Dental Emergencies in the ER: Quick Guide

Authors: Tamir Zitelny, MD; Blake Briggs, MD

Dental emergencies in the ED are like middle seats on airplanes – uncomfortable and no immediate solution. These presentations can often be frustrating to ED clinicians, as there isn’t much we can do to help acutely. While rarely emergent, the ones we can help with demand quick thinking and solid ED management to preserve teeth, prevent systemic spread, and avoid lasting damage. Let’s chew through the most common emergencies: avulsions, abscesses, and fractures.

Dental Avulsions: Save That Tooth!

Dental avulsion, or complete displacement of a tooth from its socket, occurs from oropharyngeal trauma, most commonly in children aged around 7-11 years. To get a bit more technical, avulsions occur when certain injuries cause shearing to the periodontal ligaments of the teeth, causing a disruption between the connection between the alveolar bone and the cementum that covers teeth roots at this site. This type of injury requires quite a bit of force, so make sure you evaluate for this in cases of MVCs, assault, sports injuries, and higher-risk mechanism falls. Unlike primary (baby) teeth that have no need for reimplantation, permanent teeth deserve your full “resuscitative effort”.

Time is Tooth. Reimplantation ideally happens within 30 minutes and leaves teeth viable within 1 hour. Beyond that, the periodontal ligament cells start to croak, and success rates plummet [1,2].

Management:

• If the tooth is still out, gently rinse it with saline – do NOT scrub or handle the root.
• Reimplant immediately in the ED if the patient is alert and cooperative.
• If not possible right away, store the tooth in an isotonic solution, such as milk (most ideal), saline, or even saliva. Avoid water – it lyses cells [3, 16]. Hank’s balanced solution is the answer on the boards but this almost never available in the ED.
• Tetanus prophylaxis and systemic antibiotics (typically doxycycline or amoxicillin, depending on age and contraindications) are indicated.
• Urge patients to follow up with their dentist within 24-48 hours for more permanent splinting and long-term care [1,4].

Pro tip: avulsed teeth with long dry times (>60 minutes) may be replaced for cosmetic reasons, but they’re essentially doomed for resorption [5].

Dental Abscesses

Odontogenic infections are the most common cause of dental abscesses, often from untreated dental caries, periodontal disease, or unaddressed tooth trauma. These infections can escalate into deep space infections, including Ludwig’s angina – a submandibular nightmare threatening the airway [6,7]. Please check out other review materials on our website and our podcast regarding Ludwig’s.

Patients with dental abscesses typically present with localized gingival swelling, erythema, and significant pain. You can often feel for dental apical abscesses using your gloved finger in the space where the buccal mucosa meets the gingival margin. You will feel a small, firm bulge in the affected area.

In terms of complications, as the infection progresses, concerning features such as fever, trismus, dysphagia, or a muffled “hot potato voice” may develop, each raising red flags for deep space involvement. Firmness or induration in the submental or submandibular regions should similarly prompt consideration of a spreading infection like Ludwig’s angina. While imaging may reveal periapical lucencies, the diagnosis is often made clinically. 

Management:

• I&D using an #11 blade scalpel if superficial and fluctuant. Make sure you do a dental block for pain control, and have suction ready at bedside.
• Antibiotics: Amoxicillin is a great first choice to send patients home on. If truly penicillin allergic, clindamycin is a backup. Think ampicillin-sulbactam for deep infections and/or signs of systemic involvement [6,8].
• Imaging (CT soft tissue neck with contrast) is only needed in febrile patients with systemic signs, deep space infections, or if the source is unclear, but as with many other time-sensitive emergencies, do not delay treatment/intervention for imaging!
• Admit the patient if there’s any systemic toxicity, or if patients fail to improve with/are refractory to oral therapy [10, 11,12].

Dental Fractures: Cracked and Crumbling

Dental fractures are among the most common dental traumas; the severity depends on how deep the fracture goes, ranging from superficial cosmetic issues to pulp-exposing, nerve-screaming catastrophes. The Ellis classification remains your go-to framework in the ED, especially when a panicked parent shoves their child’s tooth fragment in your face at 2 a.m. Additionally, if you work at a hospital with facial trauma/OMFS, they’ll be super impressed if you correctly suggest an Ellis class when you consult them. 

Ellis Class I fractures involve only the enamel. These are painless, chalky-white chips. They’re strictly cosmetic and only need routine dental referral.

Ellis Class II fractures extend beyond the enamel and into the dentin, appearing yellow and causing sensitivity to air, cold, or touch. These teeth are painful and vulnerable to bacterial invasion. Cover exposed dentin with calcium hydroxide or glass ionomer cement in the ED and arrange dental follow-up within 24 hours for definitive sealing or restoration [15]. If unavailable, cover with sterile gauze or dental wax and ensure urgent dental referral.

Ellis Class III fractures involve the pulp and are identifiable by visible red or pink tissue. These are acutely painful and carry a high risk of pulp necrosis and abscess formation. Management includes covering the pulp with a biocompatible material (if available), analgesia, and urgent dental referral. Antibiotics are not routinely required unless there’s evidence of infection, systemic symptoms, or associated soft tissue injury [15].

Root fractures, though less obvious, can be suspected when there’s mobility, bleeding from the gingiva, or sensitivity to percussion. A periapical radiograph (or panoramic film) may confirm the diagnosis. Stabilize with a splint if possible and refer urgently to a dentist.

