First Aid for Dental Problems: Part 2 Dental Emergencies

Just like other organs or structures in the body, the teeth are susceptible to acute injuries, infections, and defects.  Knowing what do when one of these occurs can help minimize discomfort and improve the outcome.  In some cases, this may even mean the difference in saving or losing a tooth. Last week’s Health Tip discussed several urgent tooth issues that could, for the most part, be managed without requiring an emergency visit to the dentist. Today’s problems represent more serious conditions that typically would warrant immediate dental attention.  If the answer to any of the following is yes, you most likely have a true dental emergency:

•   Do you have persistent bleeding from the area of a tooth or gum?
•   Do you have severe pain from a tooth or structure within the mouth?
•   Have you lost a tooth or have teeth that have been loosened from injury?
•   Do you have fever, pain and/or swelling in the mouth or jaw region? 

Dental abscess   A dental abscess is a complication of a bacterial infection in which pus becomes trapped in a pocket.  Most often, an abscess is the result of tooth decay which allows bacteria to invade the center aspect (pulp) of the tooth. Symptoms of a dental abscess include a severe toothache, a bitter or foul taste in the mouth, and sensitivity when chewing or to hot or cold.  With more advanced infections there may be fever, pus appearing near the site of the pain, redness of the soft tissue or gums, or visible swelling of the jaw.   Depending on the severity of the abscess, treatment could involve taking a course of antibiotics, having the abscess drained through the tooth or gum, or in certain instances, removal of the affected tooth.  A root canal is usually required on the involved tooth if the abscess is successfully treated without the need for extraction.

Knocked-out tooth.  Dentists refer these as “avulsed” teeth.  The sooner that an avulsed tooth is re-implanted in its socket, the greater the likelihood that the tooth can be saved.  After finding the tooth, it should be picked up only by the crown (the enameled part that you see in the mouth) in order to avoid damaging the periodontal ligaments (PDL) that connect the root of the tooth to the bone of the jaw.  If the tooth is dirty, it should be gently rinsed in water, again avoiding damage to the PDL.  If the correct orientation of the tooth can be determined, replacing the tooth into its socket offers the greatest likelihood of reattachment. If the avulsed tooth cannot be slipped back into its socket, it needs to be protected while awaiting dental attention. One of the best ways to preserve the tooth is to place it into a balanced salt solution, marketed commercially as Save-a-Tooth.  This product is approved by the Federal Drug Administration (FDA) and American Dental Association (ADA).  Its manufacturer claims that up to 90% of avulsed teeth can successfully be re-implanted when this product is used as directed.  If a tooth preservation product is not available, other options are to place the tooth between the cheek and gum or in a container of milk.  An avulsed tooth is a true dental emergency, so it is important to get to the dentist as quickly as possible. This procedure applies only to permanent teeth. Re-implantation of completely avulsed primary (baby) teeth is generally not recommended.

Chipped or broken teeth.  Teeth may be chipped or broken from injury, from biting down on something hard or because decay or fillings have weakened the tooth.   Replacement of chipped or broken teeth should not be attempted.  The pieces should be preserved in the same manner as an avulsed tooth and taken to the dentist.  For bleeding, pressure should be applied to the tooth with a gauze pad. The mouth should be rinsed with warm salt water and a cold compresses may be placed on the face to help with pain. An OTC pain medication can be taken if needed.  If only a small piece of tooth enamel was chipped off, the dentist may be able to repair the damage with a filling.  For more serious breaks a crown may be required.  If the break was caused by a cavity, compromising the health of the tooth's nerve, a root canal may be necessary.

Partially dislodged (extruded) tooth. The best chance of saving a partially dislodged tooth is to see the dentist right away.  The dentist can relocate the tooth in the socket and use one of several methods of “splinting” the loose tooth to hold it in place.  Assuming the periodontal ligaments were not seriously damaged, they should heal, reattaching the tooth to the socket. Until you reach your dentist's office, to relieve pain, apply a cold compress to the outside of the mouth or cheek in the affected area. Take an over-the-counter pain reliever (such as Tylenol or Advil) if needed.

First Aid for Dental Problems: Part 1

Just like other organs or structures in the body, the teeth are susceptible to injuries, infections, and defects.  Knowing what do when one of these occurs can help minimize discomfort and improve the outcome.  In some cases, this may even mean the difference in saving or losing a tooth. In the next two editions of “Health Tips” we’ll discuss a number of common tooth-related problems. The dental problems in Part 1 can usually be temporized until the dentist can be seen. Part 2 will deal with dental emergencies that require prompt evaluation by a dentist.

