1. Dental Emergencies Scott Farquharson Sept 24 th 2009

2. Topics Covered  Dental trauma  Dental infections  Dental blocks  Pediatrics

3. Dental Anatomy  Primary Eruption from 7-30 months Eruption from 7-30 months 20 teeth, 10 upper, 10 lower 20 teeth, 10 upper, 10 lower 2X ( 4 incisors, 2 canines, 4 molars) 2X ( 4 incisors, 2 canines, 4 molars)  Permanent Begin formation 3-4 months Begin formation 3-4 months Eruption 7-21 years Eruption 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)

4. Dental Anatomy

5. Dental Trauma  Fractures of teeth  Alveolar Fractures  Luxation  Intrusion or concussion  Avulsion  Primary vs Permanent

6. Fractures of Permanent Teeth  Enamel (Ellis 1) Chipped tooth Chipped tooth Painless unless associated with other injuries Painless unless associated with other injuries Large chips can be saved for reattachment Large chips can be saved for reattachment Non urgent dental referral for cosmetic purposes Non urgent dental referral for cosmetic purposes

7. Fractures of Permanent Teeth  Enamel and Dentin ( Ellis 2) 70 % of dental fractures 70 % of dental fractures Pain with hot or cold Pain with hot or cold Dentin is yellow colored Dentin is yellow colored Panorex to R/O other injury Panorex to R/O other injury Increased risk of pulp infection/desiccation Increased risk of pulp infection/desiccation Dental evaluation in 24hrs Dental evaluation in 24hrs Protection with dental cement Protection with dental cement Consider antibiotics Consider antibiotics

8. Fractures of Permanent Teeth  Pulp involvement May be visible (Ellis 3) May be visible (Ellis 3) Can see bloodCan see blood May be below gums (root fracture) May be below gums (root fracture) Only seen with x-rayOnly seen with x-ray Very painful as nerve exposed Very painful as nerve exposed Treatment as Ellis 2 Treatment as Ellis 2 Will need extraction or root canal Will need extraction or root canal

9. Fractures of Permanent Teeth  Alveolar Fractures Associated with fractures, luxated or avulsed teeth Associated with fractures, luxated or avulsed teeth small fractures involving 1 or 2 teeth can be treated by a dentist small fractures involving 1 or 2 teeth can be treated by a dentist Large areas of alveolar bone damage can cause significant cosmetic deformity and oral surgery should be consulted Large areas of alveolar bone damage can cause significant cosmetic deformity and oral surgery should be consulted

10. Root Fracture

11. Luxation  “Loose tooth”  Extrusion – dislodgement from alveolar bone  Lateral luxation – lateral displacement with alveolar fracture  Both should have x-rays  Reposition with firm pressure – may require local anesthesia  Temporary splinting in ED  Permanent splinting/treatment by dentist

12. Concussion and Intrusion  Displacement of tooth into socket  Concussion – pain with no movement  Intrusion – more severe displacement involving root fracture and/or alveolar fracture  Intrusion is differentiated on x-ray and requires repositioning

13. Avulsion  Complete displacement of tooth from alveolar socket  Best chance of saving tooth if reimplanted in under 3 hrs  Transport in sterile saline, milk, Hank solution or in buccal sulcus not ice or water  Avoid disruption of periodontal ligament fibers on root  Clean with normal saline  Rinse clot from socket  splint

14. Primary Vs Permanent  Avulsed primary teeth should not be reimplanted to avoid damage to underlying teeth  Primary teeth have more pulp and less dentin and are more at risk for infection  Luxations in young children are at greater risk of avulsion and aspiration – consider urgent dental splinting.  Enamel injuries can cut mucosa in young children and may need to be filed down

15. Final Thoughts  Pen or amoxicillin usually sufficient  Consider clindamycin or EES if allergic  Don’t forget tetanus immunization

16. Dental Infections  Periapical abscess  Pericoronitis  Dry socket  Buccal/facial cellulitis  Complications

17. Periapical Abscess  Complication of carries/pulpitis  Inflammation and abscess formation in periodontal and buccal tissues  lymphadenopathy  Streptococcus mutans  Painful – relieved by I&D  Definitive treatment is root canal (removal of the pulp and filling of the empty pulp chamber and canal )

18. Periapical Abscess

20. Pericoronitis  Most common in wisdom teeth  bacterial plaque and food debris accumulate beneath the flap of gum covering the partially erupted tooth.  Pain, bad taste, pus, local inflammation  can progress to cellulitis  Salt mouthwashes, irrigate under flap  ABX

21. Pericoronitis

22. Dry Socket- Alveolar Osteitis  Complication of tooth extraction  Clot covering alveolar bone is displaced  Exposed alveolar bone becomes inflamed  Normal post extraction pain decreases over 48hrs  Dry socket pain increases at 24-72 hrs  Can progress to osteomyelitis

