Emergency Advice

Very bad toothache is often caused by a tooth abscess. When a cavity in a tooth gets large enough, the living part of the tooth (or pulp) becomes damaged. The pulp can then die and start to decompose. Bacteria from the mouth can get inside the tooth and cause an abscess at the very tip of the root. The pain you feel with an abscess is actually the nerves in the jawbone that are registering the pain, not the nerve inside the tooth although the decomposing remnants of the nerve and its blood supply are the source of the infection.

A typical dental abscess symptom is greatly increased pain when biting on the tooth. From the above it is clear why: you are pushing the tooth into its own abscess therefore increasing the pressure on the abscess even further. With the nerve having died, you tooth will not be sensitive to temperature changes. If that is the case it is unlikely to be an abscess.

Your body will try and find a way out for the pus that is building up inside the abscess and it does so by eventually creating fistula into your mouth. The exit point of the fistula you will see in your mouth as a gum boil. Out of the gum boil you will intermittently get a discharge of pus, straight into your mouth. This is obviously not the healthiest thing so treatment is essential. The pain is likely to reduce the moment a fistula has formed as the pressure that was building up inside the jaw bone can escape.

With a dental abscess we have two treatment options to eradicate the infection:

Either a root filling is done with the aim to remove all the infectious debris inside the tooth which is the cause of the infection. If this is done successfully, the abscess will disappear. The success rate of root treatments is approximately 85% if no root treatment has been done before on the tooth. If a root treatment has already been done in the past and has been unsuccessful, then the chance of success with a re-root treatment is considerably lower at approximately 50%.

The second method of eradication the abscess is by extracting the complete tooth. This removes the source of the infection within it and is certain to cure the abscess. What is really important to understand is that a course of antibiotics will only alleviate the symptoms briefly but it does not remove the source of the infection. The abscess will still be there, be it slightly reduced in size but it will flare up as soon as the antibiotics have stopped working.

The mouth is a fairly hostile environment with a variety of different conditions like severe chewing pressures, bacterial attacks from the plaque and acute hot and cold variations leaving their mark on your teeth. When fillings are made, they are subject to that same environment and as a result will need replacing from time to time.

If a filling fails, it needs to be replaced as soon as possible as otherwise tooth decay will make the problem only more difficult to fix. However, if the filling comes out over a weekend or even a holiday, as a rule of thumb remember that although we really do not want to leave it any longer than necessary, if it is not painful, do not panic and make an appointment as soon as it is practically possible. When a filling has come out, the tooth may become sensitive to temperature changes because the deeper structures of the tooth are exposed and the nerve endings in the dentine will register these changes. The rough edges of the tooth can also be a problem as they can lacerate the tongue or cheek and your mouth can become very sore as a result.

If you cannot get to the surgery for whatever reason and are struggling with the symptoms described above, an emergency temporary filling material can be found in most leading chemists and may alleviate the soreness until we can fix the problem properly.

A well made crown or bridge can be a long lasting and reliable solution to lengthen the life of a damaged tooth. There will come a time though, when the crown will need replacing and if the seal of the cement which holds it in place fails unexpectedly, the crown will eventually fall out. This will leave you with a crown which, when you look inside it will be empty apart from possibly some traces of the cement layer. If the inside of the crown is full then unfortunately it is not the crown that has come loose but a fracture of the tooth has occurred. This will almost certainly mean that the crown cannot be cemented back on. A new crown however can probably still be constructed after rebuilding the core.

Under normal circumstances the crown will come loose completely when the cement fails and you must therefore be careful not to swallow your crown as retrieving it after that becomes a little harder! If there is some movement in the crown but it has not dislodged completely there may be a root filling with a screw post underneath and the cement fixing the post has failed. This can sometimes be fixed by simple re-cementation, dependant on the fit of the crown /post combination into the root.

Do attend the surgery as soon as you feel movement in a crown or bridge as it will need recementing as soon as possible. In the situation where the crown is moving around but has not come off, with every movement, bacteria will be dragged into the inside of the tooth as the vertical movement of the crown starts to work like a pump, sucking in food and plaque. This will soon lead to tooth decay in the centre of the tooth and will reduce the chances of a simple recementation drastically.

One dental problem with similar symptoms as mentioned above is where it is not the crown that is moving around but the whole tooth. This is normally caused by gum disease having compromised the bone attachment of the tooth. The difference between the the loose crown and the loose tooth is quite easy to diagnose in the surgery but hard or even impossible to distinguish by you as a patient.

