ED dental procedures 10-SECOND SUMMARY

Ideally, a community dentist or oral surgeon should be available to assist in dental emergen- cies. When one is not, the emergency physician must be prepared to perform one or more of the following procedures.

By Walter C. Guralnick, DMD Boston, Massachusetts

EDITOR'S NOTE: This article is based on a presentation made by Dr. Guralnick during the Third An- nual ACEP Scientific Assembly Oc- tober 12-14, 1971.

I would like to address myself to the treatment of dental emergen- cies as performed by the oral sur- gical service at Massachusetts General Hospital (MGH). We see an average of 60 patients in our emer- gency department (ED) each week- end who have problems ranging from simple toothache to multiple facial bone fractures. Those of you who work in hospitals without oral surgical services might conceivably encourage ED p a r t i c i p a t i o n by community oral surgeons or den- tists with an interest in oral sur- gery. Since the ED is rapidly be- coming the community's primary health care center, it would seem logical that the dentist could and, perhaps, should participate in the team effort. In the absence of den- tal assistance,, the emergency phy- sician can certainly be prepared to perform the following procedures.

BLEEDING AFTER EXTRACTION

Postoperative bleeding following tooth extraction is seen often in the emergency department. Bleed- ing from a tooth socket does not usually create a serious problem but it is terribly frightening to the Patient and frustrating to you if

you cannot control it. This bleeding is most frequently the result of lack of compression of the clot. Usually socket bleeding can be identified by a large " l iver- l ike" clot which protrudes from the socket. As long as this clot remains, bleeding will continue. It should be wiped out with a sponge or suction tip, and then a tight gauze wad should be placed directly over the socket. The pack has to be thick enough so that when the patient bites he will exert pressure upon the bleed- ing site. With pressure sustained for 20 or 30 minutes, tooth socket bleeding is usually controlled, if it is not, other measures have to be taken.

I have long advocated that all sockets be sutured after extraction, even when a single tooth is re-

moved. This simple measure, a fundamental of any surgery, will prevent postoperative hemorrhage in most cases. Suturing does not accomplish primary closure of the wounds. Rather, it compresses the mucosa tightly against the under- lying alveolar bone and causes close adaptation of the interdental papilla to the surface of the adja- cent tooth. Bleeding most frequent- ly occurs from these two si tes-- the edges of the socket or the inter- dental papilla.

In cases of persistent bleeding, inject a local anesthetic with a vasoconstrictor, e i t h e r doing a nerve block or infiltrating. This makes it possible to operate with- out pain to the patient and also de- creases the bleeding. Redundant clot should be removed and appro- priate sutures placed across the socket. An excellent material for this use is 3-0 catgut on a cutting needle. Obviously, proper light and suction are essential for this sim- ple maneuver whether it is per- formed in a dental or ENT chair or on an operating table. An assistant to retract and use the suction is invaluable.

When neither pressure nor sutur- ing is success fu l , absorbable

Two central incisors which were avulsed and replanted have been stabilized by an arch bar.

Jan/Feb 1972 Journal of the American College of Emergency Physicians Page 23

DENTISTRY

hemostatic agents (such as Gel- foam or Surgicel) placed in the socket prior to suturing will be helpful. Finally, bleeding diatheses must be considered. I believe that patients on anti-coagulant medica- tion can have teeth safely extract- ed if they are prepared for extrac- tion by regulation of their drug dosage and confirmation of a safe prothrombin time (PT) prior to the procedure. A patient who comes to the ED with socket hemorrhage should be questioned about med- ications. If the PT is greater than one-and-a-half times the normal, the local measures already de- scribed should be taken and Vita- min K1 oxide given in addition. This is usually effective.

Patients with a history of overt or suspicious hemorrhagic disorder pose a different problem and ap- propriate laboratory studies are called for after local measures have been taken to slow bleeding. The patient should be admitted and blood or blood fraction replace- ment initiated on the basis of hematological findings. Whatever the underlying condition, it is ob- vious that the control of post- extraction bleeding begins with ob- taining anesthesia, proper cTeaning and debriding of the wound and then suturing.

Radiograph of replanted teeth.

REPLANT AVULSED TEETH

Another common emergency de- partment case is that which in- volves avulsed teeth. Children es- pecially will fall and knock out one or two incisor teeth, often with associated lacerations of the lips or chin. Teeth that have been avulsed will survive, in most cases, if they are quickly replanted.

At MGH we wash the tooth with sterile saline and immerse it in a penicil l in-streptomycin solution. It is then re-inserted into the socket. A local anesthetic is often required for this procedure, and it is im- portant to stabilize the tooth by suturing medial and distal to it or by using periodontal packing as a cementing device. Another quick and simple tactic is to wire the re- placed tooth to firm adjacent teeth. Antibiotics should be prescribed for seven to ten days and the pa- tient restricted to a soft diet.

