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MANAGING
DENTAL EMERGENCIES
March 24, 2011
Lianne Beck, MD
Assistant Professor
Emory Family Medicine
Objectives
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Basic dental anatomy
Diagnosis and treatment planning
Pulpitis
Dental abscess and cellulitis
Trauma
Anesthesia for dental procedures
Extraction
Drugs in dentistry
Emergency dental kit
Dental Emergencies
“In remote or under-developed regions where
the nearest dentist may be many days’ journey,
doctors and nurses frequently find themselves required
to deal with pain, infection and trauma in the mouth.”
“Dental conditions are not usually dangerous to life,
but they are often exceedingly painful”
J.N.W. McCagie, Oral Surgeon
Introduction
• Dental disease is evident in all patient populations
regardless of medical conditions.
• Most commonly occurs because of dental neglect,
however, certain populations have unique oral health
issues.
• Dental care consistently ranks in the top 5 of unmet
needs in Statewide Statement of HIV/AIDS Needs
Survey.
BASIC DENTAL ANATOMY
• Dentition
• Soft tissues
• Blood and nerve supply
• Lymphatic drainage
Anatomy
Nerve & Blood Supply
Maxilla
Mandible
Red - Blood Supply
Yellow - Nerve supply
Buccal region
Buccal region
Blue - Areas where local
anesthetic can be
delivered
Palatal region
Lingual region
Lymphatic Drainage
• Lymphatic drainage is
to the submental,
submandibular and
deep cervical nodes.
DIAGNOSIS
&
TREATMENT PLANNING
Emergency vs Urgency
• Emergencies interrupt normal eating,
working and sleeping.
• Emergencies occur within 2 days.
• Pain medications for emergencies are
usually ineffective.
What is a true dental emergency?
• The presence of pain does not necessarily
constitute a dental emergency.
• An acute dental emergency requires the
presence of:
– Swelling
– Fever
– Pus
– Bleeding
Swelling – Questions to Ask
• Is it
– Diffuse
• Does it spread up to the eye or cheeks?
• Does it spread down the neck?
– Discreet
– Fluctuant
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Is this first time?
When did it start?
Does it interfere with swallowing or breathing?
Does it change the way patient speaks?
Swelling
• Differentiate between cellulitis and abscess
• Evaluate airway and swallowing
• Can be difficult to evaluate intraorally if trismus is
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present
Trismus suggests infection in posterior region
Infection causes a reactive myospasm
Do not force mouth open
Will resolve once infection resolves
Ludwig’s Angina
• Cellulitis involving bilateral
sublingual, submandibular
and submental spaces
• Tongue is elevated toward
palate
• Rapid spread of infection
into lateral and
retropharyngeal spaces
leading to airway
obstruction
When to Admit?
• Deep fascial space threatening the airway
• Patient is dehydrated and requires IV
fluids
• General anesthesia needed for surgical
procedure
What is a true dental emergency?
• The presence of pain does not necessarily
constitute a dental emergency.
• An acute dental emergency requires the
presence of:
– Swelling
– Fever
– Pus
– Bleeding
Fever
• Painful submandibular and cervical
lymphadenopathy would be expected
• A tooth causing fever would be tender to
touch, percussion and palpation
What is a true dental emergency?
• The presence of pain does not necessarily
constitute a dental emergency.
• An acute dental emergency requires the
presence of:
– Swelling
– Fever
– Pus
– Bleeding
Pus
• Drainage intra-orally is
preferred
• Extra-oral drainage
leads to scarring
– Discourage hot
compress to skin
overlying the
infection
Intra-oral Drainage
• Rinse with hot salt water mouth rinses q 2 hrs
until drainage occurs
• As hot as you drink your tea
• Swish over swollen area until water starts to
cool, spit out and do again for at least 5 minutes
• Continue QID until dental treatment obtained
What is a true dental emergency?
• The presence of pain does not necessarily
constitute a dental emergency.
• An acute dental emergency requires the
presence of:
– Swelling
– Fever
– Pus
– Bleeding
Bleeding
• Occurs most commonly
in patients who have
had a recent tooth
extracted
• Associated with liver
disease, platelet
dysfunction, pts on
asa, nsaids, coumadin
Dental Pain
• Majority originates in the teeth or peridontium
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and is relatively easy to treat with analgesia and
antibiotics
Treatments starts in the medical clinic but dental
referral is required
Dental problems do NOT “cure themselves”
Treating the pain without addressing the
underlying problem only prolongs the problem.
