dental emergencies scott farquharson sept 24 th 2009

Dental EmergenciesDental Emergencies

Scott FarquharsonScott Farquharson

Sept 24Sept 24thth 2009 2009

Topics CoveredTopics Covered

Dental traumaDental trauma Dental infectionsDental infections Dental blocksDental blocks PediatricsPediatrics

Dental AnatomyDental Anatomy

PrimaryPrimary Eruption from 7-30 monthsEruption from 7-30 months 20 teeth, 10 upper, 10 lower20 teeth, 10 upper, 10 lower 2X ( 4 incisors, 2 canines, 4 molars)2X ( 4 incisors, 2 canines, 4 molars)

PermanentPermanent Begin formation 3-4 monthsBegin formation 3-4 months Eruption 7-21 yearsEruption 7-21 years 32 teeth ( including wisdom teeth)32 teeth ( including wisdom teeth) 2x ( 4 incisors, 2 canines, 4 premolars, 6 molars) 2x ( 4 incisors, 2 canines, 4 premolars, 6 molars)

Dental AnatomyDental Anatomy

Dental TraumaDental Trauma

Fractures of teethFractures of teeth Alveolar FracturesAlveolar Fractures Luxation Luxation Intrusion or concussionIntrusion or concussion AvulsionAvulsion Primary vs PermanentPrimary vs Permanent

Fractures of Permanent TeethFractures of Permanent Teeth

Enamel (Ellis 1)Enamel (Ellis 1) Chipped toothChipped tooth Painless unless associated with other injuriesPainless unless associated with other injuries Large chips can be saved for reattachmentLarge chips can be saved for reattachment Non urgent dental referral for cosmetic Non urgent dental referral for cosmetic

purposes purposes


Enamel and Dentin ( Ellis 2)Enamel and Dentin ( Ellis 2) 70 % of dental fractures70 % of dental fractures Pain with hot or coldPain with hot or cold Dentin is yellow coloredDentin is yellow colored Panorex to R/O other injuryPanorex to R/O other injury Increased risk of pulp infection/desiccationIncreased risk of pulp infection/desiccation Dental evaluation in 24hrsDental evaluation in 24hrs Protection with dental cementProtection with dental cement Consider antibioticsConsider antibiotics


Pulp involvement Pulp involvement May be visible (Ellis 3)May be visible (Ellis 3)

• Can see blood Can see blood May be below gums (root fracture)May be below gums (root fracture)

• Only seen with x-ray Only seen with x-ray Very painful as nerve exposedVery painful as nerve exposed Treatment as Ellis 2Treatment as Ellis 2 Will need extraction or root canalWill need extraction or root canal


Alveolar FracturesAlveolar Fractures Associated with fractures, luxated or avulsed Associated with fractures, luxated or avulsed

teethteeth small fractures involving 1 or 2 teeth can be small fractures involving 1 or 2 teeth can be

treated by a dentist treated by a dentist Large areas of alveolar bone damage can Large areas of alveolar bone damage can

cause significant cosmetic deformity and oral cause significant cosmetic deformity and oral surgery should be consulted surgery should be consulted

Root FractureRoot Fracture

LuxationLuxation

““Loose tooth”Loose tooth” Extrusion – dislodgement from alveolar boneExtrusion – dislodgement from alveolar bone Lateral luxation – lateral displacement with Lateral luxation – lateral displacement with

alveolar fracturealveolar fracture Both should have x-raysBoth should have x-rays Reposition with firm pressure – may require local Reposition with firm pressure – may require local

anesthesiaanesthesia Temporary splinting in EDTemporary splinting in ED Permanent splinting/treatment by dentist Permanent splinting/treatment by dentist

Concussion and IntrusionConcussion and Intrusion

Displacement of tooth into socketDisplacement of tooth into socket Concussion – pain with no movementConcussion – pain with no movement Intrusion – more severe displacement Intrusion – more severe displacement

involving root fracture and/or alveolar involving root fracture and/or alveolar fracturefracture

Intrusion is differentiated on x-ray and Intrusion is differentiated on x-ray and requires repositioning requires repositioning