In about three weeks, the re- planted tooth will be quite firm and its prognosis will be good. The longer the tooth has been out of the mouth, the poorer its prog- nosis. But replantation should al- ways be attempted. Time is a fac- tor and if the emergency physician is the only one available to give treatment, it is something that he

must do. Incidentally, lacerations of the mucosa and through and through l a c e r a t i o n s should be closed. The old practice of leaving intra-oral wounds open has no va- lidity. The mucosa should be as carefully sutured as the skin sur- face.

Occasionally, a group of teeth with attached alveolar bone, is dis- lodged. In such cases, reduction is accomplished by manipulation, usu- ally under local anesthesia. The vi- abil ity of both the bone and teeth is surprisingly good but depends

,on i m m o b i l i z a t i o n for several weeks.

ACUTE ALVEOLAR ABSCESS

Another common dental problem which is frequently seen in the emergency department is acute al- veolar abscess with or without cel- lulitis. The patient is in severe pain and desperately needs emergency treatment for a condition which differs from other acute inflamma- tory diseases only in its etiology. As with any other abscess, the treatment is drainage if there is fluctuation, removal of the offend- ing agent (a tooth in this instance) if this can be accomplished atrau- matically, the institution of anti- biotic therapy and supportive care when surgical intervention is im- possible.

If intra- or extra-oral fluctuation is discovered, incise and drain us- ing either local or general anes- thesia. Along with surgery, antibio- tics should be given. Statistically, the predominant organism in odon- togenic infections is a penicillin- sensitive streptococcus. Patients with severe cellulit is should be giv- en 10 million units of aqueous pen- icil l in per day in divided doses, piggy-backed to an open intra- venous line. For less severe infec- tions, oral penicil l in should be pre- scribed, 500 mg of V-Cillin, four times a day being a suggested regime. For those patients who are allergic to penicill in, erythromycin, Lincomycin, Cleocin and Ampicil l in are effective alternatives.

Page 24 Journal of the American College of Emergency Physicians Jan/Feb 1972

Dr. Guralnick is clinical professor and chair- man of the Harvard School of Dental Med- icine and chief of Oral Surgical Service at Massachusetts General Hospital. He is a diplomate of the American Board of Oral Sur- gery, president of the Massachusetts Dental Service Corporation, director of the Massa- chusetts Blue Cross and a fellow of the Inter- national Association of Oral Surgeons.

Fracture of mandible between lateral incisor and cuspid tooth. Note discrepancy in alignment.

USE ANTIBIOTICS AND SEDATION

Should dental services be un- available, the emergency physician will help the patient by utilizing both appropriate antibiotics and sedation. It should be noted that toothache pain is extremely intense and, therefore, a narcotic should be prescribed. In all cases of odon- togenic infection entering the ED, consideration should be given to the possible need for hospital ad- mission.

FACIAL TRAUMA

A large percentage of ED cases involve trauma. The initial evalua- tion and treatment of the patient with facial fractures may determine whether or not he survives. Al- though it is preferable to repair such fractures promptly, definitive treatment is not compromised if it must be deferred for as long as seven to ten days because of con- comitant life-threatening injuries. Initial attention is focused upon pat- ency of the airway, control of hem- orrhage, neurological abnormalities and internal injuries.

Respiratory e m b a r r a s s m e n t is common in cases of mandibular or mid-face fractures. It may be due to mechanical obstruction by the tongue falling back into the ore- pharynx due to a fracture at the symphysis of the mandible. This re- sults in release of the genial at- tachments. In such a case, bringing the tongue forward with a ligature tied extra-orally will relieve the ob- struction promptly. Severe hemor- rhage caused by tongue or other lacerations or nasal bleeding may also compromise respiration. Con- trol of bleeding sites must be ac-

Jan/Feb 1972

complished quickly or an alternate airway has to be provided by either endotracheal intubation or emer- gency tracheostomy. Foreign bod- ies, such as broken fragments of dentures or teeth, may occlude the airway. Suspicion of this possibility leads one to rapid, but careful, in- spection of the mouth and throat. Incidentally, dentures are not radi- opaque so missing f ragmen ts should be the subject of a thor- ough search.

After establishing an airway and arresting hemorrhage, the physi- cian should assess the patient's neurological status. Neurosurgical consultation may or may not be indicated, but will take precedence over treatment of the facial frac- tures if the history and examina- tion suggest its relevance. At the same time, thoracic and abdominal injuries must be considered before proceeding with extensive exam- ination of the facial injuries.

CLINICAL FINDINGS IMPORTANT

Both clinical and radiographic examination are important. How- ever, the ordering of appropriate films is dependent upon clinical findings. The classical signs and symptoms of lower jaw fractures are pain, either remote or at the site of impact; abnormal mobility, often evidenced by eccentric mo- tion of the entire jaw or segments of the dentition; deformity, an ob- vious finding when parts have been

Occlusal view of anterior fracture of mandible.

displaced; swell ing and ecchymo- sis; and malocclusion, a distortion of the patient's occlusion (bite).

