Dental Emergencies

Educational Objectives

The goal of this program is to improve treatment of dental emergencies. After hearing and assimilating this program, the clinician will be better able to:

1. Perform basic dental nerve blocks.

2. Evaluate and treat common dental infections.

3. Recognize and manage dental trauma.

Summary

Dental anatomy: crown — top of tooth; root — bottom of tooth; specialized structures — enamel, dentin, pulp (location of neurovascular bundle); below gingival line, enamel changes to cementum; acts as bridge between periodontal ligament (PDL) and gingiva; attachment apparatus holds tooth in place and includes PDL (which forms attachments between roots, gingiva, and alveolar bone), cementum, and alveolar bone; periodontium refers to attachment apparatus and gingiva; deciduous teeth — 20 baby teeth; identify incisors, canines, and molars; succedaneous teeth — 32 adult teeth (including wisdom teeth); adult teeth numbered for reference; recognize type of tooth and describe area of involvement

Physical examination: intra-oral — feel along floor of mouth and underneath tongue; check for trismus; check for lesions and occult abscesses; extra-oral — check cranial nerves; look inside ears, around eyes, below mandible, and around thyroid and neck

Imaging: most patients do not require imaging; indications for computed tomography (CT) of face (including mandible) — complicated infections; intrusion or avulsion injuries; mandible fractures; alveolar ridge fractures; radiation exposure — 0.002 to 0.005 mSv from single dental x-ray; panoramic x-ray (Panorex) exposes patient to 2-fold more radiation than single film; CT of maxilla and mandible exposes patient to ≈3 mSv (background radiation for 1 yr)

Dental blocks: reassure patient pain will disappear within 1 to 2 min after sting from injection; establish rapport with patient to ensure adequacy of anesthetic procedure; apply topical anesthetic to dried mucosa (dulls 75% of pain from injection); superior alveolar nerve — branches off maxillary nerve for upper teeth (V2); inferior alveolar nerve — branches off mandibular nerve for lower teeth (V3)

Maxillary nerve block: supraperiosteal block — works for upper or lower teeth; use as local or field block for individual tooth; retract lip and reflect mucobuccal fold; aim for apex of tooth root; deposit anesthetic at base along periosteum; cancellous bone absorbs anesthesia to anesthetize nerve roots entering tooth; effective for single tooth and may be effective for tooth in front and behind involved tooth

Superior alveolar nerve block: zygomatic arch comes out to inferior alveolar rim; anterior and middle branches of superior alveolar nerve lie in front; target location where infraorbital nerve comes out from orbital rim and deposit 2 mL of anesthetic into mucosa; go to back side of zygomatic arch to locate posterior branch of superior alveolar nerve

Inferior alveolar nerve block: place finger inside patient’s mouth and touch anterior ramus of mandible; place thumb behind ramus and cradle ramus between finger and thumb; target location inside mouth between finger and thumb; approach from opposite side of mouth to insert needle into mucosa until hit bone, then back up and inject anesthetic; modified block (Akinosi block) useful in patients with trismus

Infections: start in pulp; cracked or decaying tooth causes inflammation of pulp; edema or swelling create compartment syndrome inside tooth; increasing inflammation, pressure, and pain progress to apex of root; inflammation of PDL and attachment apparatus (ie, apical periodontitis) can progress to apical abscess, periapical abscess, and periodontal abscess; infection ascends attachment area, enters bone, and exits gingiva; patient presents with osteomyelitis, periostitis, or dental abscess

Localized periodontal abscess: most common dental infection; pus emerges from gingival sulcus when pushing on tooth; perform nerve block before examination; use dental elevator for incision and drainage; prescribe oral antibiotics and chlorhexidine (Peridex) rinse; encourage soft diet; splint tooth (if required); patient should follow up with dentist in 24 hr

Intra-oral periodontal abscess: presents as large fusiform swelling typically on labial (not palatal) surface; technique — perform nerve block; incise along bone (fails when incision does not occur along periosteum); insert forceps to break up loculations; consider injection of local anesthetic with epinephrine before breaking up loculations to minimize bleeding; place Penrose drain and remove in 1 to 3 days; considered high-risk extra-oral infection with increased risk for spread and complications; start intravenous antibiotics; order CT and contact ear, nose, and throat department for definitive management