Toothache.   The most common cause of toothache is a dental cavity.  Other causes include food getting lodged between teeth, tooth grinding, and more seriously, a dental abscess. The first steps to take with a tooth ache are to rinse the mouth with warm water, gently floss between teeth to dislodge any trapped food particles, and take an over-the-counter pain medication, such as ibuprofen (Advil®) or acetaminophen (Tylenol®).  If this is unsuccessful, there may be some benefit to the application of an over-the-counter oral anesthetic containing benzocaine (Anbesol, Orajel, Benzodent, others) or clove oil (eugenol).  Clove oil is available in drugstores and in the spice section of some supermarkets. Aspirin or other oral pain relievers should not be placed against the teeth or gums since they have the potential to “burn” the gums. Persistent pain, such as that due to dental cavity, will require attention from the dentist. A dental abscess is a more serious problem that will be discussed in next week’s Health Tip.

Food or object caught between teeth. Popcorn hulls are notorious for getting stuck between the teeth or lodged in the gum.  The best way to remove these or other objects caught between the teeth is with the use of dental floss. In most cases, gentle flossing will remove the stuck particle. The American Dental Association discourages the use of toothpick or other sharp objects for removing stick food or objects because of concerns regarding injury to the teeth or gums.  It may be necessary to see the dentist if the object is unable to be removed with dental floss.

Lost crown.   A dental crown (also known as a “cap”) is a prosthetic tooth that is placed over a damaged tooth to restore its shape and function. Commonly made of porcelain bonded to a metal shell, crowns are cemented onto the tooth after it has been prepared to accept the crown.  Some of the reasons that a crown may loosen or come off include clenching or grinding teeth, inadequate tooth structure to hold the crown in place, or loss of adhesion from the cement.  Losing a crown can be painful because with the crown gone, sensitive nerves within the tooth are more exposed.  If so, applying a small amount of clove oil to the sensitive area with a cotton swab will help with pain relief.  After losing a crown, the best option is to see the dentist as soon as possible to have it replaced.  When this is not possible, the crown can be temporarily replaced using an over-the-counter dental adhesive.  Recapit and Temparin are two of the commercially available products made for this purpose. The crown should be clean and dry before the adhesive is applied to its inside and slipped back onto the tooth. Superglue should never be used to temporarily replace a crown.  Even if the temporary cement holds the crown in place, it is important to follow-up with the dentist for more permanent fixation of the crown.

Lost filling.  A lost filling, like a lost crown can be painful because with the filling gone, nerves within the tooth are more exposed to the effects of temperature, pressure and air. Topical anesthetics, such as clove oil can offer temporary relief from the pain, but a better solution while awaiting dental attention is to use a temporary filling material. Options for this include sugarless gum or an over-the-counter temporary filling product.  Dentemp, Temparin and Refilit are zinc-oxide based products that are commercially available for this purpose.  After pressing this material into the hole left by the lost filling, it hardens to provide relief of pain and protection to the tooth.  As with dental adhesives, these represent a temporary measure and the filling will need to be replaced by the dentist.

Broken braces and wires.  Occasionally, an orthodontic wire can come loose from its bracket or band, uncomfortably poking the cheek, tongue or gum.  Pushing the wire into a more comfortable position with the eraser end of a pencil may take care of the problem until return to the orthodontist’s office.  If this doesn’t help, covering the end of the wire with a pea-sized piece of dental wax, available at most drug stores, should provide temporary relief. It is not advised to try to cut the wire yourself due to concerns of swallowing or aspirating the cut end of the wire.

Our clients are fortunate to be able to access expert dental information through our eDent service.  For any questions you may have regarding dental issues feel free to contact our eDentist, Dr. Robert Tramel.

Takotsubo Cardiomyopathy. How Do You Mend a Broken Heart?

Nicknamed "broken heart syndrome", Takotsubo Cardiomyopathy (TCM) is a temporary condition associated with sudden, severe weakness of the heart muscle. "Cardio" refers to the heart and "myopathy" means muscle disease. Another name for this condition is "stress-induced cardiomyopathy", since it is triggered by emotional or physical stress. The disease was first described in 1990 in Japan, but has not been recognized by American doctors until fairly recently.

Who is Takotsubo?

This is actually a Japanese word that translates into "octopus pot" and does not refer to an individual. A takotsubo is a round-bottomed, narrow-necked vessel used by Japanese fishermen to trap octopuses. When imaging studies of the heart were performed in people with this condition, it was noted that one of the chambers of the heart (left ventricle) assumed the shape of an octopus pot when the heart muscle contracted.
 

Who gets TCM?

Over 90% of reported cases are in post-menopausal women ages 58 to 75. Emotional stress, such as the unexpected death of a loved one, is a common trigger. Cases have also been triggered by learning bad financial news, domestic violence, legal problems, experiencing natural disasters and being diagnosed with a serious medical problem. Physical triggers include the exacerbation of a chronic medical illness, a car accident, an asthma attack, and a seizure.
 

What are its symptoms?

