Insights – Dental Emergencies in Urgent Care: Management Strategies That Improve Outcomes – Q2 2023

5 Things That Will Change Your Practice

  1. Milk is a practical storage medium for avulsed permanent teeth. Unflavored oral rehydration solution is also an option if the patient has it on hand.
  2. Account for all teeth; any that are unaccounted for may have been aspirated, swallowed, or embedded in a laceration. An intrusive luxation mimicking avulsion should also be considered.
  3. NSAIDs are the best analgesic option for most atraumatic dental pain. Orofacial nerve blocks can be considered if the pain is localized to a single nerve distribution.
  4. Manage alveolar osteitis pain with NSAIDs or a nerve block and fill the socket with dry socket paste (if available) or use packing gauze with eugenol. The patient should be advised to seek prompt follow-up care from the clinician who performed the extraction.
  5. Consider using the “syringe” technique for mandibular reduction. No procedural sedation is needed with this technique, and it eliminates the risk for clinician injury.

Risk Management Pitfalls in Oral Injuries

  1. “They didn’t find the tooth at the scene after the injury, but I assumed it was just left on the pavement somewhere.” All teeth must be accounted for. If all teeth are not accounted for, consider intrusive luxation mimicking avulsion, aspiration of teeth, swallowing of teeth, or the possibility that a tooth is embedded in a laceration.
  2. “The patient had three mobile teeth, but I didn’t know how to splint them, so I let her go.” Become comfortable and familiar with usage of calcium hydroxide paste for fractures and with periodontal splinting material for luxation and avulsion injuries, as they can improve outcomes in patients with traumatized teeth. If splinting is not possible in your practice setting, establish communication and protocols to ensure that these patients are promptly and appropriately managed.
  3. “The patient required a complex lac repair, so I just left the tooth on the table.” More than 60 minutes of extraoral dry time makes replantation almost always unsuccessful. If not immediately replanted, teeth should be stored in an appropriate storage medium.
  4. “The patient’s tooth was fractured, but he said he could follow up with his dentist in a few days, so I let him go.” Failure to appropriately manage dental fractures that involve the dentin or pulp with calcium hydroxide coverage and failure to obtain consultation or prompt follow-up can lead to unnecessary morbidity.
  5. “I told him to follow up with a dentist. I assumed he understood to see the dentist the next day.” It is important to provide appropriate and feasible dental follow-up for many of these patients with acute dental emergencies, as many of the urgent treatments are only temporizing.
  6. “I put that patient’s tooth back in, splinted it, and he came back two days later after it came out while eating a steak!” All patients who have subluxation, luxation, or avulsion injuries should be advised to maintain a soft diet and be prescribed chlorhexidine rinses. For avulsion injuries, prescribe antibiotics, such as doxycycline or penicillin.
  7. “That patient’s neck was pretty full, but I never would have guessed there was a big abscess there.” The clinical examination has relatively limited sensitivity for detection of deep neck infections or to fully describe their extent based on physical examination findings alone. Liberal usage of contrast-enhanced CT scan should be considered for any patient suspected of having a deep neck infection. “The patient had diabetes and HIV, but it seemed to just be an infected tooth. I didn’t think she would end up needing surgery.” Have a high index of suspicion for patients in an immunocompromised state, as the incidence and the severity of deep neck infections is much higher in these populations.