Acute Dental Problems Flashcards
Frequency/Nature of Oral Pain
Oral pain is common, with over 40% of adults reporting oral pain in the past year.
Oral pain can be difficult to localize and diagnose as it can originate from many different sources. Pain may be referred to the face or ear.
Diagnosis in children is particularly challenging given their inability to clearly articulate what they feel. Children may present with behavioral problems rather than specific oral complaints.
Diagnosing Oral Pain
Diagnosis requires:
* A history that includes:
* Duration of pain
* If chewing, temperature change, or sweet foods trigger pain
* A head and neck examination that includes:
* Extra-oral examination to evaluate for swelling and external masses
* Teeth
* Intra-oral soft tissues
The differential diagnosis should include sources of referred pain and pain of nondental origin.
Dental & Non-Dental Etiologies
Dental:
* Caries and its sequelae
* Eruption problems (e.g., pericoronitis)
* Periodontal problems
* Trauma
Non-dental:
* Sinusitis
* Otitis media / otitis externa
* Oral ulcerations
* Temporomandibular joint
Analgesia for Oral Pain
Nonsteriodal Anti-inflammatory Drugs (NSAIDS)
* Typically highly effective for oral pain and is medication of choice for most patients.
* Less side effects than many other analgesic options when used appropriately.
* No potential for abuse.
Opioids
* May occasionally be required for severe pain.
* Have significant potential for abuse.
* Care should be taken when evaluating the need for opioids as drug seekers often complain of oral pain.
Oil of Cloves (Eugenol) & Other Topical Agents
* Although often used topically for oral pain, eugenol has not been shown to be effective.
* FDA reclassified eugenol indicating insufficient data to support efficacy.
* Topical local anesthetics have little effect on dental pain and should not be used in young children where overdosage is a concern.
Reversible Pulpitis
Reversible pulpitis is caused when a carious lesion approaches the dental pulp. The destruction of the protective dentin allows triggers such as hot, cold, and sweet foods to inflame the pulp, causing acute pain.
Symptoms
* Pain with hot, cold, and sweet triggers
* Resolves with trigger removal
Treatment & Referra
* Dental filling will insulate the pulp and relieve the symptoms
* Analgesics are not generally necessary
Irreversible Pulpitis
As a carious lesion progresses, the pulp becomes infiltrated with bacteria and inflamed. Ultimately, pulp necrosis results. If untreated, inflammation will reach the apex of the tooth, eventually leading to periapical periodontitis (inflammation of the apical area of the periodontal ligament) and subsequent periapical abscess or cellulitis.
Symptoms
* Tooth is often sensitive to percussion
* Pain is severe, persistent, and poorly localized
Treatment & Referral
* Root canal or tooth extraction
* Root canal involves removal of the pulp and filling of the residual space, followed by placement of a crown
* Analgesics are often necessary
Periapcial Abscess
A periapical abscess is a localized, purulent form of periapical periodontitis.
The abscess can track through the bone to the soft tissue creating a localized fluctuant swelling, normally adjacent to the affected tooth root. The abscess will then fistulize and drain or spread to surrounding tissues causing cellulitis.
Symptoms
* Pain is well localized.
* Tooth is typically percussion sensitive.
* Pain may be severe, spontaneous, and persistent.
* If the abscess is draining, pain may be less severe.
Treatment & Referral
* Arrange urgent dental referral for root canal or extraction.
* If tooth is not definitively treated, abscess is likely to recur.
* Incision and drainage can provide temporary relief if not naturally draining.
* Analgesics are necessary.
* Antibiotics required only if concurrent cellulitis is present.
Facial Cellulitis
Facial cellulitis occurring secondary to a dental abscess is a true dental emergency!
Untreated infection can spread to deep facial spaces resulting in airway compromise, sepsis, or infection of the orbit and brain.
Symptoms
* Pain, often with fever
* Facial swelling
* Patients with severe infection may exhibit:
* Swelling involving orbit or deep spaces of the neck
* Trismus and dysphagia
* Unstable vital signs and other evidence of invasive infection
Treatment & Referral
* Localized cellulitis in select patients:
* Outpatient oral antibiotics and analgesics
* Prompt dental referral
* Severe cellulitis involving deep facial spaces or with sepsis:
* Hospitalize with surgical consultation
* CT imaging to rule out deep space involvement
* IV antibiotics and appropriate analgesics
* Extraction or root canal to prevent recurrence
Pericoronitis
Pericoronitis is an infection of the gum flap overlying partially erupted molars, most commonly the wisdom teeth. Food and plaque are trapped under the gum causing inflammation, swelling, and pain. Secondary cellulitis of the surrounding soft tissues can develop.
