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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
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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”.
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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 ...