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GEMC- Dental Emergencies and Common Dental Blocks- Resident Training


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This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License:

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GEMC- Dental Emergencies and Common Dental Blocks- Resident Training

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Dental Emergencies and Common Dental Blocks Author(s): Joe Lex, MD (Temple University School of Medicine) License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2
  3. 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 3
  4. 4. Disclosure No conflicts of interest 4
  5. 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 5
  6. 6. Teeth 6 Vlad2i (Wikimedia Commons)
  7. 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 7
  8. 8. How to Name the Teeth 8 Gray's Anatomy (Wikipedia)
  9. 9. How to Number the Teeth 9
  10. 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. 11. Definitions •Interproximal: surfaces between two adjacent teeth •Mesial: interproximal surface facing toward midline •Distal: interproximal surface facing away from midline •Occlusal: chewing surface 12
  12. 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
  13. 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
  14. 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
  15. 15. 16 Sam Fentress (Wikipedia)
  16. 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 17
  17. 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
  18. 18. Healthy teeth Dozenist (Wikipedia) 19
  19. 19. Healthy teeth Source Undetermined 20
  20. 20. Teething Mathowie (Flickr) ratterrell (Flickr) 21
  21. 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
  22. 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
  23. 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
  24. 24. Teething Capital M (Flickr) 25
  25. 25. Teething Boston Public Library (Flickr) 26
  26. 26. Toothache 27
  27. 27. Impacted Wisdom Teeth 28 Source Undetermined
  28. 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 29
  29. 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
  30. 30. Operculum = lid Pericoronitis 31 Source Undetermined
  31. 31. Pericoronitis 32 Source Undetermined
  32. 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 33
  33. 33. Dental Caries 34 Source Undetermined
  34. 34. Dental Caries Source Undetermined 35
  35. 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
  36. 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
  37. 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
  38. 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
  39. 39. Widened periodontal ligament space 40 Source Undetermined
  40. 40. Periapical lucency Source Undetermined 41
  41. 41. Periapical abscess 42 Source Undetermined
  42. 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. 43. Parulis = Fistula = Gum Boil 44 Source Undetermined
  44. 44. Parulis = Fistula Source Undetermined 45
  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. 46. Dry Socket 47 Source Undetermined
  47. 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. 48. 49
  49. 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
  50. 50. Upper Incisors & Canines Dozenist (Wikipedia) 51
  51. 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
  52. 52. Upper Incisors & Canines 53 Source Undetermined
  53. 53. Infraorbital Nerve Block Area of Anesthesia Infraorbital N. Barry Langdon- Lassagne (Wikimedia Commons) 55
  54. 54. Infraorbital Nerve Block 57 Source Undetermined
  55. 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. 56. Upper Premolars •Infiltrate buccal fold next to tooth •1.0 – 1.5 ml at apex 62 Source Undetermined
  57. 57. Supplemental Palate Injection •Use small volume (~0.5 ml) – hurts like crazy 63 Source Undetermined
  58. 58. Palatal Nerve Block 64 Source Undetermined
  59. 59. Upper Molars 69 Source Undetermined
  60. 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. 61. Upper Molars 71 Source Undetermined
  62. 62. So for most upper teeth… Local infiltration is sufficient 73
  63. 63. Lower Incisors & Canines 75 Source Undetermined
  64. 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. 65. Lower Incisors & Canines •Buccal soft tissue: mental nerve •Lingual gingiva & periosteum: sublingual nerve 78
  66. 66. Lower Incisor Block •Patient supine •Inject through buccal fold near tooth 79
  67. 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. 68. Mental Nerve Block Area of Anesthesia Nerve Block Barry Langdon- Lassagne (Wikimedia Commons) 82
  69. 69. Mental Nerve Block 84 Source Undetermined
  70. 70. Supplementary Lingual Nerve Block •Use 0.5 – 1 mL Source Undetermined 85
  71. 71. Lower Molars •Apices embedded in thick compact bone •Local blocks don't work •Inferior alveolar nerve 87
  72. 72. Inferior Alveolar Nerve Block 91 Source:
  73. 73. Inferior Alveolar Nerve Block Source: 92
  74. 74. Inferior Alveolar Nerve Block Source Undetermined 93
  75. 75. Facial Landmarks 95 Gray's Anatomy (Wikipedia)
  76. 76. 96
  77. 77. Frenum Diastema i.e., gap-toothed 97 Source Undetermined
  78. 78. Tetracycline Staining 98 Source Undetermined
  79. 79. Gums Source Undetermined 99
  80. 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. 81. Periodontal Disease 101 Source Undetermined
  82. 82. Periodontal Disease Source Undetermined 102
  83. 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. 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 104
  85. 85. ANUG 105 Source Undetermined
  86. 86. ANUG 106 Source Undetermined
  87. 87. ANUG Source Undetermined 107
  88. 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. 89. Gingival Hyperplasia 109 Source Undetermined
  90. 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. 91. Bleeding Gums 111 Source Undetermined
  92. 92. Bleeding Gums Source Undetermined 112
  93. 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 113
  94. 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 114
  95. 95. Pyogenic Granuloma 115 Source Undetermined Source Undetermined
  96. 96. Pyogenic Granuloma Source Undetermined 116
  97. 97. I got a tooth knocked out msspider66 (Wikimedia Commons) 117
  98. 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 118
  99. 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 119
  100. 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 120
  101. 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. 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 122
  103. 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. 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 124
  105. 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 125