1. Dental Emergencies Devin Herbert, R3 Sept 6, 2012
We won’t be covering dental anesthesia or maxillofacial trauma.

2. Clavulin Percocet See your dentist Questions?
Some of us in the room may have a fairly basic understanding of dental emergencies and what we can do in the ED.
My goal is help us expand on this solid foundation, so we can feel a little more confident when a dental case walks through the door.

3. Objectives Communication Dental anatomy Nontraumatic emergencies
Pediatric issues
Whenever we speak with consultants, being able to speak their language is key. For dental cases, there is a new set of terms we must become familiar with.
To sound intelligent and trustworthy, we’ll need to know both the spacial anatomy of the mouth and the specific structure of a tooth.
We will cover these topics and then discuss the meat of the presentation…. Dental emergencies, both traumatic and non. Then, we’ll discuss a few (very few) pediatric-specific issues.

4. premolar Individual teeth can be described by name or number.
For this slide I’d like us to focus on the numbering system. There are just eight per quadrant.
Start at the right upper third molar, or wisdom tooth. This is number one.
Count around to the top left, tooth 16.
Down to the bottom left, tooth 17.
Around to the bottom right, tooth 32 (be sure to ask about wisdom tooth extraction)

5. As mentioned, another acceptable way to accurately identify a specific tooth is by name.
In each quadrant, we have two incisors, one canine, two premolars and three molars.
So, upper right first premolar, etc.

6. 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
Now that we know which tooth we are talking about, lets discuss which part of the tooth is involved.
Using these spatial terms is key to sounding smart.
You may encounter other terms. There are papers as recent as 2009 discussing the need for streamlining of the dental lexicon, as there is so much confusion and redundancy.

7. Finally, a tooth. This diagram outlines the basic anatomy of a single tooth.
It shows each of the structures we will be discussing throughout the talk and is worth remembering, although we will see it more than once.
The tip of the root, with its surrounding alveolar bone, is called the apex, or radicular portion, of the tooth.

8. Nontraumatic emergencies
Now that we have some basic understanding of dental anatomy and terminology, lets look at some core nontraumatic dental emergencies.
Largely infectious in etiology and will present as pain. Before dismissing the cases we see as “dental or apical abscesses” lets learn about this spectrum of disease in a little more detail.
Nontraumatic emergencies

9. Two pathophysiologic processes account for the majority of the nontraumatic dental emergencies we will see.
“Diseases of the pulp” refer to infections involving the enamel, dentin, pulp cavity and root canal.
“Diseases of the periodontium” involve the gingiva, periodontal ligament and surrounding alveolar bone.
As you can see, infections that travel down either the pulp cavity or periodontal apparatus will eventually involve the periapical or periradicular area, making this basic differentiation less helpful in cases of more advanced disease.

10. Dental caries Sensitive to cold
Decalcification of enamel by acid producing plaque bacteria
Eventually dentin layer breached
“diseases of the pulp”. A spectrum of disease, from simple caries to pulpitis to periapical abscess.
Most often asymptomatic, but we won’t see those.
First symptom often sensitivity to cold. Can also be heat, sweet and sour.
Typically occur in locations that plaque can accumulate (deep pits, interproximal areas).
Require dentist, analgesia is our only role.

11. 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
When enamel layer compromised, infection extends down microtubular dentin layer into pulp.
Pain from pulpal inflammation and necrosis.
Reversible and irreversible pulpitis distinguished by duration of pain (seconds vs. minutes-hours) following a noxious, often thermal, stimulus.
The role of antibiotics is to prevent progression of disease and sequelae (ie. abscess, deep space infection).

12. Periapical abscess
Spontaneous or unremitting pain, reproducible with percussion
Extension of infection to periapical bone
Drainage, antibiotics, NS rinses
May have an associated parulis
Periapical abscess is also known as a periradicular abscess.
A parulis is a soft tissue gingival swelling at the site of the affected tooth. Can have an associated fistula. May be fluctuant and drainable, or not.

