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Dental Emergencies

Dental Pain

Toothache or tooth pain is caused when the nerve root of a tooth is irritated. Dental (tooth) infection, decay, injury, or loss of a tooth are the most common causes of dental pain.

The first step in the evaluation of oral pain should be to determine its aetiology. Dental sources are most common. However, pain arising from non-dental sources such as myofascial inflammation, migraine, maxillary sinusitis, nasal tissues, ears, temporomandibular joints, anginas and neuralgias always must be considered and excluded.

Caries is initially asymptomatic. Pain does not occur until the decay impinges on the pulp, and an inflammatory process develops.

Reversible pulpitis is characterised by pain caused by stimuli such as cold. It usually does not last for very long, and usually stops on removing the stimuli. If left untreated it can progress to irreversible pulpitis.

Irreversible Pulpitis
Irreversible
Figure 1: Carious lesion

If a carious lesion causing reversible pulpitis is not treated, the condition will progress to irreversible pulpitis, a severe inflammation of the pulp (Figure 1).

Signs and Symptoms
  • Pain becomes severe, spontaneous, and persistent, and is often poorly localized.
  • Patient may complain of pain with hot foods and liquids.
  • Pain during recumbence and even spontaneous pain.
Management
  • The only way to definitively treat the discomfort is root canal treatment (removal of the pulp and filling of the empty pulp chamber and canal) or extraction of the tooth.
  • The pain should be managed with appropriate analgesia such as a non-steroidal anti-inflammatory drug (NSAID) or a weak opioid combined with an NSAID or acetaminophen.
  • Patients should be warned of the risks of further complications if they do not have prompt definitive treatment.
Apical Periodontitis

A severely inflamed pulp will eventually undergo necrosis, causing apical periodontitis, which is inflammation around the apex of the tooth (figure 2).

Signs and Symptoms
  • Pain is severe, spontaneous, persistent and localizes to the affected tooth.
  • The tooth is sensitive to percussion with a metal object.
  • Regional lymphadenopathy can be present.
Management

Root canal treatment or extraction.

Apical
Figure 2 and 3: Apical Abscess
Apical Abscess

Apical abscess is a localized, purulent form of apical periodontitis (Figures 2 and 3).

Signs and Symptoms
  • It may present clinically as a fluctuant buccal or palatal swelling, with or without a draining fistula.
  • Regional adenopathy is usually present.
  • If pus is draining, pain usually is not severe.
Management
  • Antibiotics are not necessary unless concurrent cellulitis is present.
  • Acute incision and drainage of the fluctuant area results in immediate relief to the patient
  • Definitive therapy is root canal treatment or extraction.
Cellulitis

Cellulitis may follow apical periodontitis if the infection spreads into the surrounding tissues(Figure 2).

Signs and Symptoms
  • Diffuse, tense, painful swelling of the affected tissues occurs.
  • Regional lymphadenopathy is common, and fever may be present.
  • The infection can spread into the major fascial spaces of the head and neck, with the attendant risk of airway compromise.
  • Maxillary infection also may spread to the periorbital area, increasing the risk of serious complications that include loss of vision, cavernous sinus thrombosis, and central nervous system involvement.
Management
  • The examination should focus on determining if the cellulitis remains localized or has spread regionally.
  • Patients with localized cellulitis are treated with antistreptococcal oral antibiotics, such as oral penicillin in a dosage of 500 mg three times daily in adults or 50 mg per kg per day divided into three doses in children.
  • In the event of true penicillin allergy, erythromycin or clindamycin may be substituted.
  • Appropriate pain medication should be provided.
  • Definitive therapy is root canal treatment or extraction, which in selected cases may be delayed until swelling has subsided.
  • If infection extends regionally into the deep spaces of the head and neck as evidenced by severe swelling, the risk of life-threatening complications such as airway compromise is substantial.
  • Generally, these patients should be hospitalized and provided with surgical and infectious disease consultation. Imaging, usually with computed tomographic scanning, is mandatory, as is surgical drainage if abscess formation is detected.
  • Intravenous broad-spectrum antibiotic treatment should be started immediately and should include coverage for anaerobes.
Paediatric Considerations

In general, the same principles of initial evaluation and management apply to the primary and permanent dentition. However, carious lesions of the primary teeth less frequently cause pain and abscesses and more frequently drain cutaneously than lesions of the permanent dentition. The systemic effects of infection are more pronounced in children, with rapid temperature elevations, greater risk of dehydration, and more rapid spread of infection.