AvulsionAvulsion Complete displacement of tooth from alveolar Complete displacement of tooth from alveolar

socketsocket Best chance of saving tooth if reimplanted in Best chance of saving tooth if reimplanted in

under 3 hrsunder 3 hrs Transport in sterile saline, milk, Hank solution or Transport in sterile saline, milk, Hank solution or

in buccal sulcus in buccal sulcus not ice or waternot ice or water Avoid disruption of periodontal ligament fibers on Avoid disruption of periodontal ligament fibers on

rootroot Clean with normal salineClean with normal saline Rinse clot from socketRinse clot from socket splint splint

Primary Vs PermanentPrimary Vs Permanent

Avulsed primary teeth should not be reimplanted Avulsed primary teeth should not be reimplanted to avoid damage to underlying teethto avoid damage to underlying teeth

Primary teeth have more pulp and less dentin Primary teeth have more pulp and less dentin and are more at risk for infectionand are more at risk for infection

Luxations in young children are at greater risk of Luxations in young children are at greater risk of avulsion and aspiration – consider urgent dental avulsion and aspiration – consider urgent dental splinting.splinting.

Enamel injuries can cut mucosa in young Enamel injuries can cut mucosa in young children and may need to be filed downchildren and may need to be filed down

Final ThoughtsFinal Thoughts

Pen or amoxicillin usually sufficientPen or amoxicillin usually sufficient Consider clindamycin or EES if allergicConsider clindamycin or EES if allergic Don’t forget tetanus immunization Don’t forget tetanus immunization

Dental InfectionsDental Infections

Periapical abscessPeriapical abscess PericoronitisPericoronitis Dry socket Dry socket Buccal/facial cellulitisBuccal/facial cellulitis ComplicationsComplications

Periapical AbscessPeriapical Abscess

Complication of carries/pulpitisComplication of carries/pulpitis Inflammation and abscess formation in Inflammation and abscess formation in

periodontal and buccal tissuesperiodontal and buccal tissues lymphadenopathylymphadenopathy Streptococcus mutansStreptococcus mutans Painful – relieved by I&DPainful – relieved by I&D Definitive treatment is root canal (removal Definitive treatment is root canal (removal

of the pulp and filling of the empty pulp of the pulp and filling of the empty pulp chamber and canal )chamber and canal )

Periapical AbscessPeriapical Abscess

PericoronitisPericoronitis

Most common in wisdom teethMost common in wisdom teeth bacterial plaque and food debris bacterial plaque and food debris

accumulate beneath the flap of gum accumulate beneath the flap of gum covering the partially erupted tooth. covering the partially erupted tooth.

Pain, bad taste, pus, local inflammationPain, bad taste, pus, local inflammation can progress to cellulitiscan progress to cellulitis Salt mouthwashes, irrigate under flapSalt mouthwashes, irrigate under flap ABXABX

PericoronitisPericoronitis

Dry Socket- Alveolar OsteitisDry Socket- Alveolar Osteitis

Complication of tooth extractionComplication of tooth extraction Clot covering alveolar bone is displacedClot covering alveolar bone is displaced Exposed alveolar bone becomes inflamedExposed alveolar bone becomes inflamed Normal post extraction pain decreases Normal post extraction pain decreases

over 48hrsover 48hrs Dry socket pain increases at 24-72 hrsDry socket pain increases at 24-72 hrs Can progress to osteomyelitisCan progress to osteomyelitis

Dry SocketDry Socket

Analgesia – Nsaids, Narcotics, Nerve Analgesia – Nsaids, Narcotics, Nerve blockblock

Referral back to dentist in 24 hrsReferral back to dentist in 24 hrs Will need frequent packingWill need frequent packing

ABX? ABX? If caught early and timely follow up is If caught early and timely follow up is

available probably not needed available probably not needed

ComplicationsComplications

Dental infections can progress to life threatening Dental infections can progress to life threatening complicationscomplications Facial or buccal cellulitisFacial or buccal cellulitis Submandibular space infections (Ludwig’s angina)Submandibular space infections (Ludwig’s angina) Parapharyngeal space infectionsParapharyngeal space infections Airway compromiseAirway compromise Orbital infectionsOrbital infections CNS infectionsCNS infections Mediastinal infectionsMediastinal infections Cavernous sinus thrombosisCavernous sinus thrombosis

