dental emergency

MANAGINGMANAGING DENTAL EMERGENCIESDENTAL EMERGENCIES

March 24, 2011

Lianne Beck, MDAssistant Professor

Emory Family Medicine

ObjectivesObjectives

• Basic dental anatomyBasic dental anatomy• Diagnosis and treatment planningDiagnosis and treatment planning• PulpitisPulpitis• Dental abscess and cellulitisDental abscess and cellulitis• Trauma Trauma • Anesthesia for dental proceduresAnesthesia for dental procedures• ExtractionExtraction• Drugs in dentistryDrugs in dentistry• Emergency dental kitEmergency dental kit

Dental EmergenciesDental 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

IntroductionIntroduction

• Dental disease is evident in all patient Dental disease is evident in all patient populations regardless of medical conditions.populations regardless of medical conditions.

• Most commonly occurs because of dental neglect, Most commonly occurs because of dental neglect, however, certain populations have unique oral however, certain populations have unique oral health issues.health issues.

• Dental care consistently ranks in the top 5 of Dental care consistently ranks in the top 5 of unmet needs in Statewide Statement of HIV/AIDS unmet needs in Statewide Statement of HIV/AIDS Needs Survey.Needs Survey.

BASIC DENTAL ANATOMYBASIC DENTAL ANATOMY

• DentitionDentition

• Soft tissuesSoft tissues

• Blood and nerve supplyBlood and nerve supply

• Lymphatic drainageLymphatic drainage

AnatomyAnatomy

Nerve & Blood SupplyNerve & Blood Supply

Red - Blood Supply

Yellow - Nerve supply

Blue - Areas where local anesthetic can be delivered

Maxilla Mandible

Buccal region

Palatal region

Buccal region

Lingual region

Lymphatic DrainageLymphatic Drainage

• Lymphatic Lymphatic drainage is to the drainage is to the submental, submental, submandibular and submandibular and deep cervical deep cervical nodes.nodes.

DIAGNOSIS DIAGNOSIS &&

TREATMENT PLANNINGTREATMENT PLANNING

Emergency vs UrgencyEmergency vs Urgency

• Emergencies interrupt normal eating, Emergencies interrupt normal eating, working and sleeping.working and sleeping.

• Emergencies occur within 2 days.Emergencies occur within 2 days.

• Pain medications for emergencies Pain medications for emergencies are usually ineffective.are usually ineffective.

What is a true dental emergency?What is a true dental emergency?

• The presence of pain does not necessarily The presence of pain does not necessarily constitute a dental emergency.constitute a dental emergency.

• An acute dental emergency requires the An acute dental emergency requires the presence of:presence of:– SwellingSwelling– FeverFever– PusPus– BleedingBleeding

Swelling – Questions to AskSwelling – Questions to Ask• Is it Is it

– DiffuseDiffuse

•Does it spread up to the eye or cheeks?Does it spread up to the eye or cheeks?

•Does it spread down the neck?Does it spread down the neck?– DiscreetDiscreet– FluctuantFluctuant

• Is this first time?Is this first time?

• When did it start?When did it start?

• Does it interfere with swallowing or breathing?Does it interfere with swallowing or breathing?

• Does it change the way patient speaks?Does it change the way patient speaks?

SwellingSwelling

• Differentiate between cellulitis and abscessDifferentiate between cellulitis and abscess

• Evaluate airway and swallowingEvaluate airway and swallowing

• Can be difficult to evaluate intraorally if trismus is Can be difficult to evaluate intraorally if trismus is presentpresent

• Trismus suggests infection in posterior regionTrismus suggests infection in posterior region

• Infection causes a reactive myospasmInfection causes a reactive myospasm

• Do not force mouth openDo not force mouth open

• Will resolve once infection resolvesWill resolve once infection resolves

Ludwig’s AnginaLudwig’s Angina

• Cellulitis involving Cellulitis involving bilateral sublingual, bilateral sublingual, submandibular and submandibular and submental spacessubmental spaces

• Tongue is elevated Tongue is elevated toward palatetoward palate

• Rapid spread of infection Rapid spread of infection into lateral and into lateral and retropharyngeal spaces retropharyngeal spaces leading to airway leading to airway obstructionobstruction

When to Admit?When to Admit?

