1. How medical professionals can help
Dental Emergencies!!!
How medical professionals can help
Dr. Flore-Anne Foellmi
Old Massett Dental Clinic

2. Topics: Basics of tooth anatomy and diagnosis
Dealing with dental pain and infection
Dealing with dental trauma
Dealing with post-op complications

3. Why might you get stuck managing a dental emergency???
1) Some patients don’t know there is a dental clinic in Massett!!!
2) Dental clinic is closed
We are closed 1 week every month
Hours are 8:30-4:30, Mon-Fri
3) Dental clinic is overloaded
Triage system
Usually same day appointments for facial swelling, severe pain, trauma
4) Finances
5) Dental Phobia!!!
Extremely common!
Not always obvious
We can offer options for anxiety management, referral for sedation, etc…IF PATIENT BOOKS A DENTAL APPOINTMENT!!!

4. Basic dental anatomy

5. Overview of dental disease}
May resolve with filling
Reversible Pulpitis: Non-lingering sensitivity to hot, cold, sweet, percussion. NO SPONTANEOUS PAIN!!!
Irreversible Pulpitis: Severe lingering thermal sensitivity, pain on percussion. SPONTANEOUS PAIN!!!
Necrosis + Apical Periodontitis/Abscess: Severe pain on percussion, +/- swelling. SPONTANEOUS PAIN!!! }
Only tx is root canal or extraction!!!
More detailed info at

6. Understanding Dental infections
Most dental infections are caused by mix of aerobic (Streptococcus milleri group) and anaerobic (Peptostreptococcus, Prevotella, Porphyromonas, Fusobacterium)
Four stages
Inoculation: Soft and doughy
Cellulitis: Hard and very tender
Abscess: Fluctuant (liquefaction)
Resolution: After drainage (spontaneous or surgical)
Acute Apical Abscess
Chronic Apical Abscess VS
Rarely painful! Needs tx but not an emergency!
Painful! Needs urgent tx!

7. treating Dental infections
Clinical presentation:
Pain (usually constant, spontaneous, radiating, “pressure”, “throbbing”)
Swelling (intraoral, extraoral, or both)
What would a dentist do?
What can you do?
Diagnosis
Pain history, E/O and I/O exam, Xrays, Vitality testing (cold, electricity, percussion)
Pain history, E/O and I/O exam, Percussion
Treatment (any or all of the following)
Initiate root canal or extract tooth (*IF ABLE TO FREEZE)
Analgesics
Antibiotics
Incision and Drain
Reminder to book dental appointment ASAP!
*Local anesthetics are very pH sensitive. Infected tissue has a lower pH than normal, which may deactivate the anesthetic and prevent adequate freezing!!!

8. Treating dental infections - detailed
Analgesics
NSAIDS tend to work best unless contraindicated
Naproxen 250mg or Ibuprofen 600mg every 6-8 hrs
Acetaminophen 500mg every 4-6 hrs if unable to take NSAIDS
Consider alternating ibuprofen and acetaminophen every 4 hrs
Advise pt to return for re-eval if insufficient pain relief – do not take more than recommended dosage
2) Antibiotics
When to prescribe:
E/O swelling, diffuse cellulitis, swelling beyond the alveolar process (bony ridges supporting the teeth), rapidly progressing infection, trismus, lymphadenopathy, fever
Inability to achieve suitable local anesthesia
Judgement call: significant I/O swelling, severe pain
What to prescribe:
Amoxicillin 500mg TID x 7 days (better absorbed orally that pen V)
Clindamycin mg QID x 7 days
If allergic to amoxicillin, no resolution with amoxicillin
Risk of pseudomembranous colitis (take with probiotic), but good bone penetration
Augmentin (Amox + clavulanate) 500mg TID
Broad spectrum, complex infections
3) Incision and Drain
Highly recommended in cases of obvious I/O swelling
Local anesthetic (Articaine works well!), #15 blade, small (1cm) incision at most fluctuant area, dissect with hemostat, saline irrigation, leave open to drain or suture drain, gauze for hemostasis, recommend saline rinses at home
Watch out for nerves!!! Mental nerve, infraorbital nerve, lingual nerve
Remind patients that antibiotics are NOT A CURE!!! Unless the source of the problem is dealt with, infection will recur!!!

