Oral dental emergencies

1. Oral dental emergencies Prepared by Mick Svoboda Resented by Dr. Cardinal

2. Oral and dental anatomy • Pediatrics • 20 primary teeth- 8 incisors, 4 canines, 8 molars • Adults • 32 teeth- 8 incisors, 4 canines, 8 premolars, 12 molars • Each tooth consists of dentin which surrounds the pulp or neurovascular supply. • The crown is the visible portion of the tooth consisting of enamel, the hardest substance in the body. • The root is the portion of the tooth that extends into the bone.

3. Orofacial pain • Tooth eruption (primary/deciduous teeth). • Irritability, drooling, decreased intake • No evidence to support assoc. w/ fever. • Pericoronitis • Inflammation of the surface over the erupting tooth (operculum). • Often 2º to trauma or food/debris beneath the operculum leading to inflammation and possible infection. • Tx. • Pen VK, clindamycin, or erythromycin • Saline mouth rinse • NSAIDS • Dental f/u

4. Dental caries and pupal path. • Dental caries • Loss of tooth enamel integrity 2º to acidic metabolic by-products of plaque bacteria. • Sensitivity to temp. and sweet stimulus. • Pulpitis • Inflammation of the pulp as result of dental caries extending through the dentin. • Pain most commonly from thermal stimulus. • Reversible pulpitis- pain lasting seconds. • Irreversible pulpitis- Pain lasting minutes to hours. • Tx. • Analgesics, dental f/u.

5. Facial Cellulitis • Result of odontogenic infection spread into facial spaces. • Ludwig angina • cellulitis of B.L submandibular spaces. • Brawny induration of the suprahyoid region, elevation and post. displacement of the tongue. • Tx. • Secure airway • Appropriate IV abx. Admission for I&D. • Cavernous sinus thrombosis • Infra/periorbital cellulitis as result of retrograde spread w/ rapid developing meningeal signs, sepsis, and coma.

6. Postextraction alveolar osteitis • Periosteitis- pain 24-48 hrs after extraction. • Postextraction alveolar osteitis (dry socket) • 2-3 days postextraction. • Displacement of the clot from the socket leaves the alveolar bone exposed resulting in inflammation and localized osteomyelitis. • Tx. • Analgesia • Saline irrigation and packing w/ oil of cloves or eugenol-impregnated gauze. • Abx • Close dental f/u.

7. Periodontal disease • Gingivitis • Inflammation and bleeding of the gingiva • Risk factors- plaque build-up, pregnancy, medication (phenytoin), hormonal variations of puberty. • Periodontal abscess • Result from blockage of periodontal pockets by plaque or debris. • Tx. • analgesics • Warm saline rinses • Pen VK or erythromycin • I&D if indicated • Dental f/u.

8. Periodontal disease • Acute necrotizing ulcerative gingivitis • Localized ulceration and necrosis of the gingiva. • Diagnostic triad- pain, ulceration, and bleeding. • Other signs • fetid breath, metallic taste, pseudomembrane formation,tooth mobility, fever, malaise. • Opportunistic inf. in a host w/ a lowered immune system, most frequently HIV. • Tx. • Bacterial control w/ Chlorhexidine rinses, debridement and abx.

9. Trigeminal neuralgia • F>M • Unilateral, follows distribution of effected CN (usually maxillary branch of CN V). • Episodes are recurrent, excruciating, electrical shock-like sensation of short duration. • Tx. • Carbamazepine 100mg PO bid, titrate up to max dose 1200mg daily.

10. Soft tissue lesions of the oral cavity • Oral Candidiasis • Most common type is thrush • Tx. w/ nystatin oral suspension or fluconazole. • Aphthous stomatitis “canker sore” • Affects 20% of the population. • Painful ulcers, frequently multiple. • Herpes simplex • Type 1> type 2, but indistinguishable. • Prodrome (burning, tingling 1-2 days before outbreak) • Painful ulcerations on gingiva and mucosal surfaces. • Tx. Mainly supportive, antivirals may decrease duration if started during prodrome.

