Dental Emergencies

Devin Herbert, R3 Sept 6, 2012

Clavulin

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ObjectivesCommunication

Dental anatomy

Nontraumatic emergencies

Traumatic emergencies

Pediatric issues

premolar

TerminologyLower aka Mandibular

Upper aka Maxillary

Lingual - mandibular teeth toward tongue

Palatal - maxillary teeth toward tongue

Labial - anterior teeth toward lips

Buccal - posterior teeth toward cheeks

Interproximal - surface between two adjacent teeth

Occlusal/Incisal - biting surface

Cervical - junction of crown and root

Nontraumatic emergencies

Dental cariesSensitive to cold

Decalcification of enamel by acid producing plaque bacteria

Eventually dentin layer breached

PulpitisPain, to thermal stimulus

Reversible - Short duration of discomfort

Likely to benefit from antibiotics

Irreversible - longer duration of discomfort

Require root canal or extraction

Periapical abscessSpontaneous or unremitting pain,

reproducible with percussion

Extension of infection to periapical bone

Drainage, antibiotics, NS rinses

May have an associated parulis

PeriodontitisTypically less pain

Inflammation of the tooth attachment apparatus

Often will drain spontaneously

Can form periodontal abscess (can be difficult to differentiate from periapical abscess)

Drainage, antibiotics, NS rinses

Drainage techniqueIntraoral vs. extraoral

Local or regional anesthesia

No. 11 blade incision

Mosquito hemostat to disrupt loculations

NS irrigation

Packing gauze, sutured to mucosa

Antibiotics, NS rinses

PericoronitisPain, foul taste or odour

Involves erupting tooth, often 3rd molar

Inflammation of the gingival tissue overlying the erupting crown

Drainage, antibiotics, NS rinses

Alveolar osteitis (dry socket)Pain, foul taste or odour

Inflammation of exposed alveolar bone

2-5 days post tooth extraction

Clot dislodged prematurely

Can progress to osteomyelitis

Packing, antibiotics

Deep space infectionsSpread of odontogenic infection

Maxillary teeth to upper face

Mandibular teeth to lower face

Fascial planes of head, neck, mediastinum

Airway at risk if altered voice, stridor, drooling

Parenteral antibiotics, CT, admission

Ludwig’s anginaSwollen floor of mouth, elevated tongue

Cellulitis of bilateral submandibular spaces and sublingual space

Direct connection to parapharyngeal space

Airway at risk!

Cavernous sinus thrombosisInfraorbital or periorbital cellulitis

Retrograde spread of infection through ophthalmic veins to cavernous sinus

Meningeal signs, altered LOC to coma

Traumatic emergencies

Dental crown fracturesEllis I - enamel only, painless

White fracture surface

Ellis II - enamel and dentin, painful Yellow fracture surface

Ellis III (complicated) - pulp involved, painful Red fracture surface

(Complicated)

Dental trauma terminologyConcussion - pain but stable, nondisplaced

Subluxation - loose, nondisplaced

Luxation - loose, displaced, malocclusion Can be intrusive, extrusive or lateral

Avulsion - completely removed from socket

Intrusion - forced into alveolar bone

AvulsionWhere is the tooth?

Consider XR if “missing”

Reimplant or place tooth in physiologic medium ASAP

Avoid traumatizing periodontal ligament

Chance of successful reimplantation inversely proportional to time out of socket

Pediatric pearls

Pediatric dental emergency pearlsPrimary dentition consists of 20 teeth (2 incisors, 1 canine, 2 molars per quadrant)

Eruption begins ~ 6 months complete by ~ 2 years

Permanent dentition begins ~ 6 years

Avulsed primary teeth should NOT be reimplanted

SummaryED management is temporizing

Communicate clearly to consultants

Consider sealing, splinting and drainage of accessible infections

Recognize true dental emergencies

Recognize true medical emergencies

Floss

Edmonton’s ED dental kit:Dycal - $55.75 Fuji I glass ionomer - $135.00mix pad 3x3 - $1.49 disposable spatulas pk 50 - $35.50disposable mirrors pk 60 - $27.43 disposable instruments pk 10 - $97.50 Arista hemostatic powder - ? Pricegelfoam substitute pk 24 - $56.25 cotton rolls box 2000 - $25.15 dental wax - ? price