Dental Pain
• Dental History
– Ask the client to voice their complaint or point to area
which is hurting
– Onset and duration of complaint
– Triggers – hot, cold, sweet stimuli, spontaneous
– Relieving factors (analgesics or rinses)
– Type of pain – sharp or dull; moderate or severe, poorly
localized
– Brief (pulpitis) or prolonged duration (abscess)
HISTORY TAKING
• Medical History
– General state of health
– Current medications
– Particular conditions
• CHD, prosthetic valve
• Drug allergy (penicillin)
• Bleeding tendency
• Immunodeficiency
Non-dental Sources of Pain
• Myofascial inflammation
• Migraine headache
• Maxillary sinusitis
• TMJ
• OM/OE
• Trigeminal neuralgia
CLINICAL EXAMINATION
• General State
– Temp, appearance
• Extra oral examination
– Swelling
– Palpate lymph nodes
CLINICAL EXAMINATION
• Intra oral
– A good light is essential
– Mirror and probe
CLINICAL EXAMINATION
• Intra oral
– Inspect soft tissues:
• Inflammation
• Swelling
• Tenderness
• Ulceration
– Inspect the teeth
• Decay
• Mobility
• Fractured teeth
DIAGNOSIS &
TREATMENT PLANNING
• Make a diagnosis
• Treatment planning for:
– Relief of pain
– Treatment of pathology
– Long term view
COMMON CONDITIONS
• Dental caries
• Pulpitis
• Dental Abscess
• Facial swelling and cellulitis
• Dry socket
• Fractured teeth
• Fractured jaw
DENTAL CARIES
• One of the most
common diseases
• Starts in enamel,
extends to
dentine and if not
treated into pulp
DENTAL CARIES
Management
Remove decay
using an excavator
Place temp filling
Using a flat plastic
DENTAL CARIES
Filling Materials
“Cavit”
(temporary filling)
“Glass Ionomer Cement”
(semi-permanent filling)
PULPITIS
• Inflammation of the pulp
• Dental caries extending into
dentine
causes a sharp pain with hot
and cold
• Early stages reversible
• Remove decay
• Cavit dressing
• When pain settled permanent
filling placed
DENTAL ABSCESS
• Periapical abscess
• Result of decay and infection
extending into pulp of tooth
• Pain is severe, persistent,
& throbbing
• Tooth is tender to touch
• If not treated pus tracks to surface
inside or outside the mouth
DENTAL ABSCESS
“Treatment”
• Periapical abscess – “drainage”
1. Open tooth into pulp chamber using excavator (if
possible) and dressing
2. Antibiotics
3. Extraction of tooth
DENTAL ABSCESS
• Extra oral Swelling
– Can spread into the
tissues
– Leading to cellulitis
– Systemic involvement
– Drainage required
DENTAL ABSCESS
• Extra oral Swelling
“Treatment”
– Antibiotics
– Incision and drainage
• Anesthesia with topical paste or ethyl chloride
• Number 11 blade for incision extra orally
• Open tissues using mosquitos
• Allow pus to drain/insert rubber drain suture to keep patent
– Ultimately extract tooth under LA
– http://www.youtube.com/watch?v=SYVtcL-VDf0
• Intra oral Swelling
– http://www.youtube.com/watch?v=o7Bg0ItHTpA
DRY SOCKET
• Dry Socket
– Localized osteitis
– Severe pain 2 - 4 days
post extraction
– TREATMENT
• LA
• Debride socket
• Dressing – Alvogyl
DENTAL TRAUMA
• Fractured front tooth
– Ellis I – Dentine
– Ellis II - Dentine/Enamel
– Ellis III - Dentine/Enamel/Pulp
• Treatment
– Pain control
– Tetanus
– Cover exposed dentine
w/zinc oxide or calcium
hydroxide paste (Dycal).
http://emedicine.medscape.com/article/82755-media
DENTAL TRAUMA
• Avulsed Tooth
– A good chance of the tooth re-implanting into the socket
successfully if done within an hour.
– The tooth should be located and picked up by the crown
or enamel portion NOT the root.
– If the tooth is dirty/contaminated, gently rinse in cold
running tap water and then re-implanted.
– If immediate on-scene re-implantation is not possible,
transport tooth in whole cold milk, saline, or saliva.
DENTAL TRAUMA
• Place tooth back into socket.
• Splint the tooth to stabilize
– Wire and glass ionomer
cement
– Dental wax and foil
• Antibiotics - Amoxicillin
FACIAL TRAUMA
• Emergency Management of Facial Fractures
• Attempt to stabilize the jaw
• Give Antibiotics, Td
• Soft foods
• Get to hospital ASAP
Barton Bandage
ADMINISTERING
LOCAL ANAESTHESTIC
• 2% Lidocaine w/ epi
• Syringe
– Dental syringe and
needle
– 5 ml syringe and 25-,
27-, or 30-gauge
needle
ADMINISTERING
LOCAL ANAESTHETIC
Mandible
Maxilla
Buccal
Palatal
Blue - Areas where
local anesthetic can
be delivered
Inf. Mandibular
Lingual
INFILTRATION
• Should achieve anesthesia within 5 minutes
• Can be safely repeated if unsuccessful
• Do not give where there is grossly infected tissue
Supraperiosteal
infiltrations:
Anesthetizes individual
teeth. Use this technique
only with the maxillary
incisors, canines, and
premolars
Anterior superior
alveolar nerve block:
Anesthetizes the maxillary
canine, the central and
lateral incisors, and the
mucosa above these teeth,
with occasional crossover to
the contralateral maxillary
incisors
Middle superior
alveolar nerve block:
Anesthetizes the maxillary
premolars with occasional
overlap to the canine and
first molar
Posterior superior
alveolar nerve block:
Anesthetizes maxillary
molar teeth
Infraorbital nerve
block:
Anesthetizes the lower
eyelid, upper cheek, part
of the nose, and upper lip
Nasopalatine nerve
block:
Anesthetizes the
anterior hard palate and
associated soft tissues
Greater palatine
nerve block:
Anesthetizes the posterior
two thirds of the hard
palate
Inferior alveolar
nerve block:
Anesthetizes all teeth on
the ipsilateral side of
mandible, as well as the
ipsilateral lip and chin via
the mental nerve
INFERIOR ALVEOLAR NERVE BLOCK
• Mandible
– Palpate the anterior ramus
border at the coronoid notch.
