What is the immediate treatment for a broken infected tooth in the Emergency Room (ER)?

Immediate Treatment for a Broken Infected Tooth in the Emergency Room

The immediate treatment for a broken infected tooth in the emergency room includes pain management with NSAIDs (ibuprofen) or acetaminophen, antibiotics if there is evidence of infection, and appropriate referral to a dentist based on the severity of the fracture and presence of pulp exposure. 1

Assessment and Classification of Tooth Fracture

• Tooth fractures should be classified based on the extent of damage to determine appropriate management and urgency of dental referral 2:
  • Enamel-only fractures (uncomplicated): Minimal sensitivity, no immediate dental referral needed 2
  • Enamel and dentin fractures (uncomplicated): May cause sensitivity, referral within a few days 2
  • Crown fractures with exposed pulp (complicated): Require immediate dental referral for appropriate pulp therapy 2

Immediate Management in the ER

Pain Control

• Administer NSAIDs such as ibuprofen as first-line treatment for pain management 1
• Acetaminophen is an alternative when NSAIDs are contraindicated 1
• Apply cold compresses to reduce swelling and discomfort 1

Antibiotic Therapy for Infection

• For infected teeth with evidence of spreading infection or cellulitis, antibiotics should be prescribed 3, 4:
  • First-line: Penicillin V or amoxicillin 3
    • Adult dosage: 500 mg every 8 hours or 875 mg every 12 hours 5
  • For penicillin-allergic patients: Clindamycin is preferred over macrolides 3
    • Adult dosage: Based on severity of infection and renal function 6

Preservation of Tooth Fragments

• If tooth fragments are available, they should be stored properly for possible reattachment by the dentist 1
• Do not store tooth fragments in water as this causes osmotic lysis of cells 2
• Appropriate storage media include milk or saline solution 1

Referral Guidelines Based on Severity

• Immediate dental referral (same day) is necessary for 1:

  • Crown fractures with pulp exposure
  • Severe mobility
  • Significant pain or evidence of infection

• Referral within a few days is recommended for 1:

  • Enamel and dentin fractures with sensitivity
  • Cases with moderate pain but no pulp exposure

• Less urgent referral (within a week) is suitable for 2:

  • Enamel-only fractures with minimal symptoms

Special Considerations for Infected Teeth

• Drainage of abscesses may be necessary alongside antibiotic therapy 4

• In cases of severe infection with cellulitis, more aggressive antibiotic therapy may be required 3:

  • Second-line regimens include amoxicillin-clavulanate, cefuroxime, or penicillin with metronidazole 3

• Some evidence suggests that immediate extraction of severely infected teeth may be beneficial for faster resolution of infection, decreased pain, and earlier return of function 7

Common Pitfalls to Avoid

• Delaying referral for crown fractures with pulp exposure can lead to pulpal necrosis 1
• Underestimating pain from dentin exposure requires prompt coverage to prevent bacterial contamination 2
• Using water to store avulsed teeth or tooth fragments causes osmotic lysis of cells 2
• Failing to prescribe antibiotics in cases of spreading infection or cellulitis 4
• Over-aggressive removal of infected dentin in deep cavities can lead to pulp exposure and necessitate root canal treatment 8