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Dental Trauma in the ED: Fractures and Luxations

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Dental Trauma in the ED: Fractures and Luxations Resident Grand Rounds Elizabeth Haney 10 May 2007 Outline Review of anatomy, and pertinent basics Injury Overview ... – PowerPoint PPT presentation

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Title: Dental Trauma in the ED: Fractures and Luxations


1
Dental Trauma in the ED Fractures and Luxations
  • Resident Grand Rounds
  • Elizabeth Haney
  • 10 May 2007

2
Outline
  • Review of anatomy, and pertinent basics
  • Injury Overview
  • Management
  • New products coming and how to use them
  • Thanks to Dr. Greenfield,
    Dr. Kalaydjian and Dr. Lobay

3
Goal
  • For you to leave today feeling more confident
    with your management and disposition of dental
    injuries.

4
Emerg Issues in Dental Injuries
  • Pain Management
  • Oral Meds
  • Nerve Blocks
  • Covering the Exposed Root
  • Keep tooth alive
  • Transient Storage Media
  • Stabilization until definitive management (ie
    referral to our Dental colleagues)
  • Periodontal Paste

5
Numbers in the CHR
  • Interrogation of CHR initial complaints
  • April 1 2006 March 31 2007
  • FMC, RGH, PLC
  • 1868 Dental/Oral related visits as primary
    complaint
  • 2006 Health Records Info
  • 196 discharge codes for Dental specific Dx

6
Anatomy of a Tooth
7
Which tooth is it?
Upper Right 1 Upper Left 2
Lower Right 4 Lower Left 3
  • Numbering System Differences
  • 32 adult teeth
  • 4 incisors (most commonly injured)
  • 2 canines
  • 4 premolars
  • 6 molars

8
Tooth Surface Terminology
  • Lingual surface faces tongue
  • Buccal surface faces cheek
  • Mesial surface faces midline
  • Distal surface faces ramus of mandible

9
Fractures
  • Ellis classification used in Emerg
  • General description used/preferred by Dentists
  • ie instead of Ellis III, saying exposing the
    pulp

10
Enamel Fractures
  • Non painful
  • Chalky white appearance
  • Reassurance
  • Consider filing sharp edges
  • Non-urgent Dentistry referral

11
Dentin Fractures
  • May have sensitivity (temp, air, percussion)
  • Yellow dentin visible
  • Management
  • Block the tooth
  • Dry tooth
  • Cover the tooth (CaOH)
  • Dental f/u within 24h

12
Pulp Fractures
  • Yellow dentin and pink blush or frank blood
  • Usually Painful
  • Block the tooth
  • Dry the tooth
  • Cover the tooth (Calcium Hydroxide)
  • Dental Consult if unable to manage pain
  • Most require eventual root canal

13
Fractures Summary
  • All require Dentistry follow-up
  • Enamel s non-urgent (1-2 weeks)
  • Dentin s within 24 hours
  • Pulp s Immediate if possible, next day at
    latest

14
Subluxation, Luxation, Avulsion
  • Subluxation Loose Tooth
  • Luxation Displaced Tooth
  • Intrusive displaced into socket (apically)
  • Extrusive displaced out of socket
  • Lateral displaced any other way
  • Avulsion Completely Out
  • Pain Control!

15
Subluxation
  • Increased mobility due to torn PDL fibers
  • Tender to touch
  • Not displaced
  • If minimally mobile
  • Soft diet
  • Non-urgent dental f/u
  • If grossly unstable
  • Stabilize Dentist Consult, or stabilize in ED
    and Dentist in AM

16
Intrusive Luxation
  • Apical displacement into alveolar bone
  • Crushes PDL /- neurovascular supply rupture
  • Immobile
  • R/O avulsion if completely intruded
  • Consult Dentistry semi-urgent basis

17
Extrusive Luxation
  • Tooth appears long
  • Mobile
  • Gently reposition into socket
  • Stabilize
  • Consult Dentistry

18
Lateral Luxation
  • Tooth displaced, apex moved close to bone
  • Usually immobile
  • Reposition
  • Stabilize
  • Consult Dentistry

19
Avulsion
  • Completely out of socket
  • Torn PDL w/ fragments on root and in socket
  • Locate tooth!
  • Place the avulsed tooth in cold, isotonic
    solution
  • Consult Dentistry
  • 1 chance of successful reimplantation lost q1min
    out of socket (dry)

