Accidents are a part of life.  Some accidents involve teeth, so it certainly helps to know what to do if you or a loved one suffers dental trauma.

First and foremost, severe bodily or life-threatening injuries should be addressed.  If the patient is unconscious or seems confused, this may be a sign that the brain has been injured, and emergency medical services should be contacted immediately.  Likewise, if there are any other signs of significant bodily injury, seek urgent medical attention.

If injuries are limited to teeth, promptly call your family dentist.  If your family dentist is unavailable, endodontists and oral surgeons may also be called, because they are dental specialists who have additional training and experience in treating dental trauma.

When a tooth gets knocked out of the mouth, dentists refer to that as an “avulsion”.  These teeth may be saved if you know how to handle the tooth properly.  The main goal is to keep the cells on the root surface alive because these cells are responsible for keeping the root of the tooth healthy:

DO NOT scrub the root of a tooth, DO NOT dry the root, DO NOT keep the tooth in water; doing so can kill the cells on the root surface.  

The best thing you can do for an avulsed adult tooth is to hold it by the crown (the top white part of the tooth), briefly rinse debris off with water (less than 10 sec), and push it firmly back into the socket!  If possible, hold it in position by having the patient bite on something soft like a shirt.  Baby teeth should NOT be placed back in the socket to avoid damaging the adult tooth growing in the gums underneath it.

If you are uncomfortable placing an adult tooth back in the socket (or if you are unsure whether it is an adult tooth), the next best thing is to IMMEDIATELY place the tooth in a special solution sold specifically for temporarily storing avulsed teeth. Many sports teams have such solutions available in their emergency kits. These special solutions are sold as “Save-A-Tooth” and other brands.  Putting the tooth in a jar of milk works almost just as well.  A last resort would be to have the patient spit in a cup and keep the tooth moist in the patient’s saliva (spit).  DO NOT store the tooth in plain water.  Do not delay.  After only 30 minutes of being exposed to air, the chances for a favorable outcome drop precipitously.

Putting the tooth in a storage solution will buy you only a limited amount of time to find someone who is able to put the tooth back in its socket.  Every minute a tooth spends out of its socket decreases the long term prognosis of the tooth, so act quickly!  

Once the tooth has been replaced in its socket, repositioned properly, and stabilized by the dentist, the tooth will require root canal treatment in about one week.  The pulp (or “nerve”) inside that tooth will not survive after avulsion, and the inside of the root will need to be cleaned out before the necrotic tissue becomes another source of inflammation.  Development of severe inflammation or infection from a necrotic pulp can then damage the bony socket and the root which you tried so hard to preserve.

Additional information for dental professionals about treatment of dental trauma can be found by following the links below.

http://dentaltraumaguide.org

http://www.aae.org/uploadedfiles/publications_and_research/guidelines_and_position_statements/2004traumaguidelines.pdf

In this blog, we hope to address some of the questions people have about dental specialties, including endodontics (the specialty typically associated with root canal treatment).
 

Dentists with additional training: All dentists attend three to four years of dental school learning to perform a vast array of routine dental procedures such as extractions, fillings, crowns, bridges, root canals, etc.  Dental specialists are dentists who have gone on to receive additional post-doctoral training in a particular, limited field.  The recognized dental specialties include oral surgery, prosthodontics, periodontics, orthodontics, public health, oral pathology, oral radiology, and endodontics.  Endodontic residency programs are 2-3 years long. These years of additional education make dental specialists better equipped to handle more complex cases.  Specialists are also good sources of information for general dentists regarding newer, proven techniques and materials (1).
 

Why did my dentist refer me to a specialist? One must first understand that not all teeth are created equal.  Some teeth are more difficult to treat.  Some conditions are more difficult to diagnose.  General dentists often refer their patients to specialists for these complex cases.  Being referred to a specialist does NOT mean your general dentist is incompetent.  On the contrary!  The most skilled, experienced dentists are aware of their limitations and know when it is best to refer!  Your referral to a specialist indicates that your dentist is fulfilling an ethical obligation to ensure you receive the highest level of dental care. Dentists who are members of the American Dental Association abide by a code of ethics and professional conduct, which states, “Dentists shall be obliged to seek consultation, if possible, whenever the welfare of patients will be safeguarded or advanced by utilizing those who have special skills, knowledge, and experience.” (2)
 

What are specific reasons for being referred to an endodontic specialist? The reasons for a referral to an endodontist are too numerous to list, but we will mention a few.  Any one or a combination of conditions may be reasons for referral.  These conditions include, but are not limited to: Difficult diagnosis, questions about prognosis, limited mouth opening, aggressive infection/pain, difficulty with radiographic imaging, difficult-to-access canals, challenging tooth/root morphology, and complications with previously-done root canal therapy (3).  In the end, perhaps the most important reason for referral to a specialist is to provide the patient with the best dental care possible.
 

