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Dental Emergencies


Dental Emergencies Scott Farquharson Sept 24th 2009 Topics Covered Dental trauma Dental infections Dental blocks Pediatrics Dental Anatomy Primary Eruption from 7-30 ... – PowerPoint PPT presentation

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Title: Dental Emergencies

Dental Emergencies
  • Scott Farquharson
  • Sept 24th 2009

Topics Covered
  • Dental trauma
  • Dental infections
  • Dental blocks
  • Pediatrics

Dental Anatomy
  • Primary
  • Eruption from 7-30 months
  • 20 teeth, 10 upper, 10 lower
  • 2X ( 4 incisors, 2 canines, 4 molars)
  • Permanent
  • Begin formation 3-4 months
  • Eruption 7-21 years
  • 32 teeth ( including wisdom teeth)
  • 2x ( 4 incisors, 2 canines, 4 premolars, 6

Dental Anatomy
Dental Trauma
  • Fractures of teeth
  • Alveolar Fractures
  • Luxation
  • Intrusion or concussion
  • Avulsion
  • Primary vs Permanent

Fractures of Permanent Teeth
  • Enamel (Ellis 1)
  • Chipped tooth
  • Painless unless associated with other injuries
  • Large chips can be saved for reattachment
  • Non urgent dental referral for cosmetic purposes

Fractures of Permanent Teeth
  • Enamel and Dentin ( Ellis 2)
  • 70 of dental fractures
  • Pain with hot or cold
  • Dentin is yellow colored
  • Panorex to R/O other injury
  • Increased risk of pulp infection/desiccation
  • Dental evaluation in 24hrs
  • Protection with dental cement
  • Consider antibiotics

Fractures of Permanent Teeth
  • Pulp involvement
  • May be visible (Ellis 3)
  • Can see blood
  • May be below gums (root fracture)
  • Only seen with x-ray
  • Very painful as nerve exposed
  • Treatment as Ellis 2
  • Will need extraction or root canal

Fractures of Permanent Teeth
  • Alveolar Fractures
  • Associated with fractures, luxated or avulsed
  • small fractures involving 1 or 2 teeth can be
    treated by a dentist
  • Large areas of alveolar bone damage can cause
    significant cosmetic deformity and oral surgery
    should be consulted

Root Fracture
  • Loose tooth
  • Extrusion dislodgement from alveolar bone
  • Lateral luxation lateral displacement with
    alveolar fracture
  • Both should have x-rays
  • Reposition with firm pressure may require local
  • Temporary splinting in ED
  • Permanent splinting/treatment by dentist

Concussion and Intrusion
  • Displacement of tooth into socket
  • Concussion pain with no movement
  • Intrusion more severe displacement involving
    root fracture and/or alveolar fracture
  • Intrusion is differentiated on x-ray and requires

  • Complete displacement of tooth from alveolar
  • Best chance of saving tooth if reimplanted in
    under 3 hrs
  • Transport in sterile saline, milk, Hank solution
    or in buccal sulcus not ice or water
  • Avoid disruption of periodontal ligament fibers
    on root
  • Clean with normal saline
  • Rinse clot from socket
  • splint

Primary Vs Permanent
  • Avulsed primary teeth should not be reimplanted
    to avoid damage to underlying teeth
  • Primary teeth have more pulp and less dentin and
    are more at risk for infection
  • Luxations in young children are at greater risk
    of avulsion and aspiration consider urgent
    dental splinting.
  • Enamel injuries can cut mucosa in young children
    and may need to be filed down

Final Thoughts
  • Pen or amoxicillin usually sufficient
  • Consider clindamycin or EES if allergic
  • Dont forget tetanus immunization

Dental Infections
  • Periapical abscess
  • Pericoronitis
  • Dry socket
  • Buccal/facial cellulitis
  • Complications

Periapical Abscess
  • Complication of carries/pulpitis
  • Inflammation and abscess formation in periodontal
    and buccal tissues
  • lymphadenopathy
  • Streptococcus mutans
  • Painful relieved by ID
  • Definitive treatment is root canal (removal of
    the pulp and filling of the empty pulp chamber
    and canal )

Periapical Abscess
Periapical Abscess
  • Most common in wisdom teeth
  • bacterial plaque and food debris accumulate
    beneath the flap of gum covering the partially
    erupted tooth.
  • Pain, bad taste, pus, local inflammation
  • can progress to cellulitis
  • Salt mouthwashes, irrigate under flap
  • ABX

Dry Socket- Alveolar Osteitis
  • Complication of tooth extraction
  • Clot covering alveolar bone is displaced
  • Exposed alveolar bone becomes inflamed
  • Normal post extraction pain decreases over 48hrs
  • Dry socket pain increases at 24-72 hrs
  • Can progress to osteomyelitis

Dry Socket
  • Analgesia Nsaids, Narcotics, Nerve block
  • Referral back to dentist in 24 hrs
  • Will need frequent packing
  • ABX?
  • If caught early and timely follow up is available
    probably not needed

  • Dental infections can progress to life
    threatening complications
  • Facial or buccal cellulitis
  • Submandibular space infections (Ludwigs angina)
  • Parapharyngeal space infections
  • Airway compromise
  • Orbital infections
  • CNS infections
  • Mediastinal infections
  • Cavernous sinus thrombosis