• Deep fascial space threatening the Deep fascial space threatening the airwayairway

• Patient is dehydrated and requires IV Patient is dehydrated and requires IV fluidsfluids

• General anesthesia needed for surgical General anesthesia needed for surgical procedureprocedure

FeverFever

• Painful submandibular and cervical Painful submandibular and cervical lymphadenopathy would be expectedlymphadenopathy would be expected

• A tooth causing fever would be A tooth causing fever would be tender to touch, percussion and tender to touch, percussion and palpationpalpation

PusPus• Drainage intra-orally Drainage intra-orally

is preferredis preferred

• Extra-oral drainage Extra-oral drainage leads to scarringleads to scarring– Discourage hot Discourage hot

compress to skin compress to skin overlying the overlying the infectioninfection

Intra-oral DrainageIntra-oral Drainage

• Rinse with hot salt water mouth rinses q 2 hrs Rinse with hot salt water mouth rinses q 2 hrs until drainage occursuntil drainage occurs

• As hot as you drink your teaAs hot as you drink your tea

• Swish over swollen area until water starts to Swish over swollen area until water starts to cool, spit out and do again for at least 5 minutescool, spit out and do again for at least 5 minutes

• Continue QID until dental treatment obtainedContinue QID until dental treatment obtained

BleedingBleeding

• Occurs most Occurs most commonly in commonly in patients who have patients who have had a recent tooth had a recent tooth extractedextracted

• Associated with liver Associated with liver disease, platelet disease, platelet dysfunction, pts on dysfunction, pts on asa, nsaids, asa, nsaids, coumadincoumadin

Dental PainDental Pain

• Majority originates in the teeth or Majority originates in the teeth or peridontium and is relatively easy to treat peridontium and is relatively easy to treat with analgesia and antibioticswith analgesia and antibiotics

• Treatments starts in the medical clinic but Treatments starts in the medical clinic but dental referral is dental referral is requiredrequired

• Dental problems do NOT “cure themselves”Dental problems do NOT “cure themselves”

• Treating the pain without addressing the Treating the pain without addressing the underlying problem only prolongs the underlying problem only prolongs the problem.problem.

Dental PainDental Pain• Dental HistoryDental History

– Ask the client to voice their complaint or point to area which Ask the client to voice their complaint or point to area which is hurtingis hurting

– Onset and duration of complaintOnset and duration of complaint

– Triggers – hot, cold, sweet stimuli, spontaneousTriggers – hot, cold, sweet stimuli, spontaneous

– Relieving factors (analgesics or rinses)Relieving factors (analgesics or rinses)

– Type of pain – sharp or dull; moderate or severe, poorly Type of pain – sharp or dull; moderate or severe, poorly localizedlocalized

– Brief (pulpitis) or prolonged duration (abscess)Brief (pulpitis) or prolonged duration (abscess)

HISTORY TAKINGHISTORY TAKING• Medical HistoryMedical History

– General state of health General state of health

– Current medicationsCurrent medications

– Particular conditionsParticular conditions•CHD, prosthetic valveCHD, prosthetic valve•Drug allergy (penicillin)Drug allergy (penicillin)•Bleeding tendencyBleeding tendency• ImmunodeficiencyImmunodeficiency

Non-dental Sources of Non-dental Sources of PainPain

• Myofascial inflammationMyofascial inflammation

• Migraine headacheMigraine headache

• Maxillary sinusitisMaxillary sinusitis

• TMJTMJ

• OM/OEOM/OE

• Trigeminal neuralgiaTrigeminal neuralgia

CLINICAL EXAMINATIONCLINICAL EXAMINATION

• General StateGeneral State– Temp, appearanceTemp, appearance

• Extra oral examinationExtra oral examination– SwellingSwelling– Palpate lymph nodesPalpate lymph nodes


•Intra oralIntra oral

– A good light is essentialA good light is essential

– Mirror and probe Mirror and probe


• Intra oralIntra oral

– Inspect soft tissues:Inspect soft tissues:• InflammationInflammation•SwellingSwelling•TendernessTenderness•UlcerationUlceration

