Tintinalli Tuesday: Oral and Dental Emergencies

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July 24, 2012 by EmerJencyWEBB

Welcome to this week’s Tintinalli Tuesday. For those of you who don’t know, these posts are weekly reading assignments chosen at random from the ‘Bible’ of Emergency Medicine. I’ll provide a brief (not all-inclusive) outline of key points of this chapter, and add multimedia, EBM updates, and pearls whenever/wherever appropriate. This is a big chapter, so for those of you following along at home (which I hope you are), I have re-organized the chapter for purposes of flow. Let’s get started with this week’s pick!

ORAL AND DENTAL EMERGENCIES

DENTAL/PERIODONTAL DISEASE
Basic Anatomy:
Normal Adult has 32 teeth: 8 incisors, 4 canines, 8 premolars, 12 molars
Know tooth numbering scheme
Layers: Enamel, Dentin, Pulp
Gross Anatomy: Crown (visible portion), Root (embedded in alveolar bone)
Periodontium: Gingival and Periodontal components
Periodontal component: periodontal ligament (connects root of tooth to alveolar bone via cementum)

Causes of Dental Pain:
Tooth eruption

Pericoronitis: inflammation of operculum overlying erupting tooth, may progress to infection, treat with antibiotics directed to typical mouth flora, local irrigation and rinses, dental referral for removal of operculum, offending tooth. Image 2
Caries: aka cavity, formed when acid producing bacteria damage enamel.
if dentin is also compromised, bacteria have access to pulp (NV supply to tooth)
Pulpitis: caused by inflammatory reaction to infection from above. May lead to pulpal necrosis. Treatment of irreversible pulpitis is tooth extraction or root canal procedure.
Periradicular/Periapical Abscess: complication of the above caused by inflammatory reaction and pulp necrosis with an accumulation of purulent infiltrate. Panorex may be able to visualize more extensive lesions, but is not mandatory.
Parulis: fistulous connection between gingiva and draining infected tooth

Dental Trauma

Fractures:
Ellis Class I: Enamel only, No intervention required in ED, Refer to Dentistry
Ellis Class II: (pt’s right upper in pic) Dentin involvement, Treat by covering exposed surface with dental cement (prevents bacterial access to pulp), and Dentist referral in 24 hours
Ellis Class III: (pt’s left upper in pic) Pulp exposure, Treat same as Class II

Concussion
Minor injury, no instability, damages supporting structures of tooth, treat with pain medicine, and dental referral.

Luxation
Subluxation: damage to supporting structures WITH mobility. Splint if terribly loose, otherwise pain control and close follow-up.
Extrusive Luxation: partial avulsion (disconnect from alveolar bone) with significant mobility. Treat with repositioning, splint with Coe-Pak dressing, and dentistry follow-up in 24 hours
Lateral Luxation: same as above, except there is increased risk of alveolar bone fracture.
Intrusive Luxation: significant damage to surrounding structures and alveolar bone. Allow these to self-extrude and refer to orthodontist for possible intervention.

Avulsion
Complete dislocation of tooth. Reimplantation in 2-3 hours if possible. Clean with sterile saline, without scrubbing or significant handling of root area to prevent damage to connective tissue.
Transport solutions: Hank solution, sterile saline, milk.
Radiographs necessary if tooth cannot be found (impaction/aspiration)
Soaking may be required depending on how long tooth has been dry.
Remember to temporarily stabilize after re-insertion and obtain close follow up.
NEVER reimplant primary teeth
VIDEO OF REIMPLANTATION PROCEDURE

Another splinting trick/tip

Complications of dental procedures:
Post-extraction Alveolar Osteitis
aka Dry Socket, occurs 2-3 days after extraction, clot displacement exposes alveolar bone, and can lead to local osteomyelitis.
Obtain radiograph to rule out retained root or foreign body
Treat with irrigation and packing with oil of cloves/eugenol gauze
Give antibiotics to cover mouth flora and refer to dentist in a day
VIDEO OF PROCEDURE

Post-extraction Bleeding
Treat with firm gentle pressure of gauze to site. If still bleeding, may try pro-coagulant products such as Gelfoam. May require loose suturing of gingiva to hold these products/hemostasis in place.

Periodontal Disease
Abscess: may form when trapped debris forms inflammatory reaction/secondary infection and infiltration. May require I&D if large, but usually responds to warm rinses, and typical antibiotics.

Acute Necrotizing Ulcerative Gingivitis (ANUG): Destructive process of gingiva due to opportunistic infection in compromised host (HIV, transplant patients, etc…). Includes invasive anaerobes. Treatment consists of chlorhexidine rinses, debridement by oral surgeon, and directed antibiotic therapy (i.e. flagyl).

SOFT TISSUE INFECTIONS
Oral Candidaisis: risk factors are age extremes, malnourishment, immunocompromised, antibiotic therapy. Treat with topical antifungal.
Aphthous Stomatitis: usually on mucosal surfaces, with small ulceration leading to eschar. Self limiting. More severe episodes may require topical corticosteroids.
Herpes Simplex: both types 1 and 2 may affect oral cavity, and are clinically identical. Virus hides out in sensory ganglion of face. Typical vesicular lesions. If started during prodromal phase, anti-retrovirals may lessen severity/duration.
Varicella Zoster: basically shingles of the oral cavity/face. Beware of eye involvement.
Herpangina: Coxsackievirus, with viral prodrome followed by eruption of micro-vesicles primarily on posterior oral/pharyngeal structures. Symptomatic therapy.
Hand, Foot, Mouth Disease: Coxsackievirus (different types), small vesicles on tongue, gingiva, palate, and buccal mucosa. May also affected palmar/plantar surfaces. Symptomatic therapy.

BENIGN ORAL LESIONS: not included in this outline. Please refer to text.

MALIGNANT ORAL LESIONS
Leuko- and erythroplakia: white and red patches respectively, cannot be scraped off, doesn’t look like another disease process, pre-cancerous, refer to oral surgeon/ENT for follow up.

Most common cancer: Squamous cell carcinoma, Image 2, Image 3
Others include: lymphoma, Kaposi sarcoma, and melanoma

Take home point: if it looks funny and you are concerned in any way about cancer, refer for further work up.

MEDICATION REACTIONS

Gingival Hyperplasia: phenytoin, cyclosporine, CCBs
EM minor/major: drug reaction
Mucositis/Stomatitis: chemotherapeutic agents

SYSTEMIC PRESENTATIONS
Leukemia: spontaneous gingival bleeding, petechia, opportunistic infections, hyperplastic gingivitis
AIDS: oral candidiasis, linear gingival erythema, ANUG, viral oral infections, Hairy leukoplakia, Kaposi sarcoma, lymphoma.

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