An adult tooth knocked clean out can often be put back and kept — if it goes back in the socket within minutes, is held by the crown, and is never scrubbed. Almost nobody knows any of that at the moment it happens.

The salvage clock

A tooth is on the pavement and the clock is already running. Choose what you do, in the order you would really do it — every action costs the time it costs, and the log stamps it. Nothing can be undone here, which is the point: this is the one emergency where the first two minutes are worth more than everything that follows.

The knocked-out tooth, without the clock

The dental problem that belongs in a hospital

• An abscess does not resolve on its own. The pain sometimes stops, which feels like recovery and is usually the nerve dying — the infection is still there and will come back. Treatment is drainage plus dealing with the tooth; antibiotics alone are a delay, not a cure.
• Antibiotics are for spread, not for pain. They are appropriate when the infection is spreading or the person is systemically unwell, and they cannot reach the inside of a dead tooth. Repeated courses without treating the tooth select resistance and postpone the fix.
• Painkillers do more than people expect. Ibuprofen plus paracetamol taken together, at proper doses and on schedule rather than when it gets unbearable, controls dental pain better than either alone and better than most weak opioids. Do not put aspirin against the gum — it burns the tissue.
• Do not squeeze, lance or heat it. Pressing on a swelling pushes infection into deeper spaces, and a hot compress on the face can point an abscess inwards. Cold on the outside is fine for comfort.
• Anyone with diabetes, immune suppression, chemotherapy, or a heart-valve problem should be assessed sooner rather than later, because these are the people in whom a contained infection stops being contained.
• Salt-water rinses help a gum swelling and do nothing for a dead tooth. Warm salty water several times a day is genuinely useful for the surface; it cannot reach an infection inside the root.

Toothache, read properly

• A tooth does not heal. Enamel and dentine do not regenerate, so a cavity is a one-way process until somebody restores it — unlike almost everything else in the body, waiting to see whether it settles is never a plan.
• Sensitivity to cold that stops immediately is usually exposed dentine or a sensitive area: fluoride toothpaste for sensitivity, and a review.
• Pain that lingers after the cold has gone, and wakes you at night, usually means the pulp is dying. That is the point at which a filling is no longer enough and a root treatment or extraction is coming; going earlier means more options.
• Pain on biting on one spot can be a cracked tooth or an infection at the root tip. Avoid chewing on it, do not test it repeatedly, and get it looked at.
• Pain that eases when hot fluid is held on it, or that is relieved by cold, points to specific pulp states that a dentist can use diagnostically — mention it rather than editing it out of your description.
• Widespread aching in the upper back teeth with a blocked nose is often sinus rather than dental. Bending forward making it worse is the useful clue.

The two-minute facts most people get wrong

1. Do not rinse after brushing. Spit, and leave the toothpaste on the teeth — rinsing washes away the fluoride that does the work. This single change is free and measurably reduces decay.
2. It is the frequency of sugar, not the amount. Every sugar exposure starts an acid attack lasting tens of minutes, so one dessert is far better than sipping a sweet drink all afternoon. Grazing is the mechanism, not the total in the shopping trolley.
3. Brush twice a day, and the one before bed matters most, because saliva flow drops overnight and there is nothing to wash acid away. Two minutes with a soft brush and fluoride toothpaste, angled at the gum line.
4. Wait after acid, not after sugar. Brushing immediately after vomiting, reflux, or fizzy drinks scrubs softened enamel away; rinse with water and wait about half an hour. Fizzy drinks include sparkling water with fruit flavouring, and diet versions erode too.
5. Clean between the teeth once a day, with floss or interdental brushes. Brushing alone leaves the surfaces where most gum disease and adult decay actually start.
6. Fluoride is the active ingredient. At least 1350–1500 ppm for adults, and check that any “natural” toothpaste actually contains it; high-fluoride prescription paste exists for people who keep getting cavities.
7. Dry mouth multiplies everything. Many common medicines — antidepressants, antihistamines, blood-pressure tablets, inhalers, opioids — reduce saliva, and saliva is the mouth's own defence. Sipping water, sugar-free gum, saliva substitutes and telling the dentist about the medicines all matter.

