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Teeth surgery
A dental emergency is an issue involving the teeth and supporting tissues that are of high importance to be treated by the relevant professional. Dental emergencies do not always involve pain, although this is a common signal that something needs to be looked at. Pain can originate from the tooth, surrounding tissues or can have the sensation of originating in the teeth but be caused by an independent source (orofacial pain and toothache). Depending on the type of pain experienced an experienced clinician can determine the likely cause and can treat the issue as each tissue type gives different messages in a dental emergency. Many emergencies exist and can range from bacterial, fungal, or viral infections to a fractured tooth or dental restoration, each requiring an individual response and treatment that is unique to the situation. Fractures (dental trauma) can occur anywhere on the tooth or to the surrounding bone, depending on the site and extent of the fracture the treatment options will vary. Dental restoration falling out or fracturing can also be considered a dental emergency as these can impact function in regards to aesthetics, eating and pronunciation and as such should be tended to with the same haste as loss of tooth tissue. All dental emergencies should be treated under the supervision or guidance of a dental health professional in order to preserve the teeth for as long as possible. By contrast, a medical emergency is often more precisely defined as an acute condition that presents an immediate threat to life, limb, vision, or long term health. Consequently, dental emergencies can rarely be described as medical emergencies in these terms. Some define a dental emergency in terms of the individual's willingness to attend for emergency dental treatment at any time at short notice, stating that persons who are fussy about when they are available for treatment are not true emergency cases. There are often divergent opinions between clinicians and patients as to what constitutes a dental emergency. E. g. a person may suddenly lose a filling, crown, bridge, etc. and although they are completely pain free, still have great cosmetic concerns about the appearance of their teeth and demand emergency treatment on the basis of perceived social disability.

Pain is described as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. It is one of the most common reasons patients seek dental treatment and many diseases or conditions may be responsible for the cause.

Odontogenic pain is pain associated with the teeth, originating in the dental pulp and/or the peri radicular tissues. The following table shows the different classifications of pulp status. The following is a list of dental trauma affecting different surfaces of the teeth and periodontium.

Trismus may be defined as inability to open the mouth due to muscle spasm, but the term is frequently used for limited movement of the jaw from any cause and usually refers to temporary limitation of movement.

Whilst haemorrhage from the oro facial region may present spontaneously, particularly from gingival tissue as a result of a bleeding diathesis or a haematological abnormality such as leukaemia, the most common cause is in response to trauma or a post operative haemorrhage following dental extraction. They are not to be confused with abscesses, which are cavities filled with pus. Cysts can cause root resorption of adjacent teeth, tooth mobility and can be associated with mandibular fracture. Cyst would usually require surgical management if indicated.

Following a tooth extraction, if a blood clot forms inadequately in the socket or it is broken down, a painful infection may develop which is often referred to as a ‘dry socket’. It is clinically characterized by a putrid odor and intense pain that radiates to the ear and neck. Pain is considered the most important symptom of dry socket. It can vary in frequency and intensity, and other symptoms, such as headache, insomnia, and dizziness, can be present. Pre disposing factors to dry socket include smoking, traumatic extraction, history of radiotherapy and bisphosphonate medication. A dry socket can be managed by irrigating the socket with chlorhexidine or warmed saline to remove debris followed by dressing of the socket with bismuth iodoform paraffin paste and lidocaine gel on ribbon gauze to protect the socket from painful stimuli.

Removable active appliance are used by dentist to tip teeth using screws, springs and bows of various types to correct malocclusion. The appliance can be taken out for cleaning and for adjustments made by orthodontists. If the appliance is loose in an emergency situation, the dentist can adjust the retentive component of the appliance to increase the retention of the appliance by using Adams pliers.

Suppose the appliance breaks, the orthodontist should be alerted as soon as possible. The wearer should not use the appliance as it could cause trauma and could pose a significant risk of airway obstruction if the wearer accidentally inhales.