With dental injuries to the teeth there are four different categories to consider:

1. The tooth is completely out of the socket
If a the tooth is completely displaced from the socket due to a severe impact then is is imperative to place the tooth back in its socket as soon as possible. The survival of tooth depends very strongly on the length of time the tooth is out of the mouth and how it is stored during that time. The best survival outcome is for teeth that are replanted immediately. If the tooth is out of the mouth for more than 5 minutes, it must be kept moist to prevent further damage to the dental cells. The tooth may be stored in fresh cold milk. Another way to protect the tooth is to keep it in your mouth, under your tongue as it is then kept moist and is protected. The tooth must not be handled by the root and should not be scrubbed to remove dirt. Holding the tooth by the crown, it can be gently washed with milk, saline or sterile water followed by re-implantation. It should then be held in place by biting on a clean handkerchief and the patient taken to a dentist immediately. This tooth should then be splinted for 7-10 days and the patient should be given appropriate antibiotics, a mouthwash and referred for a tetanus prophylaxis as required. The follow-up treatment depends on the stage of root development of the tooth.

2. The tooth is displaced but still in the socket
The main objective is to re-position the tooth back into its correct position and stabilize it to prevent further damage to the supporting structures, nerve and blood supply. As mentioned above, the timing of the re-positioning is very important in order to have the best chance of the tooth surviving. The displaced tooth will require long term follow-up with X-rays and may require root canal treatment if irreversible damage to the nerve and blood supply of the tooth has occurred.

3. Fractured of the crown part of the tooth
The fracture may involve one or all of the following dental tissues: enamel, dentine, pulp (nerve) of the tooth. Fracture like this is usually associated with extreme sensitivity to cold air and pain. The main objective following this type of injury is to maintain the vitality of the pulp and prevent pain.
If the nerve of the tooth is not involved, then the tooth can be built-up with composite (tooth-coloured filling material). If however, the nerve is exposed, depending on size of exposure and time since it occurred, the nerve might need to be treated. In most cases, even if the nerve is removed, the tooth can still be restored.

4. Root fracture
Sometimes the traumatized tooth may look normal, have increased mobility or the tooth may look displaced. Multiple dental X-rays are necessary to assess the level and extent of the fracture. Some root fractures require immobilization, and prompt treatment of such fractures increases the chance of healing and hence tooth survival.

Below is some simple advice for when a tooth has been taken out, in order to encourage a speedy recovery of the wound. Most importantly do not rinse/swill out your mouth for 3 days. Rinsing can wash away the blood clot and lead to further bleeding and delayed healing. Eating or drinking is fine once the anaesthetic has worn off which normally takes 2 to 3 hours. Whilst the area remains numb there is a risk of biting on your lips without being aware of it. Start with soft foods initially; you will find out yourself what is comfortable given the soreness of the wound.

Painkillers
For pain control it can be a good idea to take painkillers like Ibuprofen or Paracetamol before the anaesthetic wears off. Ibuprofen would be the painkiller of choice as it has an anti-inflammatory side to it as well. Avoid aspirin based painkillers as they will encourage the wound to start bleeding again. Always check the medication to see if it is suitable for you and if it does not contain anything you might be allergic to. An ice pack placed over the area will reduce pain and future swelling. Avoid smoking as it increases the risk of subsequent infections and delays the healing process.

Bleeding
A small degree of blood oozing from the wound will occur the first 24 hours. If left alone, the vast majority of the extraction wounds heal beautifully without any further action. If however fresh bleeding occurs in large quantities, you should apply pressure pack to the site. This is achieved by placing a tightly rolled, clean handkerchief directly over the site and biting hard. Pressure should be applied for 15-30 minutes after which you carefully remove the pack, trying not the pull out the clot which will now have started to form. Repeat if the bleeding restarts.

Increasing Pain
If the pain suddenly increases after 2-3 days, combined with a nasty taste in your mouth then you have almost certainly developed what is called a ‘dry socket’. This occurs when your body has not been able to establish a blood clot and you are left with an infected, dry bone wound. This is exceptionally painful and it unfortunately takes quite a while to recover from. Contact the surgery immediately if you have these symptoms as we can speed up the recovery with specific antibiotics.

NB: Of all the above instructions the most important one is NOT TO RINSE for 3 days.