– Slide the finger or thumb
posteriorly and medially until a
ridge of bone is palpated.
This is the internal oblique
ridge.
– Insert until bone is contacted
then withdraw ~1 mm. The
depth of insertion is
approximately 25 mm.
Mental nerve block:
Anesthetizes the
ipsilateral lower lip and
skin of the chin
Lingual nerve block:
Anesthetizes the anterior
two thirds of tongue
Buccal nerve block:
Anesthetizes the mucous
membrane of the cheek
and vestibule and, to a
lesser extent, a small
patch of skin on the
face.
Local Anesthetic Injection Techniques
• http://www.youtube.com/watch?v=ZHWM
TKX2T70&feature=relmfu
• http://emedicine.medscape.com/article/82
850-print
Pearls
• Obtain informed consent prior to performing a nerve
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block.
Inject slowly (30 seconds for each mL of anesthetic) to
decrease pain.
In order to aspirate properly, use a needle that is 27
gauge or larger for deep nerve blocks.
Buffering with bicarbonate is NOT recommended for oral
nerve blocks.
Pearls
• Applying pressure to the site adjacent to injection while
inserting the needle may distract the patient and,
thereby, decrease the sensation of pain.
• Massaging tissue for 10-20 seconds is thought to hasten
the onset of local anesthetic.
• Achieving anesthesia with oral nerve blocks may take as
long as 10 minutes.
Pearls
• True allergies to local anesthetics are rare.
• If the patient has an allergy to one anesthetic, an
anesthetic from the other class can be used (amide vs
ester), or an alternative agent such as benzyl alcohol or
diphenhydramine can be used.
• If the first attempt at the nerve block fails, try the block
again. Some of the blocks (ie, inferior alveolar,
infraorbital) are best attempted after a skilled clinician
has demonstrated them.
DENTAL EXTRACTIONS
• Indications
• Severe pulpitis
• Periapical abscess
• Tooth fracture
• Severe periodontal disease
DENTAL EXTRACTIONS
• Basic Instruments
DENTAL EXTRACTIONS
• http://www.youtube.com/watch?v=OjiBOOhVVNo
• There are lots of others to watch!
DENTAL EXTRACTIONS
• Post operative instructions
– Pressure on socket
– No rinsing for 24 hours
– Cold food and drink for 24 hours
– No smoking for 24-48 hours
– HSMW after 24 hours
– If bleeding pressure pack for 20 minutes
DENTAL EXTRACTIONS
• Complications
• Fractured tooth
• Bleeding
• Swelling
• Bruising
• Pain
• Trismus
• Dry Socket
DENTAL EXTRACTIONS
• Complications – Bleeding
– Apply Pressure
– Pack with hemostatic agent
– Suture
COMMONLY USED DRUGS
• Analgesics for toothache
• Acetominophen
• NSAIDs (Ketorolac 30 or 60 mg IM in the office)
• Hydrocodone (Lortab/Vicodin), oxycodone
(Percocet), codeine (T#3, 4, 5)
• Antibiotics
• Pen VK, Amoxicillin, Augmentin
• Erythromycin, Clindamycin
• Metronidazole
Necrotizing Ulcerative Periodontitis
• Deep seated
intense/severe pain
• Urgent referral to
dentist
• Narcotic Analgesics
EMERGENCY DENTAL
KIT
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Dental Mirror
Tweezers
Excavator and Flat plastic
Cotton pellets & Rolls
Extraction forceps
Syringe & needle
Sterile Dressings
11 Blade Scalpel
Gloves
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Cavit/Temp dressing
Eugenol/Oil of cloves
Glass ionomer cement
Dental Wax/Wire
Topical anesthetic
Local anesthetic
Amox/Metronidazole
Ibuprofen/Acetominophen
EMERGENCY DENTAL
KIT
• Life Systems Dental First Aid Kit
– http://www.lifesystems.co.uk/psec/first_aid_
kits/dental_first_aid_kit.htm
• Nitro-pak dental First-Aid Kit
– www.nitro-pak.com
• Dr. Stahl's Emergency Dental Kit - Deluxe
– http://www.campingsurvival.com/deemdekid
rst.html
Referral Resources
• http://www.benmasselldentalclinic.com/in
dex.html
• http://www.gfcn.org/index.php
Thank You!