Trauma

Concussion: damaged, tender tooth with no displacement or mobility; minimal damage to PDL; neurovascular bundle intact; recommend soft diet, chlorhexidine rinse, and close follow-up with dentist; good outcomes

Subluxation: more damage to PDL; tooth moves within socket; extent of injury to PDL determines outcome; splint tooth to adjacent 1 or 2 teeth using periodontal dressing material (eg, Coe-Pak)

Luxation: more catastrophic; categorized as intrusive (into bone), extrusive (out of bone), or lateral; tooth displaced out of socket; extrusive luxation — rinse and reposition tooth; repair gingival lacerations; prescribe antibiotics; endodontic repair and root canal often required; lateral luxation — unroof tooth from bony perch and replace in socket; associated with underlying fractures of alveolar bone (consult maxillofacial surgeon); intrusive luxation — tooth often pushed so far into socket that it disappears; use imaging to locate tooth; consult dentist before manipulation of tooth; immature root tolerates intrusion ≤7 mm (little tolerance with mature roots); repair gingiva; use soft splint; refer to dentist for same-day care

Avulsion: complete removal of tooth; replace tooth within ≤1 hr or preserve in medium; avoid manipulation of PDL; use saline, Hank’s Balanced Salt Solution, or milk for storage (avoid water)

Fracture: broken tooth; class 1 — enamel only; uncomplicated; low risk for infection; class 2 — down to dentin; uncomplicated but very sensitive; cover with calcium hydroxide paste; class 3 — extension to pulp; require antibiotics and temporary filling or covering; high risk for pulp infection without restorative procedure; crown-root fractures — treated like avulsion injury with replacement of tooth; refer for endodontic treatment

Pediatric considerations: do not re-implant deciduous teeth; children undergo pulpotomy (“mini” root canal)

Complications: cavernous sinus thrombosis — 10% result from complicated dental infections; present with altered mental status, headache, and cranial nerve palsies (eg, abducens nerve palsy); poor prognosis without surgical intervention and broad-spectrum antibiotics; anticoagulation controversial; Ludwig’s angina — primarily odontogenic; begins as cellulitis and progresses to deep space infection into mediastinum; airway management can be problematic; start broad-spectrum antibiotics; perform fiberoptic intubation through nose; consult surgery

Readings

Abbott P, Leow N: Predictable management of cracked teeth with reversible pulpitis. Aust Dent J. 2009 Dec;54(4):306-15; DeAngelis AF et al: Review article: maxillofacial emergencies: oral pain and odontogenic infections. Emerg Med Australas. 2014 Aug;26(4):336-42; Douglass AB, Douglass JM: Common dental emergencies. Am Fam Physician. 2003 Feb;67(3):511-17; Herrera D, Sanz RSM: The periodontal abscess: a review. J Clin Periodontol. 2000 Jun;27(6):377-86; Khalil H: A basic review on the inferior alveolar nerve block technique. Anesth Essays Res. 2014 Jan-Apr;8(1):3-8; Khan L: Dental care and trauma management in children and adolescents. Pediatr Ann. 2019 Jan 1;48(1):e3-8; Nusstein JM et al: Local anesthesia strategies for the patient with a “hot” tooth. Dent Clin North Am. 2010 Apr;54(2):237-47; Pedigo RA: Dental emergencies: management strategies that improve outcomes. Emerg Med Pract. 2017 Jun;19(6):1-24.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose. 

Acknowledgements

Dr. Barnes was recorded at the 15th Annual Emergency Medicine Update Hot Topics 2018, held November 6-10, 2018, on Maui, HI, and presented by UC Davis Health, Department of Emergency Medicine Conference and Event Services Office of Continuing Medical Education. For information about upcoming CME activities presented by UC Davis Health, Department of Emergency Medicine Conference and Event Services Office of Continuing Medical Education, please visit: health.ucdavis.edu/cme. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

EM362401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.