ORAL MEDICINE
Dr Sam Shaikh, DO
PGY-II
Sinai-Grace Emergency Medicine
Disclosures
• None
Caries
• Oral
flora develop “Dental
Bacterial Plaque”
• Metabolize
carbohydrates 
acids  Erode enamel
• After
enamel eroded 
Microporous dentin  Pulp
• Pulp
hyperemia & Inflammation
 Degeneration & necrosis
Periapical Abscess
• Pus
leaks from apex of root
• Abscess
confined within
alveolar bone
• May
erode cortical plate
mandible/maxilla 
subperiosteal spread
• If
spread through muscle
attachments  facial planes
of head & neck
Complications of Periapical Abscess
• Submaxillary,
sublingual &
submental spaces
 Ludwig's Angina
• Anterior
maxillary
teeth  Periorbital
infection
• Cavernous
Thrombosis
Sinus
•A
45 year old male
with poor dentition
presents with
submandibular
swelling and
crepitus. Which of
the following spaces
are involved in
Ludwig’s angina?
• Canine
space
• Parapharyngeal
space
• Pterygomandibular
space
• Submandibular
space
•A
45 year old male
with poor dentition
presents with
submandibular
swelling and
crepitus. Which of
the following spaces
are involved in
Ludwig’s angina?
• Canine
space
• Parapharyngeal
space
• Pterygomandibular
space
• Submandibular
space
• Cavernous
sinus
thrombosis most
commonly results
from which teeth?
• Mandibular
anterior
• Mandibular
posterior
teeth
teeth
• Maxillary
anterior
• Maxillary
posterior
teeth
teeth
• Cavernous
sinus
thrombosis most
commonly results
from which teeth?
• Mandibular
anterior
• Mandibular
posterior
teeth
teeth
• Maxillary
anterior
• Maxillary
posterior
teeth
teeth
Ideal Dental Exam
•
HOB at 45 degree angle
•
Overhead light preferred
•
Adjuncts: 2x2, Tongue depressor
•
Soft tissue, tongue, base of
tongue, milk Wharton’s duct,
Stensens duct, percussing teeth
•
Consider panoramic radiograph
•
Periapical (dental) films not
available in ED
or just wing it in The Chairs….
Methods
• ED
made “Guidelines” for management
of non-emergent dental pain
• Excluded
patients admitted/transferred,
receiving I&D, or IV antibiotics
• Encouraged
non-opiates, nerve blocks,
and immobilization
Results
• Opioid
prescribing in ~17k visit per year
ED for dental pain went from 59%  42%
• Dental
• Annals
pain visits from 26/1000  21/1000
Reply – Tramadol was not
included as opiate
•A
24 year old
female is examined
for concerns of
sialolithiasis. Which
gland(s) does
Wharton’s duct
empty saliva from?
•A
collection of minor
salivary glands
• Parotid
gland
• Sublingual
gland
• Submandibular
gland
•A
24 year old
female is examined
for concerns of
sialolithiasis. Which
gland(s) does
Wharton’s duct
empty saliva from?
•A
collection of minor
salivary glands
• Parotid
gland
• Sublingual
gland
• Submandibular
gland
•
A 24 year old female is
examined for concerns
of sialolithiasis. Where is
the opening of
Stenson’s duct located?
Floor of the mouth
inferior to ventral
surface of the tongue
• Papilla on buccal
mucosa adjacent to
mandibular first molar
• Papilla on buccal
mucosa adjacent to
maxillary first molar
• Posterior dorsal surface
of tongue
•
•
A 24 year old female is
examined for concerns
of sialolithiasis. Where is
the opening of
Stenson’s duct located?
Floor of the mouth
inferior to ventral
surface of the tongue
• Papilla on buccal
mucosa adjacent to
mandibular first molar
• Papilla on buccal
mucosa adjacent to
maxillary first molar
• Posterior dorsal surface
of tongue
•
•
A 34 yo male presents to
• Analgesics, refer to
the ED with CC-“I have an dentist
abscessed tooth and I’m
• Analgesics and
in pain.” He states the
antibiotics, refer to
pain wakes him up at
dentist
night and it is constant
and throbbing. You see a • I & D and admit
grossly decayed tooth but
• I & D with IV antibiotics
no evidence of
generalized or localized
swelling, and no signs of
an abscess. What do you
do?
•
A 34 yo male presents to
• Analgesics, refer to
the ED with CC-“I have an dentist
abscessed tooth and I’m
• Analgesics and
in pain.” He states the
antibiotics, refer to
pain wakes him up at
dentist
night and it is constant
and throbbing. You see a • I & D and admit
grossly decayed tooth but
• I & D with IV antibiotics
no evidence of
generalized or localized
swelling, and no signs of
an abscess. What do you
do?
