MANAGING DENTAL EMERGENCIES March 24, 2011 Lianne Beck, MD Assistant Professor

1. MANAGING DENTAL EMERGENCIES March 24, 2011 Lianne Beck, MD Assistant Professor Emory Family Medicine

2. Objectives • Basic dental anatomy • Diagnosis and treatment planning • Pulpitis • Dental abscess and cellulitis • Trauma • Anesthesia for dental procedures • Extraction • Drugs in dentistry • Emergency dental kit

3. Dental 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

4. Introduction • Dental disease is evident in all patient populations regardless of medical conditions. • Most commonly occurs because of dental neglect, however, certain populations have unique oral health issues. • Dental care consistently ranks in the top 5 of unmet needs in Statewide Statement of HIV/AIDS Needs Survey.

5. BASIC DENTAL ANATOMY • Dentition • Soft tissues • Blood and nerve supply • Lymphatic drainage

6. Anatomy

7. Nerve & Blood Supply Mandible Buccal region Buccal region Lingual region Palatal region

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

9. DIAGNOSIS &TREATMENT PLANNING

10. Emergency vs Urgency • Emergencies interrupt normal eating, working and sleeping. • Emergencies occur within 2 days. • Pain medications for emergencies are usually ineffective.

11. What is a true dental emergency? • The presence of pain does not necessarily constitute a dental emergency. • An acute dental emergency requires the presence of: • Swelling • Fever • Pus • Bleeding

12. Swelling – Questions to Ask • Is it • Diffuse • Does it spread up to the eye or cheeks? • Does it spread down the neck? • Discreet • Fluctuant • Is this first time? • When did it start? • Does it interfere with swallowing or breathing? • Does it change the way patient speaks?

13. Swelling • Differentiate between cellulitis and abscess • Evaluate airway and swallowing • Can be difficult to evaluate intraorally if trismus is present • Trismus suggests infection in posterior region • Infection causes a reactive myospasm • Do not force mouth open • Will resolve once infection resolves

14. Ludwig’s Angina • Cellulitis involving bilateral sublingual, submandibular and submental spaces • Tongue is elevated toward palate • Rapid spread of infection into lateral and retropharyngeal spaces leading to airway obstruction

15. When to Admit? • Deep fascial space threatening the airway • Patient is dehydrated and requires IV fluids • General anesthesia needed for surgical procedure

16. What is a true dental emergency? • The presence of pain does not necessarily constitute a dental emergency. • An acute dental emergency requires the presence of: • Swelling • Fever • Pus • Bleeding

17. Fever • Painful submandibular and cervical lymphadenopathy would be expected • A tooth causing fever would be tender to touch, percussion and palpation

18. What is a true dental emergency? • The presence of pain does not necessarily constitute a dental emergency. • An acute dental emergency requires the presence of: • Swelling • Fever • Pus • Bleeding

19. Pus • Drainage intra-orally is preferred • Extra-oral drainage leads to scarring • Discourage hot compress to skin overlying the infection

20. Intra-oral Drainage • Rinse with hot salt water mouth rinses q 2 hrs until drainage occurs • As hot as you drink your tea • Swish over swollen area until water starts to cool, spit out and do again for at least 5 minutes • Continue QID until dental treatment obtained

21. What is a true dental emergency? • The presence of pain does not necessarily constitute a dental emergency. • An acute dental emergency requires the presence of: • Swelling • Fever • Pus • Bleeding

22. Bleeding • Occurs most commonly in patients who have had a recent tooth extracted • Associated with liver disease, platelet dysfunction, pts on asa, nsaids, coumadin

23. Dental Pain • Majority originates in the teeth or peridontium and is relatively easy to treat with analgesia and antibiotics • Treatments starts in the medical clinic but dental referral is required • Dental problems do NOT “cure themselves” • Treating the pain without addressing the underlying problem only prolongs the problem.

24. Dental Pain • Dental History • Ask the client to voice their complaint or point to area which is hurting • Onset and duration of complaint • Triggers – hot, cold, sweet stimuli, spontaneous • Relieving factors (analgesics or rinses) • Type of pain – sharp or dull; moderate or severe, poorly localized • Brief (pulpitis) or prolonged duration (abscess)

26. HISTORY TAKING • Medical History • General state of health • Current medications • Particular conditions • CHD, prosthetic valve • Drug allergy (penicillin) • Bleeding tendency • Immunodeficiency

27. Non-dental Sources of Pain • Myofascial inflammation • Migraine headache • Maxillary sinusitis • TMJ • OM/OE • Trigeminal neuralgia

