Chapter 180. Defective Dental Restoration Management

The field of restorative dentistry is a complex specialty that derives from many disciplines. Patients have often invested considerable time, money, and quite possibly “blood, sweat, and tears” in their dental work. This may be particularly true with the advent of both cosmetic and implant dentistry, which involve long and complicated treatment plans that are often not covered by insurance. A patient's investment in their dental work and the technical complexity of today's dental appliances should not be taken lightly. In fact, the treatment of common dental emergencies was published in the Emergency Medicine Clinics of North America under the heading “Difficult and Advanced Procedures”.1

The urgent management of an acutely problematic dental restoration can be as simple as relieving discomfort, treating injury and infection, and employing temporizing measures until definitive treatment can be rendered by the appropriate specialist. This requires a basic understanding of dental anatomy, the pathophysiology of various dental states, and their typical treatment modalities.1,2 It goes without saying that one should also recognize the inherent and all too frequent limitation of treating these problems in the Emergency Department. The key to the successful emergent or urgent management of an acutely problematic defective dental restoration is stabilization and timely referral with great care to “first, do no harm”.

A few basic principles serve as a useful guide in treating patients with defective dental restorations. First, know your limitations. Dental pain in general, and a defective dental restoration in particular, is rarely if ever, a true emergency.2–4 Chronic problems should be treated with equal measures of conservatism and reluctance. Refer the patient to a Dentist if you are hesitant to treat or are unfamiliar with an appliance or a presentation. Always consider a secondary or comorbid process. Consider the utility of dental radiographs when in doubt. Never remove a fixed appliance without first discussing it with a specialist, preferably the one who placed it. Save anything and everything that belongs to the patient, whether it be appliance or tissue, as it may have utility for the definitive treatment.5,6 Treat pain, inflammation, and evidence of infection. Consider a reversible or temporary solution over all others. Remember to treat a tooth for dental trauma if a restoration is determined to be defective secondary to trauma. Always consider ingestion or aspiration when dealing with a multiply fragmented tooth or appliance. Consider facial, neck, chest, and abdominal radiographs if all fragments cannot be accounted for.5,7–10 Whenever a patient is actively involved in an ongoing treatment process, it is probably best to do as little as possible. Always use caution and tact when discussing the possibility of a defective dental restoration with a patient. Remember that you are not an expert. The treating specialist may have insight into the patient's current condition that you are unaware of. Attempt to consult before treating. Always arrange follow-up within 24 to 48 hours.

Patients frequently present to the Emergency Department with some sort of dental complaint and their primary concern is typically pain related.1,2,11,12 The perioral tissues are exceptionally sensitive to noxious stimuli. This is particularly true for the oral mucosa, periodontal ligament, dentin, and pulp. This concept is paramount to the effective management of any dental-related complaint. Although a patient's chief complaint may be directed at a particular tooth, be diligent in searching the entire mouth for alternative primary, comorbid, or secondary problems.

A meaningful discussion of the management of defective dental restorations requires a brief outline of the available types of dental appliances. In general, dental appliances are either fixed or removable. Fixed dental appliances are considered permanently attached to the teeth. They include crowns, bridges, implants, some forms of dentures, orthodontic bands and brackets, interdental wiring, and any type of filling (e.g., silver amalgam, gold, porcelain, or tooth-colored composite material). Removable dental appliances are those that are not permanently attached to the teeth and include partial dentures, complete dentures, space-maintenance devices, and other orthodontic devices.

Understanding whether a defective dental device is permanent or removable is often the first step in managing an acutely problematic appliance. Removing a broken or defective removable appliance is a simple and easy solution if it can be done safely and without significantly damaging the appliance. If removal would significantly alter or damage an appliance and there is no other reasonable option but to remove it, document the discussion with the patient and their consent to proceed. This is true whether the appliance is permanent or removable.

