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1. 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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3. Dental Emergencies and Common Dental Blocks Joe Lex, MD, FACEP, MAAEM Associate Professor, Department of Emergency Medicine Temple University School of Medicine Philadelphia, PA
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4. Disclosure No conflicts of interest
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5. 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
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6. Teeth
6
Vlad2i (Wikimedia Commons)

7. 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
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8. How to Name the Teeth
8
Gray's Anatomy (Wikipedia)

9. How to Number the Teeth
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10. 11
Permanent Teeth
Permanent maxillary
Right first molar
Permanent mandibular
right third molar
Permanent maxillary
Left second premolar
Permanent mandibular
left canine
Kaligula (Wikipedia)

11. Definitions •Interproximal: surfaces between two adjacent teeth •Mesial: interproximal surface facing toward midline •Distal: interproximal surface facing away from midline •Occlusal: chewing surface
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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
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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
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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
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15. 16
Sam Fentress (Wikipedia)

16. 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
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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
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18. Healthy teeth
Dozenist (Wikipedia)
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19. Healthy teeth
Source Undetermined
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20. Teething
Mathowie (Flickr)
ratterrell (Flickr)
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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
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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
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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
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24. Teething
Capital M (Flickr)
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25. Teething
Boston Public Library (Flickr)
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26. Toothache
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27. Impacted Wisdom Teeth
28
Source Undetermined

28. 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
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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
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30. Operculum = lid
Pericoronitis
31
Source Undetermined

31. Pericoronitis
32
Source Undetermined

32. 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
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33. Dental Caries
34
Source Undetermined

34. Dental Caries
Source Undetermined
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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.
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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.
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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.
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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)
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39. Widened periodontal ligament space
40
Source Undetermined

40. Periapical lucency
Source Undetermined
41

41. Periapical abscess
42
Source Undetermined

42. 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

43. Parulis = Fistula = Gum Boil
44
Source Undetermined

44. Parulis = Fistula
Source Undetermined
45

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

46. Dry Socket
47
Source Undetermined

47. 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

48. www.nysora.com/techniques/oral_maxilla/
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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
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50. Upper Incisors & Canines
Dozenist (Wikipedia)
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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
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52. Upper Incisors & Canines
53
Source Undetermined

53. Infraorbital Nerve Block
Area of Anesthesia
Infraorbital N.
Barry Langdon- Lassagne (Wikimedia Commons)
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54. Infraorbital Nerve Block
57
Source Undetermined

55. 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

56. Upper Premolars •Infiltrate buccal fold next to tooth •1.0 – 1.5 ml at apex
62
Source Undetermined

57. Supplemental Palate Injection •Use small volume (~0.5 ml) – hurts like crazy
63
Source Undetermined

58. Palatal Nerve Block
64
Source Undetermined

59. Upper Molars
69
Source Undetermined

60. Upper Molars •Buccal infiltration: puncture mesial fold close to tooth •Advance upward and backward until bone felt •Inject 1 – 2 ml solution
70

61. Upper Molars
71
Source Undetermined

62. So for most upper teeth… Local infiltration is sufficient
73

63. Lower Incisors & Canines
75
Source Undetermined

64. 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

65. Lower Incisors & Canines •Buccal soft tissue: mental nerve •Lingual gingiva & periosteum: sublingual nerve
78

66. Lower Incisor Block •Patient supine •Inject through buccal fold near tooth
79

67. 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

68. Mental Nerve Block
Area of Anesthesia
Nerve Block
Barry Langdon- Lassagne (Wikimedia Commons)
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69. Mental Nerve Block
84
Source Undetermined

70. Supplementary Lingual Nerve Block •Use 0.5 – 1 mL
Source Undetermined
85

71. Lower Molars •Apices embedded in thick compact bone •Local blocks don't work •Inferior alveolar nerve
87

72. Inferior Alveolar Nerve Block
91
Source: NYSORA.com

73. Inferior Alveolar Nerve Block
Source: NYSORA.com
92

74. Inferior Alveolar Nerve Block
Source Undetermined
93

75. Facial Landmarks
95
Gray's Anatomy (Wikipedia)

76. www.nysora.com/techniques/oral_maxilla/
96

77. Frenum Diastema
i.e., gap-toothed
97
Source Undetermined

78. Tetracycline Staining
98
Source Undetermined

79. Gums
Source Undetermined
99

80. 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

81. Periodontal Disease
101
Source Undetermined

82. Periodontal Disease
Source Undetermined
102

83. 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

84. 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
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85. ANUG
105
Source Undetermined

86. ANUG
106
Source Undetermined

87. ANUG
Source Undetermined
107

88. 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

89. Gingival Hyperplasia
109
Source Undetermined

90. 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

91. Bleeding Gums
111
Source Undetermined

92. Bleeding Gums
Source Undetermined
112

93. 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
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94. 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
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95. Pyogenic Granuloma
115
Source Undetermined
Source Undetermined

96. Pyogenic Granuloma
Source Undetermined
116

97. I got a tooth knocked out
msspider66 (Wikimedia Commons)
117

98. 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
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99. 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
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100. 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
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101. 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

102. 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
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103. I got smacked in the mouth •Tongue cuts: rarely need repair
Potter BC. Amer Fam Phys 18(5):96,1978
123
Source Undetermined

104. I got smacked in the mouth •Cheek / lip cuts: close to prevent food entrapped •Frenulum cut: let heal on own
Source Undetermined
Source Undetermined
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105. 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
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