Dental Emergencies - UCSF Medical · PDF fileDental “Emergencies ... Ellis Classification Class I – Enamel Only ... Sign-Trismus Orbital Infratemporal Lateral Pharyngeal Retropharyngeal

Dental EmergenciesDental Emergencies

Brian Bast D.M.D., M.D.Brian Bast D.M.D., M.D.Assistant Clinical ProfessorAssistant Clinical ProfessorUCSF/SFGHUCSF/SFGHDepartment of Oral and Maxillofacial Department of Oral and Maxillofacial

SurgerySurgery

Dental Dental ““EmergenciesEmergencies””

PainPain

TraumaTrauma

InfectionInfection

PathologyPathology


PainPain

TraumaTrauma

InfectionInfection

PathologyPathology







Normal AnatomyNormal Anatomy






AbAb--Normal AnatomyNormal Anatomy


FordyceFordyce’’s Spotss Spots

Palatal ToriPalatal Tori Mandibular ToriMandibular Tori

Dental PainDental Pain


Trigeminal NerveTrigeminal Nerve

AAδδ (small myelinated)(small myelinated)

C (unmyelinated)C (unmyelinated)

Transmits only PainTransmits only Pain



Analgesics Analgesics –– NSAID, Tyelenol/NarcoticNSAID, Tyelenol/Narcotic

Antibiotic Antibiotic –– Penicillen, ClindamycinPenicillen, Clindamycin

Dental Care Dental Care –– Filling, Root Canal etc.Filling, Root Canal etc.













Mucosal PainMucosal Pain

UlcerationUlceration

Differential Differential –– Neoplasm, Immune, InfectionNeoplasm, Immune, Infection

Trauma Trauma

Biopsy Directed TreatmentBiopsy Directed Treatment


Aphthous Ulcer /Aphthous Ulcer /““canker sorecanker sore””

Etiology Etiology –– Immune MediatedImmune Mediated

Incidence Incidence –– 40% Population40% Population

Minor Minor –– Small (3Small (3--10mm)10mm)

SuperficialSuperficial

Short Duration (7Short Duration (7--14d)14d)

Major Major –– Larger (greater than 10mm)Larger (greater than 10mm)

Deep (submucossal and mucsle)Deep (submucossal and mucsle)

Longer LastingLonger Lasting


Aphthous Ulcer / StagesAphthous Ulcer / Stages

ProPro--dromal dromal –– tingling, burningtingling, burning

Pre Ulcer Pre Ulcer –– red papulesred papules

Ulcer Ulcer –– superficial, white basesuperficial, white base

Healing Healing –– granulation, no scar/scar granulation, no scar/scar


Aphthous Ulcer / TreatmentAphthous Ulcer / Treatment

No TreatmemtNo Treatmemt

Topical AnestheticsTopical Anesthetics

Topical Antibiotics Topical Antibiotics –– TetracyclineTetracycline

Corticosteroids Corticosteroids –– topical, intratopical, intra--lesional, lesional,

systemicsystemic


Dental TraumaDental Trauma


ConcussionConcussionSubluxationSubluxationIntrusionIntrusionExtrusionExtrusionLateral LuxationLateral LuxationAvulsionAvulsion




ConcussionConcussionSubluxationSubluxationIntrusionIntrusion

Dental EvaluationDental EvaluationGood PrognosisGood PrognosisRoot CanalRoot CanalAnalgesics/AntibioticsAnalgesics/Antibiotics


ConcussionConcussionSubluxationSubluxationIntrusionIntrusion

Dental EvaluationDental EvaluationGood PrognosisGood PrognosisRoot CanalRoot CanalAnalgesics/AntibioticsAnalgesics/Antibiotics








ExtrusionExtrusionLateral LuxationLateral Luxation

Repositioning and SplintingRepositioning and SplintingDental EvaluationDental EvaluationAnalgesics/AntibioticsAnalgesics/AntibioticsGuarded PrognosisGuarded Prognosis






AvulsionAvulsionTime Limitations Time Limitations –– 1h1h


AvulsionAvulsionTime Limitations Time Limitations –– 1h1hStorage MediumStorage Medium

tissue culture, socket, tissue culture, socket, saliva, milk, salinesaliva, milk, saline