  • Signs of more serious illness
  • Systemic symptoms fever/chills
  • Trismus
  • Displacement of tongue
  • Altered LOC/delirium
  • Eye pain
  • Require systemic ABX
  • ENT consult
  • Possible CT imaging
  • Airway management

  • Broad range of pathogens
  • Mainly streptoccocal
  • Bacteroides sp.
  • Anaerobes
  • Simple infections
  • Pen V or amoxil
  • I prefer Amox/Clav or clinda
  • Infections extending to facial or buccal
  • IV 2nd generation cephalosporin metronidazole
  • HPTP

Dental Nerve Blocks
  • Supraperiosteal nerve block
  • Anesthesia for individual tooth
  • Inferior Alveolar Nerve Block
  • Anesthesia for lower teeth

Supraperiosteal Nerve Block
  • Select the area to be anesthetized and dry it
    with gauze.
  • Ask the patient to close the jaw slightly to
    relax the facial musculature.
  • Grasp the mucous membrane of the area with a
    piece of gauze.
  • Pull the gauze (and the mucous membrane) out and
    downward in the maxilla and out and upward in the
    mandible to extend the mucosa fully and to
    delineate the mucobuccal fold.
  • Puncture the mucobuccal fold with the bevel of
    the needle facing the bone.
  • Aspirate the area and then deposit approximately
    1 to 2 mL of local anesthetic at the apex (area
    of the root tip) of the involved tooth.
  • It is helpful to place a finger against the outer
    aspect of the lip overlying the injection site
    and apply firm and steady pressure against the
    lip while slowly injecting the local anesthetic
    into the supraperiosteal site

Supraperiosteal Nerve Block
Supraperiosteal Nerve Block
Inferior Alveolar Nerve Block
Inferior Alveolar Nerve Block
  • Palpate the retromolar fossa with the index
    finger or thumb.
  • Identify the greatest depth of the anterior
    border of the ramus of the mandible (the coronoid
  • With the thumb in the mouth and the index finger
    placed externally behind the ramus, retract the
    tissues toward the buccal (cheek) side, and
    visualize the pterygomandibular triangle.
  • This technique also moves the operators finger
    safely away from the tip of the needle.

Inferior Alveolar Nerve Block
Inferior Alveolar Nerve Block
  • Hold the syringe parallel to the occlusal
    surfaces of the teeth and angled so that the
    barrel of the syringe lies between the first and
    second premolars on the opposite side of the
  • Achieving the proper angle is important to the
    success of this block.
  • If a large-barrel syringe is used, the corner of
    the mouth may hamper efforts to obtain the proper
  • Carefully bend the 25-gauge needle about 30
    degrees to facilitate achieving the proper angle.
    The needle cap can be used to bend the needle

Inferior Alveolar Nerve Block
  • Make the puncture for the injection in the
    pterygomandibular triangle, at a point that is 1
    cm above the occlusal surface of the molars.
  • If the needle enters too low (e.g., at the level
    of the teeth), the anesthetic will be deposited
    over the bony canal and prominence (lingula) that
    house the mandibular nerve, and not over the
    nerve itself.
  • There may be slight resistance as the needle
    passes through the ligaments and the muscles
    covering the internal surface of the mandible.
    When there is more solid resistance, the needle
    has reached the bone.
  • Stop when the needle has reached bone, which
    signifies contact with the posterior wall of the
    mandibular sulcus.
  • It is important to feel the bone with the needle

Inferior Alveolar Nerve Block
Inferior Alveolar Nerve Block
  • It is important to feel the bone with the needle.
  • After reaching the bone, withdraw the needle
    slightly and aspirate to check for possible
    intravascular placement.
  • Deposit approximately 1 to 2 mL of anesthetic
    solution 3 to 4 mL of anesthetic may be required
    if needle positioning is suboptimal.

Inferior Alveolar Nerve Block
Inferior Alveolar Nerve Block
  • Failure to feel bone as the needle is advanced
    generally results from directing the needle
    toward the parotid gland (too far posteriorly)
    rather than toward the inner aspect of the
    mandible. Injecting into the parotid gland can
    anesthetize the facial nerve

Inferior Alveolar Nerve Block
  • One may anesthetize the lingual nerve by placing
    several drops of anesthetic solution while
    withdrawing the syringe. The anterior two thirds
    of the tongue can thus be anesthetized. In actual
    practice, the lingual nerve is consistently
    blocked with this procedure owing to the close
    proximity of both nerves.

Inferior Alveolar Nerve Block
  • Complications include inadvertent administration
    of anesthetic posteriorly in the region of the
    parotid gland, which will anesthetize the facial
    nerves. This is an annoying but relatively benign
    complication that will cause temporary facial
    paralysis (similar to Bells palsy) affecting the
    orbicularis oculi muscle and results in inability
    to close the eyelid. Should this occur, the eye
    must be protected until the local anesthetic has
    worn off (approximately 2 to 3 hours), and the
    patient must be reassured. Anesthesia with
    bupivacaine (Marcaine) presents a more
    significant problem if this complication occurs,
    because bupivacaine anesthesia lasts from 10 to
    18 hours in some patients.

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