Project: Ghana Emergency Medicine Collaborative

Document Title: Dental Emergencies and Common Dental Blocks

Author(s): Joe Lex, MD (Temple University School of Medicine)

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2

Dental Emergencies and

Common Dental Blocks

Joe Lex, MD, FACEP, MAAEM

Associate Professor, Department of

Emergency Medicine

Temple University School of Medicine

Philadelphia, PA 3

Disclosure

No conflicts

of interest 4

Objectives

1. Understand that teething does

not cause fever

2. Define, recognize, and treat

pericoronitis, periapical abscess,

and alveolar osteitis

3. Describe treatment for ANUG

4. State three ways to treat bleeding

gums 5

Teeth

6

Vlad2i (Wikimedia Commons)

How Many Teeth?

32 permanent

• 8 incisors

• 4 canines

(cuspids)

• 8 premolars

(bicuspids)

• 12 molars

(tricuspids)

20 primary or

deciduous

• 8 incisors

• 4 canines

• 8 molars

7

How to Name the Teeth

8

Gray's Anatomy (Wikipedia)

How to Number the Teeth

9

11

Permanent Teeth

Permanent maxillary

Right first molar

Permanent mandibular

right third molar

Permanent maxillary

Left second premolar

Permanent mandibular

left canine

Kaligula (Wikipedia)

Definitions

• Interproximal: surfaces between

two adjacent teeth

• Mesial: interproximal surface

facing toward midline

• Distal: interproximal surface

facing away from midline

• Occlusal: chewing surface

12

Definitions

• Labial: toward the lips, specific to

anterior teeth

• Buccal: toward the cheek, specific

to posterior teeth

• Palatal: toward the palate, specific

to maxillary teeth

• Lingual: toward the tongue,

specific to mandibular teeth 13

Definitions

• Apical: toward the tip of the root

of the tooth

• Radicular: associated with the

root, especially the apical region

• Coronal: toward the crown of the

tooth

• Incisal: toward the biting edge of

incisors 14

Basic Anatomy

• Dentin surrounds pulp, which is

neurovascular supply

• Crown: enamel on dentin, visible

portion of tooth

• Root: cementum on dentin,

extends into the alveolar bone

15

16

Sam Fentress (Wikipedia)

Basic Anatomy

• Periodontium = attachment

apparatus

• Periodontal ligament = collagen

fibers that extend from alveolar

bone to root of tooth

• Gingivitis and periodontal disease

destroy peridontium tooth

mobility and loss 17

Basic Anatomy

• Gingiva = keratinized stratified squamous epithelium

– Free gingiva: 2- to 3- mm-deep gingival sulcus in disease-free state

– Attached gingiva: adheres to alveolar bone and extends to oral vestibule, floor of mouth

• Nonkeratinized alveolar mucosa covers cheeks, lips, floor of mouth

18

Healthy teeth

Dozenist (Wikipedia)

19

Healthy teeth Source Undetermined

20

Teething

Mathowie (Flickr)

ratterrell (Flickr)

21

About ye seveth moneth, sometime more,

sometime lesse, after ye byrth, it is natural

for a child to breed teeth, in which time

many one is sore vexed with sondry

diseases and pains, as swelling of ye

gummes and jaws, unquiet crying fevers,

cramps, palsies, fluxes, reumes and other

infirmities, specially when it is long or ye

teeth come forth, for the sooner they appear

the better and the more ease it is to the childe.

Thomas Phayre – 1530

The Boke of Children, London

22

Death by Teething!!

• Common “Cause of Death” in

Middle Ages

• Usually weaned at same time

• Frequently lance erupting tooth

• Malnutrition from watered-down

milk

• Typhus from infected milk

23

Teething

• No data support association of

teething, fever, and diarrhea

• Possible mild dehydration from

excessive salivary production or

decreased intake

• Must seek other source

for fever, diarrhea

24

Teething

Capital M (Flickr)

25

Teething

Boston Public Library (Flickr)

26

Toothache

27

Impacted Wisdom Teeth

28

Source Undetermined

Wisdom Teeth

• Vestigial third molars

• Used to help grind down plants

• Diets changed smaller jaw

• Agenesis ranges from practically

zero in Tasmanian Aborigines to

~100% in indigenous Mexicans

• Related to PAX9 gene

29

Pain from Wisdom Teeth

• Pericoronitis: inflammation of

gingival tissue overlying occlusal

surface of erupting tooth

(operculum)

• Masseter irritation trismus

• Rx irrigate debris, analgesia,

dental referral

30

Operculum = lid

Pericoronitis

31 Source Undetermined

Pericoronitis

32

Source Undetermined

Dental Caries

• Loss of tooth enamel integrity due

to exposure to acidic metabolic

byproducts of plaque bacteria

• Early: sensitive to cold or sweet

• Later: direct communication with

dental pulp “pulpitis”

• Irreversible pulpitis: protracted

pain 33

Dental Caries

34 Source Undetermined

Dental Caries

Source Undetermined 35

Antibiotics for Toothache??

