Dental
Emergencies
Devin Herbert, R3
Sept 6, 2012
Clavulin
Percocet
See your dentist
Questions?
Objectives
Communication
Dental anatomy
Nontraumatic emergencies
Traumatic emergencies
Pediatric issues
premolar
Terminology
Lower aka Mandibular
Upper aka Maxillary
Lingual - mandibular teeth toward tongue
Palatal - maxillary teeth toward tongue
Labial - anterior teeth toward lips
Buccal - posterior teeth toward cheeks
Interproximal - surface between two adjacent teeth
Occlusal/Incisal - biting surface
Cervical - junction of crown and root
Nontraumatic emergencies
Dental caries
Sensitive to cold
Decalcification of enamel by acid producing
plaque bacteria
Eventually dentin layer breached
Pulpitis
Pain, to thermal stimulus
Reversible - Short duration of discomfort
Likely to benefit from antibiotics
Irreversible - longer duration of discomfort
Require root canal or extraction
Periapical abscess
Spontaneous or unremitting pain,
reproducible with percussion
Extension of infection to periapical bone
Drainage, antibiotics, NS rinses
May have an associated parulis
Periodontitis
Typically less pain
Inflammation of the tooth attachment
apparatus
Often will drain spontaneously
Can form periodontal abscess (can be difficult
to differentiate from periapical abscess)
Drainage, antibiotics, NS rinses
Drainage technique
Intraoral vs. extraoral
Local or regional anesthesia
No. 11 blade incision
Mosquito hemostat to disrupt loculations
NS irrigation
Packing gauze, sutured to mucosa
Antibiotics, NS rinses
Pericoronitis
Pain, foul taste or odour
Involves erupting tooth, often 3rd molar
Inflammation of the gingival tissue overlying
the erupting crown
Drainage, antibiotics, NS rinses
Alveolar osteitis (dry socket)
Pain, foul taste or odour
Inflammation of exposed alveolar bone
2-5 days post tooth extraction
Clot dislodged prematurely
Can progress to osteomyelitis
Packing, antibiotics
Deep space infections
Spread of odontogenic infection
Maxillary teeth to upper face
Mandibular teeth to lower face
Fascial planes of head, neck, mediastinum
Airway at risk if altered voice, stridor, drooling
Parenteral antibiotics, CT, admission
Ludwig’s angina
Swollen floor of mouth, elevated tongue
Cellulitis of bilateral submandibular spaces
and sublingual space
Direct connection to parapharyngeal space
Airway at risk!
Cavernous sinus thrombosis
Infraorbital or periorbital cellulitis
Retrograde spread of infection through
ophthalmic veins to cavernous sinus
Meningeal signs, altered LOC to coma
Traumatic emergencies
Dental crown fractures
Ellis I - enamel only, painless
White fracture surface
Ellis II - enamel and dentin, painful
Yellow fracture surface
Ellis III (complicated) - pulp involved, painful
Red fracture surface
(Complicated)
Dental trauma terminology
Concussion - pain but stable, nondisplaced
Subluxation - loose, nondisplaced
Luxation - loose, displaced, malocclusion
Can be intrusive, extrusive or lateral
Avulsion - completely removed from socket
Intrusion - forced into alveolar bone
Avulsion
Where is the tooth?
Consider XR if “missing”
Reimplant or place tooth in physiologic
medium ASAP
Avoid traumatizing periodontal ligament
Chance of successful reimplantation inversely
proportional to time out of socket
Pediatric pearls
Pediatric dental emergency pearls
Primary dentition consists of 20 teeth
(2 incisors, 1 canine, 2 molars per quadrant)
Eruption begins ~ 6 months
by ~ 2 years
complete
Permanent dentition begins ~ 6 years
Avulsed primary teeth should NOT be
reimplanted
Summary
ED management is temporizing
Communicate clearly to consultants
Consider sealing, splinting and drainage of
accessible infections
Recognize true dental emergencies
Recognize true medical emergencies
Floss
Edmonton’s ED dental kit:
Dycal - $55.75
Fuji I glass ionomer - $135.00
mix pad 3x3 - $1.49
disposable spatulas pk 50 - $35.50
disposable mirrors pk 60 - $27.43
disposable instruments pk 10 - $97.50
Arista hemostatic powder - ? Price
gelfoam substitute pk 24 - $56.25
cotton rolls box 2000 - $25.15
dental wax - ? price