– Inspect the teethInspect the teeth•DecayDecay•MobilityMobility•Fractured teethFractured teeth

DIAGNOSIS &DIAGNOSIS &TREATMENT PLANNINGTREATMENT PLANNING

• Make a diagnosisMake a diagnosis

• Treatment planning Treatment planning for:for:– Relief of painRelief of pain– Treatment of pathologyTreatment of pathology– Long term viewLong term view

COMMON CONDITIONSCOMMON CONDITIONS

• Dental cariesDental caries

• PulpitisPulpitis

• Dental AbscessDental Abscess

• Facial swelling and cellulitisFacial swelling and cellulitis

• Dry socketDry socket

• Fractured teethFractured teeth

• Fractured jawFractured jaw

DENTAL CARIESDENTAL CARIES

• One of the most One of the most common common diseasesdiseases

• Starts in enamel, Starts in enamel, extends to extends to dentine and if not dentine and if not treated into pulptreated into pulp

DENTAL CARIESDENTAL CARIESManagementManagement

Remove decay using an excavator

Place temp fillingUsing a flat plastic

DENTAL CARIESDENTAL CARIES

Filling Materials

“Cavit”(temporary filling)

“Glass Ionomer Cement”(semi-permanent filling)

PULPITISPULPITIS• Inflammation of the pulpInflammation of the pulp

• Dental caries extending into Dental caries extending into dentinedentine

causes a sharp pain with hot causes a sharp pain with hot and coldand cold

• Early stages reversibleEarly stages reversible

•Remove decayRemove decay

•Cavit dressingCavit dressing

• When pain settled permanent When pain settled permanent filling placedfilling placed

DENTAL ABSCESSDENTAL ABSCESS

• Periapical abscessPeriapical abscess

• Result of decay and infection Result of decay and infection extending into pulp of toothextending into pulp of tooth

• Pain is severe, persistent, Pain is severe, persistent, & throbbing& throbbing

• Tooth is tender to touchTooth is tender to touch

• If not treated pus tracks to surfaceIf not treated pus tracks to surface

inside or outside the mouthinside or outside the mouth

DENTAL ABSCESSDENTAL ABSCESS ““Treatment”Treatment”

• Periapical abscessPeriapical abscess – “drainage” – “drainage”

1. Open tooth into pulp chamber using excavator 1. Open tooth into pulp chamber using excavator (if possible) and dressing(if possible) and dressing

2. Antibiotics2. Antibiotics

3. Extraction of tooth3. Extraction of tooth

DENTAL ABSCESSDENTAL ABSCESS

• Extra oral Extra oral SwellingSwelling

– Can spread into the Can spread into the tissuestissues

– Leading to cellulitisLeading to cellulitis– Systemic Systemic

involvementinvolvement– Drainage requiredDrainage required

DENTAL ABSCESSDENTAL ABSCESS“Treatment”“Treatment”

• Extra oral SwellingExtra oral Swelling– Antibiotics Antibiotics – Incision and drainageIncision and drainage

• Anesthesia with topical paste or ethyl chlorideAnesthesia with topical paste or ethyl chloride

• Number 11 blade for incision extra orallyNumber 11 blade for incision extra orally

• Open tissues using mosquitosOpen tissues using mosquitos

• Allow pus to drain/insert rubber drain suture to keep patentAllow pus to drain/insert rubber drain suture to keep patent– Ultimately extract tooth under LAUltimately extract tooth under LA– http://www.youtube.com/watch?v=SYVtcL-VDf0http://www.youtube.com/watch?v=SYVtcL-VDf0

• Intra oral Swelling Intra oral Swelling – http://www.youtube.com/watch?v=o7Bg0ItHTpAhttp://www.youtube.com/watch?v=o7Bg0ItHTpA

DRY SOCKETDRY SOCKET

• Dry SocketDry Socket– Localized osteitisLocalized osteitis– Severe pain 2 - 4 Severe pain 2 - 4

days post extractiondays post extraction

– TREATMENT TREATMENT • LALA

• Debride socketDebride socket

• Dressing – Dressing – AlvogylAlvogyl

DENTAL TRAUMADENTAL TRAUMA

• Fractured front toothFractured front tooth– Ellis I – DentineEllis I – Dentine– Ellis II - Dentine/EnamelEllis II - Dentine/Enamel– Ellis III - Dentine/Enamel/PulpEllis III - Dentine/Enamel/Pulp