Management:

• Provide effective analgesia (NSAIDs, acetaminophen) and consider a dental nerve block
• Recommend a soft diet, avoidance of hot or cold stimuli, and no biting with the affected tooth!
• Save any tooth fragments in milk or saline for potential bonding by a dentist [15].
• Urgent dental referral – within 24 hours for Class III, sooner if severe pain or bleeding [15]

Bonus Round: Other (Less Common) ‘Dental Dilemmas’

Not all dental complaints involve knocked-out teeth or airway-threatening infections. Some conditions may seem minor but still demand appropriate ED management to prevent complications and relieve misery.

Pericoronitis refers to inflammation and infection of the soft tissues surrounding a partially erupted tooth, most commonly the mandibular third molar (wisdom tooth). Patients typically present with localized pain, swelling, halitosis, and difficulty chewing. The overlying gum tissue, known as the operculum, can become irritated and trap food debris and bacteria. Management includes gentle irrigation with saline and analgesia. Antibiotics are only indicated for more severe or spreading cases. Follow-up with a dentist is recommended, as definitive treatment often requires extraction or operculectomy [12].

Alveolar osteitis, better known as “dry socket,” is a dreaded complication of tooth extraction, usually occurring 2-5 days post-procedure. It results from premature loss of the protective blood clot within the socket, exposing the underlying bone and nerves. This REALLY HURTS, often described as a deep, throbbing pain that radiates to the ear or jaw. Treatment is simple but effective: irrigate the socket to remove debris, then pack with a medicated dressing (e.g., eugenol paste) if available, or arrange dental follow‑up for definitive repacking. NSAIDs often help, but make sure to arrange dental follow-up for continued care and re-packing as needed [13].

Tooth luxation involves displacement of the tooth without complete avulsion. On your oropharyngeal exam, the tooth may appear misaligned, mobile, or elongated, and management depends on the degree and direction of displacement. Gently reposition the tooth if feasible and stabilize with gauze or a splint if able. Prompt dental referral within 24 hours is essential, especially for permanent teeth. Intruded baby teeth are typically left alone, but permanent intrusions need urgent evaluation [1,15].

Nerve Blocks for Dental Pain: Be a Hero

Dental pain is notoriously miserable. You can throw all different kinds of analgesics at patients, but it might not always help. Skip the opioids and do it right with a nerve block! Inferior alveolar blocks cover most mandibular teeth, while infraorbital and superior alveolar blocks help with maxillary issues. While they might not love the idea of putting a needle in this space, pain-free patients will thank you [14].

Bottom Line

• Reimplant avulsed permanent teeth ASAP – ideally <30 minutes [1-4]
• Deep or spreading infections = high airway alert + IV antibiotics + CT + admit [6-10]
• Ellis III fractures and tooth luxations need urgent dental care [15]
• Use nerve blocks for definitive pain relief, not opioids [14]
• Always think airway when a patient has submandibular swelling, trismus, or voice changes! [7,9]

References

1. Andreasen JO, Flores MT, Bakland LK, et al. Guidelines for the management of traumatic dental injuries II: Avulsion of permanent teeth. Dental Traumatology. 2007;23(3):130–136.
2. Day PF, Duggal M, Nazzal H. Interventions for treating traumatised permanent front teeth: avulsed and replanted. Cochrane Database Syst Rev. 2019;(2).
3. De Brier N, Singletary EM, Zideman DA. Storage media for avulsed teeth: a systematic review and meta‑analysis. Dental Traumatology. 2020;36(3):180–189.
4. Fouad AF, Abbott PV, Tsilingaridis G, et al. International Association of Dental Traumatology (IADT) guidelines for management of traumatic dental injuries: avulsion of permanent teeth. Dental Traumatology. 2020;35(3):331–342.
5. Hernández‑Martinez D, Flores‑Treviño JJ, De La Garza Ramos MA, et al. An update on management of avulsed teeth: literature review. Oral Journal. 2022;8(4).
6. Management of Severe Odontogenic Infections: Cases and Review. Nat Rev Infect Dis‑style retrospective analysis (Sciencedirect) 2024. 
7. Management of Severe Odontogenic Infection: Case Report (fatal submandibular abscess with airway compromise). International Journal of Medical and Biomedical Studies. 2024;8(3).
8. Serious complications and treatment strategies in odontogenic infections: early diagnosis and management. European Journal of General Medicine‑style review.
9. Severe odontogenic infections: early treatment impact. Sci Direct prospective clinical study (HUH ED data). 2018. 
10. Jiménez Y. Odontogenic infections: systemic complications and mortality. Med Oral Patol Oral Cir Bucal. 2004;9(1):27–34.
11. Ogle OE. Odontogenic Infections. Dental Clinics of North America. 2017;61(2):213–235.
12. Bali RK, Sharma P, Gaba S, et al. Complications of odontogenic infections: a review of pathophysiology and risk factors. National Journal of Maxillofacial Surgery. 2015;6(2):179-184. 
13. Research Square: Odontogenic infections presenting to the Emergency Department: increasing severity and airway risk. 2023. 
14. Signa Vitae: Valacyclovir monotherapy vs standard care for acute apical abscess pain management. Signa Vitae. 2025;21(6):27–32.
15. Journal of Dental Research (broad high‑impact studies on dental trauma and pulp fracture epidemiology).
16. Blomlöf, L., & Otteskog, P. (1980). Viability of human periodontal ligament cells after storage in milk or saliva. Scandinavian journal of dental research, 88(5), 436-440.