Smiles for LifeA National Oral Health Curriculum

Second Edition

Module 4Module 4Acute Dental Problems

Smiles for Life Copyright STFM 2005-2008July 2008

Steering CommitteeSteering CommitteeAlan B. Douglass, M.D. (Editor and Group Co-Chair)

Middlesex Hospital University of ConnecticutMiddlesex Hospital, University of ConnecticutMark E. Deutchman, M.D.

University of ColoradoWanda C Gonsalves M DWanda C. Gonsalves, M.D.

Medical University of South CarolinaRussell Maier, M.D. (Group Co-Chair)

University of WashingtonUniversity of WashingtonHugh Silk, M.D.

University of MassachusettsJ T i Ph DJames Tysinger, Ph.D.

University of Texas Medical Branch, San AntonioA. Stevens Wrightson, M.D.

U i i f K kSmiles for Life

University of Kentucky

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FundersFundersOral Health Foundation

A D S M I N I T I AT I V E

Washington Dental ServiceFoundation

Community Advocates for Oral Health

Connecticut HealthFoundation

Delta Dental of KentuckyDELTA DENTAL OF COLORADOFOUNDATION

THE HEALTH FOUNDATIONOF CENTRAL MASSACHUSETTS, INC.

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Curriculum OverviewCurriculum OverviewACGME formatted educational objectives7 annotated 50 min te Po erPoint mod les7 annotated 50 minute PowerPoint modules

1. The relationship of oral to systemic health2. Child oral health2. Child oral health3. Adult oral health4. Acute dental problems5. Oral health in pregnancy6. Fluoride varnish7 Th l i ti7. The oral examination

Test questions Resources for further learning

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Resources for further learning

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AcknowledgementsAcknowledgementsThe materials in this module were originally developed in part by:

Washington Interdisciplinary Child Oral Health Project (ICOHP)University of Connecticut Schools of Medicine and Dental MedicinePhysician Oral Health Education in Kentucky (POHEC)

Steering group editors for Module 4Russell Maier, M.D.Alan B. Douglass, M.D.

Dental ConsultantJoanna M. Douglass, B.D.S., D.D.S.

Smiles for Life EditorSmiles for Life EditorAlan B. Douglass, M.D.

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Educational ObjectivesEducational Objectives

• Diagnose, initially manage, andDiagnose, initially manage, and appropriately refer:– Pain of dental origin– Oral infections– Dental trauma to primary and permanent teeth

• Distinguish true dental emergencies• Implement strategies aimed at the

prevention of oral injuries

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Oral Pain

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Photo: ICOHP

Oral PainOral Pain• 22% of adults have had oral pain in

past 6 months• Often poorly localized• Children may not

– Describe or localize pain– Identify affected tooth or region

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Oral Pain EtiologiesOral Pain Etiologies

• Dental source may present withDental source may present with sinus, jaw, ear pain

• Oral pain may have non-dental• Oral pain may have non-dental cause

Sinusitis– Sinusitis– Otitis media / otitis externa

Oral ulcerations– Oral ulcerations– Temperomandibular joint

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Analgesia for Oral PainAnalgesia for Oral Pain

• Acetaminophen or NSAIDS can beAcetaminophen or NSAIDS can be effective alone or as adjuncts

• Often pain is severe and requires• Often pain is severe and requires opioidsOil f Cl h t b f d t b• Oil of Cloves has not been found to be effective

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Oral Infections

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Reversible PulpitisReversible Pulpitis• Carious lesion encroaching

on pulpon pulp • Pain with hot, cold, sweet-

resolves spontaneously• Treatment: Filling

Smiles for LifePhoto: Joanna Douglass BDS DDS. Graphic: AAFP Home Study Program- with permission

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Irreversible PulpitisIrreversible Pulpitis• Severe pulpal inflammation • Pain severe, spontaneous,Pain severe, spontaneous,

persistent, poorly localized• Treatment: Root canal or

extractionextraction• Untreated can progress to

apical periodontitis and abscessabscess

Smiles for LifePhoto: Joanna Douglass, BDS DDS. Graphic: AAFP Home Study Program- with permission

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Periapical AbscessPeriapical Abscess• A localized, purulent form

of periapical periodontitis• Can fistulize through

gum or progress to cellulitiscellulitis

Smiles for LifePhotos: Donald Greiner DDS MS, Joanna Douglass BDS DDS. Graphic: AAFP Home Study Program- with permission

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Periapical Abscess• If ‘pointing’ can perform

i i i d d i

Periapical Abscess

an incision and drainage for temporary reliefA tibi ti i di t d• Antibiotics are indicated only if concurrent cellulitis is presentcellulitis is present