9. Severe dental infections – RARE!!!
2) Cavernous Sinus Thrombosis
Periorbital infection spreading to brain
May cause blindness, high mortality rate
Ludwig’s Angina
Rapid-spreading cellulitis that can block airway
Bilateral swelling of submandibular, submental and sublingual spaces (tongue may appear elevated)
Consider prompt referral to specialist if: difficulty breathing or swallowing, deviated uvula, severe trismus (less than 20mm), “toxic” appearance

10. Dental pain without obvious infection
Clinical presentation: Extremely varied! May be: dull or sharp, constant or episodic, identifiable triggers or spontaneous, radiating, burning, throbbing…you name it!
Possible Causes: Also extremely varied!
Odontogenic: Pulpitis (reversible or irreversible), clenching/grinding, cracked tooth, pericoronitis..
Non-Odontogenic: Maxillary sinus infection, trigeminal neuralgia, TMD, migraines, tumor, MI, atypical facial pain…
Often diffuse symptoms
Try to rule out odontogenic cause first!
What would a dentist do?
What can you do?
Diagnosis
Pain history, E/O and I/O exam, xray, vitality
Pain history, E/O and I/O exam, percussion
Treatment (any or all of the following)
Filling
Root canal or extraction
Band or crown tooth
Bite adjustment
Nightguard
Self-care instructions
Analgesics
Antibiotics
Desensitizing treatments
Monitor
Consider antibiotics if:
Strong suspicion of irreversible pulpitis/ necrosis or sinus infection
Unable to promptly refer to dentist for definite dx/tx

11. Clues to remember…you will see these!!!
Irreversible Pulpitis/Early Necrosis
Maxillary Sinus Infection
History
Spontaneous pain!!! Wakes them up at night!
May have severe thermal sensitivity
May have severe pain on biting (may not be chewing on that side, sticking to soft foods)
May report having had a deep filling on the tooth in the past
Usually will report congestion
May have noticed yellow/green nasal secretions
May have noticed worsening with position changes
Usually report dull ache from upper posterior teeth (may be severe!)
E/O
May have tenderness to palpation
Usually will not see any obvious swelling (yet!)
May have tenderness to palpation over maxillary sinus
May sound congested
I/O
Usually will not see any I/O swelling or fistulas
Usually easy to localize! Pt may be able to point straight to offending tooth
Should not see any I/O swelling or fistulas
Usually have several teeth sensitive to percussion (difficult to localize)
Look at how close the roots of the maxillary teeth are to the floor of the sinus!!!

12. Dental trauma More info at dentaltraumaguide.org For any trauma case:
Where/when/how?
Any loss of consciousness?
Any evidence of facial fractures or fracture of alveolar bone?
Any soft tissue lacerations?
Does the patient think their bite has changed?
Clinical Presentation: VARIED!!!
Concussion: Pain but no displacement/mobility
Subluxation: Pain and increased mobility, bleeding from sulcus, no displacement
Extrusion, intrusion, lateral luxation: Pain and displacement
Fracture into enamel, dentin, pulp: Symptoms vary based on depth of fracture
Root fracture: Pain, crown may be mobile
Alveolar fracture: Mobility of alveolar bone and one or more teeth as a unit
Avulsion: Tooth completely displaced out of socket
More info at dentaltraumaguide.org

13. Managing dental trauma
What would a dentist do?
What can you do?
Diagnosis
Trauma history, E/O and I/O exam, xray, vitality
Trauma history, E/O and I/O exam
Treatment
Suture soft tissue lacerations
Replace avulsed teeth
Reposition displaced teeth
Splint loose teeth
Initiate root canal treatment
Recommend soft foods and excellent oral hygiene (rinse with CHX 0.12%)
Frequent follow-ups
Recommend follow-up with dentist
Avulsed Teeth
Primary Teeth: DO NOT REPLANT
Permanent Teeth:
Store in milk, saline, or saliva, DO NOT STORE IN WATER
Handle crown of tooth, avoid touching root
Rinse with saline for 10 sec
Replant tooth with slight pressure
Systemic antibiotics (Doxycycline or Amoxicillin if under 12 years of age)
Verify need for Tetanus booster if tooth was in contact with soil
Recommend soft foods for 2 weeks, rinse with Chlorhexidine 0.12%
Refer to dentist ASAP for xray, splinting, follow-up

