1. Dental Trauma in the ED: Fractures and Luxations Resident Grand Rounds Elizabeth Haney 10 May 2007

2. Outline Review of anatomy, and pertinent basics Injury Overview Management New products coming and how to use them Thanks to Dr. Greenfield, Dr. Kalaydjian and Dr. Lobay

3. Goal For you to leave today feeling more confident with your management and disposition of dental injuries.

4. Emerg Issues in Dental Injuries Pain Management Oral Meds Nerve Blocks Covering the Exposed Root Keep tooth alive Transient Storage Media Stabilization until definitive management (ie: referral to our Dental colleagues) Periodontal Paste

5. Numbers in the CHR Interrogation of CHR initial complaints April 1 2006 – March 31 2007 FMC, RGH, PLC 1868 Dental/Oral related visits as primary complaint 2006 Health Records Info 196 discharge codes for Dental specific Dx

6. Anatomy of a Tooth

7. Which tooth is it? Numbering System Differences 32 adult teeth 4 incisors (most commonly injured) 2 canines 4 premolars 6 molars Upper Right = 1 Upper Left = 2 Lower Right = 4 Lower Left = 3

8. Tooth Surface Terminology Lingual surface faces tongue Buccal surface faces cheek Mesial surface faces midline Distal surface faces ramus of mandible

9. Fractures Ellis classification used in Emerg General description used/preferred by Dentists ie: instead of Ellis III, saying # exposing the pulp

10. Enamel Fractures Non – painful Chalky white appearance Reassurance Consider filing sharp edges Non-urgent Dentistry referral

11. Dentin Fractures May have sensitivity (temp, air, percussion) Yellow dentin visible Management: Block the tooth Dry tooth Cover the tooth (CaOH) Dental f/u within 24h

12. Pulp Fractures Yellow dentin and pink blush or frank blood Usually Painful Block the tooth Dry the tooth Cover the tooth (Calcium Hydroxide) Dental Consult if unable to manage pain Most require eventual root canal

13. Fractures Summary All require Dentistry follow-up Enamel #’s: non-urgent (1-2 weeks) Dentin #’s: within 24 hours Pulp #’s: Immediate if possible, next day at latest

14. Subluxation, Luxation, Avulsion Subluxation – Loose Tooth Luxation – Displaced Tooth Intrusive: displaced into socket (apically) Extrusive: displaced out of socket Lateral: displaced any other way Avulsion – Completely Out Pain Control!

15. Subluxation Increased mobility due to torn PDL fibers Tender to touch Not displaced If minimally mobile Soft diet Non-urgent dental f/u If grossly unstable Stabilize: Dentist Consult, or stabilize in ED and Dentist in AM

16. Intrusive Luxation Apical displacement into alveolar bone Crushes PDL +/- neurovascular supply rupture Immobile R/O avulsion if completely intruded Consult Dentistry – semi-urgent basis

17. Extrusive Luxation Tooth appears long Mobile Gently reposition into socket Stabilize Consult Dentistry

18. Lateral Luxation Tooth displaced, apex moved close to bone Usually immobile Reposition Stabilize Consult Dentistry

19. Avulsion Completely out of socket Torn PDL w/ fragments on root and in socket Locate tooth! Place the avulsed tooth in cold, isotonic solution Consult Dentistry 1% chance of successful reimplantation lost q1min out of socket (dry)

20. General Avulsion Guidelines Handle tooth by the crown (Minimize PDL damage) Transport in appropriate media (next slide) Gently rinse (wiping can remove PDL) Flush socket with saline In ED, replant tooth, stabilize

21. Tooth Storage Media Order of Preference: Hank’s (ph) balanced salt solution (HBSS) Cold milk Saliva Saline Water NEVER Dry Ozan et al. J Endod May 2007

22. Find the Tooth!

23. Dentistry Splinting Estimates

24. Periodontal Paste & Calcium Hydroxide Do we have them in the ED? NO. Not yet I’m working on getting us samples and will keep you posted via e-mail Stabilization and Capping Products

25. New Products and How to Use Them Coe-Pak Surgical dressing & Periodontal pack Supplied in 2 tubes: base & catalyst Mix together into paste Roll into appropriate width & length Press against mucosa and teeth, flanking the injured tooth Do not cover occlusal surface

26. Ca Hydroxide Rigid self-setting material used for pulp capping & as a protective base/liner under dental filling materials Supplied in 2 tubes: base & catalyst Dispense equal volumes onto paper Stir using applicator until uniform color (~10sec) Apply to dried area Remove excess Set time: 2-3 min on paper, less in mouth

27. It’s 2am….Do I Call the Dentist? Dental Emergencies: Avulsion Fracture to Pulp, if unable to control pain Any luxation Dental Hemorrhage Abscess needing drainage which is beyond our scope Jaw # - OMF surgeon If they’re coming in  Order a Panorex Thanks Dr. Kalaydjian

28. CHR Dentist’s On-Call Policy Full coverage Each dentist 1 call q 2-3 weeks Call back within 5-10 minutes, able to be at hospital within 30 minutes No formal compensation (only if pt pays) Great policy on helping ED pts! Be Kind

