Dental Emergencies

The center of the tooth is the pulp which contains the neurovascular supply for the surrounding dental structures. The pulp is covered by dentin, a thick homogenous material that makes up the majority of the tooth and provides cushioning during mastication. The crown is the visible white portion of the tooth. It is covered in enamel, the hardest substance in the body. The non-visible anchoring portion of the tooth, the root, is covered in softer cementum and extends downward into the alveolar bone of the mandible and maxilla. The periodontal ligament surrounds the root and firmly attaches the cementum and alveolar bone. Gums, or gingiva, consist of keratinized squamous epithelium and normally are firmly attached to the tooth at the junction of the enamel and dentin.

The adult dentition consists of 32 permanent teeth: 8 incisors, 4 canines, 8 premolars and 12 molars. The permanent teeth begin to erupt at 6-7 yr and are complete by young adulthood. The four third molars, or wisdom teeth, may erupt later or not at all if they become impacted. The pediatric mouth is occupied by 20 primary or deciduous teeth: 8 incisors, 4 canines, and 8 molars. The first teeth to present are usually central incisors at 6-8 mo and the pattern is complete by the age of two.

Several numbering systems exist for identifying tooth location. The Universal System for adults numbers the teeth 1-16 starting with the right to left upper third molars and 17-32 from left to right lower third molars. There are two other systems, and all three have plans for both adult and deciduous teeth. For this reason, the best means of identification is description of the tooth by name and location (e.g., right maxillary lateral incisor).

Dental Pain

• Odontalgia, or dental pain, is usually secondary to underlying dental caries. Other intraoral pathology may also cause pain including fractures, osteitis, gingivitis and periodontal abscess.
• Local extraoral and systemic processes may cause pain referred to the dentition. These diagnoses should be considered in cases where the history and exam is atypical for caries or other oral etiology.

• Pain from caries is severe and throbbing. It is exacerbated by hot/cold/sweet/sour extremes as well as head ovement. In some cases, patients are even sensitive to air.
• Although symptoms are usually poorly localized, patients are often able to identify the involved tooth.
• Caries are often the result of enamel destruction by bacteria contained in overlying plaques. Destruction progresses through the dentin and causes eventual pulpitis and/ or pulp necrosis. Note that pulpitis and pulp necrosis also occur in the absence of obvious enamel destruction. An example is the patient who sustains enamel microfractures from bruxism (grinding). In these cases, diagnosis is made by history and reproduction of pain with percussion using a tongue blade.
• Treatment involves analgesia with oral medications and referral to a general dentist. The EP may also administer a nerve block if experienced in the procedure.

• Postprocedural pain is common after extraction and instrumentation of the teeth.
• Patients may also have painful, postoperative trismus. If infection can be ruled out, analgesics and referral back to the dentist is appropriate.
• Postextraction alveolar osteitis or dry socket results from loss of the blood clot from the socket and subsequent localized osteomyelitis in exposed alveolar bone. Patients present with severe oral pain and halitosis 2-3 days postextraction. Treatment of dry socket includes local anesthesia, irrigation with saline and packing the socket with iodoform gauze soaked in eugenol (other preparations can also be used). Dental follow-up for recheck and dressing change within 24 h is suggested. Antibiotics are commonly prescribed for moderate to severe cases.

• Discussed below.

• Causes throbbing pain and pressure sensation referred to the upper teeth and the eye.
• Purulent nasal discharge, localized percussion tenderness and poor sinus illumination are also present and direct the EP towards this diagnosis.
• Treatment is with appropriate antibiotics and outpatient referral to ENT (see "Sinusitis").

• Arises from a multitude of factors and their interaction including local trauma and bruxism. Most cases are considered idiopathic. TMJ is much more common in women.
• TMJ pain is usually unilateral and located at the temporal or preauricular area. It is often referred to the ear, neck and shoulder. The pain is dull in nature and worsens with mandibular movement. Patients also complain of locking or clicking of the jaw.
• Trismus occurs secondary to spasms of the temporal and masseter muscles.
• The majority of patients improve with symptomatic therapy that includes warm compresses, NSAIDs, soft diet, nighttime muscle relaxant and follow up with a specialist.

• An idiopathic disorder that presents as paroxysmal sharp, piercing pain along the branch of cranial nerve V. In most cases, the second and/or third divisions are involved. Stimulation of "trigger points" in the face precipitate the pain. Neurologic examination and work-up are normal.
• Patients should be referred to a neurologist or ENT and are most often treated with carbamazepine.

• Acute myocardial infarction (AMI) and temporal arteritis: both should be easily ruled-out by an accurate history, physical examination, review of systems and diagnostic studies.