14. Managing dental trauma
Repositioning Displaced Permanent Teeth
First of all…are you sure the tooth is displaced??? Careful with children with erupting teeth!
Rinse with saline
Local anesthetic
Use forceps or gentle finger pressure to reposition
Recommend soft foods for 2 weeks, excellent oral hygiene
Refer to dentist right away for splinting!!!
Dealing with Crown Fracture Into Pulp
Likely very painful due to exposure of vital pulp tissue – will either look like a pink “blush” or actual bleeding from the centre of the tooth
Best tx would be referral to dentist for filling and possibly initiation of root canal treatment
If this is NOT possible, consider applying a temporary sedative dressing under local anesthetic, ex. IRM (minimal equipment needed)

15. Fyi – tooth eruption sequence

16. Post-op complications
Bleeding
Some bleeding expected for 24 hrs
Often controlled with firm biting on gauze for 30 min
For persistent bleeding, bite on moist black tea bag (tannic acid acts as a local vasoconstrictor)
Prolonged bright red bleeding , large “liver” clots: indications for follow-up dental visit (LA, irrigation, curettage, hemostatic dressing, figure-8 suture)
2) Pain
Peak pain about 12hrs post-exo, rarely more than 2 days duration
Strong analgesics are NOT indicated for most routine dental extractions!
NSAIDs best choice (ibuprofen 600mg), pre-op or before LA wears off
Acetaminophen 500mg if NSAIDs contraindicated
Tylenol #3 not usually recommended (side effects, poor metabolizers)

17. Post-op complications (continued)
3) Infection
Usually presents 3+ days post-exo
Swelling, redness, fever, pain, purulence from socket
Tx is antibiotics, analgesics
4) Dry Socket (aka Alveolar Osteitis)
Multifactorial etiology, not a true infection (although bacteria play a role!)
More common after extraction of lower teeth, female patients, smokers
Usually presents 3+ days post exo
No swelling, but severe pain, trismus, halitosis
Socket looks empty (no blood clot), extreme tenderness to palpation
Treatment is saline irrigation (+/- LA), packing of Alvogyl dressing
Repeat treatment every 2-3 days as needed until symptoms resolve
Alvogyl is an analgesic and antiseptic product for treatment of dry socket. Active ingredients are Iodoform, Butamben, Eugenol

18. Summary Questions? More info? References?
Most dental emergencies are related to injury to the dental pulp tissue
Diagnosis may be challenging without xrays, vitality testing
There are non—odontogenic problems that mimic tooth pain
Although rare, severe dental infections can be life-threatening
Antibiotics are not a cure!
Medical professionals can help manage dental emergencies and encourage patients to follow-up with dental team
Questions? More info? References?
me at

19. POP QUIZ!!! Clinical scenarios – What would you do???
1) Patient reports breaking a tooth while eating a few weeks ago. Started throbbing a few days ago. Fluctuant swelling seen in buccal vestibule but no E/O swelling.
2) Patient reports pain from a lower right molar, which had a deep filling a few weeks ago. Toothache triggered by hot , cold, and biting. Woke them up last night. No E/O or I/O swelling on exam. Tooth has a large filling which seems intact. Minor relief with extra strength Tylenol.
3) 12 year old child knocked out a front tooth while playing basketball about 30 minutes ago. Parents put tooth in ziploc bag.
4) Patient had a dental extraction of lower molar 4 days ago. Reports worsening pain from socket, foul smell. No E/O or I/O swelling on exam, socket appears packed with food.
5) Patient reports severe throbbing from upper right molars to hot, cold, biting. Tender to palpation over right maxillary sinus but no swelling. Patient also has a bad cold.