1. Hazelkorn HM, Robins LS. Building the relationship between general practice and specialty dentists. J Am Dent Assoc. 1994;125:1392-6.
2. ADA Principles of Ethics and Code of Professional Conduct
3. Rosenberg RJ, Goodis HE. Endodontic case selection: to treat or to refer. J Am Dent Assoc. 1992;123:57-63.

If the nerve in the root-canaled tooth is gone, how can I feel pain from that tooth?

As endodontists, we get this question a lot.  To answer it, we need to chat a little about… the anatomy of a tooth:  There are two basic types of nerves associated with a tooth that can cause pain:

1. The tooth has nerves in the ligament around the OUTSIDE of the root that holds the tooth in the bone (illustrated below in orange).  Healthy nerves outside the tooth report pain when you bite into that unexpected piece of bone or hard seed.
2. The tooth also has nerves in the pulp, the tissue INSIDE of the tooth (illustrated below in blue). The nerves and blood supply to the pulp enter through tiny holes at the tips of the roots.  Healthy nerves in the tooth can give brief sensitivity when a tooth is bathed in a cold drink or ice cream.

If bacteria from a deep cavity encroach upon the pulp tissue or take over the pulp space of a tooth, the bacteria and inflammatory products spill out of the tiny holes at the root tip.  This irritates the nerves outside the root tips in the ligament we described earlier (1).  When these ligament nerves become irritated, biting into even soft things can cause discomfort; there can also be constant soreness or outright pain.  In simple terms, the goal of root canal treatment is to clean out the bacteria and inflamed or dying nerves in the pulp space, which in turn gradually eliminates inflammation of the ligament at the root tip.

Finally, the answer to the question we started off with: After a root canal, the nerve inside a tooth is indeed gone, but the nerves in the ligament outside the tooth remain very much alive.  There are a variety of ways the nerves of the ligament can be irritated and cause pain in a root canaled tooth.  Such conditions may include periodontal disease, an “unhealthy” bite, sinus problems, trauma, recent dental work and cracked teeth; additional root canal treatment in these cases is generally not appropriate. In a very small portion of root canaled teeth, bacteria hide in a natural crevice or crack that is inaccessible by the treating dentist/endodontist.  Furthermore, new decay or a leaking crown (particularly in teeth that had root canal treatment a long time ago) can allow bacteria to contaminate the root fillings and migrate to the root tips.  This bacteria can continue to irritate the ligament of the tooth and cause persisting discomfort; in those cases, root canal retreatment or root-end surgery may be useful (2).  Extraction, although a relatively aggressive procedure, would also be a treatment option.

If you are having persistent problems with a tooth that has undergone root canal treatment, call our office!  At Ellis Endodontics, our experienced endodontists will perform a thorough exam to determine the cause of discomfort.  We will also discuss with you what treatment options are appropriate for your specific situation.

1. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposures of dental pulps in germ-free and conventional laboratory rats. Oral Surg Oral Med Oral Pathol 1965;20:340–9.
2. Tsesis I, Goldberger T, Taschieri S, Seifan M, Tamse A, Rosen E. The dynamics of periapical lesions in endodontically treated teeth that are left without intervention: a longitudinal study. J Endod 2013;12:1510-5.

Why didn’t I get antibiotics to treat a dental infection?

A double-edged sword: Ever since the discovery of penicillin, antibiotics have benefited humankind greatly; however, overuse of antibiotics has resulted in the development of many resistant strains of bacteria in the environment. Although penicillin is still an inexpensive, safe and effective antibiotic used to treat certain bacterial infections, more and more patients are getting infections from bacteria against which penicillin does not work. Strains of bacteria, such as methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE), are developing in the environment that are resistant to even “stronger” antibiotics (1). The number of antibiotics available to treat resistant bacterial strains is limited, particularly for those patients allergic to certain types of antibiotics (like penicillins). To help prevent the development and breeding of resistant bacterial strains, healthcare professionals have a responsibility to prescribe antibiotics only when a patient truly needs it (2). Additionally, let's not forget that medications are rarely without side-effects. Certain antibiotics are known to cause gastro-intestinal distress, yeast infections, and serious adverse drug interactions, to name a few.

Treatment of dental infections: The fact is that the normal, healthy human body has an excellent natural immune system capable of handling many low-grade infections on a daily basis. Simple mechanical removal of most of the bacteria via decay excavation followed by a filling, deep cleaning of tooth and root surfaces, extraction or root canal therapy of contaminated teeth is often sufficient in treating certain dental infections without the use of antibiotics. In fact, most of the time antibiotics alone will not completely cure dental infections; you'll need the corrective procedure too.  Feel free to ask your dentist about the appropriateness of use of antibiotics in your situation, but do not be surprised if your dentist does not write a prescription

1. ADA Council on Scientific Affairs. Combating antibiotic resistance. J Am Dent Assoc 2004;135:484.
2. Sweeney LC, Jayshree D, Chambers PA, Heritage J. Antibiotic resistance in general dental practice—a cause for concern. J Antimicrobial Chemotherapy 2004;53:567.