The Pharmaceutical Journal
Vol 278 No 7451 p561-562
12 May 2007

This article
Reprint   Photocopy

PDF 50K, Acrobat Reader

Dealing with dental disasters — a guide for community pharmacists

As a result of the new NHS dental contract in England and Wales, fewer NHS dentists are available, so community pharmacists may be increasingly called upon to give advice on treating dental problems. In this article, Tony Brown gives some advice that pharmacists can pass on

In April 2006 the Government imposed a new NHS dental contract on all dentists in England and Wales who wished to remain in the service.

From the start of the NHS in 1948, dentists had worked under a “piece work” scheme which had allowed total flexibility in the work performed by individual dentists. The new contract, in contrast, allocated a fixed number of units of dental activity (UDAs) to each dentist according to his or her previous working pattern.

Naturally, if it turns out that there are too many or too few allocated UDAs for treatment need, a problem will occur at the end of the contract year. Dentists who find themselves busier than they were previously will come to the end of their allocation before the next contract period which started on 1 April 2007.

As it has proved unlikely that they can negotiate an extra allocation, there will be no further payments to them for treatment given until the start of the next contract period. Are they to offer only private dental treatment at this time, treat patients at their own expense or shut-up shop for a few weeks?

It has become increasingly clear that NHS dental treatment has become more difficult to obtain as more dentists find the new contract unworkable and have withdrawn from the NHS, leaving the remainder struggling to provide treatment within their allocated UDAs. Community pharmacists are increasingly likely to be called upon for advice on dental problems and this article has been written with them in mind.

Ideally, emergency dental treatment requires specific skill, experience, equipment and materials. Unfortunately, these will be absent in a pharmacy but some of the following advice may be helpful in coping with dental problems on a temporary basis. Although there are kits available in the pharmacy for repairing dentures and replacing fillings, I am yet to be convinced of their practicality. The most important way to avoid, or at least minimise, unexpected dental problems is to have full and regular dental care combined with careful, daily oral hygiene. Nevertheless, some problems can still occur.

Dental problems in children

Babies and children can become unwell and suffer pain from erupting teeth. Painkillers can be beneficial in this case, with syrups such as Calpol (preferably sugar-free) suitable for infants. To minimise inflammation, it is important that the child keeps the mouth as clean as co-operation will allow.

Young people who indulge in contact sports or who are otherwise boisterous are at risk of damage to the front teeth. This can take the form of fracture or displacement of the tooth. If a tooth is broken, the fractured surface should be examined. If the broken-off piece is small and there is no red spot (the nerve) visible on the broken surface, subsequent repair should be straightforward, although the tooth may be sensitive to cold until treated so extremes of temperature should be avoided.

When a red spot is visible, the tooth may be quite painful and will require early treatment. Sometimes the impact causes a tooth to be loose, moved or knocked out completely. If moved, it will need gentle realignment which may not be possible without a local anaesthetic. If knocked out, the tooth should be retrieved, rinsed in milk and stored in the owner’s cheek or in milk to keep it moist until it can be reimplanted by a dentist (as soon as possible). The tooth should not be dried or scrubbed and, if practical, may be replaced straight away, after checking it is going in the right way around!

The early help of a dentist is then needed but, in the meantime, with a loose or reimplanted tooth, it would be preferable to make up a temporary splint to keep it in line with the neighbouring teeth. Perhaps the sticky part could be cut off a piece of elastoplast and stretched over the dried teeth, covering at least one normal tooth on each side of the replaced one.

Teenagers and young adults

Older teenagers and those in their 20s may complain of pain and pressure, particularly in the lower jaw, due to wisdom teeth erupting at the back of the mouth. Students seem to become particularly susceptible at the time of important, stressful examinations.

The mouth should be kept clean by careful brushing of the teeth after every meal (Corsodyl mouthwash will help here). Chewing on the sensitive, swollen, gum flap should be avoided. Painkillers such as ibuprofen can be taken and hot salt mouthbaths carried out (see Panel). Applying external heat, like that from a hot water bottle, should be avoided since this will increase any swelling. If the problem cannot be controlled in this way, an early trip to the dentist and antibiotics will be required. Sometimes limited space at the back of the lower jaw will prevent a wisdom tooth coming through completely and it may need to be removed.

Braces often cause considerable discomfort and tightness, particularly when first fitted and some perseverance is required. If a spring on a removable brace is pressing on the gum or cheek and causing an ulcer, Bonjela or a similar paste can be applied to the ulcer. The brace should still be worn, particularly in the middle of treatment. If a removable brace gets dropped or trodden on it may become loose or too tight. If loose, it should be kept in place, with denture fixative paste if necessary, until it can be adjusted. If it is painfully tight, it will have to be left out. Not wearing a brace for any reason will affect treatment time, since teeth left free will gradually move back to their earlier positions. If a brace cannot be worn, a dentist should be seen within a few days.