There are many components to the fixed appliance which have a potential to break off if the patient chews on hard or crunchy food. Wearers should wear a mouth guard over the appliance if when playing contact sports. If one of the components is loose or comes off, the user must call the orthodontist right away.

Separators, also known as orthodontic spacers, are usually placed between posterior teeth to open up contact point prior to placing metal orthodontic bands. The separators should ideally be kept in place until the patient's next appointment in order for the orthodontic band to fit. If the separator is lost, the orthodontist should be informed and he/she can advise for a next appointment for the patient.

The archwire in fixed orthodontic appliances should be flat against the tooth, however if the wire is protruding it can cause irritation to the surrounding soft tissues. Wire benders or a dental flat plastic can be used to bend the wire into place, or if this is not possible, the protruding wire can be covered with wax. If there are significant problems, the wire can be clipped using distal end cutters, being careful to avoid inhaling or ingesting wire fragments. As a last resort measure, the whole wire and ligatures can be removed.

De bonded brackets, if left untreated, can result in irritation of lip and cheek in short term. If a bracket de bonds from the tooth, the de bonded bracket can be removed from the archwire by initially removing the ligature holding it in place. Alternatively, orthodontic wax relief can be used to secure the de bonded bracket to the adjacent bracket as a temporary measure to prevent irritation of lip and cheek. However, it is essential to inform the orthodontist as soon as possible so that appropriate actions are taken to address the de bonded brackets immediately.

The most common allergy in orthodontics is to nickel. Nickel is found in multiple orthodontic components, such as nickel titanium (NiTi) archwires and stainless steel brackets. If patients are previously exposed to nickel, for example with nickel containing jewellery, the re exposure with orthodontic components are more likely to lead to a Type IV delayed hypersensitivity immune response. This response is usually delayed for a few days or weeks. In this case, the orthodontist must be informed immediately to make arrangements for patient to receive nickel free components. However, such immune response to nickel is rare, as it is believed that the oral mucosa requires a much higher concentration to illicit a response compared to the skin.

When a small removable appliance or a loose component obstructs a patient's airway a true medical emergency arises. If the object is visible, recline the patient and attempt to remove it while otherwise encouraging the patient to cough the object out. If this is not immediately successful call for help and an ambulance. Follow the guidelines for 'choking/aspiration' in the 'Medical Emergencies and Resuscitation' document provided by the Resuscitation Council UK.

It is not unheard of to ingest an orthodontic component or appliance, usually being asymptomatic causing no harm to the patient. No treatment is required except for monitoring stools to ensure the component has passed safely. If however the patient is having symptoms of pain or vomiting, the component may be lodged in the oesophagus or oropharynx. In such situations the patient must be sent to hospital. If the component is more than 5 cm long the patient should always be sent to A&E as there is a higher risk of obstruction or perforation of the gastrointestinal tract so removal may be advised instead of allowing the component to pass naturally. When sending a patient to hospital the referral letter must contain details regarding the components size, shape, flexibility, radio opacity as well as information about the incident for example when it was swallowed. Aspiration of an orthodontic component which was unable to be removed must be referred to A&E for chest radiographs and subsequent removal of the component. The referral letter again must include details as described above.

The treatment is cause related. For example, oil of cloves, which contains eugenol, can be used to treat dental pain; a drop can be applied with a cotton swab as a palliative After wisdom tooth extraction, for example, a condition known as dry socket can develop where nerve endings are exposed to air. A piece of sterile gauze or cotton soaked in oil of cloves may be placed in the socket after careful cleaning with saline to relieve this form of pain
Over the counter topical anesthetics containing active ingredients such as benzocaine or choline salicylate may be applied directly to the gum in order to deaden sensation. Analgesics such as aspirin, paracetamol (acetaminophen) and ibuprofen are also commonly used; aspirin and ibuprofen have the additional benefits of being anti inflammatories. Ice and/or heat are also frequently applied A dentist may prescribe an anti inflammatory corticosteroid such as Dexameth for pain relief prior to treatment.