ComplicationsComplications

Signs of more serious illnessSigns of more serious illness Systemic symptoms – fever/chillsSystemic symptoms – fever/chills TrismusTrismus Displacement of tongueDisplacement of tongue Altered LOC/deliriumAltered LOC/delirium Eye painEye pain

Require systemic ABXRequire systemic ABX ENT consultENT consult Possible CT imagingPossible CT imaging Airway managementAirway management

AntibioticsAntibiotics

Broad range of pathogensBroad range of pathogens Mainly streptoccocalMainly streptoccocal Bacteroides sp.Bacteroides sp. AnaerobesAnaerobes

Simple infectionsSimple infections Pen V or amoxilPen V or amoxil I prefer Amox/Clav or clindaI prefer Amox/Clav or clinda

Infections extending to facial or buccal cellulitisInfections extending to facial or buccal cellulitis IV 2IV 2ndnd generation cephalosporin + metronidazole generation cephalosporin + metronidazole HPTPHPTP

Dental Nerve BlocksDental Nerve Blocks

Supraperiosteal nerve blockSupraperiosteal nerve block Anesthesia for individual toothAnesthesia for individual tooth

Inferior Alveolar Nerve BlockInferior Alveolar Nerve Block Anesthesia for lower teethAnesthesia for lower teeth

Supraperiosteal Nerve BlockSupraperiosteal Nerve Block Select the area to be anesthetized and dry it with gauze. Select the area to be anesthetized and dry it with gauze. Ask the patient to close the jaw slightly to relax the facial Ask the patient to close the jaw slightly to relax the facial

musculature. musculature. Grasp the mucous membrane of the area with a piece of gauze. Grasp the mucous membrane of the area with a piece of gauze. Pull the gauze (and the mucous membrane) out and downward in Pull the gauze (and the mucous membrane) out and downward in

the maxilla and out and upward in the mandible to extend the the maxilla and out and upward in the mandible to extend the mucosa fully and to delineate the mucobuccal fold. mucosa fully and to delineate the mucobuccal fold.

Puncture the mucobuccal fold with the bevel of the needle facing the Puncture the mucobuccal fold with the bevel of the needle facing the bone. bone.

Aspirate the area and then deposit approximately 1 to 2 mL of local 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. 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 It is helpful to place a finger against the outer aspect of the lip overlying the injection site and apply firm and steady pressure overlying the injection site and apply firm and steady pressure against the lip while slowly injecting the local anesthetic into the against the lip while slowly injecting the local anesthetic into the supraperiosteal site supraperiosteal site

Supraperiosteal Nerve BlockSupraperiosteal Nerve Block

Inferior Alveolar Nerve BlockInferior Alveolar Nerve Block


Palpate the retromolar fossa with the index Palpate the retromolar fossa with the index finger or thumb. finger or thumb.

Identify the greatest depth of the anterior border Identify the greatest depth of the anterior border of the ramus of the mandible (the coronoid of the ramus of the mandible (the coronoid notch). notch).

With the thumb in the mouth and the index finger With the thumb in the mouth and the index finger placed externally behind the ramus, retract the placed externally behind the ramus, retract the tissues toward the buccal (cheek) side, and tissues toward the buccal (cheek) side, and visualize the pterygomandibular triangle. visualize the pterygomandibular triangle. This technique also moves the operator’s finger safely This technique also moves the operator’s finger safely

away from the tip of the needle.away from the tip of the needle.


Hold the syringe parallel to the occlusal surfaces Hold the syringe parallel to the occlusal surfaces of the teeth and angled so that the barrel of the of the teeth and angled so that the barrel of the syringe lies between the first and second syringe lies between the first and second premolars on the opposite side of the mandible. premolars on the opposite side of the mandible. Achieving the proper angle is important to the Achieving the proper angle is important to the

success of this block. success of this block. If a large-barrel syringe is used, the corner of the If a large-barrel syringe is used, the corner of the

mouth may hamper efforts to obtain the proper angle. mouth may hamper efforts to obtain the proper angle. Carefully bend the 25-gauge needle about 30 degrees Carefully bend the 25-gauge needle about 30 degrees

to facilitate achieving the proper angle. The needle to facilitate achieving the proper angle. The needle cap can be used to bend the needlecap can be used to bend the needle

Inferior Alveolar Nerve BlockInferior Alveolar Nerve Block Make the puncture for the injection in the Make the puncture for the injection in the

pterygomandibular triangle, at a point that is 1 cm above pterygomandibular triangle, at a point that is 1 cm above the occlusal surface of the molars. the occlusal surface of the molars.

