Tooth Fairy's Vital Message

Media item: article

Date published: 5 November 2012

This page records the media item. The original article is the property of its publisher and is not reproduced here.

Note: when baby teeth fall out, and in what order, is covered at Smile Solutions Tooth Fairy in the news.

This page carries the genuinely vital message: what to do in a dental emergency. The service page is Emergency Dentistry, and the threshold is set out at What is considered a dental emergency?

Go to a hospital emergency department NOW if

These are medical emergencies, not dental appointments.

Facial swelling that is spreading, closing an eye, or extending under the jaw or into the neck
Difficulty swallowing, difficulty breathing, or drooling because you cannot swallow
A swollen face with fever, or feeling generally very unwell
A stiff neck with a dental infection
Uncontrolled bleeding that does not stop with firm pressure
Any significant head injury, loss of consciousness, vomiting or confusion after a facial injury
A suspected jaw fracture

Dental infections can spread into the tissue spaces of the face and neck, and that is dangerous. People still die of them — see Can a dental abscess affect your general health? Do not wait for a dental appointment, and do not accept antibiotics and a wait-and-see (I have a toothache. Should I see my GP for antibiotics?).

Call 000 if breathing or swallowing is affected.

See a dentist immediately — today, within the hour if possible

A knocked-out permanent tooth

The most time-critical thing in dentistry, and the International Association of Dental Traumatology puts numbers on why: dehydration of the root surface "starts to happen in a matter of a few minutes", and "after an extra-alveolar dry time of 30 minutes, most PDL cells are non-viable". The longer version is What should I do when a tooth is knocked out?

Find the tooth. Hold it by the crown — never the root.
If dirty, rinse briefly in milk or saline. Do not scrub — the cells on the root surface are what allow it to reattach.
Put it straight back in the socket, the right way round, and bite gently on a cloth to hold it.
If you cannot replant it, keep it moist. The IADT's order of preference is milk, then HBSS or a tooth-preservation solution, then the person's own saliva — inside their own cheek if they are conscious and old enough not to swallow it — then saline. Water only as a last resort: it is a poor medium, but the IADT is explicit that it is "better than leaving the tooth to air-dry". Never let the tooth dry out.
Get to a dentist immediately.

A knocked-out BABY tooth is NOT replanted — it can damage the permanent tooth developing beneath. Still see a dentist. Children's dental emergencies are covered separately at Children’s Dental Emergencies and My child has a knocked out baby tooth: what do I do?

Severe, unrelenting toothache

Particularly pain that wakes you at night, is worse lying down, or is not controlled by ordinary analgesia. That pattern suggests irreversible pulpitis, and it does not resolve on its own. See Tooth Pain and Toothaches, I have a toothache — what could be the cause? and Root Canal.

A tooth pushed out of position, or very loose after injury

Do not force it back. It may need repositioning and splinting.

A dental abscess

A pimple-like swelling on the gum, a tooth painful to bite on, a bad taste — without the red-flag signs above. See What is a tooth abscess? Should I have it treated? and Why are dental abscesses so painful?

See a dentist soon — within a day or two

A broken or chipped tooth. Find the fragment and keep it in milk — it can often be bonded back on. See Chipped or Cracked Teeth and What should I do if I have a chipped tooth?
A lost filling or crown. Keep the crown if it came off whole; it can often be recemented (Dental Crowns). Temporary filling material from a pharmacy will usually hold in the meantime — What do I do if a temporary filling comes out?
A broken denture or a rubbing sore spot — My denture is broken. What should I do?
An orthodontic wire digging in. Cover the end with orthodontic wax, or a small ball of sugar-free chewing gum, until you can be seen — Braces and common complaints associated with conventional braces
Bleeding after an extraction that settles with pressure but keeps recurring
Increasing pain three or more days after an extraction, which is the classic timing for dry socket — see I've just had oral surgery: what can I expect during recovery? and How long does it take to recover from wisdom teeth surgery?

Can wait for a normal appointment

Mild, intermittent sensitivity to cold — What to do if you suffer from sensitive teeth
A rough edge that is not painful
Bleeding gums — which are not normal and do need attention, but not tonight (Bleeding Gums)
Cosmetic concerns
A wisdom tooth that is uncomfortable but not swollen or infected

And the standing rule, which is not an emergency but is urgent in a different sense: any ulcer, white patch, red patch or lump that has not healed in three weeks needs examining. Not in six months — Oral cancer: signs, risk factors and how your dentist can help.

What actually helps while you wait

How can I relieve a toothache? covers this in more detail.

Analgesia at the correct dose. Paracetamol and ibuprofen together, at recommended doses, are generally more effective for dental pain than either alone — check with a pharmacist, and do not exceed the labelled doses or take ibuprofen if you have been advised against it.
Cold pack on the outside of the face for swelling.
Sleep propped up. Lying flat increases pulpal pressure and makes toothache worse — which is why it wakes people at night.
Warm salt-water rinses.
Avoid extremes of temperature and chewing on that side.

