1. DENTAL EMERGENCY

2. Emergency - most common condition

3. Tooth Ache PulpPulpitis Reversible Initially very painful but get better quickly (i.e., 1-2 days) Initiated by a stimulus (i.e., chewing, cold or hot) Short duration (i.e, 30 seconds or less) Rule out: Extreme flash of sharp pain upon biting: possible cracked tooth Irreversible Dull, throbbing, intense pain Spontaneous and continuous pain Lingering pain with cold Percussion pain Pus drainage with/without “pimple like” draining pump Possible swollen Lymph nodes Possible low-grade fever

4. Cold Test Endo Ice spray refrigerant (on a cotton pellet) - test first a non involved tooth. - Normal Limits: 2-3 seconds - Slightly prolonged: 3-5 seconds - Prolonged: 5-30 seconds Percussion Test Tap lightly the surface of the tooth with a handle of an instrument. - Normal Limits: no pain - Slightly inflammated: mild pain - Inflammated: severe and prolonged pain Test of Vitality

5. Palpation Test Palpate the gum just above and surroundings of the painful tooth with your finger tip. - Normal: no pain, no swollen - Abnormal: pain, slightly tender or swelling. Test of Vitality

6. Fistula and Abscess

7. PETERSON et al., 2000 Acute/Chronic infection

8. Dental Fistulas

9. Intraoral Abscess

10. Zaia & Beber Extraoral Abscess *This is an emergency! Can change in a day and block respiration, situation where we would sent to ER.

11. Zaia & Beber Extraoral Abscess

12. Pulp polyps are usually asymptomatic (a fibrous growth from the pulp). Direct pressure during mastication may cause mild-to-moderate tenderness. Localized bleeding may occur when the soft tissue is manipulated or traumatized. All lesions are associated with a history of a long-standing carious lesion, a fractured tooth due to trauma, or a combination or these 2 insults. Mobility of the tooth and sensitivity to percussion are usually absent. Drainage of a purulent exudate is not a characteristic finding. Chronic Infection -Pulp Polyp

13. Periodontitis It is an advanced form of gum disease that can cause tooth loss and may be accompanied by pain. Gum recession, pus drainage, bleeding, dental mobility. Normally is not an emergency however researchers have found that periodontitis is associated with other health problems such as cardiovascular disease, stroke and bacterial pneumonia. Likewise, pregnant women who have periodontitis may be at increased risk for delivering pre-term and/or low birth weight babies.

14. Healthy Gingivitis Moderate Periodontitis Severe Periodontitis

15. Cases to use voucher! Pain is not spontaneous (heat/cold); no pain percussion; moderate to sharp pain to cold test (3- 5s), negative palpation. Reversible pulpits Irreversible pulpits Pain is spontaneous that get worst with stimulus and when lay down; pain percussion; severe pain to thermal (5-30s), negative/positive palpation. Healthy tooth with fistula May or may not have pain, presence of fistula Intraoral Abscess Extraoral Abscess Fracture Gingivitis Moderate Periodontitis Severe Periodontitis Intense pain, increased volume, pus drainage Intense pain, increased volume (face) Mobility, fistula/abscess, pus drainage Bleeding, swollen gum, no painBleeding, swollen gum, pain, light mobility, pus Bleeding, swollen gum, pain, severe, mobility, pus Cases Symptoms Voucher No Yes No

16. Other common conditions “differential diagnosis and common sense for referral”

17. Characteristic: - Recession of the gum normally caused by trauma (i.e., Overaggressive brushing, surgery and periodontitis). Symptoms: - Pain with cold, heat and citrus /acid foods - Short duration, thirty seconds to one minute after the stimulus is removed. - May be misdiagnosed as reversible pulpits (clinical exposure of the root) Gum Recession

18. Canker Sore or Afta Characteristics They are recurrent and with format of a shallow individual ulcer that is round or oval in shape (no more than a 1/4 inch in diameter). The tissues surrounding a canker sore lesion will appear healthy and the patient will have no distinguishing systemic features (such as a fever or malaise). Canker sores can usually be expected to heal within 4 to 14 days. Usually this healing is uneventful and with no residual scarring. Symptoms Extremely painful and may cause swollen or enlargement of the lymph nodes. Causes: Emotional Stress Hormonal alterations Iron, folic Acid or vitamin B12 deficiency Trauma Burning (Heat or chemical products); could be from changed toothpaste Systemic diseases virus infecction with fever Food Allergies Gastric disturbances

19. Candidiasis Characteristics: Affects more people who wear dentures Healthy people (it is not a problem). Patient with a weakened immune system, the symptoms may be more severe and difficult to control. Signs and symptoms Creamy, white lesions on the tongue, inner cheeks and sometimes on the roof of the mouth, gums and tonsils Lesions with a cottage cheese-like appearance Pain Slight bleeding if the lesions are rubbed or scraped Cracking at the corners of mouth A cottony feeling of mouth Loss of taste SEVERE CASES: Lesions may spread downward into the esophagus — (Candida esophagitis). Symptoms: patient may complain about difficulty swallowing or feel as if food is getting stuck in the throat.

20. Characteristics: Red patches on the surface of the tongue bordered by grayish white. The papillae are missing from the reddish areas and overcrowded in the grayish white borders. The small patches may disappear and reappear in a short period of time (hours or days), and change in shape or size. Geographic Tongue Symptoms: While it is not common for the condition to cause pain, it may cause a burning or stinging sensation. Geographic tongue may also cause numbness. Coexistence of fissures of the tongue is often noticed. Certain foods, such as spicy or citrus foods, chemicals, such as mouth washes and teeth whiteners, can aggravate the condition.

21. Patients with significant risk factors, especially those who use tobacco and alcohol, should be carefully screened. External examination Palpate the head thoroughly, including the temporal muscles, temporomandibular joints, masseter muscles, and bony mandible. Next, palpate the neck, including the parotid and submandibular glands, the lymph nodes, and the neck musculature. http://www.jaapa.com/oral-cancer-how-to-find-this-hidden-killer-in-2-minutes/article/130902/ Oral Cancer

22. http://www.jaapa.com/oral-cancer-how-to-find-this-hidden-killer-in-2-minutes/article/130902/ Screen for Oral cancer Eight-step examination of the mouth

23. Oral Cancer Leukoplakia Generally manifests as asymptomatic, white, macular lesions that do not wipe off (see Figure 2). The lesions may be isolated or diffuse in nature and occur most commonly on the tongue, the floor of the mouth, and the buccal mucosa. Erythroplakia Manifests as a patch of macular or ulcerated red lesions (see Figure 3). The lesions appear in the same locations as leukoplakia and can be asymptomatic or mildly painful. The incidences of dysplasia and carcinoma are higher in red lesions than in white lesions. Biopsy is indicated for any abnormality present for more than 14 days without an obvious etiology, such as trauma.

24. Differential Diagnosis Squamous cell carcinoma on the floor of the mouthCandidiasis Squamous cell carcinoma on the floor of the gengivaIntraoral Abscess