AvulsionAvulsionTime Limitations Time Limitations –– 1h1h

Storage MediumStorage Mediumtissue culture, socket, tissue culture, socket, saliva, milk, salinesaliva, milk, saline

Health of the ToothHealth of the Tooth


Avulsion/ReplantationAvulsion/Replantation1.1. Irrigate ToothIrrigate Tooth2.2. Local AnestheticLocal Anesthetic3.3. Irrigate SocketIrrigate Socket4.4. Replant ToothReplant Tooth5.5. SplintSplint6.6. XX--RayRay





AvulsionAvulsionDental EvaluationDental EvaluationPoor PrognosisPoor PrognosisAnalgesics/Antibiotics Analgesics/Antibiotics


Crown FractureCrown Fracture

Root FracturesRoot Fractures

Dental Alveolar Dental Alveolar




Dental Alveolar Dental Alveolar




Dental AlveolarDental Alveolar


Crown FractureCrown FractureEllis ClassificationEllis Classification

Class I Class I –– Enamel OnlyEnamel Only

Class II Class II –– Enamel and DentinEnamel and Dentin

Class III Class III –– Enamel, Dentin and PulpEnamel, Dentin and Pulp

Class IV Class IV –– Root FracturesRoot Fractures











TreatmentTreatment

Dental ReferralDental Referral

Filling, Root Canal/CrownFilling, Root Canal/Crown

AnalgesicsAnalgesics





TreatmentTreatment


Filling, Root Canal/CrownFilling, Root Canal/Crown




Ellis ClassificationEllis Classification


TreatmentTreatment


Root Canal/ CrownRoot Canal/ Crown

Possible ExtractionPossible Extraction


Antibiotics Antibiotics –– Penicillen, ClindamycinPenicillen, Clindamycin





TreatmentTreatment


Root Canal/ CrownRoot Canal/ Crown

Possible ExtractionPossible Extraction




Root FractureRoot Fracture



TreatmentTreatment


ExtractionExtraction



Oral InfectionsOral Infections


Periodontal Disease and Tooth Decay Periodontal Disease and Tooth Decay are the most common infectious are the most common infectious diseases in the United states.diseases in the United states.

Over 95% of the Population.Over 95% of the Population.








Odontogenic InfectionsOdontogenic Infections

Most common cause of an abscess in the Most common cause of an abscess in the deep spaces of the Head and Neck deep spaces of the Head and Neck

Spread of Infection depends on Spread of Infection depends on

-- Thickness of bone adjacent to toothThickness of bone adjacent to tooth

-- Position of muscle attachment in Position of muscle attachment in relation to root apexrelation to root apex

-- Host DefenseHost Defense

-- Virulence of bacteriaVirulence of bacteria


Odontogenic InfectionsOdontogenic Infections

Most common cause of an abscess in the Most common cause of an abscess in the deep spaces of the Head and Neck deep spaces of the Head and Neck

Spread of Infection depends on Spread of Infection depends on

-- Thickness of bone adjacent to toothThickness of bone adjacent to tooth

-- Position of muscle attachment in Position of muscle attachment in relation to root apexrelation to root apex

-- Host DefenseHost Defense

-- Virulence of bacteriaVirulence of bacteria


Primary SpacesPrimary Spaces

Palate Palate SublingualSublingualSubmandibularSubmandibularVestibularVestibularBuccalBuccalCanineCanineSubmentalSubmental









SublingualSublingualSubmandibularSubmandibularSubmentalSubmental

















Secondary SpacesSecondary Spaces

PterygomandibularPterygomandibular-- spread fromspread fromsubmandibularsubmandibular

MassetericMassetericTemporalTemporal

All above+ Masticator spaceAll above+ Masticator spaceSignSign-- TrismusTrismus

OrbitalOrbitalInfratemporal Infratemporal Lateral PharyngealLateral PharyngealRetropharyngealRetropharyngealPrevertebralPrevertebral



PterygomandibularPterygomandibular-- spread fromspread fromsubmandibularsubmandibular

MassetericMassetericTemporalTemporal

All above+ Masticator spaceAll above+ Masticator spaceSignSign-- TrismusTrismus

OrbitalOrbitalInfratemporal Infratemporal Lateral PharyngealLateral PharyngealRetropharyngealRetropharyngealPrevertebralPrevertebral



OrbitalOrbitalPeriPeri--OrbitalOrbital







OphthoOphthoacuity, eom, pupilsacuity, eom, pupilsCT with contrastCT with contrast

TreatmentTreatmentDrainage, AntibioticsDrainage, Antibiotics


Most odontogenic infections are caused by multiple Most odontogenic infections are caused by multiple bacterial species.bacterial species.