• TreatmentTreatment– Pain controlPain control– TetanusTetanus– Cover exposed dentine Cover exposed dentine

w/zinc oxide or calcium w/zinc oxide or calcium hydroxide paste (Dycal). hydroxide paste (Dycal).

http://emedicine.medscape.com/article/82755-media

DENTAL TRAUMADENTAL TRAUMA• Avulsed ToothAvulsed Tooth– A good chance of the tooth re-implanting into the A good chance of the tooth re-implanting into the

socket successfully if done withinsocket successfully if done within an houran hour..

– The tooth should be located and picked up by the The tooth should be located and picked up by the crown or enamel portion crown or enamel portion NOT NOT the root. the root.

– If the tooth is dirty/contaminated, gently rinse in If the tooth is dirty/contaminated, gently rinse in cold running tap water and then re-implanted.cold running tap water and then re-implanted.

– If immediate on-scene re-implantation is not If immediate on-scene re-implantation is not possible, transport tooth in whole cold milk, possible, transport tooth in whole cold milk, saline, or saliva.saline, or saliva.

DENTAL TRAUMADENTAL TRAUMA

•Place tooth back into socket.Place tooth back into socket.

•Splint the tooth to stabilizeSplint the tooth to stabilize– Wire and glass ionomer Wire and glass ionomer

cementcement– Dental wax and foilDental wax and foil

•Antibiotics - AmoxicillinAntibiotics - Amoxicillin

FACIAL TRAUMAFACIAL TRAUMA

• Emergency Management of Facial FracturesEmergency Management of Facial Fractures

• Attempt to stabilize the jawAttempt to stabilize the jaw

• Give Antibiotics, TdGive Antibiotics, Td

• Soft foodsSoft foods

• Get to hospital ASAPGet to hospital ASAP Barton Bandage

ADMINISTERINGADMINISTERING LOCAL ANAESTHESTIC LOCAL ANAESTHESTIC

• 2% Lidocaine w/ epi2% Lidocaine w/ epi

• SyringeSyringe– Dental syringe and Dental syringe and

needleneedle

– 5 ml syringe and 5 ml syringe and 25-, 27-, or 30-25-, 27-, or 30-gauge gauge needleneedle

ADMINISTERINGADMINISTERING LOCAL ANAESTHETIC LOCAL ANAESTHETIC

Blue - Areas where local anesthetic can

be delivered

Maxilla Mandible

Buccal

Palatal

Inf. Mandibular

Lingual

INFILTRATIONINFILTRATION

• Should achieve anesthesia within 5 Should achieve anesthesia within 5 minutesminutes

• Can be safely repeated if unsuccessfulCan be safely repeated if unsuccessful

• Do not give where there is grossly infected Do not give where there is grossly infected tissuetissue

Supraperiosteal infiltrations:

Anesthetizes Anesthetizes individual teeth. Use individual teeth. Use this technique only this technique only with the maxillary with the maxillary incisors, canines, and incisors, canines, and premolarspremolars

Anterior superior Anterior superior alveolar nerve alveolar nerve block:block:

Anesthetizes the Anesthetizes the maxillary canine, the maxillary canine, the central and lateral central and lateral incisors, and the incisors, and the mucosa above these mucosa above these teeth, with occasional teeth, with occasional crossover to the crossover to the contralateral maxillary contralateral maxillary incisorsincisors

Middle superior alveolar nerve block:

Anesthetizes the Anesthetizes the maxillary premolars maxillary premolars with occasional with occasional overlap to the canine overlap to the canine and first molarand first molar

Posterior superior alveolar nerve block:

Anesthetizes maxillary Anesthetizes maxillary molar teethmolar teeth

Infraorbital nerve block:

Anesthetizes the lower Anesthetizes the lower eyelid, upper cheek, eyelid, upper cheek, part of the nose, and part of the nose, and upper lipupper lip

Nasopalatine nerve block:

