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ORAL MEDICINE Dr Sam Shaikh, DO PGY-II Sinai-Grace Emergency Medicine.

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Presentation on theme: "ORAL MEDICINE Dr Sam Shaikh, DO PGY-II Sinai-Grace Emergency Medicine."— Presentation transcript:

1 ORAL MEDICINE Dr Sam Shaikh, DO PGY-II Sinai-Grace Emergency Medicine

2 Disclosures None

3

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5 Caries Oral flora develop “Dental Bacterial Plaque” Metabolize carbohydrates  acids  Erode enamel After enamel eroded  Microporous dentin  Pulp Pulp hyperemia & Inflammation  Degeneration & necrosis

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7 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

8 Complications of Periapical Abscess Submaxillary, sublingual & submental spaces  Ludwig's Angina Anterior maxillary teeth  Periorbital infection Cavernous Sinus Thrombosis

9 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

10 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

11 Cavernous sinus thrombosis most commonly results from which teeth? Mandibular anterior teeth Mandibular posterior teeth Maxillary anterior teeth Maxillary posterior teeth

12 Cavernous sinus thrombosis most commonly results from which teeth? Mandibular anterior teeth Mandibular posterior teeth Maxillary anterior teeth Maxillary posterior teeth

13 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

14 or just wing it in The Chairs….

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16 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

17 Results Opioid prescribing in ~17k visit per year ED for dental pain went from 59%  42% Dental pain visits from 26/1000  21/1000 Annals Reply – Tramadol was not included as opiate

18 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

19 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

20 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

21 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

22 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 but no evidence of generalized or localized swelling, and no signs of an abscess. What do you do? Analgesics, refer to dentist Analgesics and antibiotics, refer to dentist I & D and admit I & D with IV antibiotics

23 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 but no evidence of generalized or localized swelling, and no signs of an abscess. What do you do? Analgesics, refer to dentist Analgesics and antibiotics, refer to dentist I & D and admit I & D with IV antibiotics

24 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

25 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

26 CHIEF COMPLAINT: Toothache MCC = Dental caries Pulpitis – temperature or air Pain refers to ear, temple, eye, neck, opposite side Exam: Look, palpate, utilize ice TTP w/o temperature sensitivity suggest underlying abscess ED Management NSAIDS ± Dental block Opiates for acute presentation Be careful to evaluate for abscess which may be need I&D

27 Draining Periapical Abscess Dental Block Incise  express purulence Penrose drain or Iodoform gauze secured with 4-0 silk Penicillin V or Erythromycin f/u with Dentist or OMFS for reeval and drain removal

28 Facial Cellulitis PCN VK mg QID Airway: CT, early intubation, ENT, anesthesia Admit: suggested spread into facial planes, fever, toxic, trismus, immunocompromised

29 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

30 Facial Cellulitis IV Penicillin 15-20m U daily B fragillis –cephalosporin, clinda, flagyl Surgical – exploration for causative & loculations Remove necrotic tissue

31 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

32 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

33 Periodontal Disease Gingivitis - Inflammatory response to irritation inflammation  Alveolar Bone loss = Periodontitis Periodontitis  Gingival resorption

34 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

35 Types of Dental Abscess

36 Acute Necrotizing Ulcerative Gingivitis (ANUG) Bacteria invade non-necrotic tissue - Fusobacteria & Spirochetes Fever, malaise, lymphadenopathy Painful edematous papillae w gray- pseudomembrane Risks: immunocompromised, stress, trauma, smoking – Trench Mouth Tx: Saline/H2O2 rinses, hygiene, analgesics, ABX – PCN, Erythro, Tetra

37 OTHER CAUSES OF DENTALGIA

38

39 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

40 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

41 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

42 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

43 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 eruption pattern Periodontitis Pericoronitis

44 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 eruption pattern Periodontitis Pericoronitis

45 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

46 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

47 Oral Manifestations of Systemic Disease

48 .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

49 .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

50 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

51 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

52 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

53 Collagen Vascular Disease SLE Intraoral ulcers w necrotic borders

54 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

55 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

56 Gingival Hyperplasia Phenytoin, calcium channel blockers, cyclosporine, and phenobarbitol 40% of patients on phenytoin have some degree of hyperplasia

57 Aphthous Stomatitis – “Canker Sore” Recurrent small mucosal ulcers Stress, nutrition, trauma Self-limiting H2O2, Benzocaine, Kaopectate, Maalox, Kenalog, Sucralfate

58 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

59 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

60 Dental Trauma

61

62 Retrospective review of 264 pt/548 teeth over 56 months Mean age 8.2 years, 62% male Most common age for injuries 2-4 & % of effected teeth were permanent

63 237 teeth (43%) presented for follow up Mean time to follow up – 55 days 58% of documented/followed-up cases had uncomplicated retention of teeth at 6 months

64 Dental Trauma Most Common = Anterior Complications  Fracture  Neurovascular  Fractures of tooth  Loss of tooth=Avulsion  Subluxation

65 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

66 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

67 Fractured Teeth Ellis I – Enamel Ellis II – Enamel & Dentin Ellis III – Enamel, Dentin, Pulp

68 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 hours Cover with cotton and aluminum foil and follow up immediately

69 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 hours Cover with cotton and aluminum foil and follow up immediately

70 Ellis I

71 Ellis II

72 Ellis III Blood = pathognomonic True Dental emergency Pulpectomy If no dentist – moist cotton over pulp, cover with aluminum foil

73 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

74 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

75 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

76 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

77 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."

78 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."

79 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 Reimplantation

80 Subluxed Teeth Subluxed = Loose in socket May have associated fracture May have ring of blood in gingival crevice Minimally mobile – respond to soft diet Marked mobility – stabilize within days  Arch bar, wire ligation, enamel

81 Soft Tissue Injury Evaluation for tooth fragments Gaping wounds can become ulceration, infected, pain, need closure Mucosa 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

82 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

83 TMJ Reduction

84 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

85 Local Infiltration Maxillary arch  Introduce at the height of the mucobuccal fold

86 Trigeminal Nerve Maxillary (V2)  Infraorbital  Anterior Superior Alveolar nerve  Middle Superior Alveolar nerve  Posterior Superior alveolar nerve  Greater/Lesser Palatine nerve  Nasopalantine

87 Trigeminal Nerve Mandibular nerve (V3)  Inferior alveolar nerve  Mental nerve  Buccal nerve  Lingual nerve

88 Inferior alveolar nerve block Use ~35 mm 25 gauge needed Locate the pterygomandibular raphe Palpate coronoid notch (Entrance to IAN)

89 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

90 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

91 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

92 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

93 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

94 Mental Nerve Block Indications  Anesthesia of anterior mandibular teeth  Soft tissue of lower lip (easier than IAN block) Locate the 2 nd premolar  Inject at depth of mucobuccal fold

95 References Rosen’s 7 th edition, Oral Medicine Dr Alyssa Shaikh DDS University of Detroit Mercy Dental School coursepacks


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