Parts of fixed braces sometimes come loose and need to be temporarily repositioned until recemented. Wax, such as the red wax coating on Edam cheese, is excellent for coating any sharp points that appear and cause ulceration of the cheek. The corresponding ulcers can be soothed with Bonjela. Failing that, damp whisps of cotton wool can be wrapped around the offending part. Headgear which becomes faulty can be left off until adjusted.

Toothache

It should be determined whether the toothache is a sharp, stabbing pain or a dull, nagging ache. A sharp, stabbing pain, often with increased sensitivity to hot and cold, suggests pain from a tooth — the exact one may be able to be identified, by gently tapping each tooth with the handle of a teaspoon. If there is no defect to be seen and moderate painkillers fail to end the problem fairly quickly, there is not a lot more that can be done other than to see a dentist.

However, if a tooth is identified as broken or decayed or appears to have a large cavity, it is worth carefully applying oil of cloves on a cotton bud to the offending tooth which may relieve the pain until dental help can be obtained. This pain should be distinguished from sensitivity to touch and temperature on the neck of a tooth, near the gum. In this case there is nothing to see and toothpastes formulated for sensitivity will solve the problem in a week or two. Painkillers should not be placed in the cheek as this is no more effective than oral administration and can cause temporary ulceration.

Gum problems

A dull, nagging ache may be coming from the gums rather than the teeth. Dental floss (or cotton in an emergency) can be pulled carefully between each tooth to remove any food trapped between teeth. Tooth and gum brushing should be done scrupulously using the brush to massage the sore gum; Corsodyl mouthwash and hot salt mouthbaths can be used if desired. In a well-cared-for mouth, many of these problems are easily reversible and respond well to greater care with oral hygiene.

Vincent’s infection is ulceration and bleeding of the tips of the gums in between the teeth, associated with a characteristic bad smell. It is more common at times of stress and can be countered with hydrogen peroxide mouthwash which produces the necessary oxygen to help kill the relevant bacteria.

Swelling generally means that a substantial infection is present requiring early dental attention and antibiotics. In the meantime, painkillers and hot salt mouthbaths may relieve the symptoms a little. If a swelling spreads down the neck or into the eye, an urgent trip to hospital is required to prevent more serious complications.

Problems following dental treatment

Excessive bleeding following an extraction is not common but can happen in medically fit patients. When this occurs, a small piece of wetted cloth (part of a handkerchief) can be folded to make a small tight wedge or pack that will just fit into the gap between the adjacent teeth and stand up above the biting surfaces. If the teeth are closed together, opposing teeth will compress the wedge down onto the bleeding socket. It is important to place the pack accurately to ensure that the cloth is not just being nipped between the top and bottom teeth. The chin should be supported with a scarf or similar, placed under the chin and tied at the top of the head.

After an hour it can be gently removed but rinsing the mouth should be avoided since this will just encourage more bleeding. If it is clear that the flow has not ceased, replace the pack and scarf and leave it undisturbed until you reach a hospital or dentist to stitch the socket. In the meantime, strenuous exercise should be avoided, plenty of pillows should be used to keep the head up if lying down and liquids should be taken through a straw or tubing to avoid disturbing the pack. If blood-thinning drugs such as warfarin have been taken then an immediate trip to hospital is essential.

The opposite complication following an extraction is known as a dry socket. In this case there is little or no bleeding which leaves the socket empty and susceptible to infection if food or debris drop down into it. Pain can be most severe and the taste and smell unpleasant. Pain killers and hot salt mouthbaths may reverse the condition but an early trip to the dentist is advisable in case antibiotics are required.

Dentures

New dentures can feel strange and uncomfortable when first fitted. One should try to continue to wear the denture, putting Bonjela on any sore spots. Old dentures should only be reverted to as a last resort. If the problem does not resolve, the new denture will need to be adjusted by a dentist.

If a denture is broken, it can either be left out until repaired, stuck together with superglue (no other common adhesive will work) or the parts worn as they are. It is difficult to get an accurate fit with gluing so one should practise fitting the denture together first. If a single tooth has been broken off the denture, gluing is the only temporary option. However, be aware that permanent repair will be made more difficult by glue remnants in the crack. If one insists on wearing the individual pieces, one is at risk of swallowing them, so it is important to leave out small pieces and use a generous amount of denture fixative to glue pieces in.

If a crown or bridge becomes loose, one should check that there is a peg of tooth (not just the root) visible in the mouth at the site it was fitted. Similarly, there should be a substantial hollow inside the crown or bridge where it fits over the peg. If this is not the case, then the tooth has fractured off at gum level, leaving the top of the tooth inside the crown or bridge and there is no practical means of replacement without professional help. Where there is no fracture and crowns or bridges have simply become uncemented, patients have been known to push them back into place to wear until they can see a dentist. However, there is a high risk of swallowing them even if a denture fixative paste is used to help keep them in place.

If a filling has been lost, particularly a deep one or when it belongs to a young person, the tooth may be unpleasantly sensitive to cold. The cavity should be kept clean until the filling is replaced. Water, food and drink should be kept at body temperature to minimise pain.