20
General Avulsion Guidelines
  • Handle tooth by the crown (Minimize PDL damage) 
  • Transport in appropriate media (next slide)
  • Gently rinse (wiping can remove PDL)
  • Flush socket with saline
  • In ED, replant tooth, stabilize

21
Tooth Storage Media
  • Order of Preference
  • Hanks (ph) balanced salt solution (HBSS)
  • Cold milk
  • Saliva
  • Saline
  • Water
  • NEVER Dry

Ozan et al. J Endod May 2007
22
Find the Tooth!
23
Dentistry Splinting Estimates
24
Stabilization and Capping Products
  • Periodontal Paste Calcium Hydroxide
  • Do we have them in the ED?
  • NO. Not yet
  • Im working on getting us samples and will keep
    you posted via e-mail

25
New Products and How to Use Them
  • Coe-Pak
  • Surgical dressing Periodontal pack
  • Supplied in 2 tubes base catalyst
  • Mix together into paste
  • Roll into appropriate width length
  • Press against mucosa and teeth, flanking the
    injured tooth
  • Do not cover occlusal surface

26
Ca Hydroxide
  • Rigid self-setting material used for pulp capping
    as a protective base/liner under dental filling
    materials
  • Supplied in 2 tubes base catalyst
  • Dispense equal volumes onto paper
  • Stir using applicator until uniform color
    (10sec)
  • Apply to dried area
  • Remove excess
  • Set time 2-3 min on paper, less in mouth

27
Its 2am.Do I Call the Dentist?
  • Dental Emergencies
  • Avulsion
  • Fracture to Pulp, if unable to control pain
  • Any luxation
  • Dental Hemorrhage
  • Abscess needing drainage which is beyond our
    scope
  • Jaw - OMF surgeon
  • If theyre coming in ? Order a Panorex

Thanks Dr. Kalaydjian
28
CHR Dentists On-Call Policy
  • Full coverage
  • Each dentist 1 call q 2-3 weeks
  • Call back within 5-10 minutes, able to be at
    hospital within 30 minutes
  • No formal compensation (only if pt pays)
  • Great policy on helping ED pts!
  • Be Kind ?

29
CHR Resources
  • CHR Dental Clinic Only medically compromised
    patients as regulars
  • CHR funded Community Dental Clinics Patients
    pay 20 of actual fee
  • Call 228-3384 22-teeth
  • Sites City Hall Dental Clinic, Northeast Dental
    Clinic (Sunridge Mall), Airdrie
  • www.calgaryhealthregion.ca/hecomm/oral/reducedfeed
    ental.htm

30
Take Home Points
  • Know the terminology, or where to find it
  • Proper communication Happier consultants
  • Manage the pain
  • We temporarily manage these injuries
  • Definitive management left to the pros
  • Know your tools and resources

31
Future Initiatives
  • Stocking of Stabilization and Capping products
  • Dental Trauma Patient Instructions
  • Dedicated space in the Emerg for a dentistry
    locked box of supplies

32
References
  • Marx. Rosens Emergency Medicine Concepts and
    Clinical Practice, 6th ed. 2006. ch. 69 Oral
    Medicine
  • Andersson et al. Guidelines for the management of
    traumaticdental injuries. I. Fractures and
    luxations of permanent teeth. Dental Traumatology
    2007 23 66-71
  • Becker et al. Drug Therapy in Dental Practice
    Nonopioid and Opioid Analgesics. Anesth Prog
    2005 52140-149
  • Dale RA. Dentoalveolar trauma. Emerg Med Clin
    North Am 200018 521-38
  • Po AL, Zhang WY Analgesic efficacy of ibuprofen
    alone and in combination with codeine or caffeine
    in post-surgical pain A meta-analysis.  Eur J
    Clin Pharmacol  1998 53303
  • Benko et al., Management of Dental Emergencies.
    EM Reports. Vol 27, N. 3. January 2006
  • Lynch MT, Syverud SA, Schwab RA, et
    al Comparison of intraoral and percutaneous
    approaches for infraorbital nerve block.  Acad
    Emerg Med  1994 1514
  • Harkacz O, Carnes D, Walker W. Determination of
    periodontal ligament cell viability in the oral
    rehydration fluid Gatorade and milks of varying
    fat content. J Endod 19972368790
  • Ozan et al. Effect of Propolis on Survival of
    Periodontal Ligament Cells New Storage Media for
    Avulsed Teeth. J Endod 200733570-573
  • EMRap November 2006 Dental Trauma
  • www.calgaryhealthregion.ca/hecomm/oral/reducedfeed
    ental.htm