23. Dry Socket  Analgesia – Nsaids, Narcotics, Nerve block  Referral back to dentist in 24 hrs Will need frequent packing Will need frequent packing  ABX? If caught early and timely follow up is available probably not needed If caught early and timely follow up is available probably not needed

24. Complications  Dental infections can progress to life threatening complications Facial or buccal cellulitis Facial or buccal cellulitis Submandibular space infections (Ludwig’s angina) Submandibular space infections (Ludwig’s angina) Parapharyngeal space infections Parapharyngeal space infections Airway compromise Airway compromise Orbital infections Orbital infections CNS infections CNS infections Mediastinal infections Mediastinal infections Cavernous sinus thrombosis Cavernous sinus thrombosis

25. Complications  Signs of more serious illness Systemic symptoms – fever/chills Systemic symptoms – fever/chills Trismus Trismus Displacement of tongue Displacement of tongue Altered LOC/delirium Altered LOC/delirium Eye pain Eye pain  Require systemic ABX  ENT consult  Possible CT imaging  Airway management

26. Antibiotics  Broad range of pathogens Mainly streptoccocal Mainly streptoccocal Bacteroides sp. Bacteroides sp. Anaerobes Anaerobes  Simple infections Pen V or amoxil Pen V or amoxil I prefer Amox/Clav or clinda I prefer Amox/Clav or clinda  Infections extending to facial or buccal cellulitis  IV 2 nd generation cephalosporin + metronidazole  HPTP

27. Dental Nerve Blocks  Supraperiosteal nerve block Anesthesia for individual tooth Anesthesia for individual tooth  Inferior Alveolar Nerve Block Anesthesia for lower teeth Anesthesia for lower teeth

28. Supraperiosteal Nerve Block  Select the area to be anesthetized and dry it with gauze.  Ask the patient to close the jaw slightly to relax the facial musculature.  Grasp the mucous membrane of the area with a piece of gauze.  Pull the gauze (and the mucous membrane) out and downward in the maxilla and out and upward in the mandible to extend the mucosa fully and to delineate the mucobuccal fold.  Puncture the mucobuccal fold with the bevel of the needle facing the bone.  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.  It is helpful to place a finger against the outer aspect of the lip overlying the injection site and apply firm and steady pressure against the lip while slowly injecting the local anesthetic into the supraperiosteal site

29. Supraperiosteal Nerve Block

31. Inferior Alveolar Nerve Block

32.  Palpate the retromolar fossa with the index finger or thumb.  Identify the greatest depth of the anterior border of the ramus of the mandible (the coronoid notch).  With the thumb in the mouth and the index finger placed externally behind the ramus, retract the tissues toward the buccal (cheek) side, and visualize the pterygomandibular triangle. This technique also moves the operator’s finger safely away from the tip of the needle. This technique also moves the operator’s finger safely away from the tip of the needle.

33. Inferior Alveolar Nerve Block

34.  Hold the syringe parallel to the occlusal surfaces of the teeth and angled so that the barrel of the syringe lies between the first and second premolars on the opposite side of the mandible. Achieving the proper angle is important to the success of this block. Achieving the proper angle is important to the success of this block. If a large-barrel syringe is used, the corner of the mouth may hamper efforts to obtain the proper angle. If a large-barrel syringe is used, the corner of the mouth may hamper efforts to obtain the proper angle. Carefully bend the 25-gauge needle about 30 degrees to facilitate achieving the proper angle. The needle cap can be used to bend the needle Carefully bend the 25-gauge needle about 30 degrees to facilitate achieving the proper angle. The needle cap can be used to bend the needle

35. Inferior Alveolar Nerve Block  Make the puncture for the injection in the pterygomandibular triangle, at a point that is 1 cm above the occlusal surface of the molars.  If the needle enters too low (e.g., at the level of the teeth), the anesthetic will be deposited over the bony canal and prominence (lingula) that house the mandibular nerve, and not over the nerve itself.  There may be slight resistance as the needle passes through the ligaments and the muscles covering the internal surface of the mandible. When there is more solid resistance, the needle has reached the bone.  Stop when the needle has reached bone, which signifies contact with the posterior wall of the mandibular sulcus.  It is important to feel the bone with the needle (

36. Inferior Alveolar Nerve Block

37.  It is important to feel the bone with the needle.  After reaching the bone, withdraw the needle slightly and aspirate to check for possible intravascular placement.  Deposit approximately 1 to 2 mL of anesthetic solution; 3 to 4 mL of anesthetic may be required if needle positioning is suboptimal.

38. Inferior Alveolar Nerve Block

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

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

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