PrimarilyPrimarilyAerobic gram (+) cocciAerobic gram (+) cocciAnaerobic gram (+) cocciAnaerobic gram (+) cocciAnaerobic gram (Anaerobic gram (--) rods) rods

Aerobic / Anaerobic characteristicsAerobic / Anaerobic characteristicsAerobic InfectionAerobic Infection 55--7%7%Anaerobic InfectionAnaerobic Infection 30%30%Combination InfectionCombination Infection 70%70%


Aerobic SpeciesAerobic Species

Gram + rodsGram + rodsCorynebacterium, DiptheroidsCorynebacterium, Diptheroids

Gram Gram –– rods rods E. corrodensE. corrodensHaemophilusHaemophilusEnterobacteriaceaeEnterobacteriaceae

Gram + cocci (strep, staph)Gram + cocci (strep, staph)Gram Gram –– cocci (cocci (NeisseriaNeisseria))

SpirochetesSpirochetes

FungiFungi

Anaerobic SpeciesAnaerobic Species

Gram + rodsGram + rodsActinomyces, Lactobacillus, Actinomyces, Lactobacillus, Propionbacterium acnes, ClostridiaPropionbacterium acnes, Clostridia

Gram Gram –– rods rods Bacteroides, Fusobacterium, Bacteroides, Fusobacterium, WollinellaWollinella

Gram + cocciGram + cocciStreptococcus, PeptostreptococcusStreptococcus, Peptostreptococcus

Gram Gram -- coccicocciVeillonellaVeillonella


Trends Microbiology of Maxillofacial InfectionsTrends Microbiology of Maxillofacial Infections

Increase in Beta-Lactamase, E. Corrodens, S. Aureus , questionable decrease in Bacteroides

*Storoe et al; The changing face of odontogenic infection, JOMS, 2001: 59, 739-48

Unlikely shift in the types of bacteria seen in odontogenic infections in the last decade

* Haug RH, The changing microbiology of maxillofacial infections, Oral Maxillofacial Surg N Am, 2003: 15, 1-15.


Management of Odontogenic Management of Odontogenic InfectionsInfections

Determine severityDetermine severityHistory and PhysicalHistory and Physical

Imaging Studies Imaging Studies --PanorexPanorex--CT with contrast: CT with contrast:


Management of Odontogenic InfectionsManagement of Odontogenic InfectionsDetermine severityDetermine severity

Identifying drainable fluid collection in Identifying drainable fluid collection in face and neck regionsface and neck regions

•• Clinical exam: sensitivity Clinical exam: sensitivity 55%, specificity 73% 55%, specificity 73%

•• CT : sensitivity 95%, CT : sensitivity 95%, specificity 53%specificity 53%

•• CT and Clinical exam: CT and Clinical exam: sensitivity 95%, specificity sensitivity 95%, specificity 80%80%

Miller et al., Laryngoscope, 109 (11) 1999:1873-1879.


Hospital AdmissionHospital AdmissionAirwayAirway

Trismus, Floor of MouthTrismus, Floor of MouthLateral Pharynx Lateral Pharynx

FeverFeverWBCWBCImmunocompImmunocomp

DM, HIV, EtOHDM, HIV, EtOH


Hospital AdmissionHospital AdmissionAirwayAirway

Trismus, Floor of MouthTrismus, Floor of MouthLateral Pharynx Lateral Pharynx

FeverFeverWBCWBCImmunocompImmunocomp

DM, HIV, EtOHDM, HIV, EtOH

TreatmentTreatmentAirwayAirwayDrainageDrainageExtractionExtractionAntibioticsAntibiotics