13. This is an example of a parulis. May or may not be draining
This is an example of a parulis. May or may not be draining. Can help us identify the affected tooth.

14. Now that we’ve discussed the various “diseases of the pulp”, lets review the anatomy, paying particular attention to the gingiva and periodontal ligament.

15. 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
Next we will discuss the “diseases of the periodontum”.
Periodontal disease involves the gingiva, periodontal ligament and alveolar bone, not the internal compartment of the tooth.
In the ED it can be difficult to differentiate pulpitis from periapical abscess from periodontal abscess. Panorex XR may not be adequate.

16. 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
Most of the simple ondontogenic infections we have discussed can be drained intraorally.
For our purposes, only attempt drainage of localized, accessible abscesses, in patients who are not seriously ill. The intraoral technique is typically what we will attempt, as infections requiring extraoral drainage may involve multiple soft tissue spaces of the head and neck, requiring more complex surgical management.
Be sure to have the blade of the scalpel pointing towards the alveolar bone.
Suture the packing to the mucosa, to prevent aspiration.

17. Here we can see what looks like a localized and accessible gingival abscess. This may be periapical or periodontal in origin and would likely be amendable to drainage in the ED.

18. 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
There are a few other nontraumatic conditions we are likely to see in the ED. One of which is pericoronitis. Often seen in adolescents, with an erupting 3rd molar.
Will typically require analgesia and refer to a dentist. Drainage if abscessed. Often require tooth extraction.

19. 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
Notable absence of fever, lymphadenopathy, leukocytosis (which would suggest osteomyelitis). Also, conspicuous lack of clot in socket on exam.
Any increase in negative intraoral pressure (smoking, straw use) or excessive rinsing increases likelihood. Also preexisting periodontal disease.
Tx with repacking of socket.
First, local or regional anesthesia. Rinse and suction socket. Pack with gauze soaked in local anesthetic or Eugenol (clove oil extract), or gelfoam.
Refer back to dentist and consider antibiotics.

20. Next, we will discuss a few of the feared complications of untreated odontogenic infections, the deep space infections.

21. 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
Particuarly periapical and periodontal abscesses have the potential to break through the cortical layer of the maxillary or mandibular bone and exhibit localized spread to contiguous tissues. They present as pain with swelling or cellulitis (and often systemic symptoms).
Can progress to involve any of the fascial planes of the head and neck.
In immunocompetent hosts, infections typically will localize and spontaneously drain, but not always.
If there is any suspicion of spread to fascial planes consider impending airway compromise (difficult airway).
Abx (ie Pen G IV), CT scan, ENT/ICU admission. Consider sepsis management.

22. 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!
The feared mandibular odontogenic infection. Patients look sick, likely septic.
Exam shows bilateral, indurated, firm swelling of floor of mouth.
True emergency, as airway at risk. Trismus, resulting from direct muscle irritation and involuntary spasm, may not resolve with paralytic!
Difficult airway management, parenteral Abx, CT, ENT/ICU.

25. This is an example of a patient with Ludwig’s angina, post tracheostomy and surgical drain placement. Notice the erythematous fullness of the floor of the mouth and elevated tongue.

26. Cavernous sinus thrombosis
Infraorbital or periorbital cellulitis
Retrograde spread of infection through ophthalmic veins to cavernous sinus
Meningeal signs, altered LOC to coma
A feared complication of maxillary odontogenic infection, or facial sinus infection.
Presents as swelling or cellulitis of the infraorbital or periorbital spaces. Infection tracks up the valveless venous system. Likely associated systemic signs/sepsis.
Requires early recognition and parenteral antibiotics and imaging.

27. This patient had a history of untreated maxillary ondontogenic infection. Notice the L sided swelling of the upper face and associated periorbital involvement.

