01 September 2023

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Top tips for managing orthodontic emergencies in primary care

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In an article published recently in the British Dental Journal, orthodontist authors provide tips for general dentists when dealing with an orthodontic emergency. 

For starters, dentists should explain to patients the risks of orthodontic treatment and should be able to undertake limited orthodontic appliance emergency procedures.

While most orthodontic appliance emergencies are dealt with by dental specialists, there are occasions where the general dental practitioner (GDP) is faced with an anxious parent or patient with an emergency they may not be so familiar with. Dentists report seeing an average of one orthodontic emergency every six months and, reassuringly, most are confident in how to deal with the majority of common problems.

That said, there are times when patients can't access specialist practice facilities to deal with the problem for geographical or financial reasons, and problems relating to retention can occur long after discharge from their orthodontic practitioner.

Detailed guidance has previously been published on the management of orthodontic emergencies in a general practice, but in this short paper the authors discuss five likely presentations of orthodontic emergencies and share pragmatic tips on how the GDP can manage them.

Among the emergencies they highlight:

• Trauma from a broken fixed appliance. This is the most common cause of an orthodontic emergency and is usually a lost bracket or a protruding arch wire. The authors do not recommend that GDPs replace lost brackets but may be called upon to manage a problematic arch wire. The authors recommend that the practitioner considers why the arch wire has become traumatic.
• Pain from orthodontic tooth movement. Orofacial pain is a common side effect of orthodontic treatment, occurring in nearly all patients. The pain usually starts 12 hours after orthodontic force application, peaks after 24 hours and lasts for three to seven days. In a minority of cases, it can take up to one month to return to pre-treatment levels.
• Lost or broken retainers. Most orthodontic patients require indefinite retention to prevent long-term post-treatment changes to their occlusions. The breakage or loss of a retainer must be addressed with urgency. The authors identify retainer emergencies and recommend some basic interventions to those practitioners with limited orthodontic experience, equipment and materials.
• Demineralization. These lesions are caused by poor appliance cleaning and a cariogenic diet. They can take only four weeks to occur during orthodontic treatment and are prevalent in a significant percentage of orthodontic patients. The reinforcement of oral hygiene instructions to clean an orthodontic appliance and diet advice to reduce the frequency of sugars are paramount. The professional application of fluoride every six to eight weeks during appliance therapy is associated with a reduction in the development of demineralized lesions.
• Acute gingival conditions. Plaque-related gingivitis is common in orthodontic patients and although important to diagnose, inform and manage, in isolation it is not an orthodontic emergency. However, there are gingival conditions that present during orthodontic treatment that require urgent management. Necrotizing gingivitis or necrotizing periodontitis (NG/NP) can cause great concern to patients due to the appearance, such as severe gingival enlargement.

Deans, J., McColl, E. & Hamilton, S. "Top tips for managing orthodontic emergencies in primary care." Br Dent J 235, 236–239 (2023). https://doi.org/10.1038/s41415-023-6265-z.