•
A 34 yo male presents to
the ED with CC-“I have
an abscessed tooth and
I’m in pain.” He states
the pain wakes him up
at night and it is
constant and throbbing.
You see a grossly
decayed tooth with
swelling, fluctuance,
and purulent drainage.
What do you do?
•
Analgesics, refer to
dentist
•
Analgesics and
antibiotics, refer to
dentist
•
I & D and admit
•
I & D and discharge
with PO antibiotics
•
A 34 yo male presents to
the ED with CC-“I have
an abscessed tooth and
I’m in pain.” He states
the pain wakes him up
at night and it is
constant and throbbing.
You see a grossly
decayed tooth with
swelling, fluctuance,
and purulent drainage.
What do you do?
•
Analgesics, refer to
dentist
•
Analgesics and
antibiotics, refer to
dentist
•
I & D and admit
•
I & D and discharge with
PO antibiotics
CHIEF COMPLAINT: Toothache
• MCC
= Dental caries
• Pulpitis
• Pain
– temperature or air
refers to ear, temple, eye,
neck, opposite side
• Exam:
ED Management
• NSAIDS
± Dental block
• Opiates
for acute
presentation
Look, palpate, utilize ice • Be careful to evaluate for
abscess which may be
• TTP w/o temperature sensitivity
need I&D
suggest underlying abscess
Draining Periapical Abscess
• Dental
• Incise
Block
 express purulence
• Penrose
drain or Iodoform
gauze secured with 4-0 silk
• Penicillin
• f/u
V or Erythromycin
with Dentist or OMFS for
reeval and drain removal
Facial Cellulitis
PCN VK 250-500 mg QID
Airway: CT, early
intubation, ENT,
anesthesia
Admit:
• suggested spread into
facial planes,
• fever, toxic, trismus,
immunocompromised
Trismus
• Irritation
of internal pterygoid or
masseter
• Inability to open mouth due to
muscle spasm
• Muscular in origin  Not relieved
by paralytics
• All patients with trismus should be
presumed difficult
• Attempt awake intubation
Facial Cellulitis
• IV
Penicillin 15-20m U daily
•B
fragillis –cephalosporin,
clinda, flagyl
• Surgical
– exploration for
causative & loculations
• Remove
necrotic tissue
•A
30 year old
schizophrenic with
present with
complaints of foul
odor in her mouth.
Your physical exam
reveals the
following. What is
your diagnosis
• Abscess
• Beriberi
• HSV
• Periodontitis
•A
30 year old
schizophrenic with
present with
complaints of foul
odor in her mouth.
Your physical exam
reveals the
following. What is
your diagnosis
• Abscess
• Beriberi
• HSV
• Periodontitis
Periodontal Disease
• Gingivitis
Inflammatory
response to irritation
• inflammation

Alveolar Bone loss =
Periodontitis
• Periodontitis

Gingival resorption
Periodontitis
Rarely present to ED.
• Bloody toothbrush, sensitivity, loose
dentition
• Periodontal Abscess – food
trapped in pocket
• Stab incision, irrigate, analgesics,
ABX
• Dental follow-up
• Tetracycline preferred if > 8 yo for
G- & Anaerobes
•
Types of Dental Abscess
Acute Necrotizing Ulcerative Gingivitis
(ANUG)
• Bacteria
invade non-necrotic tissue Fusobacteria & Spirochetes
• Fever,
malaise, lymphadenopathy
• Painful
edematous papillae w graypseudomembrane
• Risks:
immunocompromised, stress, trauma,
smoking – Trench Mouth
• Tx:
Saline/H2O2 rinses, hygiene, analgesics,
ABX – PCN, Erythro, Tetra
OTHER CAUSES OF DENTALGIA
Dentalgia, continued
Cracked Tooth & Split Root Syndrome
• worse
w chewing, history of trauma or
previous endodontic. Tx like caries
Maxillary Sinusitis
• can
present as dentalgia with negative
oral exam, pain on percussion over sinus,
rhinorrhea
•
A 24 year old female
presents with worsening
pain after wisdom teeth
extraction. She is a
heavy smoker and has
continued to smoke
despite her dentists
instructions, although
she "really cut down".