If the needle enters too low (e.g., at the level of the If the needle enters too low (e.g., at the level of the teeth), the anesthetic will be deposited over the bony teeth), the anesthetic will be deposited over the bony canal and prominence (lingula) that house the canal and prominence (lingula) that house the mandibular nerve, and not over the nerve itself. mandibular nerve, and not over the nerve itself.

There may be slight resistance as the needle passes There may be slight resistance as the needle passes through the ligaments and the muscles covering the through the ligaments and the muscles covering the internal surface of the mandible. When there is more internal surface of the mandible. When there is more solid resistance, the needle has reached the bone. solid resistance, the needle has reached the bone.

Stop when the needle has reached bone, which signifies Stop when the needle has reached bone, which signifies contact with the posterior wall of the mandibular sulcus. contact with the posterior wall of the mandibular sulcus.

It is important to feel the bone with the needle ( It is important to feel the bone with the needle (


It is important to feel the bone with the It is important to feel the bone with the needle.needle.

After reaching the bone, withdraw the After reaching the bone, withdraw the needle slightly and aspirate to check for needle slightly and aspirate to check for possible intravascular placement. possible intravascular placement.

Deposit approximately 1 to 2 mL of Deposit approximately 1 to 2 mL of anesthetic solution; 3 to 4 mL of anesthetic anesthetic solution; 3 to 4 mL of anesthetic may be required if needle positioning is may be required if needle positioning is suboptimal.suboptimal.


Failure to feel bone as the needle is Failure to feel bone as the needle is advanced generally results from directing advanced generally results from directing the needle toward the parotid gland (too the needle toward the parotid gland (too far posteriorly) rather than toward the inner far posteriorly) rather than toward the inner aspect of the mandible. Injecting into the aspect of the mandible. Injecting into the parotid gland can anesthetize the facial parotid gland can anesthetize the facial nerve nerve


One may anesthetize the lingual nerve by One may anesthetize the lingual nerve by placing several drops of anesthetic placing several drops of anesthetic solution while withdrawing the syringe. solution while withdrawing the syringe. The anterior two thirds of the tongue can The anterior two thirds of the tongue can thus be anesthetized. In actual practice, thus be anesthetized. In actual practice, the lingual nerve is consistently blocked the lingual nerve is consistently blocked with this procedure owing to the close with this procedure owing to the close proximity of both nerves. proximity of both nerves.


Complications include inadvertent administration of Complications include inadvertent administration of anesthetic posteriorly in the region of the parotid gland, anesthetic posteriorly in the region of the parotid gland, which will anesthetize the facial nerves. This is an which will anesthetize the facial nerves. This is an annoying but relatively benign complication that will annoying but relatively benign complication that will cause temporary cause temporary facial paralysisfacial paralysis (similar to Bell’s palsy) (similar to Bell’s palsy) affecting the orbicularis oculi muscle and results in affecting the orbicularis oculi muscle and results in inability to close the eyelid. Should this occur, the eye inability to close the eyelid. Should this occur, the eye must be protected until the local anesthetic has worn off must be protected until the local anesthetic has worn off (approximately 2 to 3 hours), and the patient must be (approximately 2 to 3 hours), and the patient must be reassured. Anesthesia with bupivacaine (Marcaine) reassured. Anesthesia with bupivacaine (Marcaine) presents a more significant problem if this complication presents a more significant problem if this complication occurs, because bupivacaine anesthesia lasts from 10 to occurs, because bupivacaine anesthesia lasts from 10 to 18 hours in some patients.18 hours in some patients.

dental emergencies scott farquharson sept 24 th 2009

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