MANAGING DENTAL EMERGENCIES

March 24, 2011 Lianne Beck, MD Assistant Professor Emory Family Medicine

Objectives

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

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
present Trismus suggests infection in posterior region Infection causes a reactive myospasm Do not force mouth open Will resolve once infection resolves

Ludwigs 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

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

Maxilla

Mandible

Buccal

Blue - Areas where local anesthetic can be delivered

Inf. Mandibular

Palatal

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

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

Dental Mirror Tweezers Excavator and Flat plastic Cotton pellets & Rolls Extraction forceps Syringe & needle Sterile Dressings 11 Blade Scalpel Gloves

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!