Dental Complaints in the General Medicine Outpatient Setting: A Practice Flowchart for Proper Management in the Non-dent

1. Dental Complaints in the general medicine outpatient setting: A practice flowchart for proper management in the non-dental clinic Jessica Fordham, MSN, APRN, FNP-C Mississippi University for women

2. Objective • Discuss the most common dental complaint that presents to the non-dental outpatient clinic visits • Discuss the most common chief complaint associated with non-dental outpatient clinic visits • Define the tooth anatomy • Identify each tooth within the oral cavity • Discuss and define common oral pathologies such as: dental caries, pulpitis, pericoronitis, periapical abscess, dry socket, and tooth fractures • Discuss Recommended antibiotics for treatment • Define the components of the Dental Treatment Flowchart and utilize it as a user-friendly resource in clinical practice

3. The Most Common Reason for Dental Complaints in the Outpatient Setting • Cost • Lack of access to immediate dental healthcare • Unable to obtain an instantaneous appointment with a dental provider • Lack of insurance for dental services • Severe Pain during dental after-hours • Perception of patients identifying general practitioners as the primary manager of integrated and complete health care

4. The Most Common Dental complaint in the Non-dental Outpatient Setting Toothache!

5. Anatomy

6. Permanent Tooth Chart

7. Tooth Decay Define: commonly known as “dental caries or cavity”- destruction of a tooth enamel which is the hard outer layer caused by bacteria forming plaque. Plaque produces acids that attack the enamel.

8. Pulpitis Define: Inflammation of the dental pulp. Occur from carious lesions progression deep into the dentin and can extend into the pulp Symptoms and findings: • Reversible pulpitis: triggered by stimulus such as hot, cold, sweet, last for a few seconds • Irreversible Pulpitis: spontaneous, persistent, poorly localized Treatment: • Palliative treatment: NSAID mild to moderate, Narcotics-severe • Dentist Referral

9. Pericoronitis Define: Inflammation of the surrounding tissue of a tooth and its overlying flap of gingiva. Can be caused by impaction or partial eruption of the third molar Symptoms and Findings: • Dull pain with chewing • Inflammation around tooth with possible purulent drainage • In some cases Trismus Treatment: • Antiseptic Lavage • Oral Antibiotics if systemic symptoms are associated (fever, lymphadenopathy, etc.) • Dentist referral within 24-48hrs

10. Acute Apical Abscess Defined: inflammatory reaction to pulpal infection and necrosis Symptoms and Findings: • Rapid onset • Spontaneous pain • Tenderness of tooth to pressure • Pus formation • Can progress to swelling of associated Tissue Treatment: • Referral to Dentist • If patient is unable to receive immediate dental care with associate symptoms of fever, malaise facial swelling: • Pen VK • Clindamycin if patient is allergic to penicillin • Pain management

11. Recommended Antibiotics for Endodontic Infections Drug of Choice • Penicillin VK 1000mg po for Loading dose • Penicillin VK 500mg po q4-6h for 5-7 days Allergic to Penicillin • Clindamycin 600mg po Loading dose • Clindamycin 300mg po q6h for 5-7 days Serious odogenic infection or prophylaxis for immunocompromised • Amoxicillin 1000mg po for Loading dose • Amoxicillin 500mg po q8h for 5-7 days If symptoms worsens after 48-72 hours after initial treatment add the following drug in combination • Metronidazole 1000mg po Loading dose • Metronidazole 500mg po q6h for 5-7 days

12. Postextraction Alveolar Osteitis(Dry Socket) Define: the loss of some or all of the blood clot formed inside the socket after a tooth extraction Symptoms and Findings: • Extraction 24-72 hours prior to presentation • Severe pain may radiate to the ear (seen commonly with 3rd molar extraction) • no blood clot noted in extraction bony socket • Tender to palpation with possible Inflammation around surrounding tissue Treatments: • Irrigate with chlorhexidine or saline • Palliative management • Referral to Dentist

13. Fracture Define: Based upon affected depth of the tooth anatomy. Measured according to the Ellis Classification System Ellis Class I-Fracture involves the enamel Ellis Class II-Fracture expose the dentin Ellis Class III- Exposed pulp Symptoms and finding: • Ellis Class I-normally asymptomatic • Ellis Class II- sensitivity to stimulus (hot, cold, water) Normally expose pale yellow dentin • Ellis Class III—bleeding of the tooth due pulp exposure Treatment: • Non-emergent dental referral for Ellis Class I • Mild analgesic and referral to dentist for Ellis Class II • Bleeding should be controlled with a sterile gauze and referral to a dentist is urgent in Ellis Class III

14. Fordham’s Orofacial Dental Pain Flowchart Adapted from Mansour and Cox (2006) model “Management of dentofacial pain in patients presenting to a general practitioner” DX: Diagnosis, HPI: History of present illness, PE: Physical Exam, TX: Treatment

15. References American Association of Endodontics (summer, 2014). Endodontic diagnosis. Endodontics Colleagues for Excellence. Retrieved from http://www.aae.org/uploadedFiles/Publications_and_Research/Newsletters/Endodontics_Colleagues_for_Excellence_Newsletter/ECFE_Summer2014%20FINAL.pdf American Association of Endodontics (winter, 2012). Endodontic diagnosis. Endodontics Colleagues for Excellence. Retrieved from http://www.aae.org/uploadedFiles/Publications_and_Research/Endodontics_Colleagues_for_Excellence_Newsletter/ecfewinter12Final.pdf American Association of Endodontics(2006). Antibiotics and the treatment of endodontic infections. Endodontics Colleagues for Excellence. Retrieved from http://www.aae.org/uploadedFiles/Publications_and_Research/Endodontics_Colleagues_for_Excellence_Newsletter/summer06ecfe.pdf American Dental Association. Permanent Tooth Development. Retrieved from http://www.mouthhealthy.org/en/az-topics/e/eruption-charts Cohen, L., A. (2013). Expanding the physicians role in addressing the oral health of adults. American Journal of Public health, 103(3), 408-412. doi: 10.2105/AJPH.2012.300990 Davis, M. M., Hilton, T. J., Benson, S., Schott, J., Howard, A., McGinnis, P., & Fagnan, L.(2010). Unmet dental needs in rural primary care: a clinic, community, and practice based research network collaborative. Journal of the American Board of Family Medicine, 23(4) 514-516

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17. Thank You Please proceed to reviewing the pdf copy of the dental treatment flowchart and post survey evaluation.