What does not help, and does harm:

Do not put aspirin against the gum. It causes a chemical burn and does nothing for the tooth.
Do not use clove oil on the gum tissue. It burns soft tissue.
Do not apply heat to a facial swelling.
Do not attempt to drain a swelling yourself.
Alcohol does not help.
And do not rely on leftover antibiotics. Antibiotics do not treat the cause of dental pain, they can mask deterioration, and taking a partial course contributes to resistance.

Where to go, in Melbourne

Your own dental practice first. Most have an after-hours message with instructions, and most keep emergency appointment time each day — Why choose Smile Solutions in a dental emergency? and Contact Us.
Emergency dental services operate in the city and suburbs, including weekends. Directions here are on Location.
The Royal Dental Hospital of Melbourne provides emergency dental care, with eligibility-based triage. Anyone in significant pain should say so clearly rather than joining a general waiting list.
A hospital emergency department for anything on the red-flag list. Note that most general hospital EDs cannot do dental treatment — they manage the infection, the airway and the pain, and refer the tooth on. That is exactly what you need them for in an emergency.
A GP or pharmacist can help with pain relief and can assess whether something is spreading.

Save your practice's number in your phone now. That is a two-minute job that pays for itself once.

Common questions

How long is too long for a knocked-out tooth to be out of the mouth?

The clock that matters is dry time, not total time. The International Association of Dental Traumatology's avulsion guidelines state that "minimizing the dry time is critical for survival of the PDL cells" and that "after an extra-alveolar dry time of 30 minutes, most PDL cells are non-viable" — which is why a tooth belongs back in the socket, or in milk, before anyone gets in a car. The guidelines sort cases into three groups for prognosis: replanted immediately; kept in a storage medium with "total extra-oral dry time... less than 60 minutes"; and "total extra-oral dry time... more than 60 minutes, regardless of the tooth having been stored in a medium or not". Avulsion itself accounts for "0.5%–16% of all dental injuries".

It has been hours. Is it still worth putting the tooth back?

Usually yes, for a reason most people find counter-intuitive. The IADT is clear that "delayed replantation has a poor long-term prognosis" and that the expected outcome is "ankylosis-related (replacement) root resorption" — the tooth gradually being replaced by bone. But the goal shifts: "to restore, at least temporarily, esthetics and function while maintaining alveolar bone contour, width and height", so that implants or other options remain possible later. Hence its conclusion: "the decision to replant a permanent tooth is almost always the correct decision even if the extra-oral dry time is more than 60 minutes. Replantation will keep future treatment options open." For a child, ask about what may be needed later if the tooth becomes ankylosed.

Milk or water — the advice seems to contradict itself?

It does, and the contradiction resolves once you see what each source is worried about. The Victorian Department of Health's Better Health Channel says flatly: "Do not use water to rinse or store the knocked-out tooth." The IADT ranks media "in descending order of preference, milk, HBSS, saliva... or saline", and then adds the fallback: "Although water is a poor medium, it is better than leaving the tooth to air-dry." So the rule to remember is not water is fine but never let it dry. Reach for milk first — it is the one thing most kitchens and canteens have. Water is what you use when there is nothing else.

What happens at the dentist once the tooth is back in?

More than most people expect, and it runs for weeks. The IADT guidelines call for the tooth to be stabilised "for 2 weeks using a passive flexible splint such as wire of a diameter up to 0.016” or 0.4 mm" — or four weeks with a more rigid splint "in cases of associated alveolar or jawbone fracture". Then: "initiate root canal treatment within 2 weeks after replantation", "administer systemic antibiotics", "check tetanus status", and follow up. A replanted tooth is the start of a course of treatment, not the end of an incident — so book the review appointments before you leave.

Are there teeth that should not be put back?

Yes, in two categories. A knocked-out baby tooth is never replanted — the Better Health Channel's reason is direct: "This can damage the developing permanent tooth underneath the gum." See a dentist anyway, to check the permanent tooth and the rest of the mouth. For adult teeth, the IADT lists circumstances in which replantation is not indicated, decided case by case: "severe caries or periodontal disease, an uncooperative patient, severe cognitive impairment requiring sedation, severe medical conditions such as immunosuppression, and severe cardiac conditions". That is a clinical judgement made at the chair — not a reason for anyone at the scene to leave a tooth on the ground.

Practical details

Smile Solutions, Level 1, 220 Collins Street, Manchester Unity Building, Melbourne VIC 3000. Phone 13 13 96, or theteam@smilesolutions.com.au. Monday–Friday 8.00am–6.00pm, Saturday 8.30am–1.30pm, Sunday by appointment.

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This is an archive record of a published article and its date, with general information — not current clinical advice. It is not a diagnosis or a treatment plan and does not replace assessment. In an emergency call 000. For medical advice, Nurse-on-Call in Victoria is 1300 60 60 24; for poisons, the Poisons Information Centre is 13 11 26. Third-party published content is not reproduced.

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