Periodontal disease is an inflammatory destruction of the periodontal ligament and supporting alveolar bone. The main etiologic agent is bacterial plaque. Multiple bacteria are implicated, but as the disease progresses, gram-negative anaerobes predominate.

Acute Periodontal Abscess

Patients with chronic periodontal disease or patients who have a foreign object lodged in the gingiva may present with an acute periodontal abscess.

Signs and Symptoms
  • Throbbing pain with erythema and swelling over the affected tissue.
  • The tooth is normally tender to percussion and shows increased mobility.
Management
  • If left untreated, the abscess may rupture or, less commonly, progress to cellulitis.
  • Within 24 hours drainage and debridement of the infected periodontal area must be done.
  • Antibiotics are not normally indicated if debridement is successful, but they may be used depending upon the dentists discretion.

Pericoronitis is inflammation of the soft tissues surrounding the crown of a partially erupted tooth, most commonly a wisdom tooth (Figure 4). It occurs when bacterial plaque and food debris accumulate beneath the flap of gum covering the partially erupted tooth.

Signs and Symptoms
  • Inflammatory oedema, often complicated by trauma from the opposing tooth, leads to swelling of the flap, pain and tenderness.
  • Bad taste caused by pus oozing from beneath the flap.
  • Regional lymphadenopathy is common, and cellulitis and trismus (inability to open the mouth fully) can occur.
  • In severe cases, the oral airway can be compromised.
Pericoronitis
Figure 4: Pericoronitis
Management
  • If pericoronitis is well localized, hot salty mouthwashes and irrigation under the flap can resolve symptoms in the majority of cases.
  • Localized cases that do not respond to mechanical therapy and more severe disseminated cases with spreading cellulitis should be treated with penicillin and appropriate pain medication.
  • The patient should be evaluated to see if symptomatic treatment can suffice until eruption is complete or if surgical therapy to remove the gum flap or underlying tooth is necessary.

Dental Trauma

Dental trauma is extremely common. Children are particularly affected, with one third of five year olds having suffered injury to their primary teeth, and one fourth of 12 year olds having suffered injury to their permanent teeth. Injuries to teeth and their supporting structures can be classified as fractures, lateral or extrusive luxation (loosening and displacement of the tooth), intrusion (displacement of the tooth vertically into the alveolar bone), and avulsion (complete displacement of the tooth out of its socket).

The mechanism of injury and timeline are particularly important aspects of the history because they define the risk of associated injuries and available treatment options. Examination should focus on related soft tissue injuries and the need for suturing, signs of tooth loosening, displacement or fracture, and disturbance in the bite or other signs of alveolar fracture. Complete diagnosis requires at least one dental radiograph in all cases.

All patients with traumatized teeth ultimately need follow-up with a dentist for complete diagnosis and long-term care. Long-term sequelae can include pulp death, root resorption, and displacement or developmental defects of permanent tooth successors.

Trauma to the teeth is not life threatening; however, associated maxillofacial injuries and fractures can compromise the airway. Morbidity to the teeth may be individualized to primary and permanent teeth. Fractures are more common in permanent teeth; primary teeth usually become displaced.

  • Primary teeth - Failure to continue eruption, colour changes, infection, abscess, loss of space in the dental arch, ankylosis, injury to the permanent teeth, abnormal exfoliation.
  • Permanent teeth - Colour changes, infection, abscess, loss of space in the dental arch, ankylosis, resorption of root structure, abnormal root development.
Sex

The male-to-female ratio is 2-3:1.

Age

The average age of injury is variable. In youths, falls and sporting activities account for most injuries. In later teenaged years, road traffic accidents (RTA) account for most injuries.

Management
History taking

A complete medical history including a detailed account of the trauma/accident which resulted in the tooth/teeth injury should be recorded. Following which the clinical recording of the injury is done.