28. Just a periorbital cellulitis, but be sure to ask about dental pain and have a look in the mouth.

29. Traumatic emergencies
In this section we will be discussing dental fractures and luxations.

30. 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
Fractures of the teeth are common, with >70% involving the central maxillary incisors.
Ellis I involves only the enamel. The exposed enamel has a chalky-white appearance. Painless. Sharp edges of concern.
Ellis II involves the dentin. The dentin appears yellow. It is quite sensitive and requires early repair, to prevent spread of infection. The exposed dentin should be dried and sealed with calcium hydroxide (Dycal). If open >24hrs, pulp involvement likely.
Ellis III involves the pulp of the tooth. There will be red blood present and exquisite pain. A true dental emergency, as the pulp space is already compromised. Antibiotic prophylaxis recommended and sealant should be applied. Consider tetanus.
Dentists typically don’t use the Ellis classification. Prefer uncomplicated or complicated crown fractures, based on whether or not the pulp is involved.

31. (Complicated)
Here is a diagrammatic depiction of the dental crown fractures we have discussed.

32. 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
Concussed and subluxed teeth typically respond well to conservative management (ie. soft diet).
The other types of injury mentioned above will be discussed in a little more detail.

33. This is an example of extrusive luxation, with the tooth being pulled from the socket in an axial direction.

34. This is an example of intrusive luxation, where the tooth is being forced into the socket in an axial direction. This mechanism often results in apical tooth fracture, which can result in root necrosis and require eventual root canal or extraction.

35. This image shows lateral luxation and a commonly associated alveolar bone fracture.
Each of the luxations we have discussed should techically be realigned and splinted in the ED. There are commercially available splint materials available, but none are readily accessible in Calgary’s ED’s. In our situation, adequate analgesia, antibiotics and referral are appropriate. Consider tetanus.

36. 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
Consider intrusion, rather than avulsion. Also, swallowing and aspiration.
The longer the tooth is out of the socket, the higher the risk of periodontal ligament necrosis, which is the limiting factor in reimplantation. Typically, >60mins out of a physiologic medium results in death. Ideally, reimplant the tooth.
The best, readily available medium is milk. The tooth will then remain viable for 4-8hrs. If no milk or Hank’s solution, place tooth under patients tongue (if they are not at risk for aspiration).
When handling the tooth, touch the crown only. In the end, most will not be successfully reimplanted.
Antibiotics and tetanus.

37. Here is a CXR of a polytrauma patient with significant facial injury
Here is a CXR of a polytrauma patient with significant facial injury. Notice the arrow sign, pointing to a tooth, likely in the right mainstem bronchus. Aspirated teeth have the potential to cause obstruction and are a significant nidus for infection. Making the diagnosis of tooth aspiration requires suspicion, when an avulsed or fractured tooth is unaccounted for, and will require bronchoscopic removal.

38. Pediatric pearls
Next we will discuss a few quick points specific to the primary, or deciduous, dentition.

39. Pediatric dental emergency pearls
Primary dentition consists of 20 teeth (2 incisors, 1 canine, 2 molars per quadrant)
Eruption begins ~ 6 months complete by ~ 2 years
Permanent dentition begins ~ 6 years
Avulsed primary teeth should NOT be reimplanted
If a primary tooth is reimplanted, it may ankylose or fuse to the alveolar bone, impairing the ability of the permanent tooth to erupt successfully.

40. 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
True dental emergencies are the complicated crown fractures and tooth avulsions.
True medical emergencies are the deep space infections (with potentially associated sepsis, airway compromise and CNS involvement) and the sequelae of tooth aspiration.
Be vigilant to exclude a impending medical emergency when patients present with significant dental issues.

41. Edmonton’s ED dental kit:
Dycal - $ Fuji I glass ionomer - $ mix pad 3x3 - $ disposable spatulas pk 50 - $ disposable mirrors pk 60 - $ disposable instruments pk 10 - $ Arista hemostatic powder - ? Price gelfoam substitute pk 24 - $ cotton rolls box $ dental wax - ? price
One final point, consider setting up a similar kit if you are working far from dental backup.
Dycal for sealing fractured teeth
Gelfoam for packing alveolar osteitis
Dental wax for splinting luxations