Dental and oral problems

For assessment — see mouth, throat, teeth and gums examination

Oral health messages

• Do not smoke (tobacco or cannabis) — increases risk of dental, gum and mouth disease
• Clean teeth and gums morning and night with soft toothbrush and fluoride toothpaste
• Spit, don't rinse after brushing
• Avoid regular use of mouthwash containing alcohol —short-term use is OK
• Eat healthy foods — avoid sweet food and drink, especially between meals
• Don't drink fruit juices, soft drinks, cordial, sports drinks, flavoured milk or anything fizzy even if sugar free
• Drink plenty of water and some milk
• Chew sugar free gum
• Control diabetes — will lower risk of bad gums and tooth loss
• Have a yearly dental and oral health check

Managing pain in teeth or gums

©Kingon A. Solving dental problems in general practice. Aust Fam Physician 2009;38(4):211–16. Adapted with permission

Oil of Cloves (eugenol) should not be supplied to patients to take home 

Dental pain relief

Continue treatment for the shortest duration possible and no more than 3 days without review

Contraindications for NSAIDs 

• eGFR less than 25 or unknown
• Severe heart failure AND taking diuretic AND ACE inhibitor or ARB
• Severe asthma
• High cardiovascular risk
• Stomach ulcers
• Severe hepatic impairment
• Severe bleeding, eg suspected ruptured organ
• If pregnant — medical consult before giving

Child

• Paracetamol — 15mg/kg/dose up to 1g, up to 4 times a day (qid)

OR ibuprofen if no contraindications, oral — 10mg/kg/dose up to 400mg — doses — up to 3 times a day (tds)

• Can also be combined for enhanced pain management

Adult

• Mild to moderate pain
• Paracetamol oral — 1g, up to 4 times a day (qid)

AND ibuprofen if no contraindications, oral — 400mg, every 6–8 hours (no more than 4 tablets (1600mg) in a day

• Severe pain — after maximum regular doses of ibuprofen AND paracetamol have been tried
• Stop regular paracetamol, continue ibuprofen, if no contraindication

AND paracetamol-codeine oral — 1000+60mg, repeat once if required after 4 hours then medical consult

• If ibuprofen contraindicated — continue paracetamol AND do medical consult for oxycodone immediate-release, if available, oral — 5 mg, every 4 to 6 hours as necessary 

Gums and soft tissue

Dry mouth

• Reduced saliva reduces health and comfort of mouth and increases the risk of dental decay and severity of gum disease
• Main causes are mouth breathing , smoking, medicines, dehydration, infections, cancer treatments

Do

• Try to find cause — dental/medical consult if needed
• See oral health messages
• Tell person 
• Stimulate salivary glands by chewing food well, chewing sugar-free gum or sugar free sweets —non-fruit flavours are less acidic
• Use bicarbonate soda mouthwash (half teaspoon of bicarbonate soda in a glass of water) and spit out — rinse as soon as you get up and any time during day

Mouth ulcers

Common causes include

• Minor physical trauma, eg from food burn, sharp or rough food, broken tooth, broken fillings, dentures, orthodontic appliances
• Chemical trauma, eg from prolonged exposure to chewing tobacco, aspirin burn, tooth-bleaching products
• Infection, eg virus
• Immune response, autoimmune disease, eg Crohn’s disease

​Do

• Paracetamol (doses) and lidocaine (lignocaine) gel for pain
• Use saltwater OR  chlorhexidine 0.2% mouthwash — 10mL
• Rinse for 1 minute, 3 times a day (tds)
• ​Will help stop infection and keep mouth clean
• Adults with ulcers not healed within 2 weeks OR recurring — medical consult to send to hospital for biopsy — potential tumour
• Young child with severe ulcers
• Medical consult to consider antiviral treatment
• Check for dehydration — may not be drinking if mouth sore
• If child not eating — send to hospital

Chronic gum disease

Ongoing inflammation of gums without pain

• Chronic gingivitis — red, swollen gums that bleed easily
• Chronic periodontitis — can result from gingivitis
• Inflammation affects supporting bone and tissues of the teeth. May cause gum recession and bone loss and teeth loose or fall out
• Risk factors include smoking and poorly controlled diabetes

Do

• Dental consult
• If child has periodontitis — urgent dental consult
• See oral health messages
• If brushing difficult — use chlorhexidine 0.2% mouthwash — 10mL
• Rinse for 1 minute and spit out, 3 times a day (tds) for 5–10 days
• Control diabetes

Acute gum disease

• Acute ulcerative gingivitis — painful, red, swollen gums that bleed easily
• Periodontal abscess — painful local gum abscess

Acute ulcerative gingivitis

Risk factors — poor oral hygiene, smoking, stress, weakened immune system

Check

• Intense pain
• Ulcerated tissue in gums between teeth
• Spontaneous (sudden) bleeding of gums
• Very bad breath
• May also have fever, general discomfort, inflammation of lymph nodes

Do

• Give dental pain relief
• Give metronidazole oral — adult 400mg, child 10mg/kg/dose up to 400mg — doses — twice a day (bd) for 5 days
• If allergy — medical consult
• Urgent dental consult
• If painful and difficult to brush teeth — use chlorhexidine 0.2% mouthwash — 10mL, rinse for 1 minute and spit out, 3 times a day (tds) for at least 5 days
• Good oral hygiene — brushing ulcerated area may not be possible due to pain