29. CHR Resources CHR Dental Clinic: Only medically compromised patients as regulars CHR funded Community Dental Clinics: Patients pay 20% of actual fee Call 228-3384 = “22-teeth” Sites: City Hall Dental Clinic, Northeast Dental Clinic (Sunridge Mall), Airdrie www.calgaryhealthregion.ca/hecomm/oral/reducedfee dental.htm

30. Take Home Points Know the terminology, or where to find it Proper communication = Happier consultants Manage the pain We temporarily manage these injuries Definitive management left to the pros Know your tools and resources

31. Future Initiatives Stocking of Stabilization and Capping products Dental Trauma Patient Instructions Dedicated space in the Emerg for a dentistry locked box of supplies

32. References Marx. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6 th ed. 2006. ch. 69 Oral Medicine Andersson et al. Guidelines for the management of traumaticdental injuries. I. Fractures and luxations of permanent teeth. Dental Traumatology 2007; 23: 66-71 Becker et al. Drug Therapy in Dental Practice: Nonopioid and Opioid Analgesics. Anesth Prog 2005; 52:140-149 Dale RA. Dentoalveolar trauma. Emerg Med Clin North Am 2000;18: 521-38 Po AL, Zhang WY: Analgesic efficacy of ibuprofen alone and in combination with codeine or caffeine in post-surgical pain: A meta-analysis. Eur J Clin Pharmacol 1998; 53:303 Benko et al., Management of Dental Emergencies. EM Reports. Vol 27, N. 3. January 2006 Lynch MT, Syverud SA, Schwab RA, et al: Comparison of intraoral and percutaneous approaches for infraorbital nerve block. Acad Emerg Med 1994; 1:514 Harkacz O, Carnes D, Walker W. Determination of periodontal ligament cell viability in the oral rehydration fluid Gatorade and milks of varying fat content. J Endod 1997;23:687–90 Ozan et al. Effect of Propolis on Survival of Periodontal Ligament Cells: New Storage Media for Avulsed Teeth. J Endod 2007;33:570-573 EMRap November 2006 Dental Trauma www.calgaryhealthregion.ca/hecomm/oral/reducedfeedental.htm

33. Extra Slides

34. Useful Nerve Block Review Supraperiosteal - Individual Teeth Infraorbital – Maxillary Teeth and Upper Lip Inferior Alveolar – Mandibular Teeth Mental – Lower Lip

35. But 1 st  Topical Anesthesia Dry area w/ gauze Hold swab w/ 4% lidocaine to area ~ 2 minutes

36. Supraperiosteal Block Individual tooth anesthesia How to: Pt closes mouth slightly, relaxed Pull lip taut with gauze Bevel facing bone, insert @ mucobuccal fold Advance to apex Aspirate Inject 1-2 cc marcaine slowly

37. Infraorbital Nerve Block Anesthetizes the midface How to (intraoral approach): Keep a finger over the inferior border on the infraorbital rim Retract cheek Puncture opposite the upper second bicuspid (premolar) ~0.5 cm from buccal surface Needle parallel w/ tooth Advance until palpated near the foramen (~2.5cm depth) Aspirate Inject 2-3cc marcaine adjacent to, not within, the foramen

38. Inferior Alveolar Nerve Block Anesthetizes the hemimandible, lower lip & chin How to: Palpate the anterior ramus border Retract buccal tissue laterally, stabilize mandible with finger behind ramus

39. Inferior Alveolar Nerve Block Syringe barrel oriented over the contralateral mandibular bicuspids Insertion site = 1cm above occlusal surface of 3 rd molar Insert until needle point touches medial surface of ramus Back up ~1mm Aspirate Inject

40. Mental Nerve Block Anesthetizes lower lip Infiltration about the mental foramen How to (intraoral approach): Palpate the mental foramen ~1 cm inferior and anterior to the second premolar Retract lip Insert needle (45° angle) at mucosal junction of lower lip and gum beneath 2 nd premolar Aspirate Inject 1-2cc marcaine

41. Billing For the Block Specific code for dental anaesthesia (33.99B) no longer exists in Emergency But….. You can bill a local anaesthetic code 17.17A ($21.13), which is modifiable Thanks to Dr. Rick Morris

42. ED Visit Month Fracture Of ToothDislocation Of Tooth Total Dent al Trau ma Visit s FMRGPLC Total A l l S i t e s FMCRGHPLC Total A ll S it e s Jan-065321011212 Feb-0643613321619 Mar-06631101111 Apr-0633410111313 May-0692415212520 Jun-06756181 3422 Jul-0611617122522 Aug-06437229 Sep-0636716521824 Oct-067341411216 Nov-06226102212 Dec-064371411216 Cal Year 2006 Total 6533561541791642196

43. 5 th Cranial Nerve: Trigeminal V1 = Ophthalmic V2 = Maxillary (dentition) V3 = Mandibular (dentition)

44. Maxillary Nerve

45. Mandibular Nerve

46. Coe-Pak MSDS Hazardous Ingredients Denatured Alcohol 1-5%  Ethanol  Methanol Petrolatum 5-10% HEALTH HAZARD (Acute and Chronic): Denatured alcohol: Prolonged exposure to ethanol may result in irritation of mucous membrane, headache, drowsiness, and fatigue. Methanol is also narcotic and affects are cumulative. Sx & SYMPTOMS OF OVEREXPOSURE: Overexposure to methanol can result in acidosis and visual disturbances that may lead to permanent loss of vision.

47. Dycal MSDS