What is the appropriate
treatment
•
Blood patch
•
Extraction
•
Packing
•
Zygomatic arch ORIF
•
A 24 year old female
presents with worsening
pain after wisdom teeth
extraction. She is a
heavy smoker and has
continued to smoke
despite her dentists
instructions, although
she "really cut down".
What is the appropriate
treatment
•
Blood patch
•
Extraction
•
Packing
•
Zygomatic arch ORIF
Acute Alveolar Osteitis
• aka
Dry Socket
• Premature
loss of healing blood clot from
socket  localized infection of bone
• Treatment
 Anesthetic nerve block, irrigation,
 packing socket with iodoform gauze
saturated in Sed-A-Dent or Euginol
• Oral
ABX – PCN, erythromycin, NSAIDs
•A
19 yo male
presents with
localized pain that
he believes is
coming from his
third molar. Upon
examination you
see this:
• Dental
caries
• Normal
pattern
eruption
• Periodontitis
• Pericoronitis
•A
19 yo male
presents with
localized pain that
he believes is
coming from his
third molar. Upon
examination you
see this:
• Dental
caries
• Normal
pattern
eruption
• Periodontitis
• Pericoronitis
•
A 19 yo male presents
with localized pain that
he believes is coming
from his third molar.
What is the appropriate
management?
•
Emergent extraction
•
Irrigate with normal
saline and extract
•
Irrigate with normal
saline, PO antibiotics, no
extraction indicated
•
Irrigate with normal
saline, PO antibiotics,
extract after course of
antibiotics
•
A 19 yo male presents
with localized pain that
he believes is coming
from his third molar.
What is the appropriate
management?
•
Emergent extraction
•
Irrigate with normal
saline and extract
•
Irrigate with normal
saline, PO antibiotics, no
extraction indicated
•
Irrigate with normal
saline, PO antibiotics,
extract after course of
antibiotics
Oral Manifestations of Systemic
Disease
•
.A 28 year old diabetic
presents with glucose
1400, bicarb 10, anion
gap 27. She is altered
and unable to engage
in conversation, but her
mother states she has
been compliant with
her insulin. She has been
complaining of dental
pain. What is the
appropriate
management?
Airway evaluation
• Bolus insulin
• Central line
• IV fluids
•
•
.A 28 year old diabetic
presents with glucose
1400, bicarb 10, anion
gap 27. She is altered
and unable to engage
in conversation, but her
mother states she has
been compliant with
her insulin. She has been
complaining of dental
pain. What is the
appropriate
management?
Airway evaluation
• Bolus insulin
• Central line
• IV fluids
•
Diabetes
• Periodontitis
• Acute
Gingival Abscess
• Severity
of disease correlates with
glycemic control
• Dental
infection can precipitate DKA
• Consider
HIV in acute deterioration of
periodontal health
•A
42 year old with a
family history of SLE
presents with
complaint of painful
gums. Furthur history
reveals hemoptysis
and his primary
physician concerned
regarding worsening
renal failure. What is
the likely diagnosis?
• AIDS
• ANUG
• HSV
• Wegener's
•A
42 year old with a
family history of SLE
presents with
complaint of painful
gums. Furthur history
reveals hemoptysis
and his primary
physician concerned
regarding worsening
renal failure. What is
the likely diagnosis?
• AIDS
• ANUG
• HSV
• Wegener's
Collagen Vascular Disease
SLE
• Intraoral
ulcers w
necrotic borders
•
Upon oral examination
you notice gingival
hyperplasia on a 52 yo
female. She states that
she is currently taking
amlodipine, HCTZ, low
dose aspirin, and
metformin. Which
medication may be
contributing to this
condition?
•
Amlodipine
•
HCTZ
•
low dose Aspirin
•
Metformin
•
Upon oral examination
you notice gingival
hyperplasia on a 52 yo
female. She states that
she is currently taking
amlodipine, HCTZ, low
dose aspirin, and
metformin. Which
medication may be
contributing to this
condition?
•
Amlodipine
•
HCTZ
•
low dose Aspirin
•
Metformin
Gingival Hyperplasia
• Phenytoin,
calcium
channel blockers,
cyclosporine, and
phenobarbitol
• 40%
of patients on
phenytoin have
some degree of
hyperplasia
Aphthous Stomatitis – “Canker Sore”
• Recurrent
small
mucosal ulcers
• Stress,
nutrition, trauma
• Self-limiting
• H2O2,
Benzocaine,
Kaopectate, Maalox,
Kenalog, Sucralfate
• An
8 yo male
presents with a low
grade fever and
multiple
erythematous
"ulcers on his lips
and gingiva. Mom
says he does not
want to eat. What is
your diagnosis?