Periodontal abscess

Risk factors — existing gum disease, uncontrolled diabetes, poor oral hygiene

Check

• Pain, discomfort — can be difficult to localise
• Swollen gum next to tooth/teeth without hole or decay
• Can be on palate and difficult to see

Do

• Give dental pain relief if needed
• If abscess with no systemic features — antibiotic cover only if not receiving dental care within 24 hours OR if weakened immune system
  
• Amoxicillin+clavulanic acid oral — adult 875+125mg (child 2 months or older: 22.5+3.2mg/kg up to 875+125 mg) — doses — twice a day (bd) for 5 days

OR If allergy to penicillin — clindamycin oral — adult 300mg, child 7.5mg/kg up to 300mg — doses — 3 times a day (tid) for 5 days

• Dental consult about lancing, debriding, extraction

Facial swelling due to spreading infection

Spreading odontogenic infection with severe or systemic features can rapidly become life threatening — because of the risk of airway obstruction and sepsis

• Localised tooth-related infections are caused by
• Pulp necrosis (death of tooth nerve) due to decay or trauma
• Periodontal disease (gum infections)
• Infection around crown of erupting tooth, eg wisdom tooth
• Facial swelling (spreading odontogenic infection) may be with OR without severe or systemic features
  
• Severe — significant facial swelling and pain, trismus (difficulty opening jaw), neck swelling, difficulty breathing or airway compromise
• Systemic — pallor, sweating, tachycardia, an axillary temperature more than 38°C or sepsis
• Do not treat with antibiotics alone — must do dental/medical consult about treating underlying cause

Check

• Mouth, throat, teeth and gums examination
• If severe or systemic features — must assess for limited mouth opening
• If mouth opens less than 2cm — must assess for airway problems
• Difficult or noisy breathing
• Difficulty swallowing
• Tongue raised and rigid

Do if airway compromised

• Remember — see Life support — DRS ABC
• If facial swelling (spreading infection) with severe or systemic features — medical consult to send to hospital urgently
• Give oxygen
• to target O₂ sats 94–98%
• OR if moderate/severe COPD 88–92%
• Put in IV cannula
• Give metronidazole IV — adult 500mg, child 12.5mg/kg/dose up to 500mg — doses — every 12 hours (bd)
• AND benzylpenicillin IV — adult 1.2g, child 30mg/kg/dose up to 1.2g — doses — every 6 hours (qid)
• If allergy to penicillin — medical consult

Do if airway satisfactory

• Make sure person is hydrated
• Give dental pain relief
• Give amoxicillin+clavulanic acid oral — 875+125 mg (child 2 months or older: 22.5+3.2 mg/kg up to 875+125 mg), twice a day (bd) for 5 day — doses
• If allergy to penicillin — give clindamycin oral — 300mg, child 7.5 mg/kg up to 300 mg, 3 times a day for 5 days — doses
• If skilled and abscess pointing — lance
• Urgent dental/medical consult to drain pus and remove cause, eg extract tooth/teeth

Follow-up

• Review in 2–3 days
• If not improving — medical consult

Dental trauma

Knocked out adult tooth

Check

• Head-to-toe exam — with attention to head and neck injuries
• Immunisation status — tetanus 

Do not

• Do not touch root of tooth — only crown
• Do not allow tooth to dry out — store in milk or saline (not water) or wrap in cling wrap
• Do not replant primary (baby) teeth 

Do

• If RHD, artificial heart valve, heart transplant, history of bacterial endocarditis or congenital heart problem — give IV preventive antibiotics before replacing tooth
• Replace and splint tooth in place as quickly as possible — see Replacing knocked out adult tooth
• Recommend short-term use of chlorhexidine mouthwash after replantation while the tooth is splinted 
• chlorhexidine 0.2% mouthwash — 10mL rinsed in the mouth for 1 minute and spit out, 3 times a day
• If chlorhexidine used for more than a few days — may cause discolouration of teeth and fillings
• Give doxycycline oral — adult 100mg, child — doses — once a day for 7 days
• If pregnant — medical consult
• If allergy — medical consult
• Urgent dental/medical consult

Broken or loose tooth

See Broken tooth (fractured tooth crown) OR Loose or displaced tooth — adult or child

Broken jaw

• If unconscious with jaw injury — secure airway, pull jaw forward (jaw thrust) — see Life support — DRS ABC, Injuries — head
• Treat any serious injury to face below cheek bones as broken jaw — can lead to bone infection if not treated
• If mechanism or injuries suggest neck injury — put on cervical collar (may make jaw more painful) AND assess situation

Ask

• About pain, especially when moving jaw
• Any trouble swallowing or eating

Check

• Head-to-toe exam — with attention to
• Bony tenderness or numbness of any part of jaw
• Swelling, bleeding, bleeding in floor of mouth, wounds — most jaw fractures are compound
• Do upper and lower teeth meet together properly — ask person to bite on spatula
• Do teeth line up properly along each jaw
• Look for difference in outline between one side of jaw/face and other side
• Feel for step in line of teeth or jaw
• Immunisation status — tetanus 

Do

• Medical consult to determine antibiotic choice
  
• Sit person up — lean them forward to let blood and saliva drain
• Give antiemetic to stop vomiting
• Give pain relief