What is a dental emergency?
Once you have determined that a person has a dental emergency, you have to “triage” the patient. Triage is the process of determining the patient’s needs based upon the severity of their situation. The term triage comes from the French verb ”trier,” which means separating, shifting, or selecting. (Wikipedia.org) Telephone Triage When The Office Is Closed If a patient calls when your office is closed, you need to determine the severity of the dental emergency. Is the patient having difficulty breathing? Are they in severe pain? Are they badly bleeding? Are they severely swollen? If you have any concern that the patient’s dental emergency could be a life-threatening medical emergency, you must refer them to a hospital or an appropriate office. If the patient’s dental emergency is not life-threatening, tell them when your office will be open and ask them how soon they can make it in? If the patient is a patient of record, you may want to ask them if they would like you to call in a prescription for an antibiotic and pain medication. It is essential to record the time of the call. Write notes of your conversation. Record the patient notes in the treatment record when you get to your office. If you call in a prescription, be sure to include the medication and pharmacy phone number in the patient’s treatment record. If the dental emergency patient is a new patient that you have not seen, do not call in a prescription. For multiple reasons, you want to get your patient in as soon as possible. You do not want the patient going to another office, especially if this is a patient you have seen before. If you had pain, bleeding, or swelling, you would want to be seen as soon as possible. Regular Office Hours When a dental emergency patient calls during regular office hours, we like to ask them how soon they can get to the office? We have had patients tell us their dentist could not see them for a week or two. This is not a good thing. Your receptionist must be instructed to specifically ask the patient how soon they can make it in. It may require adjusting your schedule or letting your patient know that you fit them into the schedule. Worst case, if it is okay with your patient, get them in within the next day or two. We don’t recommend this and do not like to do this. Your receptionist must be courteous to the dental emergency patient. If you are busy, your receptionist may not want to start calling patients and spend time adjusting your schedule. But it is crucial. If you had pain, bleeding, or swelling, you would want to be seen as soon as possible. It is the right thing to do to treat your patient the same way you would like to be treated. Make A Quick Assessment. When the patient walks into your office, if your receptionist believes a patient has a life-threatening emergency, they should immediately come and get you. A quick referral needs to be made to a hospital or an Oral Surgeon. Assuming the patient is not having a life-threatening dental emergency, have them complete a medical and dental questionnaire. Look the questions over. I like to sit down knee to knee—eye to eye. I do not want to be looking down on a patient. If I don’t want to sit down and the dental chair is down low, I raise the chair and tilt the back upright so that the patient is sitting upright. I want to be talking to the patient eye to eye. Talking eye to eye is more comfortable, making it easier to establish rapport with a patient. The goal is to get the patient out of pain as quickly as possible. Observe the patient. Do they appear to be swollen? Ask them the following question: Is it hard to breathe? If the patient says it is hard to breathe, it is a medical emergency. Refer them to a hospital or an oral surgeon. I like to say to the patient: Tell me about your pain. If it is apparent that the patient is extremely uncomfortable, I don’t like to talk too much. If I have reviewed the patient’s medical and dental questionnaires and there are no contraindications, I like to get the patient numb as soon as possible. It can be challenging to have a conversation when a patient is in excruciating pain. If the patient is not in severe pain, I like to ask them to complete a pain diagnosis form. Pain Diagnosis Form
After the Pain Diagnosis Form is completed, we scan it into the patient chart. It is good to have a written record of their response. If you do not give the patient a pain diagnosis form, you can still ask the same or similar questions. Record their answers in the patient chart. An excellent way to do things is to ask the patient questions. Have your assistant typing while you are asking your questions. Before you look in a patient’s mouth, ask them to point to the pain. Occasionally patients will have multiple teeth that are very severely damaged. There may be teeth broken or decayed to the gum line. You do not want to assume that a tooth broken off to the gum line is causing pain. I have often seen patients with multiple teeth that have been severely damaged, broken off to the gum, and the teeth do not hurt. Imagine seeing a patient with teeth number 17, 18, and 19 broken off to the gum. When you ask the patient to tell you where the pain is, they point to tooth #29. Tooth #29 clinically appears to be okay. Tooth #29 may have deep interproximal decay into the nerve. An X-ray is needed to make the diagnosis. When I first look in a patient’s mouth, I look at the area where the patient pointed. I also quickly look at their entire mouth. Do they appear to have broken teeth throughout their mouth? Do their teeth appear to be in good shape except for the area where they pointed? When making a diagnosis and recommending a treatment plan, you want to consider both short-term and long-term patient objectives. X-rays are always part of our diagnostic workup. We will take a 3D Cone Beam X-ray, a periapical X-ray, and a bitewing X-ray in many situations. Some Doctors may object to taking a 3D Cone Beam X-ray. Our 3D Cone Beam X-ray is very high speed and there is very little radiation exposure. If a patient lost a minor occlusal restoration on tooth #19 and the rest of their mouth is perfect, then a 3D Cone Beam X-ray would probably not be necessary. Using a 3D Cone Beam X-Ray has helped us find a tremendous amount of pathology over the years. Differential Diagnosis A Differential Diagnosis distinguishes a particular disease or condition from others that present similar clinical features. When making your diagnosis, you have to consider all the possible causes of pain. It is crucial that you definitively identify the cause of the patient’s pain. Tempro Mandibular Joint (TMJ) pain occasionally appears as dental pain. You do not want to treat a patient for dental pain and not eliminate their pain because it comes from their TMJ. Do not perform a treatment if you cannot diagnose the cause. When you cannot diagnose a cause for dental pain, consider referring the patient to a specialist. Or possibly consider delaying treatment until you can identify the cause. After considering all the possible causes, you have to develop a treatment plan with the patient. The usual order of treatment is the following:
While the above is the usual treatment order, you have to determine each patient’s best action plan. If a dental emergency patient is swollen or in severe pain, they will need to be numbed to have treatment. Before I numb them, I will preface it by saying, “Sometimes when there is swelling or severe pain, the anesthetic may not work. In which case, we will give you an antibiotic and pain medication. We will have you come back in 5 to 7 days.” When you tell a patient something in advance, it is considered a diagnosis. After the fact, it may be regarded as an excuse. What you do not want is to attempt to numb a dental emergency patient. They do not get adequately numb for treatment because of their infection. And they blame you for being incompetent. HELPFUL HINT: Occasionally, it is difficult to numb a lower tooth. The patient’s lip and tongue feel numb, but it hurts when you try to perform their treatment. Try giving the patient a MYLOHYOID INJECTION. A mylohyoid injection can provide a patient with very profound anesthesia. For what ever reason, a MYLOHYOID INJECTION is not normally taught in school. I can tell you it is an incredible game changer when it comes patient comfort. |