Anesthetizes the Anesthetizes the anterior hard palate anterior hard palate and associated soft and associated soft tissues tissues

Greater palatine nerve block:

Anesthetizes the Anesthetizes the posterior two thirds of posterior two thirds of the hard palate the hard palate

Inferior alveolar nerve block:

Anesthetizes all teeth Anesthetizes all teeth on the ipsilateral side on the ipsilateral side of mandible, as well of mandible, as well as the ipsilateral lip as the ipsilateral lip and chin via the and chin via the mental nervemental nerve

INFERIOR ALVEOLAR NERVE INFERIOR ALVEOLAR NERVE BLOCKBLOCK

• MandibleMandible

– Palpate the anterior ramus border Palpate the anterior ramus border at the coronoid notch.at the coronoid notch.

– Slide the finger or thumb Slide the finger or thumb posteriorly and medially until a posteriorly and medially until a ridge of bone is palpated. ridge of bone is palpated. This is the internal oblique ridge. This is the internal oblique ridge.

– Insert until bone is contacted Insert until bone is contacted then then withdraw ~1 mm. The depth of withdraw ~1 mm. The depth of insertion is approximately 25 mm.insertion is approximately 25 mm.

Mental nerve block:

Anesthetizes the Anesthetizes the ipsilateral lower lip ipsilateral lower lip and skin of the chinand skin of the chin

Lingual nerve block:

Anesthetizes the Anesthetizes the anterior two thirds of anterior two thirds of tongue tongue

Buccal nerve block:

Anesthetizes the Anesthetizes the mucous membrane mucous membrane of the cheek and of the cheek and vestibule and, to a vestibule and, to a lesser extent, a small lesser extent, a small patch of skin on the patch of skin on the face.face.

Local Anesthetic Injection Techniques

• http://www.youtube.com/watch?http://www.youtube.com/watch?v=ZHWMTKX2T70&feature=relmfuv=ZHWMTKX2T70&feature=relmfu

• http://emedicine.medscape.com/http://emedicine.medscape.com/article/82850-printarticle/82850-print

PearlsPearls

• Obtain informed consent prior to performing a Obtain informed consent prior to performing a nerve block. nerve block.

• Inject slowly (30 seconds for each mL of Inject slowly (30 seconds for each mL of anesthetic) to decrease pain.anesthetic) to decrease pain.

• In order to aspirate properly, use a needle that is In order to aspirate properly, use a needle that is 27 gauge or larger for deep nerve blocks. 27 gauge or larger for deep nerve blocks.

• Buffering with bicarbonate is NOT recommended Buffering with bicarbonate is NOT recommended for oral nerve blocks.for oral nerve blocks.

PearlsPearls

• Applying pressure to the site adjacent to injection Applying pressure to the site adjacent to injection while inserting the needle may distract the while inserting the needle may distract the patient and, thereby, decrease the sensation of patient and, thereby, decrease the sensation of pain. pain.

• Massaging tissue for 10-20 seconds is thought to Massaging tissue for 10-20 seconds is thought to hasten the onset of local anesthetic. hasten the onset of local anesthetic.

• Achieving anesthesia with oral nerve blocks may Achieving anesthesia with oral nerve blocks may take as long as 10 minutes. take as long as 10 minutes.

Pearls Pearls • True allergies to local anesthetics are rare. True allergies to local anesthetics are rare.

• If the patient has an allergy to one anesthetic, an If the patient has an allergy to one anesthetic, an anesthetic from the other class can be used anesthetic from the other class can be used (amide vs ester), or an alternative agent such as (amide vs ester), or an alternative agent such as benzyl alcohol or diphenhydramine can be used.benzyl alcohol or diphenhydramine can be used.

• If the first attempt at the nerve block fails, try the If the first attempt at the nerve block fails, try the block again. Some of the blocks (ie, inferior block again. Some of the blocks (ie, inferior alveolar, infraorbital) are best attempted after a alveolar, infraorbital) are best attempted after a skilled clinician has demonstrated them.skilled clinician has demonstrated them.