  • Different physical and clinical findings present depending on where the tooth is fractured. Note the fracture's extent and the patient's age. The Ellis classification has been designed for evident fractures.
    • Ellis Class I fractures involve only the enamel; these injuries may show minor chipping with rough edges.
    • Ellis Class II fractures involve enamel and dentin; patients may complain of pain to touch and sensitivity to air. Patients younger than 12 years have immature teeth with much less dentin spanning the space between the pulp and enamel. The chance of infection and damage to the pulp in this age group is much greater.
    • Ellis Class III fractures involve enamel, dentin, and pulp. Patients complain of pain with manipulation, air, and temperature. Pinkish or reddish markings around surrounding dentin or blood in the centre of the tooth from the exposed pulp may be present.
  • Root fractures are clinically difficult to diagnose; patients may notice abnormal mobility and sensitivity to percussion of the tooth.
  • Dentoalveolar fractures may cause patients to complain of malocclusion and mobility with findings of a mobile group of teeth.
Primary Tooth
  • Treatment options for an enamel-dentin crown fracture with pulpal exposure in the primary dentition include: Direct pulp capping, Cvek pulpotomy, cervical-depth pulpotomy, pulpectomy or extraction.
  • The indication for a partial (Cvek) pulpotomy is a small and recent pulpal exposure less than 2 weeks old.
  • Indications for a deep cervical pulpotomy include: A large pulpal exposure, pulpal exposures older than 2 weeks, or if hemostasis cannot be obtained during a Cvek pulpotomy procedure.
  • When the trauma has resulted in chronic inflammation or necrosis of the pulp, a pulpectomy should be considered.
Permanent Tooth
  • Treatment for a case of enamel infraction consists of sealing the cracks – using any enamel adhesive system.
  • For an Ellis Class I dental fracture, dental care involves removing the sharp edges to prevent injury to the soft tissues of the mouth. Alternatively, the fracture may be restored with composite material.
  • For an Ellis Class II fracture, the dentin should be coated with a protective covering– as an interim measure. Allow up to 8 weeks for the injured tooth to recover before placing the final composite restoration.
  • For an Ellis Class III complex fracture of the permanent tooth with incomplete root formation: the main goal is to retain a viable dental pulp, and permit completion of root growth. Therefore, if the pulp exposure is very recent or very small, a direct pulp cap may be performed. For an exposure larger than 2mm, a Cvek pulpotomy may be performed, removing only a millimetre or two of infected pulp tissue. For an exposure older than two hours, a cervical-depth pulpotomy may be needed – ideally using only saline irrigation to achieve haemostasis.
  • For an Ellis Class III in permanent teeth with complete root formation, root canal treatment is advised.
Luxation, Lateral displacement, Extrusion
A. Diagnosis
  • Luxation involves displacement of a tooth in a labial, lingual, or lateral direction. If the displacement is less than 5 mm, the dental pulp will remain vital in about 50% of the cases.
  • Lateral luxation is an angular displacement of the tooth while it remains within the socket. There is usually an associated fracture of the supporting alveolar bone, especially with labial and palatal luxations.
  • An extrusion occurs when a tooth is only partially removed from the socket.

In the primary dentition, the alveolar bone surrounding the tooth is relatively elastic, so the most common injury in toddlers is a dental luxation (displacement injury) – with gingival hemorrhage.

B. Management
I. Primary Tooth
  • A primary tooth with a luxation in the labial direction needs to be extracted, to avoid further damage to the developing permanent tooth bud.
  • In other cases, however, it is possible to splint the luxated primary tooth back into normal position using resin-modified glass ionomer cement. The cement is mixed fairly thick, and placed on the labial and lingual surfaces of the luxated tooth – and a few adjacent teeth. The luxated tooth is held in the ideal position while the cement is setting. The splint is removed after 10 days.
II. Permanent Tooth
  • For any severe luxation injury: an anti-inflammatory agent, an analgesic and an antibiotic are prescribed.
  • For a lateral luxation, treatment includes: repositioning after local anesthesia, and applying a semi-rigid splint for 2-3 weeks. A post-treatment radiograph should be performed to assure proper position of the tooth in the socket.
  • For an extrusive luxation, treatment includes: immediate repositioning and placement of a semirigid (flexible) splint for 7-14 days.
III. Subluxation/ Dental Concussion (tooth was hit)
A. Diagnosis

Concussion results in mild injury to the periodontal ligament without tooth mobility or displacement. Subluxation causes significant injury to the periodontal ligament, resulting in some tooth mobility. There is usually bleeding at the marginal gingival and the tooth is tender to percussion in subluxation.

B. Management:
I. Primary Tooth

Radiographs are taken to rule out root fractures. The child is then put on a soft diet for a week, at the end of which a recall exam is performed.

II. Permanent Tooth

If the tooth is very mobile, and can be moved more than 2mm, a flexible wire and composite splint may be placed for 7-10 days by periodic evaluation.