Gum disease, which behaves like glaucoma

• It is painless bone loss. Periodontitis destroys the attachment and the bone around teeth without hurting, so the first symptom is often a tooth that has become loose — by which point the bone is gone and does not come back.
• Bleeding when you brush is not normal and is not a reason to stop. It is inflammation; brushing that area properly for a fortnight usually stops the bleeding, which is the opposite of what most people conclude.
• Smoking both causes it and hides it, by reducing the bleeding that would otherwise be the warning, which is one reason smokers lose more teeth.
• Diabetes and gum disease worsen each other, and treating the gums measurably improves glucose control. It is one of the clearest two-way links in medicine and almost never mentioned in either clinic.
• Bad breath usually comes from the tongue and the gums, not the stomach. Cleaning the back of the tongue and between the teeth does more than any mouthwash, and persistent bad breath with bleeding gums is worth investigating.
• What is lost cannot be regrown, but the process can be stopped, which makes the value of going now high even when nothing hurts — exactly the logic of screening for the silent eye diseases.

Children, and the myth that baby teeth do not matter

• Decay in baby teeth causes pain, infection, missed school and general anaesthetics, and it predicts decay in the permanent teeth. “They will fall out anyway” is the single most expensive sentence in children's dentistry.
• Brush from the first tooth, with a smear of fluoride paste, and keep doing it for them until about seven — children cannot physically brush well before then, however capable they seem.
• No bottle in bed, and no sweetened drinks in a bottle at all. Milk or juice pooling around the front teeth overnight produces the pattern dentists can recognise across a room.
• A knocked-out baby tooth is not put back, unlike an adult one, because replanting it can damage the developing permanent tooth. Still get the child seen: the socket, the lip and any missing fragment need checking.
• A knocked-out permanent tooth in a child follows the same clock as in an adult — back in the socket in minutes, or into milk. Every parent, coach and teacher should know the milk part.
• Mouthguards for contact sport are worth the argument. A custom guard costs less than one broken front tooth and prevents a lifetime of replacements — a lost front tooth at twelve is a maintenance commitment for sixty years.

The check nobody knows the dentist is doing

• Any ulcer, red or white patch, or lump in the mouth lasting more than three weeks needs looking at. That single rule is the whole early-detection strategy for mouth cancer, and survival depends enormously on stage at diagnosis.
• It is usually painless at first, which is why it gets ignored, and it can appear on the tongue, the floor of the mouth, the gums or the tonsil area.
• Tobacco in any form and alcohol are the main risks, and together they multiply rather than add. Chewing tobacco, betel quid and areca nut carry particularly high risk.
• HPV-related throat cancers are rising, often in younger people without the traditional risk factors, which is one argument for the vaccine reaching boys as well as girls.
• A routine dental examination includes a soft-tissue check of the tongue, floor of mouth, cheeks and throat. That is part of what the appointment is for, and one reason to keep going when the teeth feel fine.
• Also worth mentioning: a hoarse voice for more than three weeks, difficulty or pain on swallowing, a lump in the neck, numbness in the lip or tongue, or a tooth becoming loose without gum disease.

When the barrier is money, not knowledge

• Ask about emergency and urgent-care routes, which are usually cheaper and faster than they look. Most countries have some out-of-hours dental service, a hospital dental department for genuine emergencies, and a phone line that can direct you; the route is rarely obvious and is usually there.
• Dental schools treat patients at reduced cost, supervised and often to a very high standard because the work is checked. Waiting lists are long but the price difference is large.
• Say the money part out loud at the appointment. Treatment plans have alternatives — a filling instead of a crown, extraction instead of root treatment, staged work over months — and a dentist can only offer the cheaper version if they know it is needed.
• Ask about a payment plan before treatment, not after, and ask which items are the ones that stop things getting worse if you have to choose an order.
• Check what you are entitled to. Exemptions and subsidies for children, pregnancy, low income, disability and some conditions exist in most systems and go unclaimed constantly.
• What not to do: pull your own tooth, use a friend's antibiotics, buy antibiotics without prescription, or use DIY kits sold online for filling cavities and straightening teeth — the harm from these arrives in the same year as the saving.

The drill: 16 decisions

Sixteen ordinary moments — a tooth on a football pitch, a face swelling towards an eye, a child's bottle at bedtime, a filling lost on holiday. Most have an instinctive answer that costs a tooth, a night, or occasionally more. Pick your move; every answer explains why.

The card

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