Symptoms
* Patients complain of pain, gum swelling, and inability to bite down on the affected side
Treatment & Referral
* Mild cases can be managed with irrigation under the flap
* Cellulitis should be treated with antibiotics
* Administer analgesics as needed
* Recurrent cases may require removal of tooth or gum flap
Periodontal Abscess
Periodontal disease is an inflammatory-bacterial destruction of the supporting structures of the tooth. Severe exacerbations may result in localized periodontal abscesses.
Symptoms
* Patient may experience continuous localized pain
* Tooth is loose and sensitive to touch
* Overlying gum may be red or swollen
* Fistulized abscesses may drain through the periodontal pocket or through the gums
* Cellulitis may also occur
Treatment & Referral
* Referral to oral health provider for evaluation and initial treatment of lesion. Referral to periodontist may be indicated
* Analgesics
* Antibiotics if concurrent cellulitis is present
ABX options
Antibiotics used to treat oral infections include:
* Penicillin VK, 25-50 mg/kg/day, divided four times daily (due to increasing beta-lactamase production of oral anaerobes, especially Prevotella and Fusobacterium spp, treatment failure with penicillin antibiotic monotherapy has been well documented. For ill or complicated patients, consider broader spectrum antibiotics at the outset.)
* Amoxicillin, 35-50 mg/kg/day, divided three times daily
* Amoxicillin-clavulanate, 35-50 mg/kg/day of the amoxicillin component, divided three times daily
For penicillin allergic patients:
* Clindamycin, 10-25 mg/kg/day, divided three times daily
For severe infections, consider broad spectrum agents:
* Ampicillin-sulbactam
* Cefotaxime
* Piperacillin-tazobactam
* Imipenem-cilastatin
Traige Procedure order
- Check airway (to look for missing or broken teeth), breathing, and circulation.
- Determine if other life-threatening injuries are present.
- Perform a neurologic exam.
- Assess the cervical spine.
- Check for skull, orbit, zygomatic, or mandibular fractures.
- Evaluate extraoral soft tissue injuries.
- Conduct intraoral examination.
- Determine if injury is to primary or permanent teeth.
- Assess availability of dental care
Intraoral Exam in Trauma
Irrigate to remove blood, clots, and debris.
Examine mouth, including:
* Soft tissues
* Teeth
* Bony structures
Assess the injured area, for the following:
* Tenderness and swelling
* Lacerations
* Damaged or mobile teeth: if fractured or avulsed tooth parts cannot be located, ascertain that the fragment is not embedded in the soft tissues or aspirated. Soft tissue x-rays may be needed
* Occlusion-ensure patient can bite together normally. Altered occlusion can indicate condyle or mandibular fractures while “steps” in the occlusal plane can indicate alveolar fracture.
* Mobile jaw segments
* Pain or limitation on opening which can indicate trauma to the temporomandibular joint or condyles.
Alveolar Bone Fracture
Jaw fractures typically present in the emergency room, usually in conjunction with other facial injuries associated with blunt trauma. Current imaging recommendations lean toward facial and head CT, as plain films often miss facial fractures. MRI has proven benefits in assessing traumatic soft tissue injuries.
Symptoms & Findings
* Localized tenderness
* Step-offs in occlusion of the teeth and alveolar bone on palpation represent alveolar bone fractures. Visible displacement may not be present even with fracture
* Movement of segmental alveolar fractures when assessing tooth mobility
* Gingival laceration
Referral
* See dentist or oral surgeon emergently
* Reduction is easier before swelling occurs
Chin Trauma & Condylar Fractures
While major jaw fractures are usually present in conjunction with other severe injuries, a less significant blow, such as an impact to the chin from a bicycle or trampoline fall, can result in a fracture of the mandibular condyles and/or posterior teeth.
Symptoms and Findings
* Preauricular swelling
* Pain
* Limited ability to open mouth
* Deviation on mouth opening
* Palpable movement of condylar heads
* Altered occlusion
* Posterior tooth fracture (not always visualized)
Referral
* Refer to oral surgeon emergently
* Fractured posterior teeth should prompt concern for condyle fracture and cervical spine injury
Dental Referrals (Terminology)
* Concussion
* Subluxation
* Luxation
* Intrusion
* Extrusion
* Avulsion
- Concussion: Tooth is tender but not displaced or mobile
- Subluxation: Tooth is mobile with no displacement, though it may have hemorrhage from the gingival crevice
- Luxation: Tooth is loose with some degree of lateral displacement
- Intrusion: Tooth is pushed deeper into its socket
- Extrusion: Tooth is partially displaced axially from its socket
- Avulsion: Tooth has been completely displaced or knocked out of its socket
Characteristics of Primary Teeth & Injury Types
The alveolar bone is more pliable in children than adults, making intrusion and luxation injuries of primary teeth more common. As permanent teeth develop in close proximity to primary teeth, intrusion or subluxation of primary teeth present a risk for damage the developing underlying permanent tooth.