IV. Dental Intrusion (tooth was pushed in)
A. Diagnosis
  • An intrusion injury is the most severe type of luxation injury. The intruded tooth is impacted into the alveolar bone, and the alveolar socket is fractured. The forces that drive the tooth into the socket wall crush the periodontal ligament, and rupture the blood and nerve supply to the teeth. The tooth may not be visible, and can be mistaken for an avulsion.
  • Some studies have shown that intrusions of up to 3 mm have an excellent prognosis, whereas the prognosis of incisors with severe intrusions (> 6mm) is hopeless. If a permanent tooth is involved, radiographs may show an alveolar fracture, or tooth displacement into the nasal cavity. Pulpal necrosis (death of the dental pulp) occurs in 96% of cases of intruded permanent teeth.
  • If a primary incisor is involved in an intrusion injury, a lateral anterior radiograph should be taken of the traumatized region to determine the proximity of the intruded primary root tip to the developing adult tooth bud.
B. Management
I. Primary Tooth
  • Allow the primary tooth to spontaneously erupt over a 2 to 3 month period - as long as the developing permanent tooth bud has not been injured. If re-eruption does not begin within 2 months, extraction of the intruded primary tooth will be necessary.
  • A much intruded primary incisor, whose root tip is displaced into the developing permanent tooth, should be extracted. Extraction of the intruded tooth will prevent further damage or hypoplasia to the adult tooth bud.
II. Permanent Tooth
  • Current management strategies for intruded permanent incisors include: surgical reduction (immediate repositioning), repositioning with traction (active repositioning), and waiting for the tooth to return to it pre-injury position (passive repositioning).
  • Incisors intruded less than 3mm may be allowed to reposition themselves.
  • Incisors intruded between 3–6 mm are unpredictable, but they may be orthodontically extruded within 3-6 weeks.
  • Incisors that have been intruded beyond 6 mm should be immediately repositioned (surgically) to their normal position – followed by root canal treatment.
  • Root canal treatment is recommended in permanent teeth with complete root development. If there is any doubt about pulp vitality, or if root resorption begins, then a pulpectomy must be performed, followed by interim placement of intra-canal calcium hydroxide. After apical closure and root health are confirmed, the canal is filled with a standard root canal material (gutta percha).
RootFracture
Figure 5: Root Fracture
A. Diagnosis
  • Root fractures occur in only 7% of dental injuries. Horizontal root fractures occur in anterior teeth, and are caused by direct trauma. Vertical root fractures usually occur in molars, and may be caused by clenching or trauma to the mandible. Vertical root fractures are more difficult to detect, and may not be found until extensive tooth destruction has occurred.
  • A horizontal root fracture is classified based on the location of the fracture in relation to the root tip (apex). Horizontal root fractures may occur in: the apical third, middle third, or cervical third of the root. The prognosis worsens the further cervically (towards the crown) the fracture has occurred. Tooth fractures are often not apparent during a clinical examination, and can usually only be diagnosed using appropriate radiographs. Radiographs with at least two views are required for making this diagnosis.
B. Management
I. Primary Tooth

As long as no abscess or excessive mobility occurs, the primary tooth with a fractured root can simply be monitored for health. If a portion of the root is abscessed or extremely mobile, it can be extracted, and the remaining root fragment will resorb normally. For coronal third fractures in primary teeth, the coronal third is extracted, leaving the apical portion of the root to resorb normally. Do not “chase” apical third fragments.

II. Permanent Tooth
  • The most important factor in the success and treatment of a horizontal root fracture is the immediate reduction of the fractured segments, and complete immobilization of the coronal segment. Root fractures must be diagnosed before the body tries to “repair” the problem, and before the blood clot prevents apposition of the fractured segments. If more than 24-72 hours have elapsed, it may be impossible to obtain close apposition of the segments.
  • Treatment for horizontal root fractures consists of rigid fixation (immobilization) in an attempt to get the cementum and dentin to heal. The tooth is splinted to the adjacent normal teeth with a very rigid wire and composite splint for 8 weeks. Serial radiographs are then taken at 6 month intervals after the splint is removed.
  • Sometimes extraction may be the only option; especially in vertical root fractures.
A. Diagnosis

The alveolar bone, which supports the teeth, may experience a fracture at: the alveolar socket wall, the alveolar process, or as a comminuted (shattered) fracture of the supporting bone. Segmental fractures involve multiple teeth and their supporting alveolar process.

