symptomatic cases that develop pulp necrosis and experience breakdown of marginal bone or bony resorption have a worse prognosis and often require root canal therapy or endodontic evaluation.[49]

Tooth Avulsions

The prognosis for replanted tooth avulsions depends on several items, particularly the extra-alveolar period. While replantation should be attempted for all avulsed teeth, the outcomes are best for cases where replantation occurs within 30 minutes, the tooth is stored in an appropriate storage medium, and there are minimal concomitant dentoalveolar injuries. The success of replanted teeth markedly decreases once the tooth exceeds 60 minutes of extra-alveolar time.[69]

Infectious Dental Emergencies

While dental infections historically carried a high mortality rate over a century ago, when recognized and treated early, uncomplicated dental infections carry a good prognosis. However, if left untreated, dental infections can spread both contiguously and hematogenously, with the potential to cause numerous complications. The sequela of resultant severe sepsis, septic shock, bacteremia, osteomyelitis, deep neck space infections, mediastinitis, endocarditis, or meningitis carries significant morbidity and mortality.[51]

Additionally, studies have shown that teeth and periodontal tissue that experience repeated infections or have preexisting periodontal disease carry a worse prognosis.[70][71] The prognosis is generally improved in situations where risk factors and comorbidities (such as tobacco use, uncontrolled diabetes, and immunological diseases) are addressed and managed appropriately.

Post-procedural Dental Emergencies

Post-operative Bleeding

In most cases, patients experiencing post-extraction and post-operative bleeding do well with local interventions. Patients with congenital coagulopathies tend to have a fair prognosis with local interventions when they are pre-operatively treated with factor replacement therapies. However, some individuals in this population still experience secondary bleeding and require systemic treatment despite early clotting factor replacement.[28]

While discontinuing anticoagulant therapy remains controversial, several studies suggest that it is safest for patients to continue their anticoagulation therapy for procedures with a moderate risk of bleeding, given the efficacy and availability of hemostatic agents.[23][25][55][56][57]

Alveolar Osteitis

Alveolar osteitis is self-limiting, not known to cause long-term morbidity, and typically resolves within a few days after initiating treatment. The prognosis without treatment is also excellent, as the symptoms still resolve relatively quickly without treatment.

Complications

The relevant complications for the various dental emergencies differ depending on the specific diagnosis and category being considered.

Traumatic Dental Emergencies

Complications of traumatic dental emergencies include pulp necrosis, pulpal obliteration, tooth discoloration, dental or periodontal abscesses, fistula formation, and root resorption.[72] Tooth avulsions are especially at risk for loss of pulp vitality, especially as the risk increases with each minute the avulsed tooth remains outside the alveolar socket.[17]

Infectious Dental Emergencies

The most common complication of dental infections is tooth loss. However, if left untreated, dental infections can spread both contiguously and hematogenously, with the potential to cause numerous complications. Through contiguous spread, dental and periodontal infections can lead to osteomyelitis of the mandible or maxilla, deep neck space infections (which include Ludwig angina, retropharyngeal abscess, and mediastinitis), and rarely intracranial infections (which include cavernous sinus thrombosis, meningitis, and subdural empyema). If patients with dental infections become bacteremic, there is the potential for hematogenous spread, which can lead to endocarditis.[51]

Specifically, Ludwig’s angina and retropharyngeal abscesses can compromise a patient’s airway. Patients experiencing Ludwig’s angina may present with soft tissue edema involving the face, oral cavity, and neck, which leads to trismus, respiratory distress, voice changes, and the inability to tolerate oral secretions. In these cases, stridor is an ominous sign, and the provider should have a low threshold to intubate before respiratory distress develops utilizing advanced airway equipment, such as video laryngoscopy or fiber optics.[13]

Patients presenting with retropharyngeal abscesses are also ill-appearing and present similarly to patients with Ludwig’s angina; however, they are less likely to have facial or neck edema and are more likely to experience neck stiffness with their discomfort usually exacerbated with cervical extension.[73] All these sequelae portend high morbidity and mortality. Because their presentations can be varied, healthcare providers must include them in the differential diagnosis for ill-appearing patients experiencing dental infections. 

Post-procedural Dental Emergencies

The most frequent complication for patients with post-extraction or postoperative bleeding experience is a return visit to their dental practitioner or the emergency department. They may also develop large intraoral hematomas that rarely can compromise their airway. In cases where hemostasis is difficult to achieve, patients may require blood transfusions or hospitalization.[5] Alveolar osteitis is self-limiting, and there is no evidence correlating it as a risk factor for developing additional dental complications.