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March 24, 2011 Lianne Beck, MD Assistant Professor Emory Family Medicine
Objectives
Basic dental anatomy Diagnosis and treatment planning Pulpitis Dental abscess and cellulitis Trauma Anesthesia for dental procedures Extraction Drugs in dentistry Emergency dental kit
Dental Emergencies
In remote or under-developed regions where the nearest dentist may be many days journey, doctors and nurses frequently find themselves required to deal with pain, infection and trauma in the mouth. Dental conditions are not usually dangerous to life, but they are often exceedingly painful
J.N.W. McCagie, Oral Surgeon
Introduction
Dental disease is evident in all patient populations
regardless of medical conditions.
Anatomy
Buccal region
Palatal region
Lingual region
Lymphatic Drainage
Lymphatic drainage is
to the submental, submandibular and deep cervical nodes.
Emergency vs Urgency
Emergencies interrupt normal eating,
working and sleeping.
Is this first time? When did it start? Does it interfere with swallowing or breathing? Does it change the way patient speaks?
Swelling
Differentiate between cellulitis and abscess Evaluate airway and swallowing Can be difficult to evaluate intraorally if trismus is
present Trismus suggests infection in posterior region Infection causes a reactive myospasm Do not force mouth open Will resolve once infection resolves
Ludwigs Angina
Cellulitis involving bilateral
sublingual, submandibular and submental spaces
When to Admit?
Deep fascial space threatening the airway
Patient is dehydrated and requires IV
fluids
Fever
Painful submandibular and cervical
lymphadenopathy would be expected
Pus
Drainage intra-orally is
preferred
Extra-oral drainage
Intra-oral Drainage
Rinse with hot salt water mouth rinses q 2 hrs
until drainage occurs
Bleeding
Occurs most commonly
in patients who have had a recent tooth extracted
Dental Pain
Majority originates in the teeth or peridontium
and is relatively easy to treat with analgesia and antibiotics Treatments starts in the medical clinic but dental referral is required Dental problems do NOT cure themselves Treating the pain without addressing the underlying problem only prolongs the problem.
Dental Pain
Dental History
Ask the client to voice their complaint or point to area which is hurting Onset and duration of complaint
HISTORY TAKING
Medical History
General state of health
Current medications
Particular conditions CHD, prosthetic valve Drug allergy (penicillin) Bleeding tendency Immunodeficiency
CLINICAL EXAMINATION
General State
Temp, appearance
CLINICAL EXAMINATION
Intra oral
A good light is essential
CLINICAL EXAMINATION
Intra oral
Inspect soft tissues: Inflammation Swelling Tenderness Ulceration
Inspect the teeth Decay Mobility Fractured teeth
COMMON CONDITIONS
Dental caries Pulpitis Dental Abscess Facial swelling and cellulitis Dry socket Fractured teeth Fractured jaw
DENTAL CARIES
One of the most
common diseases
Starts in enamel,
DENTAL CARIES
Filling Materials
PULPITIS
Inflammation of the pulp
Early stages reversible Remove decay Cavit dressing When pain settled permanent
filling placed
DENTAL ABSCESS
Periapical abscess
Result of decay and infection
extending into pulp of tooth
DENTAL ABSCESS
Extra oral Swelling
Can spread into the tissues Leading to cellulitis Systemic involvement Drainage required
DENTAL ABSCESS
Extra oral Swelling
Treatment
Antibiotics Incision and drainage Anesthesia with topical paste or ethyl chloride
Number 11 blade for incision extra orally Open tissues using mosquitos Allow pus to drain/insert rubber drain suture to keep patent Ultimately extract tooth under LA http://www.youtube.com/watch?v=SYVtcL-VDf0
http://www.youtube.com/watch?v=o7Bg0ItHTpA
DRY SOCKET
Dry Socket
Localized osteitis Severe pain 2 - 4 days post extraction TREATMENT LA Debride socket Dressing Alvogyl
DENTAL TRAUMA
Fractured front tooth
Ellis I Dentine Ellis II - Dentine/Enamel Ellis III - Dentine/Enamel/Pulp
Treatment
Pain control Tetanus Cover exposed dentine w/zinc oxide or calcium hydroxide paste (Dycal).
http://emedicine.medscape.com/article/82755-media
DENTAL TRAUMA
Avulsed Tooth
A good chance of the tooth re-implanting into the socket successfully if done within an hour.