Removable dental appliances can predispose patients to several easily treatable mucosal conditions such as ulcerations, abrasions, or mucosal infections.13,15 Compromised cellular immunity, broad-spectrum antibiotics, low salivary flow, poor oral hygiene, and trauma from poorly fitting dentures can all contribute to oral candidal overgrowth.13,16 Patients often complain of burning pain. Treat the oral cavity with nystatin or clotrimazole troches. The appliance itself may harbor the organism and must be treated. Instruct the patient to take the appliance out of their mouth for 24 to 48 hours and soak it overnight in a nystatin suspension [5 mL nystatin in 250 mL (8 ounces) of tap water]. Instruct the patient to scrub the denture daily with an approved product to clean it.13–15

Oral candidiasis must be differentiated from other mucosal ulcerating conditions such as simple traumatic ulcers, aphthous ulcers, and oral herpes. Herpetic lesions occur on attached mucosa only, whereas aphthous ulcers occur on unattached mucosa.13–16 Traumatic ulcers, minor aphthae, and major aphthae can be treated with topical corticosteroid ointment, such as triamcinolone, applied with a cotton-tipped applicator. The symptoms associated with herpetic outbreaks can be diminished if treated with acyclovir or a similar antiviral agent.13–15 Orthodontic or interdental wiring that is impinging upon the oral mucosa may lead to traumatic ulcerations. Apply soft dental wax directly to the irritating appliance to relieve the impingement. This can be easily removed or replaced and is available over the counter at many local pharmacies.

In general, all patients with painful mucosal conditions may benefit from soft and bland diets, frequent use of ice chips for discomfort, and frequent warm saltwater rinses to avoid superinfection.13,14 A stomatitis cocktail or BMX solution may be helpful for patients with severe mucosal pain. Mix equal amounts of Benadryl (12.5 mg/5 mL), Maalox, and Xylocaine (2% viscous lidocaine). Instruct the patient to swish 30 mL in their mouth for 1 minute and then spit it out.

The repair of broken or defective removable appliances in the Emergency Department is not recommended even though multiple over-the-counter products are available for home use (Figure 180-1).16 Under the best of circumstances these procedures can be tedious, time consuming, and fraught with complications—even for the trained dental professional.3 Most importantly, a botched repair attempt can result in patient discomfort, morbidity, and irreversible damage to an otherwise salvageable appliance. In this light, it seems best to simply recommend removal and a dental referral to the patient seeking care for a broken removable appliance.16 Although far less than ideal, a home repair kit may be a viable option for some patients under certain circumstances.

The temporary urgent repair of defective fixed dental restorations by nondental personnel is advocated throughout the literature.2,3,11,12,14,17–19 Use caution, however, when evaluating a new or recently placed fixed restoration because sensitivity from recent dental procedures can occur due to pulpal or periodontal ligament (PDL) irritation.20 This may be a normal and expected sequelae of the dental procedure and not necessarily an indication that the restoration is defective.1,20,21 Trauma from occlusion can result if a new dental restoration is left “too high” and does not fit properly with the opposing dentition.3,14,18–20 These patients complain of pain with mastication and are sensitive to percussion secondary to PDL irritation. Do not alter a fixed restoration if it is firmly in place. Simple temporizing measures include dental blocks (Chapter 176), oral analgesics, a soft diet, and possibly removing the tooth from occlusion by placing a small amount of soft dental wax (or something similar) between the teeth on the opposite side.3

Long-standing fixed dental restorations may be defective secondary to microleakage or recurrent decay around the margins of the restoration.1,20 Estimates suggest that approximately one in three restorations in existence may be defective in some fashion.20,21 A faulty restoration that sits within or upon a tooth can lead to dentinal exposure regardless of the etiology. Exposed dentin is highly sensitive and prone to further decay. Dentinal sensitivity (also known as reversible pulpitis) is typically nonspontaneous and fleeting.1,16,18,22 Patients who complain of spontaneous and lasting sensitivity have an irreversible pulpitis that is most likely due to recurrent decay. Sensitivity to percussion is indicative of periapical involvement and suggests the possibility of a periapical periodontitis or an abscess.1,14,16,18,22

Evaluate the tooth and its restoration for recurrent decay or a possible dentinal exposure if a patient present complaining of sensitivity associated with a tooth that has a long-standing restoration. A temporary restoration can easily be fabricated in the Emergency Department if the restoration in question is missing, broken, or easily removed.

Consideration should be given to a possible pulpal pathology, as outlined above, if a restoration is firmly in place. Provide dental anesthesia, oral analgesics, antibiotics as necessary, and a referral to a Dentist. Refer to Chapter 177 for the details regarding the management of dental abscesses.

Replace any previously fixed, permanent or temporary, dental restoration that has completely or partially fallen out or that is easily removed with a dental explorer. Replace any previously fixed, permanent or temporary, crown that has fallen out or is easily removed with a dental explorer and is in the patient's possession.

