Download Dental Emergencies - Calgary Emergency Medicine

Dental Emergencies
Scott Farquharson
Sept 24th 2009
Topics Covered
 Dental
trauma
 Dental infections
 Dental blocks
 Pediatrics
Dental Anatomy

Primary
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Eruption from 7-30 months
20 teeth, 10 upper, 10 lower
2X ( 4 incisors, 2 canines, 4 molars)
Permanent
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Begin formation 3-4 months
Eruption 7-21 years
32 teeth ( including wisdom teeth)
2x ( 4 incisors, 2 canines, 4 premolars, 6 molars)
Dental Anatomy
Dental Trauma
 Fractures
of teeth
 Alveolar Fractures
 Luxation
 Intrusion or concussion
 Avulsion
 Primary vs Permanent
Fractures of Permanent Teeth
 Enamel
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(Ellis 1)
Chipped tooth
Painless unless associated with other injuries
Large chips can be saved for reattachment
Non urgent dental referral for cosmetic
purposes
Fractures of Permanent Teeth
 Enamel
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and Dentin ( Ellis 2)
70 % of dental fractures
Pain with hot or cold
Dentin is yellow colored
Panorex to R/O other injury
Increased risk of pulp infection/desiccation
Dental evaluation in 24hrs
Protection with dental cement
Consider antibiotics
Fractures of Permanent Teeth
 Pulp

involvement
May be visible (Ellis 3)
• Can see blood

May be below gums (root fracture)
• Only seen with x-ray
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Very painful as nerve exposed
Treatment as Ellis 2
Will need extraction or root canal
Fractures of Permanent Teeth
 Alveolar
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Fractures
Associated with fractures, luxated or avulsed
teeth
small fractures involving 1 or 2 teeth can be
treated by a dentist
Large areas of alveolar bone damage can
cause significant cosmetic deformity and oral
surgery should be consulted
Root Fracture
Luxation
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“Loose tooth”
Extrusion – dislodgement from alveolar bone
Lateral luxation – lateral displacement with
alveolar fracture
Both should have x-rays
Reposition with firm pressure – may require
local anesthesia
Temporary splinting in ED
Permanent splinting/treatment by dentist
Concussion and Intrusion
 Displacement
of tooth into socket
 Concussion – pain with no movement
 Intrusion – more severe displacement
involving root fracture and/or alveolar
fracture
 Intrusion is differentiated on x-ray and
requires repositioning
Avulsion
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Complete displacement of tooth from alveolar
socket
Best chance of saving tooth if reimplanted in
under 3 hrs
Transport in sterile saline, milk, Hank solution or
in buccal sulcus not ice or water
Avoid disruption of periodontal ligament fibers on
root
Clean with normal saline
Rinse clot from socket
splint
Primary Vs Permanent

Avulsed primary teeth should not be reimplanted
to avoid damage to underlying teeth
 Primary teeth have more pulp and less dentin
and are more at risk for infection
 Luxations in young children are at greater risk of
avulsion and aspiration – consider urgent dental
splinting.
 Enamel injuries can cut mucosa in young
children and may need to be filed down
Final Thoughts
 Pen
or amoxicillin usually sufficient
 Consider clindamycin or EES if allergic
 Don’t forget tetanus immunization
Dental Infections
 Periapical
abscess
 Pericoronitis
 Dry socket
 Buccal/facial cellulitis
 Complications
Periapical Abscess
 Complication
of carries/pulpitis
 Inflammation and abscess formation in
periodontal and buccal tissues
 lymphadenopathy
 Streptococcus mutans
 Painful – relieved by I&D
 Definitive treatment is root canal (removal
of the pulp and filling of the empty pulp
chamber and canal )
Periapical Abscess
Periapical Abscess
Pericoronitis
 Most
common in wisdom teeth
 bacterial plaque and food debris
accumulate beneath the flap of gum
covering the partially erupted tooth.
 Pain, bad taste, pus, local inflammation
 can progress to cellulitis
 Salt mouthwashes, irrigate under flap
 ABX
Pericoronitis
Dry Socket- Alveolar Osteitis
 Complication
of tooth extraction
 Clot covering alveolar bone is displaced
 Exposed alveolar bone becomes inflamed
 Normal post extraction pain decreases
over 48hrs
 Dry socket pain increases at 24-72 hrs
 Can progress to osteomyelitis
Dry Socket
 Analgesia
– Nsaids, Narcotics, Nerve
block
 Referral back to dentist in 24 hrs

Will need frequent packing
 ABX?