28. CLINICAL EXAMINATION • General State • Temp, appearance • Extra oral examination • Swelling • Palpate lymph nodes

29. CLINICAL EXAMINATION • Intra oral • A good light is essential • Mirror and probe

30. CLINICAL EXAMINATION • Intra oral • Inspect soft tissues: • Inflammation • Swelling • Tenderness • Ulceration • Inspect the teeth • Decay • Mobility • Fractured teeth

31. DIAGNOSIS &TREATMENT PLANNING • Make a diagnosis • Treatment planning for: • Relief of pain • Treatment of pathology • Long term view

32. COMMON CONDITIONS • Dental caries • Pulpitis • Dental Abscess • Facial swelling and cellulitis • Dry socket • Fractured teeth • Fractured jaw

33. One of the most common diseases Starts in enamel, extends to dentine and if not treated into pulp DENTAL CARIES

34. DENTAL CARIESManagement Remove decay using an excavator Place temp filling Using a flat plastic

35. DENTAL CARIES Filling Materials “Cavit” (temporary filling) “Glass Ionomer Cement” (semi-permanent filling)

36. PULPITIS • Inflammation of the pulp • Dental caries extending into dentine causes a sharp pain with hot and cold • Early stages reversible • Remove decay • Cavit dressing • When pain settled permanent filling placed

37. DENTAL ABSCESS • Periapical abscess • Result of decay and infection extending into pulp of tooth • Pain is severe, persistent, & throbbing • Tooth is tender to touch • If not treated pus tracks to surface inside or outside the mouth

38. DENTAL ABSCESS“Treatment” • Periapical abscess – “drainage” 1. Open tooth into pulp chamber using excavator (if possible) and dressing 2. Antibiotics 3. Extraction of tooth

39. DENTAL ABSCESS • Extra oral Swelling • Can spread into the tissues • Leading to cellulitis • Systemic involvement • Drainage required

40. DENTAL ABSCESS“Treatment” • Extra oral Swelling • Antibiotics • Incision and drainage • Anesthesia with topical paste or ethyl chloride • Number 11 blade for incision extra orally • Open tissues using mosquitos • Allow pus to drain/insert rubber drain suture to keep patent • Ultimately extract tooth under LA • http://www.youtube.com/watch?v=SYVtcL-VDf0 • Intra oral Swelling • http://www.youtube.com/watch?v=o7Bg0ItHTpA

41. DRY SOCKET • Dry Socket • Localized osteitis • Severe pain 2 - 4 days post extraction • TREATMENT • LA • Debride socket • Dressing – Alvogyl

42. DENTAL TRAUMA • Fractured front tooth • Ellis I – Dentine • Ellis II - Dentine/Enamel • Ellis III - Dentine/Enamel/Pulp • Treatment • Pain control • Tetanus • Cover exposed dentine w/zinc oxide or calcium hydroxide paste (Dycal). http://emedicine.medscape.com/article/82755-media

43. DENTAL TRAUMA • Avulsed Tooth • A good chance of the tooth re-implanting into the socket successfully if done withinan hour. • The tooth should be located and picked up by the crown or enamel portion NOT the root. • If the tooth is dirty/contaminated, gently rinse in cold running tap water and then re-implanted. • If immediate on-scene re-implantation is not possible, transport tooth in whole cold milk, saline, or saliva.

44. DENTAL TRAUMA • Place tooth back into socket. • Splint the tooth to stabilize • Wire and glass ionomer cement • Dental wax and foil • Antibiotics - Amoxicillin

45. FACIAL TRAUMA • Emergency Management of Facial Fractures • Attempt to stabilize the jaw • Give Antibiotics, Td • Soft foods • Get to hospital ASAP Barton Bandage

46. ADMINISTERING LOCAL ANAESTHESTIC • 2% Lidocaine w/ epi • Syringe • Dental syringe and needle • 5 ml syringe and 25-, 27-, or 30-gauge needle

47. ADMINISTERING LOCAL ANAESTHETIC Mandible Inf. Mandibular Buccal Palatal Lingual

48. INFILTRATION • Should achieve anesthesia within 5 minutes • Can be safely repeated if unsuccessful • Do not give where there is grossly infected tissue

49. Supraperiosteal infiltrations:Anesthetizes individual teeth. Use this technique only with the maxillary incisors, canines, and premolars

50. Anterior superior alveolar nerve block:Anesthetizes the maxillary canine, the central and lateral incisors, and the mucosa above these teeth, with occasional crossover to the contralateral maxillary incisors