Relative contraindications for the placement of a temporary dental filling, or temporarily recementing a crown, include patients who are involved with an extensive ongoing dental treatment plan, have a consulting specialist readily available, are at a significant aspiration risk, or have obvious extensive comorbid or secondary processes including antecedent trauma.

• 10 mL syringe
• 18 gauge angiocatheter
• Normal saline solution
• Local anesthetic solution containing epinephrine
• Dental mirror
• Dental explorer
• 2 × 2 gauze squares
• Sterile cotton rolls
• Dental floss
• Clear nail polish
• Cavit-G
• IRM (zinc oxide and eugenol)
• Dycal (calcium hydroxide paste)
• Copalite (cavity varnish) or clear acrylic nail polish
• Tin foil
• Cotton-tipped applicators
• Discoid-cleoid dental carver
• Articulating paper
• Frazier suction catheters
• Suction source and tubing
• Petrolatum-based lubricant (Vaseline)
• Good overhead lighting or a headlamp

Explain the procedure, its risks, complications, and aftercare to the patient and/or their representative. Obtain an informed consent for the procedure. The simple placement of a temporary filling does not usually require local anesthesia. However, consider the use of a dental block if the patient is uncomfortable. Refer to Chapter 176 for the complete details regarding dental anesthesia and analgesia.

Prepare the patient. Seat the patient in a multipositional procedure chair. Gently irrigate the area with a syringe that contains warm normal saline and is armed with an 18 gauge angiocatheter to remove any food debris. Warm saline is usually less sensitive to the exposed dentin.1 Gently remove any debris that does not irrigate away with a dental explorer. Do not attempt to remove any decay because doing so may lead to a complicating pulpal exposure.1 Remove the loose portion of the restoration. Do not remove any firmly fixed portion of the restoration.

It is mandatory to have a dry field when performing this procedure. Dry the area to be filled with sterile cotton pellets or compressed air. Remember that the tooth may be sensitive.

Replacing a Temporary or Permanent Filling

Treatment of defective fillings depends upon the relative size of the defect. There are no specific guidelines of what size (i.e., how many millimeters) the defect must be to perform each of these techniques. Paint small dentinal exposures with calcium hydroxide paste followed by cavity varnish or clear acrylic nail polish to relieve sensitivity.1,10,14,19 Alternatively, place a simple tin foil dressing over the tooth to act as a bandage following placement of the calcium hydroxide paste.10,14,19

Larger defects require a filling to avoid food impaction and other sequelae. Cavit-G is an excellent choice for temporary filling material, especially in inexperienced hands.1,10,12,23 This material is premixed, nonirritating, and sets quickly (approximately 30 minutes) upon contact with saliva. IRM, or a mixture of zinc oxide and eugenol, is similar material with the benefit of pulpal sedative properties. The use of IRM is operator dependent and requires a longer setting time.23 Oddly enough, multiple mixtures of zinc oxide and eugenol are available over-the-counter for home use (Dentemp, Tempanol, Thin Set; Figure 180-2).

Cavit-G is recommended for Emergency Department use. Determine whether the missing filling exposes an open endodontically treated root (i.e., root canal). Place a small sterile cotton pellet into the canal prior to placing the filling material if the pulp cavity is exposed.23 Express a small amount of Cavit-G from the container. Apply it onto the cavity and condense it into the cavity with the moistened end of a cotton-tipped applicator or a dental explorer (Figure 180-3A). A temporary restoration placed by nondental personnel is always better “short” and out of occlusion with the opposing tooth for patient comfort. Work quickly because Cavit-G can set rapidly and it may be difficult to remove once it sets. Remove any excess Cavit-G with the stick end of the cotton-tipped applicator. Instruct the patient to fully occlude on the new restoration and grind their teeth back and forth in all directions for 5 to 10 minutes. This will form the occlusal aspect of the filling to fit the opposing teeth if it is not made “short”.

Remove any excess material with the stick end of the cotton-tipped applicator. Use the discoid-cleoid dental carver to remove excess material once it begins to harden (Figure 180-3B). Use dental floss to contour a proper embrasure and clear excess material from the gingival tissues. Use the dental floss in a downward direction only. Never bring the dental floss back up toward the occlusal surface because doing so risks dislodging the new restoration. Simply pull the dental floss through after one downward pass around the tooth.