In the child’s skull pictured on the right, the tip of the root of the right primary incisor has a moth-eaten appearance, indicating that the tooth died. Since no decay is evident, this was probably caused by an injury - most likely intrusion as the tooth appears shorter than the adjacent teeth.
The primary tooth death resulted in chronic infection that damaged the entire facial surface of developing enamel of the underlying permanent tooth, causing hypoplasia (brown discoloration) of the enamel.
Intrusion of Primary Teeth
An intruded tooth is driven into its socket, causing a crushing fracture of alveolar bone.
Treatment
* Do not attempt to remove intruded tooth.
* Administer analgesics and recommend good oral hygiene.
* Refer patient for dental evaluation in one day to one week based on symptoms.
Dental Care & Expected Outcome
* Dentist will take a radiograph.
* Extraction is indicated if the intruded tooth is impinging on a developing permanent tooth bud.
* Most teeth re-erupt to some degree in two to six months.
* Follow-up monitoring by the dentist to assess re-eruption and monitor tooth vitality.
* Teeth that become necrotic typically require extraction.
* Cannot accurately predict outcome of injured permanent teeth.
Luxation of Primary Teeth
A luxated tooth is loose and has some lateral displacement, but remains in its socket.
Treatment
* Management depends on degree of mobility and displacement.
* Highly mobile teeth or teeth interfering with occlusion need immediate dental referral.
* Less traumatized teeth require good oral hygiene, a soft diet, and dental referral in one day to one week based on symptoms.
Dental Care & Expected Outcome
* Dentist will take a radiograph.
* Highly mobile teeth or teeth interfering with occlusion may be treated by:
* Extraction
* Repositioning and splinting
* Less traumatized teeth will be monitored.
* Follow-up monitoring by the dentist will assess return of normal physiologic mobility and monitor tooth vitality.
* Teeth that become necrotic typically require extraction.
Avulsion of Primary Teeth
An avulsed tooth has been completely displaced or knocked out of its socket.
Treatment
* Avulsed primary teeth are NOT re-implanted to prevent further injury to the developing successor tooth.
* Locate the tooth to ensure it is not:
* Intruded
* Aspirated
* Swallowed
* Take appropriate radiographs if aspiration is suspected.
* Refer patient to dentist in one day to one week.
Dental Care & Expected Outcome
* Dentist will take radiograph to ensure tooth not intruded and rule out injuries to adjacent teeth.
* Effect on permanent teeth cannot accurately be predicted.
Fractures of Primary Teeth
There are three basic types of tooth fractures that clinicians need to be aware of. Urgency of care depends on the type of fracture present.
Simple Crown Fracture
* Involves only enamel and dentin
* Routine dental referral for smoothing or restoration
Crown Fracture with Pulp Involvement
* Involves enamel, dentin, and pulp
* May extend below the gumline
* Urgent-one day referral for pulp treatment or extraction
Root Fracture
* Often not detectable clinically unless mobile
* Routine referral for diagnosis and extraction of mobile fragment
Intrusion of Permanent Teeth
Intrusion of permanent teeth, especially mature permanent teeth where the root has completed development, is the injury with the poorest prognosis.
Treatment
* Do not attempt to remove intruded tooth.
* Refer patient to dentist immediately for evaluation and possible repositioning.
Dental Care & Expected Outcome
* Dental care may include allowing for spontaneous eruption (preferable in immature teeth) or active repositioning (orthodontic or surgical with splinting).
* Root canal treatment is often required, especially in mature permanent teeth.
* Risk for complications is high and includes: Tooth death, Root resorption, Tooth ankylosis
Avulsion of Permanent Teeth (Pt Procedure)
Avulsed permanent teeth are a true dental emergency!
Time and appropriate management are of the essence. Immediate reimplantation, within five minutes, has the best outcome. Everyone - parents, coaches, sports trainers, and clinicians - must know what to do when a permanent tooth is knocked out.
The longer that the tooth is out of the socket, the less chance of survival. Options, if less optimal, remain available even if a tooth has been out of the mouth for longer than 60 minutes.
Patient Procedure at the Time of Accident
Locate the tooth.
* If you can’t find it, consider aspiration, ingestion, or intrusion.
Hold the tooth by the crown (not the root) to avoid damaging the periodontal ligament that is critical for tooth survival.
* Rinse off any debris gently with saline or milk.
* DO NOT touch, rub, or scrub the root.
Replace the tooth in the socket. Be careful not to reverse it!
* Bite down on a gauze or handkerchief for stabilization while going to the dentist.