MANDIBULAR FRACTURES

In the case of a suspected man- dibular f rac tu re , several radi- ographic views should be obtained. They include lateral oblique projec- tions, which are particularly useful in visualizing the body of the man- dible, and postero-anterior (PA) views which are helpful in assess- ing the symphysis, the condyles and possible lateral displacement of the body of the mandible. If a fracture at the symphysis is suspected, an occlusal view will be more helpful than any other in confirming it. Finally, the rather new panoramic projection we find will reveal more, in a single film, than any other radiograph of the mandible.

MID-FACE FRACTURES

Assessment of the zygomatic- maxillary complex 'is somewhat more complicated. Extensive ede-

Postoperative panoramic radiograph of fractured mandible.

DENTISTRY

ma occurs rapidly, making it diffi- cult to diagnose the underlying skeletal injuries. Still, a systematic examination, combined with proper radiographs, will result in accurate diagnosis.

On inspection, an elongated face and bilateral circumorbital ecchy- mosis will be noted in mid-face f ractures-- the result of dropping of the maxilla. At the same time, in LeFort II or III type fractures, the posterior teeth often cause "gagging" of the occlusion (pre- vent closure) and the patient will appear to have an open bite. If the patient is seen shortly after injury, flattening of the upper part of the cheek may be noted and will indi- cate a zygomatic fracture. It is best to inspect for this finding by stand- ing behind the patient and sighting from above the superior orbital margin. Bleeding from the nose or ears can mark cerebrospinal fluid (CSF) leakage. Although it is some- times difficult to confirm CSF leak- age, the presence of this leakage is suggestive of a LeFort II or III type fracture.

INSPECT THE EYES

Other important findings will be gained from inspection of the eyes.

Note any discrepancy of the ocular level as judged by a line projected between the pupils. A "blow-out" fracture with herniation of the or- bital contents into the antrum will cause the injured orbit to be at a lower level than the normal one. Subconjunctival ecchymosis may indicate fracture of the lateral or- bital wall, part of the typical tripod fracture of the zygomatic complex. Restriction of ocular movements will be diagnostic of muscle en- trapment in orbital floor injury, and diplopia is also suggestive of dis- ruption of the orbit by a zygomat- icomaxillary fracture.

Inspection should be followed by palpation. The index finger should be moved over the entire orbital rim to note tenderness, step de- fects and crepitus. Pay particular attention to the zygomaticofrontal and zygomaticomaxil lary sutures. if the patient is conscious and re- sponsive, any anesthesia of the cheek, nose and lip is very sug- gestive of a fracture through the infraorbital or zygomatic branches of the Trigeminal nerve.

ORAL EXAMINATION

Next, intra-oral e x a m i n a t i o n should be done. Gross mobility of

Skeletal fixation for fractures of middle third of face.

the maxilla should be tested by holding the bridge of the nose with one hand while grasping the upper anterior teeth with the other hand. Movement can be seen and felt as it is transmitted to the firmly grasped nasal bones. There may be ecchymosis of the upper buccal sulcus as well as anesthesia of the gingiva and teeth in the area. Frac- tures of the lateral antral wall and zygomatic buttress can sometimes be palpated. During this examina-

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Another view of case no. 6 .

Journal of the American College of Emergency Physicians

Testing maxi l la mobility.

Jan/Feb 1972

tion, gagging (open-bite) may oc- cur due to displacement of the maxilla, or limitation of mandibular movement may result from impinge- ment of a fractured zygomatic arch upon the coronoid process of the mandible.

X-RAY VIEWS

On the basis of clinical findings, we suggest certain radiographic views. The Waters and Caldwell views (also known as the Occipito- mental projection) is the single most useful film for demonstrating fractures of the zygomaticomaxil- lary complex. The orbital rims, zygomatic arches and antra are all visualized. In addition, a sub- mento-vertical (Jug Handle) view will demonstrate a zygomatic arch fracture which other films might miss. No radiographic examination of a patient with multiple facial fractures is complete without a PA and lateral skull films to investigate possible cranial injury. The useful- ness of tomograms is probably lim- ited to cases of questionable blow- out fractures where tomography may confirm what was suggested in a Waters view.

Eyebrow approach to zygomatico.facial complex fractures.

Blephoroplasty approach for exploration of orbital floor fractures.

TREATMENT

Before transferring your accident victim to the operating room for definitive surgery, you may want to consider following the advice of James Cooke, who wrote The Mar- row of Surgery in the 17th century.

"To restore f r ac tu res of the jaws," h e said, "put your thumbs into the patient's mouth, pressing them on the in and out sides, till smooth set; if need, extend. If any of the teeth be new taken out, put them in their own sockets where they may fix. The splints to be made of leather, divided at the chin. The ligatures two fingers broad, with four ends. Two to fast- en each side of the cap crown, the other two to the cap on the nape of the neck. Purge oft, and let the diet be liquid and sparing. 'Tis well set, the teeth being in order. 'Tis knit in twenty days, if inflammation happen noW' [ ]

Inspection of orbital floor.

Insertion of silasfi¢ implant.

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