11. Soft tissue lesions of the oral cavity • Varicella-Zoster • Oral involvement may precede skin involvement. • Herpes zoster- prodrome of pain may be mistaken as HA or toothache. Look for unilateral rash. • Herpangina- limited to posterior oral involvement. • Hand, foot, and mouth • Traumatic lesions • Traumatic ulcers caused by direct trauma • Causes- rough/jagged teeth or restorations, ill fitting dentures, burns from hot food

12. Medication related soft tissue abnormalities • Gingival hyperplasia • Common offending agents • Phenytoin • CCB, especially nifedipine • Cyclosporine • Poor oral hygiene increases likelihood and severity. • Stevens-Johnson syndrome • Erythema multiforme w/ mucosal involvement.

13. STDs • Occur via oral-genital contact. • Gonorrhea- Most common, presents as pharyngitis w/ or w/out exudate. • Oral herpes • HPV- similar oral lesions as venereal warts. • Syphilis • Tx is the same as for genital STDs, tx partner.

14. Lesions of the tongue • Erythema migrans (geographic tongue) • Multiple, well-demarcated areas of papillae atrophy. • Smooth, red, concentrate on the tip and lateral aspect of the tongue. • Tx not indicated. • Strawberry tongue • Associated w/ strep. Inf. (rheumatic fever), Kawasaki's ds. • Leukoplakia • White patch on the tongue that does not scrape off. • Oral precancer • Possible risk factors- tobacco, Etoh, UV light, HPV.

15. Oral CA • Most commonly Squamous cell. • Similar risk factors as leukoplakia. • Generally painless, nonhealing ulcer that is fixed to its surrounding tissue. • Tx depends on site of involvement and staging.

16. Dental fractures • Goal in ED management of fractured tooth. Preserve pulp vitality by creating a barrier between dental pulp and oral env. • Ellis classification • Ellis class I- involves only enamel. No tx • Ellis class II- involves the dentin. Pulp exposed by way of dentin tubules. Pulp at risk for contamination. • Ellis class III- exposed pulp. As w/ class II cover w/ dental cement or calcium hydroxide base, refer to dentist w/in 24 hrs.

17. luxation • Luxation- injury to the support apparatus resulting in loosening of the tooth. • Five types. • Concussion- tenderness to percussion w/out mobility of the tooth. • Subluxation- mobility of the tooth w/out clinical or radiographic evidence of dislodgement. Tx same above- NSAIDs, soft diet, dental f/u. • Extrusive luxation- partial avulsion- Tx reposition the tooth and splint. • Intrusive luxation- dislodgement of the tooth into the socket w/ fx to the alveolar bone. Tx allow tooth to erupt on its own. • Lateral luxation- lat displacement of the tooth w/ alveolar fx. Tx as extrusion.

18. Avulsion • Reimplant tooth ASAP, If possible at the scene. • Rinse tooth w/ NS or tap water, handling only by the crown. Don’t scrub the root. • Can transport in sterile saline, Hank soln., or milk. • Survival of the periodontal ligament is key to successful reimplantation.

19. Avulsion of primary teeth • Never reimplant or reposition. • Can damage permanent teeth. • Severe luxations are usually extracted.

20. Soft tissue trauma • Intraoral lacerations • Lip and tongue lacerations • Care should be taken to approximate wound-edges (eg. vermilion border). • Maxillary frenulum laceration • Unless large do not require tx. • Hemorrhage • Spontaneous • After dental exams (scaling, curettage) • Systemic ds.( leukemia, clotting dis., end-stage liver ds.) • Postsurgical • Postextraction bleeding • Tx w/ firm pressure- pt bite down on folded 2x2 gauze pad for 20min or until hemostasis. • If unsuccessful can put Surgicel into socket.

21. Oral manifestation of systemic ds. • Leukemia • Spontaneous gingival bleeding, bruising of the oral soft tissue 2º thrombocytopenia. • Prone to oral candidiasis, herpetic inf., and neutropenic ulcerations. • HIV • Initial inf w/ sore throat, mucosal erythema and focal ulceration. • Oropharyngeal candidiasis is most common oral finding, often leading to diag. of HIV/AIDS.