• Acute
herpetic
gingivostomatitis
• ANUG
• Aphthous
stomatitis
• Pemphigus
Vulgaris
• An
8 yo male
presents with a low
grade fever and
multiple
erythematous
"ulcers on his lips
and gingiva. Mom
says he does not
want to eat. What is
your diagnosis?
• Acute
herpetic
gingivostomatitis
• ANUG
• Aphthous
stomatitis
• Pemphigus
Vulgaris
Dental Trauma
• Retrospective
review of 264 pt/548 teeth
over 56 months
• Mean
• Most
• 53%
age 8.2 years, 62% male
common age for injuries 2-4 & 8-10
of effected teeth were permanent
• 237
teeth (43%) presented for follow up
• Mean
• 58%
time to follow up – 55 days
of documented/followed-up cases
had uncomplicated retention of teeth at
6 months
Dental Trauma
• Most
Common =
Anterior
• Complications
Fracture
Neurovascular
Fractures of tooth
Loss of
tooth=Avulsion
Subluxation
•A
33 year old male
presents after
getting hit in the
face with a rock.
Examination of tooth
6 reveals visible
dentin, but no pulp
or blood. What type
of fracture is this?
• Ellis
I
• Ellis
II
• Ellis
III
• Ellis
IV
•A
33 year old male
presents after
getting hit in the
face with a rock.
Examination of tooth
6 reveals visible
dentin, but no pulp
or blood. What type
of fracture is this?
• Ellis
I
• Ellis
II
• Ellis
III
• Ellis
IV
Fractured Teeth
• Ellis
I – Enamel
• Ellis
II – Enamel & Dentin
• Ellis
III – Enamel, Dentin, Pulp
•A
33 year old male
presents after getting
hit in the face with a
rock. Examination of
tooth 6 reveals visible
dentin and bleeding
from the center of the
tooth. What is the
ideal management of
this patient.
• Anticoagulants
• Blood
patch
• Cover with cotton
and aluminum foil
and follow up in 48-72
hours
• Cover with cotton
and aluminum foil
and follow up
immediately
•A
33 year old male
presents after getting
hit in the face with a
rock. Examination of
tooth 6 reveals visible
dentin and bleeding
from the center of the
tooth. What is the
ideal management of
this patient.
• Anticoagulants
• Blood
patch
• Cover with cotton
and aluminum foil
and follow up in 48-72
hours
• Cover with cotton
and aluminum foil
and follow up
immediately
Ellis I
Ellis II
Ellis III
• Blood
=
pathognomonic
• True
Dental emergency
• Pulpectomy
• If
no dentist – moist
cotton over pulp, cover
with aluminum foil
•
A frantic parent
presents in with her 7
year old son saying that
he knocked his front
tooth out about 30
minutes ago. She hands
you a cup of water with
the tooth in it. What
solution would have
been best for preserving
the tooth while out of
the socket?
•
Distilled water
•
Hank's balanced salt
solution
•
Milk
•
Saliva
•
A frantic parent
presents in with her 7
year old son saying that
he knocked his front
tooth out about 30
minutes ago. She hands
you a cup of water with
the tooth in it. What
solution would have
been best for preserving
the tooth while out of
the socket?
•
Distilled water
•
Hank's balanced salt
solution
•
Milk
•
Saliva
•A
frantic parent
presents in with her 7
year old son saying
that he knocked his
front tooth out
about 30 minutes
ago. She hands you
a cup of water with
the tooth in it. What
do you do next?
• Disinfect
the tooth with a wipe
and place back into the
socket
• Gently rinse any debris with
saline and place it back into
the socket
• Sterilize tooth in an autoclave
and place back into socket
after it cools
• Thoroughly dry off the tooth
and place it back into the
socket
•A
frantic parent
presents in with her 7
year old son saying
that he knocked his
front tooth out
about 30 minutes
ago. She hands you
a cup of water with
the tooth in it. What
do you do next?
• Disinfect
the tooth with a wipe
and place back into the
socket
• Gently rinse any debris with
saline and place it back into
the socket
• Sterilize tooth in an autoclave
and place back into socket
after it cools
• Thoroughly dry off the tooth
and place it back into the
socket
•
A frantic parent
presents in with her 7
year old son saying that
he knocked his front
tooth out about 30
minutes ago. She hands
you a cup of water with
the tooth in it. After
replantation, mother
asks “what is the
chance of the tooth
living”
"Absolutely, 100%"
• "For every minute the
tooth is out there is a 1%
loss of success rate, so it
is difficult to say."