• Undifferentiated dental pain

without overt infection

• Penicillin vs. placebo

• Evaluation at enrollment, again at

5- to 7-day follow-up

• Outcome measure: overt dental

infection at follow-up

Acad Emerg Med. 2004 Dec;11(12):1268-71. 36

Antibiotics for Toothache??

• 13 / 134 patients (9%) developed

infection

– 6/64 (9%) in penicillin group

– 7/70 (10%) in placebo group

• No significant difference in

baseline characteristics,

compliance, VAS pain scores

Acad Emerg Med. 2004 Dec;11(12):1268-71. 37

Antibiotics for Toothache??

• CONCLUSIONS: “These data

support the hypothesis that

penicillin is neither necessary nor

beneficial in the treatment of

undifferentiated dental pain in the

absence of overt infection.”

Acad Emerg Med. 2004 Dec;11(12):1268-71. 38

Periapical Abscess

• Most common source of severe

odontogenic pain: periapical

• Most common lesion: periapical

granuloma = periradicular

periodontitis, results from pulpitis

• X-ray widened periodontal

ligament space (radiolucent stripe)

39

Widened periodontal

ligament space 40

Source Undetermined

Periapical lucency Source Undetermined

41

Periapical abscess 42

Source Undetermined

Periapical Abscess

• Exquisite pain with percussion

• Suppurative periodontitis = parulis

• X-rays rarely indicated

• Rx antibiotic (penicillin still best),

analgesia, referral

• Definitive treatment: extraction or

root canal

43

Parulis = Fistula = Gum Boil

44 Source Undetermined

Parulis = Fistula

Source Undetermined 45

Postextraction Pain

• Periosteitis: 24 to 48 hours,

common, easily treated

• Alveolar osteitis = dry socket:

second or third post-op day

exquisite oral pain due to bone

exposed to oral environment

46

Dry Socket

47 Source Undetermined

Dry Socket

• Up to 35% after impacted 3rd molar removal

• X-ray for retained root tip

• Irrigate socket with sterile saline

• Pack socket with gauze soaked in oil of cloves or eugenol

• Relief is immediate

• Antibiotic if severe

48

www.nysora.com/techniques/oral_maxilla/

49

Upper Incisors & Canines

• Innervated by superior alveolar

nn, branches of infraorbital n.

• Anastamose over midline

• Nasopalatine innervates palatal

gingiva, mucosa, periosteum

• Maxillary bone has porous lamina

50

Upper Incisors & Canines

Dozenist (Wikipedia)

51

Upper Incisors & Canines

• Anesthetized by buccal fold

infiltration

• Introduce near bone, inject

adjacent to tooth

• Slow injection 1 – 2 ml solution

• Central incisors: avoid nasal spine

52

Upper Incisors & Canines

53

Source Undetermined

Infraorbital Nerve Block

Area of Anesthesia

Infraorbital N.

Barry Langdon- Lassagne (Wikimedia Commons)

55

Infraorbital Nerve Block

57

Source Undetermined

Upper Premolars

• Convergent branches of superior,

posterior, and anterior alveolar

nerves superior dental plexus

• Greater palatine nerve palate

• Both irregular, may vary from

person to person

59

Upper Premolars

• Infiltrate buccal

fold next to

tooth

• 1.0 – 1.5 ml at

apex

62 Source Undetermined

Supplemental Palate Injection

• Use small

volume (~0.5

ml) – hurts

like crazy

63 Source Undetermined

Palatal Nerve Block

64

Source Undetermined

Upper Molars

69

Source Undetermined

Upper Molars

• Buccal infiltration: puncture mesial

fold close to tooth

• Advance upward and backward

until bone felt

• Inject 1 – 2 ml solution

70

Upper Molars

71 Source Undetermined

So for most upper teeth…

Local infiltration

is sufficient

73

Lower Incisors & Canines

75

Source Undetermined

Lower Incisors & Canines

• Innervated by incisive nerve

• Lies within bone, but can be

anesthetized by diffusion through

thin, porous mandibular bone

lamina

• Tip of needle must contact bone in

lower front

77

Lower Incisors & Canines

• Buccal soft tissue:

mental nerve

• Lingual gingiva &

periosteum: sublingual

nerve

78

Lower Incisor Block

• Patient supine

• Inject through

buccal fold near

tooth

79

Lower Premolars

• Local blocks don’t work

• Primarily inferior alveolar nerve

• Premolar buccal gingiva buccal

nerve

• Lingual gingiva sublingual

nerve

• Mental foramen: below and

between premolar apices 81

Mental Nerve Block

Area of Anesthesia Nerve Block

Barry Langdon- Lassagne (Wikimedia Commons)

82

Mental Nerve Block

84

Source Undetermined

Supplementary Lingual Nerve Block

• Use 0.5 – 1 mL

Source Undetermined

85

Lower Molars

• Apices embedded in thick

compact bone

• Local blocks don't work

• Inferior alveolar nerve

87

Inferior Alveolar Nerve Block

91 Source: NYSORA.com

Inferior Alveolar Nerve Block

Source: NYSORA.com 92

Inferior Alveolar Nerve Block

Source Undetermined 93

Facial Landmarks

95 Gray's Anatomy (Wikipedia)

www.nysora.com/techniques/oral_maxilla/

96

Frenum Diastema

i.e., gap-toothed 97 Source Undetermined

Tetracycline Staining

98 Source Undetermined

Gums Source Undetermined

99

Periodontal Disease

• Gingivitis: accumulation of plaque

along gum margins

• Causes: bad hygiene, hormonal

variations (puberty, pregnancy),

medications (phenytoin), etc.