DENTAL EXTRACTIONSDENTAL EXTRACTIONS

• IndicationsIndications

•Severe pulpitisSevere pulpitis

•Periapical abscessPeriapical abscess

•Tooth fractureTooth fracture

•Severe periodontal diseaseSevere periodontal disease

DENTAL EXTRACTIONSDENTAL EXTRACTIONS•Basic InstrumentsBasic Instruments

DENTAL EXTRACTIONSDENTAL EXTRACTIONS• http://www.youtube.com/watch?

v=OjiBOOhVVNo

• There are lots of others to watch!


•Post operative instructionsPost operative instructions

– Pressure on socketPressure on socket– No rinsing for 24 hoursNo rinsing for 24 hours– Cold food and drink for 24 hoursCold food and drink for 24 hours– No smoking for 24-48 hoursNo smoking for 24-48 hours– HSMW after 24 hours HSMW after 24 hours – If bleeding pressure pack for 20 minutesIf bleeding pressure pack for 20 minutes


• ComplicationsComplications

•Fractured toothFractured tooth•BleedingBleeding•SwellingSwelling•BruisingBruising•PainPain•TrismusTrismus•Dry SocketDry Socket


•Complications – Complications – BleedingBleeding

– Apply PressureApply Pressure

– Pack with hemostatic agentPack with hemostatic agent

– SutureSuture

COMMONLY USED DRUGSCOMMONLY USED DRUGS

• Analgesics for toothacheAnalgesics for toothache •AcetominophenAcetominophen•NSAIDs (Ketorolac 30 or 60 mg IM in the office)NSAIDs (Ketorolac 30 or 60 mg IM in the office)•Hydrocodone (Lortab/Vicodin), oxycodone Hydrocodone (Lortab/Vicodin), oxycodone

(Percocet), codeine (T#3, 4, 5)(Percocet), codeine (T#3, 4, 5)

• AntibioticsAntibiotics•Pen VK, Amoxicillin, AugmentinPen VK, Amoxicillin, Augmentin•Erythromycin, ClindamycinErythromycin, Clindamycin•MetronidazoleMetronidazole

Necrotizing Ulcerative Necrotizing Ulcerative PeriodontitisPeriodontitis

• Deep seated Deep seated intense/severe intense/severe painpain

• Urgent referral to Urgent referral to dentistdentist

• Narcotic Analgesics

EMERGENCY DENTALEMERGENCY DENTAL KIT KIT

• Dental MirrorDental Mirror

• TweezersTweezers

• Excavator and Flat Excavator and Flat plasticplastic

• Cotton pellets & RollsCotton pellets & Rolls

• Extraction forcepsExtraction forceps

• Syringe & needleSyringe & needle

• Sterile DressingsSterile Dressings

• 11 Blade Scalpel11 Blade Scalpel

• GlovesGloves

• Cavit/Temp dressingCavit/Temp dressing

• Eugenol/Oil of clovesEugenol/Oil of cloves

• Glass ionomer cementGlass ionomer cement

• Dental Wax/WireDental Wax/Wire

• Topical anestheticTopical anesthetic

• Local anestheticLocal anesthetic

• Amox/MetronidazoleAmox/Metronidazole

• Ibuprofen/AcetominophenIbuprofen/Acetominophen

EMERGENCY DENTALEMERGENCY DENTAL KIT KIT

• Life Systems Dental First Aid KitLife Systems Dental First Aid Kit– http://www.lifesystems.co.uk/psec/http://www.lifesystems.co.uk/psec/

first_aid_kits/dental_first_aid_kit.htmfirst_aid_kits/dental_first_aid_kit.htm

• Nitro-pak dental First-Aid KitNitro-pak dental First-Aid Kit– www.nitro-pak.comwww.nitro-pak.com

• Dr. Stahl's Emergency Dental Kit - Dr. Stahl's Emergency Dental Kit - DeluxeDeluxe– http://www.campingsurvival.com/http://www.campingsurvival.com/

deemdekidrst.htmldeemdekidrst.html

Referral ResourcesReferral Resources

• http://http://www.benmasselldentalclinic.com/www.benmasselldentalclinic.com/index.htmlindex.html

• http://www.gfcn.org/index.phphttp://www.gfcn.org/index.php

Thank You!Thank You!

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