B. Management
I. Primary Tooth
  • For any severe luxation injury: an anti-inflammatory agent , an analgesic , and an antibiotic are prescribed.
  • Treatment of alveolar process fractures requires manually repositioning the segment of displaced teeth back into proper arch alignment. A very rigid splint is applied for two months.
II. Permanent Tooth
  • For any severe luxation injury: an anti-inflammatory agent, an analgesic , and an antibiotic are prescribed.
  • Treatment of alveolar process fractures requires manually repositioning the segment of displaced teeth back into proper arch alignment. A very rigid splint is applied for two months.
Prevention of dental injuries

Dental injuries increase sixfold to eightfold when mouth protection is not used. Education of athletes and coaches may encourage greater use of mouth guards. Educating physicians and the public about first aid for dental injuries may reduce complications later.

A. Diagnosis

A dental avulsion occurs when a tooth is completely displaced or knocked out of the dental socket. Dental avulsion injuries occur most frequently in children between the ages of 7 and 9, an age when the alveolar bone surrounding the tooth is relatively resilient. Adult teeth that are avulsed (knocked-out) should be considered for immediate replantation in order to enhance the tooth’s long-term prognosis.

The best way to preserve a tooth that has been knocked out (avulsed) is to put it back into its socket as quickly as possible. The single most important factor to ensure a favourable outcome after replantation is the speed with which the tooth is reimplanted. If immediate replantation isn't possible, the tooth should be placed into a protective solution.

Avulsions are associated with poor post-treatment outcomes. Almost all replanted teeth show replacement resorption and ankylosis – because immediate replantation rarely happens. Replacement resorption leads to fusion of the tooth root with the adjacent alveolar bone. In children who have not achieved skeletal maturity, replacement resorption leads to progressive infraocclusion (the tooth appears unerupted) during the adolescent growth spurt.

Every tooth has a protective layer surrounding the root, which is called the periodontal ligament. The periodontal ligament is very sensitive, and will quickly dry out and die - unless the tooth is immediately placed in a protective solution, such as milk or saline. With every minute that the tooth is left out of the mouth to dry, more cells in the periodontal ligament will die. After 15 minutes of dry storage, irreversible damage to the periodontal cells (the root covering) occurs. If the cells of the periodontal ligament are allowed to die, the child will eventually lose the tooth. The goal of reimplanting the tooth into the socket is to preserve the health of the tooth's outer periodontal ligament.

B. First Aid for an Avulsed Tooth
I. Primary Tooth

A primary tooth that has been avulsed is usually not reimplanted. The risk of injury to the developing permanent tooth bud is high.

II. Permanent Tooth
  • Do not touch the root of the tooth. Handle the tooth by the crown only.
  • Rinse the tooth off only if there is dirt covering it. Do not scrub or scrape the tooth.
  • Attempt to reimplant the tooth into the socket with gentle pressure and hold it in position.
  • If unable to reimplant the tooth, place it in a protective transport solution, such as Hank's solution, milk, or saline. This will hydrate and nourish the periodontal ligament cells which are still attached to the root. A small container of Hank's Balanced Salt Solution can be purchased in dental emergency kit form at many drug stores.
  • The tooth should not be wrapped in tissue or cloth. The tooth should never be allowed to dry.
  • Take the child to a dentist or hospital emergency room for evaluation and treatment.
  • Radiographs may need to be taken of the airway, stomach, and mouth if the tooth cannot be found.
  • Tetanus prophylaxis should be considered if the dental socket is contaminated with debris.
C. Management
I. Primary Tooth

The primary avulsed tooth is generally not reimplanted – to avoid injury to the developing permanent tooth bud.