• "Let me call the dentist
to find out"
• "Not a chance, but at
least he will look normal
for his party this
weekend."
•
•
A frantic parent
presents in with her 7
year old son saying that
he knocked his front
tooth out about 30
minutes ago. She hands
you a cup of water with
the tooth in it. After
replantation, mother
asks “what is the
chance of the tooth
living”
"Absolutely, 100%"
• "For every minute the
tooth is out there is a 1%
loss of success rate, so it
is difficult to say."
• "Let me call the dentist
to find out"
• "Not a chance, but at
least he will look normal
for his party this
weekend."
•
Reimplantation
•
Remove from storage solution, rinse off
gently
•
Reimplant by manipulating crown
•
Avoid damaging periodontal ligament fibers
•
Stabilize with Coe-Pak
•
Initiate PCN or Erythromycin. Check Tetanus.
•
Liquid diet
•
Follow up with dentist. May (likely) need
revision
Subluxed Teeth
• Subluxed
= Loose in socket
• May
have associated fracture
• May
have ring of blood in gingival crevice
• Minimally
• Marked
mobile – respond to soft diet
mobility – stabilize within 10-14 days
 Arch bar, wire ligation, enamel
Soft Tissue Injury
•
Evaluation for tooth fragments
•
Gaping wounds can become ulceration,
infected, pain, need closure
•
Mucosa - 4-0 absorbable or silk.
•
Gingival or Tongue – silk, less irritating material
•
Small <1cm lacerations best left untouched
•
Removal intraoral sutures in 7 days
•
Consider antibiotics for through-and-though lac
TMJ Dislocation
• Most
commonly due to
extreme opening
• Yawn,
laugh, dystonia
• Bilateral
more common
than unilateral
•1
episode  risk for future
• Obtain
imaging in trauma
Mandibular, Panorex, CT
TMJ Reduction
Dental Blocks
• Most
nerves are within bone
• Nerves
enter teeth at the apex of root
• Maxillary
bone is porous, Mandible is nonporous
 Maxillary arch—local infiltration
 Mandibular arch—nerve block
Local Infiltration
• Maxillary
arch
 Introduce at the height of the
mucobuccal fold
Trigeminal Nerve
• Maxillary (V2)
Infraorbital
 Anterior Superior Alveolar nerve
 Middle Superior Alveolar nerve
Posterior Superior alveolar nerve
Greater/Lesser Palatine nerve
Nasopalantine
Trigeminal Nerve
• Mandibular
nerve (V3)
 Inferior alveolar nerve
 Mental nerve
 Buccal nerve
 Lingual nerve
Inferior alveolar nerve block
• Use
~35 mm 25 gauge needed
• Locate
the pterygomandibular raphe
• Palpate
coronoid notch
(Entrance to IAN)
•
What landmarks
should you look for
when attempting
an IAN block?
Coronoid notch and
maxillary first molar
• Coronoid notch and
pterygomandibular
raphe
• Maxillary first molar and
pterygomandibular
raphe
• Maxillary first molar and
mandibular plane of
occlusion
•
•
What landmarks
should you look for
when attempting
an IAN block?
Coronoid notch and
maxillary first molar
• Coronoid notch and
pterygomandibular
raphe
• Maxillary first molar and
pterygomandibular
raphe
• Maxillary first molar and
mandibular plane of
occlusion
•
Inferior alveolar nerve block
• Come
from contralateral side
• Aim
3/4 from coronoid notch
to pterygomandibular raphe
• Advance
needle until bone is
hit, withdraw 1-2 mm,aspirate
• Deposit
anesthetic
•A
21 yo male fell
down the steps after
his 21st birthday
party. He has a
laceration to the left
of midline on his
lower lip. What kind
of nerve block
should you do?
• Left
mental nerve
• Lingual
nerve
• Local
infiltration
around the lower
left anterior teeth
• Right
and left
mental nerve
•A
21 yo male fell
down the steps after
his 21st birthday
party. He has a
laceration to the left
of midline on his
lower lip. What kind
of nerve block
should you do?
• Left
mental nerve
• Lingual
nerve
• Local
infiltration
around the lower
left anterior teeth
• Right
and left
mental nerve
Mental Nerve Block
• Indications
 Anesthesia of anterior mandibular teeth
 Soft tissue of lower lip (easier than IAN block)
• Locate
the 2nd premolar
 Inject at depth of mucobuccal fold
References
• Rosen’s
• Dr
7th edition, Oral Medicine
Alyssa Shaikh DDS
• University
of Detroit Mercy Dental School
coursepacks