• Dental evaluation required for definitive qcare: root canal or extraction

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Facial Cellulitis EmergencyFacial Cellulitis Emergency

• If localized- outpatient oral antibiotics and prompt dentalantibiotics and prompt dentalevaluation

• Spread to deep fascial spaces scan be life threatening with airway compromise or sepsis– Hospitalize with surgical and ID p g

consultations – IV antibiotics, analgesics

CT imaging– CT imaging• Root canal or extraction is

necessary to prevent recurrence

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Antibiotic OptionsAntibiotic Options• Penicillin VK 25-50 mg/kg/day,

divided 4 times dailydivided 4 times daily• Amoxicillin 35-50 mg/kg/day,

divided 3 times dailydivided 3 times daily• For penicillin allergic patients:

Clindamycin 10 25 mg/kg/dayClindamycin 10-25 mg/kg/day, divided 3 times daily

• For severe infections consider broadFor severe infections consider broad spectrum agents

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PericoronitisPericoronitis• Patient complains of pain• Gum flap traps food and

plaque over partially erupted molar

• Secondary cellulitis possibleSeco da y ce u t s poss b e• Treatment: irrigation,

antibiotics if cellulitis, removal of gum flap or toothremoval of gum flap or tooth

Smiles for LifePhoto: © Eastman Dental Institute www.eastman.ucl.ac.uk. Graphic: AAFP- with permission

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Dental Trauma

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Photo: ICOHP

EpidemiologyEpidemiology • Dental injuries are

common:common:– 30% of preschoolers

25% of 12 y o have– 25% of 12 y.o. have injured permanent teeth

• Common causes: bikes, ,falls, sports injuries, automobile accidents, violenceviolence

• Anterior maxillary incisors are most often injured

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are most often injuredPhoto: ICOHP

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HistoryHistory• Take history

When? Where? How?

• Determine tetanus statusDetermine tetanus statusConsider prophylaxis for intrusion, avulsion, deep laceration or contaminated wound if not updated in past 5 yearsupdated in past 5 years

• Assess symptomsPain, change in occlusion, difficulty opening mouth

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Extra-Oral ExamExtra Oral ExamTriage

Ai (ABC)• Airway (ABC)• Other life-threatening

injuriesinjuries• Neurologic exam• Assess the Cervical SpineAssess the Cervical Spine• Check for skull, orbit, or

zygomatic fractures• Primary vs. permanent teeth• Availability of dental care

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Extra-oral ExamExamine mouth• Irrigate to remove blood,

Extra oral Exam

Irrigate to remove blood, clots, and debris

• Soft tissues• Teeth: Primary or PermanentTeeth: Primary or Permanent• Bony structuresAssess:• Tenderness and Swelling• Tenderness and Swelling• Lacerations• Damaged or mobile teeth• Occlusion• Occlusion• Mobile jaw segments• Pain or limitation on opening

Smiles for LifePhoto: © Eastman Dental Institute www.eastman.ucl.ac.uk

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Alveolar Bone Fracture EmergencyAlveolar Bone Fracture Emergency

• Often associated with gingival lacerationlaceration

• Palpate alveolar ridge for step-offs

• Segmental alveolar fractures move when assessing tooth mobilityy

• Diagnose radiographically• See oral surgeon emergently,

id ll ithi hideally within one hour. Reduction is easier before swelling occurs

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Chin TraumaChin TraumaSuspect:•Mandibular condyle fractureMandibular condyle fracture•Tooth fracturePhysical evaluationy•Mouth opens normally?•Normal bite?•Chin deviation on opening?•Palpable movement of condylar heads?

•Fractured teeth in the molar areas?

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areas?Photos: ICOHP

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Missing TeethMissing Teeth• Do not assume missing teeth were

lost at scene• Consider X-ray to determine if

missing teeth are:– swallowed– aspirated – intruded into sinus or other structures

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Trauma to PrimaryTrauma to Primary TeethTeeth

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Trauma to Primary TeethTrauma to Primary Teeth • Permanent teeth

develop close to primarydevelop close to primary teeth

• Alveolar bone more pliable in children-intrusion/subluxation of primary teeth moreprimary teeth more common

• Intrusion or subluxationIntrusion or subluxation may damage developing permanent dentition

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Intrusion of Primary ToothIntrusion of Primary Tooth• Tooth pushed into gum-

deeper into socketp• Cannot accurately predict

outcome of permanent dentitiondentition

• Do not attempt to remove intruded tooth

• Analgesics, warm saline rinses, consider antibioticsantibiotics

• Dental evaluation in 1 day to 1 week based on symptoms

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symptoms

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Avulsion of Primary ToothAvulsion of Primary Tooth