If caught early and timely follow up is
available probably not needed
Complications

Dental infections can progress to life threatening
complications
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Facial or buccal cellulitis
Submandibular space infections (Ludwig’s angina)
Parapharyngeal space infections
Airway compromise
Orbital infections
CNS infections
Mediastinal infections
Cavernous sinus thrombosis
Complications

Signs of more serious illness
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Systemic symptoms – fever/chills
Trismus
Displacement of tongue
Altered LOC/delirium
Eye pain
Require systemic ABX
 ENT consult
 Possible CT imaging
 Airway management
Antibiotics
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Broad range of pathogens
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Simple infections
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Mainly streptoccocal
Bacteroides sp.
Anaerobes
Pen V or amoxil
I prefer Amox/Clav or clinda
Infections extending to facial or buccal cellulitis
 IV 2nd generation cephalosporin + metronidazole
 HPTP
Dental Nerve Blocks
 Supraperiosteal

Anesthesia for individual tooth
 Inferior Alveolar

nerve block
Nerve Block
Anesthesia for lower teeth
Supraperiosteal Nerve Block
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Select the area to be anesthetized and dry it with gauze.
Ask the patient to close the jaw slightly to relax the facial
musculature.
Grasp the mucous membrane of the area with a piece of gauze.
Pull the gauze (and the mucous membrane) out and downward in
the maxilla and out and upward in the mandible to extend the
mucosa fully and to delineate the mucobuccal fold.
Puncture the mucobuccal fold with the bevel of the needle facing the
bone.
Aspirate the area and then deposit approximately 1 to 2 mL of local
anesthetic at the apex (area of the root tip) of the involved tooth.
It is helpful to place a finger against the outer aspect of the lip
overlying the injection site and apply firm and steady pressure
against the lip while slowly injecting the local anesthetic into the
supraperiosteal site
Supraperiosteal Nerve Block
Supraperiosteal Nerve Block
Inferior Alveolar Nerve Block
Inferior Alveolar Nerve Block

Palpate the retromolar fossa with the index
finger or thumb.
 Identify the greatest depth of the anterior border
of the ramus of the mandible (the coronoid
notch).
 With the thumb in the mouth and the index finger
placed externally behind the ramus, retract the
tissues toward the buccal (cheek) side, and
visualize the pterygomandibular triangle.

This technique also moves the operator’s finger safely
away from the tip of the needle.
Inferior Alveolar Nerve Block
Inferior Alveolar Nerve Block

Hold the syringe parallel to the occlusal surfaces
of the teeth and angled so that the barrel of the
syringe lies between the first and second
premolars on the opposite side of the mandible.
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Achieving the proper angle is important to the
success of this block.
If a large-barrel syringe is used, the corner of the
mouth may hamper efforts to obtain the proper angle.
Carefully bend the 25-gauge needle about 30
degrees to facilitate achieving the proper angle. The
needle cap can be used to bend the needle
Inferior Alveolar Nerve Block

Make the puncture for the injection in the
pterygomandibular triangle, at a point that is 1 cm above
the occlusal surface of the molars.
 If the needle enters too low (e.g., at the level of the
teeth), the anesthetic will be deposited over the bony
canal and prominence (lingula) that house the
mandibular nerve, and not over the nerve itself.
 There may be slight resistance as the needle passes
through the ligaments and the muscles covering the
internal surface of the mandible. When there is more
solid resistance, the needle has reached the bone.
 Stop when the needle has reached bone, which signifies
contact with the posterior wall of the mandibular sulcus.
 It is important to feel the bone with the needle (
Inferior Alveolar Nerve Block
Inferior Alveolar Nerve Block
 It
is important to feel the bone with the
needle.
 After reaching the bone, withdraw the
needle slightly and aspirate to check for
possible intravascular placement.
 Deposit approximately 1 to 2 mL of
anesthetic solution; 3 to 4 mL of anesthetic
may be required if needle positioning is
suboptimal.
Inferior Alveolar Nerve Block
Inferior Alveolar Nerve Block
 Failure
to feel bone as the needle is
advanced generally results from directing
the needle toward the parotid gland (too
far posteriorly) rather than toward the inner
aspect of the mandible. Injecting into the
parotid gland can anesthetize the facial
nerve
Inferior Alveolar Nerve Block
 One
may anesthetize the lingual nerve by
placing several drops of anesthetic
solution while withdrawing the syringe.
The anterior two thirds of the tongue can
thus be anesthetized. In actual practice,
the lingual nerve is consistently blocked
with this procedure owing to the close
proximity of both nerves.
Inferior Alveolar Nerve Block

Complications include inadvertent administration of
anesthetic posteriorly in the region of the parotid gland,
which will anesthetize the facial nerves. This is an
annoying but relatively benign complication that will
cause temporary facial paralysis (similar to Bell’s palsy)
affecting the orbicularis oculi muscle and results in
inability to close the eyelid. Should this occur, the eye
must be protected until the local anesthetic has worn off
(approximately 2 to 3 hours), and the patient must be
reassured. Anesthesia with bupivacaine (Marcaine)
presents a more significant problem if this complication
occurs, because bupivacaine anesthesia lasts from 10 to
18 hours in some patients.