triaging patients with dental pain: when antibiotics are ... north/fri_room8_1630_walsh...triaging...
TRANSCRIPT
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Triaging Patients with Dental Pain: When Antibiotics are NOT
the Way to go!
Laurence J. Walsh
BDSc, PhD, DDSc, GCEd, FFOP(RCPA),
FAQDI, FICD, FPFA, FIADFE
© 2014
Friday 430 & 530 PM
WS61
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Take home messages:When is a dental consult essential?
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Diagnostic sieve• Infections
• Dental caries
• Periapical infections
• Periodontal diseases
• Oral fungal infections
• Oral malodour
• Degenerative conditions• Dental erosion
• Accelerated tooth wear
• Cervical dentinal hypersensitivity
• Neoplasia• SCC
• Salivary gland lesions
• Other oral cancers
• Developmental conditions
• Inflammatory conditions• Oral mucosal pathology
• Oral ulcerative diseases
• Auto-immune diseases
• TMJ problems
• Manifestations of systemic diseases
• Medication-induced side effects
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Time bombs for medical GPs !
• Endodontic and periodontal abscesses• Sunset rule
• Beta lactamase producing
• Irreversible pulpitis/ pulpal necrosis• Unstimulated toothache which
keeps patient awake
• Root filling or extract
• Endodontic pathology in oncology immune compromised patients• Fevers of unknown origin
• Mucormycosis or sinusitis• Symptom of maxillary toothache
• Untreated periodontitis and recurring fungal infections in diabetics
• Impaired nutrition• Third molars, pericoronitis and
trismus
• TMJ dysfunction
• Primary or reactivated HSV infection intraorally
• Oral cancer• Lip, floor of mouth, tongue
• Maxillary anterior teeth• Dangerous triangle for cavernous
sinus thrombosis
• Mandibular molar teeth• Ludwig’s angina
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Common causes of pain in teeth
• Localized to teeth• Dental caries
• Restoration leakage and recurrent caries
• Pulpitis (reversible or irreversible)
• Cervical dentinal hypersensitivity
• Cracked tooth syndrome
• Zingers
• Tooth supporting apparatus “sore to bite on”
• Periapical inflammation from numerous factors• trauma to teeth
• Clenching
• Infection
• orthodontic tooth movement
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Other dental causes of pain
• TM joint• Arthritis
• Disc displacement
• Muscle spasm
• Jaws• Trauma, fractures
• Inflammation and infection
• Neoplasia – central lesions of the jaws
• MX sinus pathology
• Maxillary sinusitis
• Mucormycosis
• Cardiac ischaemia –referred pain
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Tooth fracture
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Heavily restored teeth and fractured cusps
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Dental erosion
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Dental erosion from subclinical dehydration (e.g. athletes)
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Dental erosion from GERD
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Dento-alveolar infections
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Endodontic and periodontal abscesses
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Systemic signs and symptoms
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Periapical infections: LPS and cytokines from Porphyromonas gingivalis and P endodontalis : greater fever, swelling, pain (more IL-1 and TNF)
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Fate of localized infections• Local spread through alveolar bone and
soft tissues
• Sinus tract on the skin
• Systemic mediator release
• Total burden of infection
• Osteomyelitis (MX, MD)
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Osteomyelitis
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Spread of infection
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Cellulitis
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Mandibular molars:Dental abscess extending into the submandibular space
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Maxillary tooth infections
• Danger triangle: anterior teeth• Cavernous sinus thrombosis
• Canine teeth• Canine fossa and orbital involvement
• Molars• MX sinus involvement
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Maxillary anterior teeth and the “dangerous triangle”
• Veins of the head do not contain one way valves
• Blood can flow back into the skullto be drained via the internal jugular vein
• Infections can spread to the venous sinuses surrounding the brain.
• Always treat infections promptly and aggressively.
• “Never let the sun set on pus"
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Cavernous sinus
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CS thrombosis symptoms• Rapid onset
• Peri-orbital oedema
• Decrease or loss of vision
• Bulging eye(s) as cranial BP rises
• Headache
• Photophobia
• Paralysis of the cranial nerves which course through the CS.
• Life-threatening
• iv ABT 3-4 wks• Mortality 20% with ABT
Tx, but 80-100% without
• Sometimes surgical drainage in addition
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Drainage of pus
http://www.airahospital.org/?tag=denatal-abscess
3 months
pregnant,
severely
anemic, highly
febrile and
hypoglycemic
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Ludwig’s angina• Serious, potentially life-threatening
cellulitis of the floor of mouth
• Spreads to the sublingual space via the fascial planes, not by the lymphatics
• The tongue is forced upward and backward, causing airway obstruction. • Tracheostomy needed for airway support• High dose iv ABTs and surgical
decompression
• Mortality: No ABT: 50%; ABT and surgical therapies: less than 5%
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Ludwig’s angina
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Keeping infection localized:what can allow “escape” ?
• Depressed CMI or bone marrow activity• Primary and secondary immune
deficiencies• Immunosuppressive drugs• Cytotoxic chemotherapy• Malignancies
• Altered PMN numbers or function response• Trisomy 21, diabetes mellitus• Various syndromes
• Reduced healing capacity• Impaired nutrition• Smoking• Advanced age• Chronic hepatitis
Fistula
Necrotic
pulp
Periapical
infection
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Haematogenous spread of infectionfrom the mouth to distant sites
• Immune compromised patients
• Pyrexias of unknown origin in oncology patients 30% dental origin
• Systemic sepsis and intravascular coagulation
• Orbit
• Brain
• Liver
• Lung
• Spleen
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Causes of pain in oral soft tissues
• Trauma
• Ulcerations (31 types)
• Chemical burns
• Infective lesions
• Infection of mucosal breaches
• Acute gingival and periodontal conditions
• Abscesses and suppuration
• Medication side effect
• Lichen planus
• BMMP and other mucosal disorders
• Atypical facial pain
• Psychiatric conditions
• Burning mouth syndrome
• Malignancy with perineural invasion
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Post-surgical wound infections by anaerobes
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Pericoronitis
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Aphthous ulceration
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Aphthous ulceration
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Herpetic gingivostomatitis
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Kaposi’s sarcoma
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Oral lichen planus
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Aspirin chemical burn
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Mucositis from chemo/radiotherapy
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