• Sulcus deepens pockets

periodontitis mineralization

bone loss tooth loss

100

Periodontal Disease

101 Source Undetermined

Periodontal Disease

Source Undetermined 102

ANUG

• Acute Necrotizing Ulcerative

Gingivitis = Vincent ´s disease =

trench mouth

• Diagnostic triad: pain + ulcerated

or “punched out” interdental

papillae + gingival bleeding

• Etiology unclear, but opportunistic

• Anaerobes always present

103

ANUG

• Invades otherwise healthy tissue

• Treatment:

– Identify, treat predisposing factors

– Chlorhexidine oral rinses twice daily

– Debridement and scaling by dentist

– Metronidazole 250 mg tid

– Supportive therapy: soft diet rich in

protein and vitamins

104

ANUG

105 Source Undetermined

ANUG

106 Source Undetermined

ANUG

Source Undetermined 107

Gingival Hyperplasia

• Associated with many commonly

used medications

• 50% of patients on chronic

phenytoin

• Also calcium channel blockers

(especially nifedipine) and

cyclosporine.

• Treatment: fastidious oral hygiene

108

Gingival Hyperplasia

109 Source Undetermined

Bleeding Gums

• Hemorrhage after scaling easily

controlled with peroxide mouth

rinses or direct gingival pressure

• Clotting factor deficiencies,

leukemia, and end- stage liver

disease may first present as

spontaneous gingival hemorrhage

• Treatment: based on cause

110

Bleeding Gums

111 Source Undetermined

Bleeding Gums

Source Undetermined

112

Post-Extraction Bleeding

Usually a dislodged clot

1. Firm pressure usually adequate:

folded 2 × 2 gauze pad placed over

extraction site, then firm pressure by

clenching teeth for 20 minutes

2. Tea bag: tannic acid is hemostatic

3. Gel-Foam, Avitene, or Instat sutured

snugly into socket

4. Infiltrate lidocaine with epinephrine 113

Pyogenic Granuloma

• “Pregnancy tumor”

• Benign proliferation of connective

tissue, primarily on gingiva

• Not pyogenic, not a granuloma

• Usually recurs if removed during

pregnancy

• If not regressed 2 to 3 months

postpartum, definitive removal 114

Pyogenic Granuloma

115

Source Undetermined

Source Undetermined

Pyogenic Granuloma

Source Undetermined 116

I got a tooth knocked out

msspider66 (Wikimedia Commons)

117

I got a tooth knocked out

• Rinse with water; do not scrub

• Hold gently by crown, not root

• In cooperative adult, gently put

back in socket

• Transport tooth to doctor or dentist

in saline, milk, or saliva

– Dry tooth will damage in minutes

118

I got a tooth knocked out

• Child, uncooperative adult: "tooth

saver" solution

• Loosened, pushed in, broken

teeth: avoid eating or drinking

• Tooth broken in pieces: retrieve

parts and transport in suggested

solutions as above

119

I got a tooth knocked out

• 90% of replantations performed

within 30 minutes are successful

• If wait 2 hours, falls to 5%

• Insert slowly into socket, hold

pressure for 10 to 15 minutes

– If forced abruptly, will be extruded

• Consult dentist

Lind GL. Anesth Analg

61(5):469, May 1982 120

I got a tooth knocked out

• Stabilization with arch bars and

wires for two weeks

• If primary (baby) tooth, no long-

term problems anticipated

– Primary tooth: blue-white

– Permanent tooth: yellow-white

– No reimplantation if primary

121

I got smacked in the mouth

• Remove debris, especially tooth or

denture fragments

• Irrigate copiously

• Avoid radical debridement

• Can close up to 24o after injury

• Penicillin (or erythromycin) for

through and through, but no

studies Potter BC. Amer Fam Phys

18(5):96,1978 122

I got smacked in the mouth

• Tongue cuts:

rarely need

repair

Potter BC. Amer Fam Phys

18(5):96,1978 123

Source Undetermined

I got smacked in the mouth

• Cheek / lip cuts:

close to prevent

food entrapped

• Frenulum cut: let

heal on own

Source Undetermined

Source Undetermined 124

And finally…

Intentional pain

And the taste of gums bleeding

Prevent toothlessness

Morsels sit between my teeth

Minty, waxy nylon thread

Saves my smile

Two Flossing Haiku

125