• Assess for other associated injuriesj• DO NOT REPLACE• Not necessary to save• Not necessary to save• Refer to dentist within 24 hrs• Underlying permanent tooth may be

damaged

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Trauma to PermanentTrauma to PermanentTeeth

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Classification of LoosenedClassification of Loosened (luxated) Permanent Teeth

C i• ConcussionTooth is tender but not displaced or mobile

• SubluxationTooth is mobile, may have hemorrhage from the gingival crevice

• LuxationLuxationTooth is loose, with no or some degree of displacement from socket

• IntrusionIntrusionTooth is pushed deeper into its socket

• ExtrusionTooth is partially displaced from its socket

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Tooth is partially displaced from its socket

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Intrusion of Permanent ToothIntrusion of Permanent Tooth• See dentist immediately for

repositioning and splint• Do not attempt to remove intruded

tooth• Dental care may include:Dental care may include:

– splinting– soft diet

gentle tooth brushing with a soft brush– gentle tooth brushing with a soft brush– chlorhexidine mouthrinse

• High risk for complicationsf– Tooth death, root resorption, infection

– May require subsequent root canal therapy

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Avulsion of Permanent ToothAvulsion of Permanent ToothEmergency

• A true dental emergency!• A true dental emergency!• Preservation of

periodontal ligament isperiodontal ligament is critical for tooth survival

• Rinse off any debris gently with saline or milk

Hold tooth by crown onlyDO NOT t h b lDO NOT touch, rub, clean, or scrub the root

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Avulsion of Permanent ToothAvulsion of Permanent ToothEmergencyRe-implant immediately, ensuring correct orientation

• Best outcomes with 5 minutes

• Bite on gauze or hold tooth in place

• Antibiotic prophylaxis with p p ypenicillin or doxycycline for 7 days recommended

• See dentist immediately for yradiograph, splinting

If can’t re-implant on scene, transport in saline, milk, or

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p , ,buccal sulcusPhoto: ICOHP

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Tooth Fracture ClassificationTooth Fracture Classification

R t f tRoot fracture

Enamel, dentin and pulp

Enamel and dentin

Enamel, dentin and pulp

Enamel only

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Tooth FracturesTooth Fractures Management depends upon severity andupon severity and patient symptoms

• Routine referral if i lpainless

• Urgent – 1 day – if pain or pulp exposed

ICOHP

J D l BDS DDSJoanna Douglass, BDS, DDS

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Tooth Fractures Emergency

• Tooth may or may not bebil d di

Tooth Fractures Emergency

mobile depending on fracture locationR di h d t f• Radiograph mandatory for diagnosis

• See dentist same daySee dentist same day• Treatment is reduction and

splinting or extractionp g• Complications: root resorption,

pulpal necrosis

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Oral Piercing ComplicationsOral Piercing Complications

• Tooth fracture or injury• Stud aspiration• Allergic reactiong• Nerve damage• Speech impedimentp p• Gingival recession• InfectionInfection

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Injury PreventionInjury Prevention

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Photo: ICOHP

Mouth Guards Prevent InjuriesMouth Guards Prevent Injuries• Most trauma occurs in soccer,

f tb ll b b ll d h kfootball, baseball and hockey • Skateboarding, basketball,

bi li i j ibicycling injuries are common• A well-fitting mouth guard can decrease

i k f i jrisk of injury• By separating mandible from base of

k ll th d l dskull, mouth guards may also reduce cerebral and dental concussion

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Mouth Guards TypesMouth Guards Types

Custom

Boil and bite

StockSmiles for Life

StockPhotos: ICOHP

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Injury PreventionInjury Prevention

• Use a mouth guard – any is good, g y g ,best are custom fitted

• A well fitting mouthguard is most likely g g yto be used consistently

• Remove oral piercings for athleticsp g• Include review of mouth guards in

adolescent well child checks or sports pphysicals

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Take Home MessagesTake Home Messages• Consider dental and non-dental sources of

painpain• Two true dental emergencies:

– Facial cellulitis needs immediate treatment and possible hospitalization

– Re-implant avulsed permanent teeth immediately• Accurately assess and describe dental trauma• Accurately assess and describe dental trauma

for optimal triage and referral• Clinicians should promote the use of mouthClinicians should promote the use of mouth

guards and other protective equipment to prevent oral injuries

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Questions?Questions?

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How would you manage these?How would you manage these?

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