Is this a dental emergency? A checklist

Any difficulty breathing or swallowing, or a voice that has changed in quality. Call 911. Swelling from a dental infection can track into the spaces around the airway, and that is a hospital problem from the moment it starts, not a dental one.

Swelling that has closed the eye, crossed to the other side of the face, or raised the floor of the mouth so the tongue is pushed up. Fever above 38.5°C with facial swelling. An inability to open the mouth more than a couple of centimetres in the presence of swelling.

Bleeding that does not stop after twenty minutes of firm, continuous pressure. Any head injury with loss of consciousness, vomiting or confusion. A jaw that will not close correctly, a bite that has changed after an impact, or numbness of the lip and chin after a blow — those suggest a fracture. Any injury to the eye or change in vision.

A knocked-out permanent tooth is the one true clock in dentistry. Hold it by the crown, never the root; do not scrub it; rinse briefly in milk or saline if it is dirty; put it back in the socket if you can, or keep it in milk. Then be seen within the hour, because time out of the socket is what determines whether it survives. A knocked-out baby tooth is not replanted, and the child should still be seen.

Facial swelling without airway involvement, a localised abscess, or a tooth that has become tender to touch and feels raised in the bite. Pain that has not responded to over-the-counter analgesia at proper doses. Post-operative bleeding that has restarted and is not settling with gauze pressure.

A tooth loosened, pushed out of position or fractured through to the pulp after an impact. A dental infection in a patient who is immunosuppressed, is having chemotherapy, has poorly controlled diabetes, or takes a bone-modifying medication — the same infection in those patients moves faster and is managed sooner.

A chipped tooth with no pain, a lost filling or a crown that has come off. A sore wisdom tooth with mild swelling that is confined to the gum around it and no fever. A broken denture. A sharp edge cutting the tongue or cheek, which a piece of orthodontic wax will manage until the appointment.

An ulcer, patch or lump that has been present for less than two weeks in the absence of other symptoms — though anything still there at two to three weeks should be looked at rather than watched further. Persistent mild sensitivity to cold that settles within seconds. Food packing into an extraction site during the second or third week after surgery, which is expected and is managed with an irrigating syringe.

Dull, generalised jaw ache that is worse on waking and improves through the day, and clicking on opening without locking. Both point towards the joint and the muscles rather than a tooth, and both are assessed on an ordinary appointment. Treating them as emergencies takes an urgent slot from a patient with facial swelling, which is the one thing an urgent slot exists for.

Pain is a poor guide to urgency. Severe pain frequently accompanies a condition that is entirely local — an exposed pulp or a dry socket — and a spreading infection sometimes hurts less as it spreads, because the pressure that caused the pain has escaped into the surrounding tissue. Patients occasionally describe feeling better on the day the infection becomes serious.

Swelling describes where the infection has reached, and that is the question that changes management. Swelling confined to the gum is one thing. Swelling that has crossed into the cheek, under the jaw, up towards the eye, or into the floor of the mouth has entered a fascial space, and the treatment is drainage and antibiotics, sometimes in hospital.

The other reliable signals are systemic: fever, feeling generally unwell, a rising heart rate, and any change in swallowing or voice. A dental problem that has started producing symptoms outside the mouth has stopped being a dental problem in the ordinary sense, and it should be assessed the same day.