OralOral 24h24h 1wk1wk

PenicillinPenicillin VV $0.56$0.56 $9.99$9.99

AmoxicillinAmoxicillin $0.93$0.93 $13.89$13.89

AugmentinAugmentin $10.95$10.95 $104.99$104.99

CephalexinCephalexin $4.28$4.28 $24.89$24.89

ClindamycinClindamycin $3.92$3.92 $31.29$31.29

$16.88$16.88 $118.27$118.27

MetronidazoleMetronidazole $2.88$2.88 $10.02$10.02

CiprofloxacinCiprofloxacin $8.30$8.30 $80.59$80.59

* * Flynn et al., Oral Maxillofacial Surg Clin N Am 15 (2003), 34.Flynn et al., Oral Maxillofacial Surg Clin N Am 15 (2003), 34.


IntravenousIntravenous

24h24h 1wk1wk

Penicillin G Penicillin G $21.28$21.28 $148.96$148.96

Ampicillin Ampicillin $21.24$21.24 $148.68$148.68

UnasynUnasyn $73.80$73.80 $516.60$516.60

Cefazolin Cefazolin $17.70$17.70 $123.90$123.90

Clindamycin Clindamycin $53.64$53.64 $375.68$375.68

Metronidazole Metronidazole $77.36$77.36 $541.52$541.52

Ciprofloxacin Ciprofloxacin $68.00$68.00 $476.00$476.00

* * Flynn et al., Oral Maxillofacial Surg Clin N Am 15 (2003), 34.Flynn et al., Oral Maxillofacial Surg Clin N Am 15 (2003), 34.


PericornitisPericornitis

Bacterial infection and Bacterial infection and inflammation of the soft tissue inflammation of the soft tissue around a partiallly erupted around a partiallly erupted third molar.third molar.

Pain, Trismus, FeverPain, Trismus, Fever

FOM SoftFOM Soft




TreatmentTreatment


Antibiotics Antibiotics –– PCN, ClindamycinPCN, Clindamycin

Chlorhexidine(.12%)/H2O2Chlorhexidine(.12%)/H2O2




TreatmentTreatment


Antibiotics Antibiotics –– PCN, ClindamycinPCN, Clindamycin

Chlorhexidine(.12%)/H2O2Chlorhexidine(.12%)/H2O2


Acute Necrotizing Ulcerative GingivitisAcute Necrotizing Ulcerative Gingivitis

Fusiform and Spirochete Bacterial Fusiform and Spirochete Bacterial infection of the gingiva.infection of the gingiva.

Signs and SymptomsSigns and Symptoms

Pain, bleeding, gingival necrosis, fever, Pain, bleeding, gingival necrosis, fever,

Foul oral odor.Foul oral odor.

TreatmentTreatment

Antibiotic Antibiotic ––PCN, ClindamycinPCN, Clindamycin

Chlorhexidine/H2O2Chlorhexidine/H2O2

Dental CleaningDental Cleaning

Oral PathologyOral Pathology


Bone PathologyBone Pathology

CystsCysts

TumorsTumors



CystsCysts

TumorsTumors



CystsCysts

TumorsTumors


Soft Tissue PathologySoft Tissue Pathology

MucoceleMucocele

Mucus ExtravisationMucus Extravisation

Mucus RetentionMucus Retention

Painless, recurrent swelling with Painless, recurrent swelling with periods of drainageperiods of drainage

TreatmentTreatment: excision of gland.: excision of gland.



CarcinomaCarcinoma

90% SCCa90% SCCa

Painful, nonhealing ulcerPainful, nonhealing ulcer

White White –– leukoplakialeukoplakia

Red Red –– erythroplakia erythroplakia



CarcinomaCarcinoma

90% SCCa90% SCCa



Red Red –– erythroplakiaerythroplakia

Adenopathy Adenopathy



CarcinomaCarcinoma

90% SCCa90% SCCa




Risk Factors:Risk Factors:

Tobacco, EtohTobacco, Etoh

No Risk FactorsNo Risk Factors



CarcinomaCarcinoma

90% SCCa90% SCCa




Biopsy Directed TreatmentBiopsy Directed Treatment

Documents

Dental Emergencies - UCSF Medical · PDF fileDental “Emergencies ... Ellis Classification Class I – Enamel Only ... Sign-Trismus Orbital Infratemporal Lateral Pharyngeal Retropharyngeal