Replacing a Temporary or Permanent Crown

The patient preparation required for this procedure is essentially the same as that for replacing a temporary filling. However, avoid dental anesthesia if possible to allow better patient proprioception. This will provide the Emergency Physician with a crucial aid in assessing the orientation and occlusion of the final restoration.1 The same over-the-counter mixtures for repairing a filling may be used to temporarily replace a crown (Figure 180-2).

Reapply the crown to ensure that it fits properly. It is often necessary to remove a small amount of the existing cement from within the patient's existing restoration in order to provide an adequate seal and a proper occlusion.1 This may or may not be possible to do with the discoid-cleoid dental carver. Do not use rotary instruments as these may irreversibly damage the inside of the coping. Reinsert the patient's crown after removing some of the cement to assure a proper fit and proper occlusion. Make an attempt using the alternative technique described below if sufficient preexisting cement cannot be removed and the crown seats properly. Treat dentinal sensitivity as outlined above (i.e., as replacing a filling) if the appliance does not seat at all.

Proceed with this technique if the restoration appears to fit and a small amount of the preexisting cement can be removed from the inside. Prepare the area. Apply a thin layer of petrolatum-based lubricant (i.e., Vaseline) to the mucosal tissues surrounding the tooth to aid in the cleanup. Do not contaminate the prepared tooth with the lubricant.

Prepare or mix a thin consistency of zinc oxide and eugenol cement. Place a very small amount of the mixture into the preexisting crown with a cotton-tipped applicator.3,14,18 Place the crown on the tooth and in the proper orientation. Firmly and fully seat the crown with firm finger pressure. Remove any excess cement material from around the margin of the newly cemented restoration. This may be easier once the material has hardened. Instruct the patient to gently and fully occlude on the restoration. Ensure proper occlusion. Ask the patient to provide a subjective report if their occlusion feels like baseline (i.e., does their bite feel funny). Confirm this using articulating paper to ensure that the contact marks are light or minimal. Wipe the petrolatum-based lubricant from the mucosal tissues.

A simpler, alternative, and far more temporary method of replacing a crown involves using Vaseline as the cementing agent.1 Apply a thin layer of Vaseline to the inside of the coping. It may be necessary to remove a small amount of the preexisting cement. Seat the crown on the tooth in the proper orientation. Ensure proper occlusion. Warn the patient that the crown may come off again and about the risk of aspiration. Instructions may be given to the patient for repeating the procedure at home.

Check the patient's occlusion. It may be necessary to use articulating paper to ensure minimal or no contact with the opposing teeth with the temporary filling. The newly cemented crown restoration must primarily be assessed for proper occlusion. The patient's subjective opinion is invaluable in this regard.

Instruct the patient not to eat or chew on their new restoration for at least 1 hour. Additional instructions should include a soft diet, avoidance of extremely hot or cold substances, avoidance of chewing gum, and avoidance of other such “sticky” foodstuffs. They may brush their teeth normally, but should not floss adjacent to the new restoration. Warn them that they may experience some continued sensitivity. Nonsteroidal anti-inflammatory drugs will provide any needed analgesia. Arrange follow-up within 24 to 48 hours.

Typical complications of replacing a filling include improper occlusion and poor retention of the restoration. The solution for both problems is replacing the restoration. Adjust the occlusion with the discoid-cleoid dental carver. Treat the restoration as a dental restoration that is “too high” if using the discoid-cleoid dental carver is not effective. Treat the tooth as a simple dentinal exposure if a temporary restoration is continually falling out. An unlikely complication would be a pulpal exposure, manifested as minimal bleeding from within the tooth defect.1,10,12 Manage this as a dental trauma or fractured tooth.

Typical complications for replacing a crown are similar to those listed in replacing a temporary filling. These restorations are often easily removed with a slight twisting motion. A restoration that is seated “too high” should be replaced. Treat the tooth as a simple dentinal exposure if a restoration is consistently “too high”.

Management of the patient with a dental complaint may initially seem intimidating to the Emergency Physician. The recognition and treatment of dental pain, minor defective dental restorations, and painful mucosal conditions can be relatively simple provided a minimal understanding of basic dentistry. Emergency Physicians must be cognizant of the inherent limitations involved in treating these patients in the Emergency Department. Have a low threshold for referral. Pain, inflammation, and infection should always be treated. Refer patients to the appropriate specialist within 24 to 48 hours.