The tooth should be located and picked up by the crown or enamel portion NOT the root. If the tooth is dirty/contaminated, gently rinse in cold running tap water and then re-implanted. If immediate on-scene re-implantation is not possible, transport tooth in whole cold milk, saline, or saliva.
DENTAL TRAUMA
Place tooth back into socket. Splint the tooth to stabilize
Wire and glass ionomer cement Dental wax and foil
Antibiotics - Amoxicillin
FACIAL TRAUMA
Emergency Management of Facial Fractures
Attempt to stabilize the jaw Give Antibiotics, Td Soft foods Get to hospital ASAP
Barton Bandage
Mandible
Buccal
Inf. Mandibular
Palatal
Lingual
INFILTRATION
Should achieve anesthesia within 5 minutes
Can be safely repeated if unsuccessful Do not give where there is grossly infected tissue
Supraperiosteal infiltrations:
Anesthetizes individual teeth. Use this technique only with the maxillary incisors, canines, and premolars
Mandible
Palpate the anterior ramus border at the coronoid notch. Slide the finger or thumb posteriorly and medially until a ridge of bone is palpated. This is the internal oblique ridge. Insert until bone is contacted then withdraw ~1 mm. The depth of insertion is approximately 25 mm.
http://www.youtube.com/watch?v=ZHWM
TKX2T70&feature=relmfu
http://emedicine.medscape.com/article/82
850-print
Pearls
Obtain informed consent prior to performing a nerve
block. Inject slowly (30 seconds for each mL of anesthetic) to decrease pain. In order to aspirate properly, use a needle that is 27 gauge or larger for deep nerve blocks. Buffering with bicarbonate is NOT recommended for oral nerve blocks.
Pearls
Applying pressure to the site adjacent to injection while
inserting the needle may distract the patient and, thereby, decrease the sensation of pain.
Pearls
True allergies to local anesthetics are rare. If the patient has an allergy to one anesthetic, an
anesthetic from the other class can be used (amide vs ester), or an alternative agent such as benzyl alcohol or diphenhydramine can be used.
If the first attempt at the nerve block fails, try the block
again. Some of the blocks (ie, inferior alveolar, infraorbital) are best attempted after a skilled clinician has demonstrated them.
DENTAL EXTRACTIONS
Indications
Severe pulpitis
Periapical abscess
Tooth fracture Severe periodontal disease
DENTAL EXTRACTIONS
Basic Instruments
DENTAL EXTRACTIONS
http://www.youtube.com/watch?v=OjiBOOhVVNo There are lots of others to watch!
DENTAL EXTRACTIONS
Post operative instructions
Pressure on socket No rinsing for 24 hours Cold food and drink for 24 hours No smoking for 24-48 hours HSMW after 24 hours If bleeding pressure pack for 20 minutes
DENTAL EXTRACTIONS
Complications
Fractured tooth Bleeding Swelling Bruising Pain Trismus Dry Socket
DENTAL EXTRACTIONS
Complications Bleeding
Apply Pressure Pack with hemostatic agent
Suture
Antibiotics
Urgent referral to
dentist
Narcotic Analgesics
Cavit/Temp dressing Eugenol/Oil of cloves Glass ionomer cement Dental Wax/Wire Topical anesthetic Local anesthetic Amox/Metronidazole Ibuprofen/Acetominophen
Referral Resources
http://www.benmasselldentalclinic.com/in
dex.html
http://www.gfcn.org/index.php
Thank You!