At its onset, TCM mimics a heart attack with chest pain, trouble breathing, dizziness and weakness. An important difference, however, between TCM and heart attack is the underlying cause. A heart attack occurs after the arteries that supply blood to the heart become blocked, resulting in damage or death of portions of the heart muscle. In TCM, the heart muscle becomes overwhelmed by an outpouring of stress hormones, such as adrenaline, after experiencing emotional or physical trauma.
 

How is TCM managed?

Since TCM shares many of the features of a heart attack, including changes on electrocardiogram and elevation of heart muscle enzymes, it is managed in the same way as a heart attack initially. This could include admission to a coronary care unit and imaging studies (dye test) of the heart. In fact, the diagnosis of TCM is usually confirmed during the dye test because an important feature of TCM (along with the takotsubo-shaped ventricle) is that the coronary arteries are found to be normal. This is in direct contrast to the narrowed or blocked coronaries in someone with coronary heart disease. Once it is known that the heart is merely "stunned" rather than damaged, treatment becomes supportive until the heart muscle regains its strength. Medications may be required to improve blood pressure, lower the heart's workload or prevent blood clots.

Sobering findings from a study of alcohol-related deaths

Many times, we tend to think of long-standing conditions, such as chronic liver disease, as being responsible for causing deaths due to excessive alcohol consumption.  A recent study from the Centers for Disease Control (CDC), however, has shed new light on the actual causes of alcohol-attributable deaths. The main goal of this study was to update a previous analysis of alcohol-attributable deaths (AAD) and years of potential life lost (YPLL) in the United States that was performed in 2001.  The study looked specifically at the rates of AAD and YPLL in each state and estimated the number of deaths and YPLL that specifically involved those younger than 21 years. Here are a few of the findings (in bold type) from that study:

• During the study period of 2006 through 2010, an average of 87,798 deaths occurred each year that were attributed to excessive drinking.  Among working-age adults (ages 20-64), this amounted to approximately one in every ten deaths.  Excessive drinking plays a role in causing a number of conditions including liver failure, acute pancreatitis, psychosis, esophageal cancer, breast cancer, oral cancer, falling injuries, suicide and drowning.

• It was estimated that excessive drinking was responsible for the loss of approximately two and a half million potential years of life lost each year.  In other words, excessive alcohol consumption shortened the lives of those who died by about 30 years.   

• Binge drinking, defined as four or more drinks in a sitting for women or five for men, was found to be responsible for 51 percent of all deaths due to excessive drinking.   Binge drinking is the most common pattern of excessive alcohol use in the United States, and most people who binge drink are not alcohol dependent. Binge drinking is linked to an increased incidence of injuries (motor vehicle crashes, falls, drowning, etc.), violent acts (homicide, suicide, intimate partner violence, etc.), acute alcohol poisoning, and miscarriage.  In the United States, a standard drink is considered to be 12-ounces of beer (5% alcohol), 5-ounces of wine (12% alcohol) or 1 ½ ounces of distilled spirits (40% alcohol). 

• The majority of alcohol-attributable deaths (71%) and YPLL (72%) involved males. One factor that could have contributed to this statistic is that binge drinking has been found to be twice as common among men as compared to women. Among drivers in fatal motor-vehicle traffic crashes, men are almost twice as likely as women to have been intoxicated.

• The most common cause of chronic AAD was alcoholic liver disease, while the most common cause of acute AAD was motor-vehicle traffic crashes.  In 2011, the number of alcoholic liver disease deaths was found to be 16,749.  Alcohol-impaired driving crashes caused 10,228 deaths in 2010.

• The highest rate of annual alcohol-related deaths occurred in New Mexico (51 deaths annually per 100,000 people), while the lowest was reported in New Jersey (19 per 100,000).  The study’s authors offered several possible explanations for this difference including state policies on selling alcohol, differences in drinking patterns, and differences in access to health care, including emergency departments.

• During the years 2006-2010, an average of 4,358 AAD and 249,727 YPLL involved individuals under the age of 21.  Approximately three fourths of these were males. The three leading causes of death in this age group were acute, rather than chronic conditions.  These were--- motor-vehicle accidents, homicide, and suicide. Of these, traffic crashes alone accounted for 36% of the total.

Because of the way that data was gathered, the authors of this study felt that they most likely underestimated, rather than overestimated, the toll on life and life expectancy related to excessive alcohol intake. Of particular concern from this study is the finding that binge drinking is as great a concern as is chronic alcoholism.  The Dietary Guidelines for Americans defines moderate drinking as no more than 1 drink per day for women and no more than 2 drinks per day for men.  The CDC, however, points out that there are some persons who should not drink alcohol at all, including those who are:

• Pregnant or trying to become pregnant.

• Taking prescription or over-the-counter medications that may cause harmful reactions when mixed with alcohol.

• Younger than age 21.

• Recovering from alcoholism or are unable to control the amount they drink.

• Suffering from a medical condition that may be worsened by alcohol.

• Driving, planning to drive, or participating in other activities requiring skill, coordination, and alertness.