33
Extra Slides
34
Useful Nerve Block Review
  • Supraperiosteal - Individual Teeth
  • Infraorbital Maxillary Teeth and Upper Lip
  • Inferior Alveolar Mandibular Teeth
  • Mental Lower Lip

35
But 1st ? Topical Anesthesia
  • Dry area w/ gauze
  • Hold swab w/ 4 lidocaine to area
  • 2 minutes

36
Supraperiosteal Block
  • Individual tooth anesthesia
  • How to
  • Pt closes mouth slightly, relaxed
  • Pull lip taut with gauze
  • Bevel facing bone, insert _at_ mucobuccal fold
  • Advance to apex
  • Aspirate
  • Inject 1-2 cc marcaine slowly

37
Infraorbital Nerve Block
  • Anesthetizes the midface
  • How to (intraoral approach)
  • Keep a finger over the inferior border on the
    infraorbital rim
  • Retract cheek
  • Puncture opposite the upper second bicuspid
    (premolar) 0.5 cm from buccal surface
  • Needle parallel w/ tooth
  • Advance until palpated near the foramen (2.5cm
    depth)
  • Aspirate
  • Inject 2-3cc marcaine adjacent to, not within,
    the foramen

38
Inferior Alveolar Nerve Block
  • Anesthetizes the hemimandible, lower lip chin
  • How to
  • Palpate the anterior ramus border
  • Retract buccal tissue laterally, stabilize
    mandible with finger behind ramus

39
Inferior Alveolar Nerve Block
  • Syringe barrel oriented over the contralateral
    mandibular bicuspids
  • Insertion site 1cm above occlusal surface of
    3rd molar
  • Insert until needle point touches medial surface
    of ramus
  • Back up 1mm
  • Aspirate
  • Inject

40
Mental Nerve Block
  • Anesthetizes lower lip
  • Infiltration about the mental foramen
  • How to (intraoral approach)
  • Palpate the mental foramen 1 cm inferior and
    anterior to the second premolar
  • Retract lip
  • Insert needle (45 angle) at mucosal junction of
    lower lip and gum beneath 2nd premolar
  • Aspirate
  • Inject 1-2cc marcaine

41
Billing For the Block
  • Specific code for dental anaesthesia (33.99B) no
    longer exists in Emergency
  • But..
  • You can bill a local anaesthetic code 17.17A
    (21.13), which is modifiable

Thanks to Dr. Rick Morris
42
ED Visit Month Fracture Of Tooth Fracture Of Tooth Fracture Of Tooth Fracture Of Tooth Dislocation Of Tooth Dislocation Of Tooth Dislocation Of Tooth Dislocation Of Tooth Total Dental Trauma Visits
ED Visit Month FM RG PLC Total All Sites FMC RGH PLC Total All Sites Total Dental Trauma Visits
Jan-06 5 3 2 10 1 1 2 12
Feb-06 4 3 6 13 3 2 1 6 19
Mar-06 6 3 1 10 1 1 11
Apr-06 3 3 4 10 1 1 1 3 13
May-06 9 2 4 15 2 1 2 5 20
Jun-06 7 5 6 18 1   3 4 22
Jul-06 11 6 17 1 2 2 5 22
Aug-06 4 3 7 2 2 9
Sep-06 3 6 7 16 5 2 1 8 24
Oct-06 7 3 4 14 1 1 2 16
Nov-06 2 2 6 10 2 2 12
Dec-06 4 3 7 14 1 1 2 16
Cal Year 2006 Total 65 33 56 154 17 9 16 42 196
43
5th Cranial Nerve Trigeminal
  • V1 Ophthalmic
  • V2 Maxillary (dentition)
  • V3 Mandibular (dentition)

44
Maxillary Nerve
45
Mandibular Nerve
46
Coe-Pak MSDS
  • Hazardous Ingredients
  • Denatured Alcohol 1-5
  • Ethanol
  • Methanol
  • Petrolatum 5-10
  • HEALTH HAZARD (Acute and Chronic)
  • Denatured alcohol Prolonged exposure to ethanol
    may result in irritation of mucous membrane,
    headache, drowsiness, and fatigue. Methanol is
    also narcotic and affects are cumulative.
  • Sx SYMPTOMS OF OVEREXPOSURE Overexposure to
    methanol can result in acidosis and visual
    disturbances that may lead to permanent loss of
    vision.
  •  

47
Dycal MSDS
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