Dental

Dental Emergencies
Emergencies
EMPA Residency
UTHSCSA
 Dental Emergencies
t.1484
Dental Pain is probably one of the least
satisfying aspects of Emergency
Medicine

“Pain is Not an Emergency” - unless of

course that pain is your pain.
 Dental Anatomy
• Tooth is mostly Dentin
• Dentin surrounds the pulp - the neurovascular
supply of the tooth
• Dentin is produced by pulpal ondontoblasts
throughout your life
• The crown or enamel visible to the eye is
made of hydroxyapetite and is produced prior
to erruption of the tooth into the mouth
• Teeth are embedded in the alveolar bone
 Normal Periodontium
• Gingival component
– Junctional epithelium, gingival tissue and
gingival fibers
• Periodontal component
– Periodontal ligament, alveolar bone,
cementum at the root of the tooth
 Orofacial Pain
• Erruption or normal development is associated with pain
and gingival irritation
• Fever and diarrhea associated with normal development
is controversial and should prompt a search for other
explanations
• Pericoronitis is associated with food debris trapped
under the gingival surface above the errupting tooth
and can result in infection
– Tx: Antibiotics, NSAIDS, Saline rinses, analgesics.
 Parapharngeal Space
infections
• Infections invoving 3 molars can easily involve the
rd

masticator space
– Associated trismus suggests extension into the
parapharyngeal spaces
• Consider CT neck to characterize size of abscess
• Panorax
• Antibiotics: PCN-VK, Clindamycin, analgesia
• OMS consult
• These infections can progress and obstruct the airway -
Think Ludwigs Angina
 Dental Caries
• Extremely Common
• Caused by acidic by products of plaque bacteria
• Continued neglect leads to irreversible damage
to the pulp associated with longer lived pain
• Treatment for irreversible pulpitis is root canal
or extraction
 Triage PA’s work fast but
remember lessons learned
in Resusitation
Patient with left mandible pain, 55
years old, and associated SOB
 Ludwigs Angina
• Infection of submental, sublingual and
submandibular spaces:
• Rapid upward posterior displacement of tongue
with the potential for complete obstruction of
the airway
• Recussitation Room for emergency airway
management as needed, antibiotics, ENT for
fiberoptic evaluation, CT neck if time allows.
 Postextraction Alveolar
Osteitis
• Periosteitis - Occurs within 48 hours of
extraction and responds well to analgesics
• Postextraction Alveolar Osteitis – Dry Socket –
usually occurs after the 2nd or 3rd postoperative
day and causes exquisite pain
– Caused by displacement or disolution of the clot
– Results in exposure of alveolar bone and localized
osteomyelitis
 Postextraction Alveolar
Osteitis
Dental radiographs to exclude retained root tip
Thorough irrigation of the socket
Packing with oil of cloves or eugenol gauze results in
almost immediate improvement in comfort
Dental anasthesia may be necessary to pack
Antibiotics for the worst cases, analgesics
24 hour referral to dentist
More common in 3rd molar
Trismus postoperatively is common and should peak
after 24 hours if it worsens after this time it is
worrisome for infection of the TMJ
 Periodontal Pahtology
• Periodontitis is generally secondary to gingivitis
• Plaque along the gingival margin causes progressive
inflamation ultimately affecting the periodontal
attachment apparatus. The gingival sulcus also deepens.
• The net result is bone and tooth loss
• Periodontal abscess is common –pcn-vk, analgesics,
possible I&D
 Acute Necrotizing Ulcerative
Gingivitis(AKA-Vincent Disease
or Trench Mouth)
• Ulcerative local lesions spread to surrounding tissues
including bone with occasional fatal outcome
• Anaerobic bacteria – Treponema, Selenomonas,
Fusobacterium, Prevotella are uniformly identified
• Predisoposing conditions HIV, previous history of
ANUG- Also, poor, young, poor hygiene, malnourihed,
white, etoh, tobacco
• Clinical triad of pain, puched out interdental papillae
and gingival bleeding
 Acute Necrotizing Ulcerative
Gingivitis(AKA-Vincent Disease
or Trench Mouth
• Very difficult to differentiate from
herpes gingivostomatitis
• Treatment with Metronidazole and
chlorhexidine rinses are mainsty
• Surgical debridement may be
necessary
 Dental Fractures
• Ellis Classifications: types I-III
• Type I: Involves enamel portion only
– Generally no ED treatment needed.
 Ellis Classifications:
types I-III
70% are type II
• Type II: involves the dentim of the tooth
• Dentim is creamy yellow when exposed communication
with the pulp and infection are concern
• Painful stimuli includes hot, cold and even air passing
over tooth when breathing
• Covering the exposed dentim to decrease the chance of
pulpal infection with a dental cement
• Followed by 24 hour referral to dentist to ensure tooth
vitality
 Ellis Classifications:
types I-III

• Type III : The crown and dentim is

fractured to the level of the pulp
• One should attempt to cover with dental
cement after drying with sterile gauze
• Endodontic or Root canals are appropriate
• 24 hour referral to dentist
 Concussions, Luxations
and Evulsions
• Forces that may cause fracture may
also cause loosening of the tooth from
the attachment apparatus-Carefully
palpate for laxity or tenderness
• Panorax to rule out mandible fracture
 Tooth Concussion
• Concussion to a tooth is damage to
supporting structures with tenderness
but no radiographic evidence of injury
and no mobility
• If present referral to a dentist is
appropriate
 Tooth Subluxation
• Subluxation: no radiographic evidence
of injury but tenderness and mobility
present
 Tooth Subluxation
• Luxations are partial or complete avulsion of the tooth
with or without alveolar fracture
• Gentle pressure to replace the tooth will usually
succeed unless a clot has formed apically beneath the
apex.
• Splinting must then be done and maintained for two
weeks followed by more definitive splinting or surgery
by dentistry
• If there is more than minimal alveolar fracture then
splinting by dentistry or OMS in the ED is necessary
 Tooth Subluxation
• If a tooth is completely avulsed then a quick rinse
with water followed by immediate reimplantation is
recommended.
• If the patient has immediate aspiration risks then
reimplantation within 2-3 hours is necessary in order
to maintain viability. Transportation in NS or milk is
recommended. Hank solution is the best transport
medium and can help restore cell viability in a tooth
that has not been kept in solution and has been dry
for less than 20 minutes
 Tooth Subluxation
• Clean tooth with normal saline or Hank solution and
avoid handling apex.
• Dislodge clots with NS rinse in socket
• Primary teeth in patients 6-12 years of age are never
reimplanted.
• Follow up with dentistry is always recommended