II. Permanent Tooth
  • Place the tooth in Hank's Balanced Salt Solution.
  • Take a medical and dental history, and perform a physical examination. Rule out CNS injury.
  • Examine the orofacial area. Inspect the oral soft tissue for embedded tooth fragments, lacerations, or ecchymosis (bruising). Palpate the teeth and dentoalveolar area to check for mobility. Evaluate TMJ function.
  • If the tooth is missing, rule out aspiration or ingestion.
  • Take a maxillary occlusal radiograph, as well as a lateral anterior radiograph of the injured area. Consider taking a panoramic radiograph to rule out condylar or mandibular fractures.
  • Gently aspirate the injured area without entering the socket. If a clot is present, dislodge and remove it using light saline irrigation. Do not curette the socket.
  • The tooth should be carefully held by the crown, and not by the root. The avulsed tooth should be reintroduced into the dental socket slowly.
Tooth Reimplantation Guidelines
  1. For a mature tooth with a closed apex: If the extra oral dry time is < 60 minutes, re-implant as soon as possible. If the extra-oral dry time is> 60 minutes, soak in citric acid or curette the root; then soak in stannous fluoride for 10 minutes. Rinse with saline. Perform root canal therapy one week following the trauma.
  2. For an immature tooth with an open apex: If the extra-oral dry time is < 60 minutes, soak in doxycycline (1mg/20 ml saline) for 5 minutes. If the extra-oral dry time is >60 minutes, provide the same treatment as for a closed apex.
  3. Apply a flexible, functional splint for 7 to 10 days. If an alveolar fracture is present, provide a very rigid splint for 4-6 weeks.
  4. After re-implantation, gently compress the facial and lingual bony plates. Suture any lacerations.
  5. Provide antibiotic coverage for 10 days to prevent infection. Consider prescribing tetracycline or penicillin.
  6. Prescribe chlorhexidine gluconate rinses, and provide oral hygiene and diet instructions.
  7. Provide analgesics to control pain. For children, consider prescribing acetaminophen and codeine for mild to moderate pain. The dose is 15 mg/kg/dose of acetaminophen, every 4 hours. Do not exceed 2.6 g/day of acetaminophen.
  8. Arrange for tetanus vaccination if the wound was dirty, or if the vaccination requires updating.
Follow-Up Care After 7 To 10 Days
  • For a tooth with an open apex, the goal is revascularization of the pulp. For a tooth with an open apex and extra-oral dry time 60 minutes no endodontic treatment is initially required. Re-evaluate every 3-4 weeks for pathosis. In case of pulp pathosis, begin an apexification procedure.
  • For a tooth with an open apex and extra-oral dry time >60 minutes: begin an apexification procedure.
  • For a tooth with a closed apex: provide traditional endodontic treatment and obturation. This is done to prevent of eliminate toxins from entering the root canal space.
  • Remove the splint at this 7 to 10 day treatment visit.
  • Patients are recalled to the dental office every 3-4 weeks of sensitivity testing. Thermal tests may be used.
  • Long-term follow-up is essential for 2 to 3 years after the re-implantation procedure.
Endodontic Obturation for Avulsed Teeth with Closed Apices
  • For a tooth with endodontic treatment started 7 to 10 days after avulsion, obturate after 1 to 2 months of treatment with calcium hydroxide paste.
  • For a tooth with radiographic signs of resorption or pathosis, or for a tooth which had endodontic treatment started more than 14 days after the avulsion, treat long term with a dense mix of calcium hydroxide. The calcium hydroxide is changed about every 3 months. Obturate when an intact lamina dura can be visualized.

Summary

Diagnosis Definition Presentation Complications Treatment
Reversible Pulpitis Pulpal inflammation Pain with hot, cold, or sweet stimuli Periapical abscess, cellulitis Filling
Irreversible Pulpitis Pulpal inflammation Spontaneous, poorly localized pain Periapical abscess, cellulitis RCT, extraction
Abscess Localized bacterial infection Localized pain and swelling Cellulitis I & D and RCT or extraction
Cellulitis Diffuse soft tissue bacterial infection Pain, erythema and swelling Regional spread Antibiotics and RCT or extraction
Pericoronitis Inflamed gum over partially erupted tooth Pain, erythema and swelling Cellulitis Irrigation, antibiotics if cellulitis also present
Tooth Fracture Broken tooth Clinical examination and radiography Pulpitis and sequelae Fillings, with or without RCT, extraction
Tooth Luxation Loose tooth Clinical examination and radiography Aspiration, pulpitis and sequelae Splinting, with or without RCT, extraction
Tooth Avulsion Missing tooth Clinical examination Ankylosis, resorption Re-implantation and splinting
Tooth Subluxation Tooth was hit Clinical examination and radiography Pulpitis and sequelae Splinting, periodic evaluation, RCT, extraction
Tooth Intrusion Tooth is pushed in Clinical examination and radiography Pulpitis and sequelae Periodic evaluation, repositioning, RCT
Root Fracture Root is broken-vertical or horizontally Clinical examination and radiography Pulpitis and sequelae RCT or extraction
Dentoalveloar Fracture Fracture of supporting alveolar process Clinical examination and radiography Loss of teeth Repositioning and splinting
RCT: Root Canal Treatment; I & D: Incision and Drainage.
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