Dental in GP Flashcards
What is bruxism
Teeth grinding/clenching/gnashing
Management of bruxism
Education of patient and management of stress/anxiety can help with daytime bruxism
Night time bruxism is likely to require a dental mouthguard
Anatomy of tooth
Crown: enamel (insensate), dentine (sensate), pulp chamber (neurovascular nest)
Root: cementum (attaches to periodontal ligament and alveolar bone)
Periodontal tissues: periodontal ligament, alveolar bone, gingiva
Identification of permanent teet
32 teeth in adults
Identify with double digit (1st being 1-4 depending on quadrant counted clockwise from upper left looking at patient, 2nd being 1-8 medial-lateral)
Common names: central and lateral incisors, canines, 1st/2nd premolar, 1st/2nd/3rd molars
Primary teeth - permanent teeth
AKA deciduous teeth
Up to 20
First tooth (central incisor) at 8-12 months, full set of teeth by 3y
Primary teeth identified using quadrants 5-8
Permanent teeth begin to erupt around 6y with first molar being the first. All permanent teeth by 13y except 3rd molars (17-21y if at all)
Important history to elicit in patients who present with dental injury
Tetanus status
Missing teeth
History of dental trauma
Previous orthodontics, root canals or fillings
Reported pain, sensitivity or mobility on presentation
Important features of examination in someone with dental injury
Altered occlusion on biting down - ?jawbone fracture
Examine oral cavity for lacerations, embedded teeth, degloving injuries
Tooth by tooth examination for tenderness, sensitivity and mobility
Types of injuries to tooth itself
Fracture
- may or may not affect pulp (red tissue visible in the tooth)
If advanced, may be infection present
Management of dental fractures
Analgesia
Refer to dentist ASAP
- may require root canal and restoration
- if pulp is involved, likely will need intra-oral xrays
Types of injuries to periodontal tissues
- Concussion (inflammation of periodontal ligament)
- Subluxation (abnormally mobile tooth WITHIN the socket)
- Intrusion (displacement of tooth INTO socket)
- Extrusion (displacement of tooth OUT of socket)
- Luxation (lateral, labial or lingual displacement, root may be visible - often associated with alveolar bone fracture)
- Avulsion (complete disarticulation of tooth from socket)
General management of most dental injuries
Simple analgesia
Stabilise tooth if mobile with splint
Soft diet
Review by dentist ASAP
If indicated (and trained) - nerve block and reposition tooth so anatomically correct
Management of avulsed permanent tooth in ED/GP
- chest imaging if unsure of location of tooth (check not aspirated)
DO NOT handle tooth by root - Dental block if trained and required
- gently irrigate tooth and socket with saline
- replace with correct tooth and orientation
- apply splint
- antibiotic (amoxil) + chlorhex mouthwash
- urgent referral to dentist for better immobilisation - soft diet until then if not seen immediately
First aid management of avulsed tooth
Don’t handle root
Only wipe/wash away obvious contaminants, otherwise don’t touch with water
Store in socket if clean, or side of cheek/milk/saline
Time limit for successful reimplantation of avulsed tooth
Ideally within 15 minutes
Definitely within 2h
Best storage mediums for avulsed teeth
- Commercial dental storage medium
- Contact lens solution
- Milk
- Held inside patient’s cheek/in plastic with patient’s saliva
DO NOT put in tap water as this will rapidly cause damage (within 20 minutes)
Presentation and treatment of injuries to dental supporting bone
Presents with pain, supporting bone visible (either on avulsed tooth or in tooth socket)
Segment mobility and dislocation
Treatment:
- urgent referral to dentist (if alveolar fracture only) or maxfac/tertiary ED
Presentation and treatment of injuries to gingival or oral mucosa
Presentation: visible breach of oral mucosa areas with variable degrees of bleeding
Treatment: haemostasis (pressure +/- adrenaline soaked gauze)
Closure - sutures only required if larger laceration or gaping
Materials to fashion a dental splint in ED/GP
- Blu tack
- Aluminium foil
- Skin glue + pre-moulded piece of malleable metal from Hudson mask
- Chewing gum
Progression of a dental infection
Begins as pulpitis (contained in tooth structure)
- > local alveolar bone invasion = periapical abscess
- > erosion through cortical plate -> spread into tissue planes of face and neck (can cause cellulitis)
Deep extension (more likely in mandibular teeth)
-> submasseteric or submandibular space -> sublingual or submental space
Maxillary -> infraorbital -> periorbital cellulitis or cavernous sinus thrombosis OR encephalitis/meningitis
Presentation of early dental infection
Localised pain
Facial swelling
Halitosis
General malaise
Symptoms of extensive dental infection
Trismus
Inability to protrude tongue or swallow saliva (extension to sublingual space)
Dysphagia, dyspnoea, stridor, hoarse voice(extension to parapharyngeal space ?airway patency)
Important examination findings in dental infections
IS AIRWAY PATENT
- facial swelling/induration - has it crossed the lower border of the mandible
- how far can patient open their mouth (<20-30mm = intubation difficulty)
- ask to protrude tongue and swallow ?sublingual extension
- is there buccal swelling or visible punctum
- examination of individual teeth
- examination for other causes of presenting complaint (e.g. sinus, tonsils, salivary glands)
Indications for inpatient management/maxfac referral for dental infections
Airway compromise Significant facial swelling Trismus Systemically unwell Significant medical comorbidities (e.g. immunosuppressed, poorly controlled DM etc. )
Appropriate outpatient management for dental infections
ALL NEED TO SEE DENTIST PROMPTLY FOR DEFINITIVE MANAGEMENT, ANTIBIOTICS ALONE IS INADEQUATE
If cannot see dentist same day, commence antibiotics (cover aerobic + anaerobic e.g. Augmentin, amox + metro, or clindamycin)
If possible, make the dentist appointment yourself to improve compliance
How long should you treat a dental infection BEFORE referring for extraction/definitive management
Should not delay at all! Delay may cause life-threatening infection, definitive surgical management should be provided ASAP
Definitive management for dental infections
Incision and drainage of abscess
+
Tooth-saving techniques, root canal or extraction
Likely cause of dental pain presenting with sensitivity to hot/cold/sweet stimuli
pulpitis
- reversible if disappears on removal of stimulus
- irreversible if does not disappear on removal of stimulus
Presentation of pulpitis
Localised tooth pain with sensitivity to hot/cold/sweet stimuli
Management of pulpitis in GP
Arrange for patient to see dentist ASAP
Avoid triggers Analgesics (NSAIDs) Cover if obvious cavity (e.g. with chewing gum, temporary filling material) Toothache drops Dental nerve block if pain severe
NO antibiotics
Likely dental management of pulpitis
May be able to restore tooth if reversible
Root canal therapy or extraction if irreversible pulpitis
Presentation of a non-viable tooth
Localised pain with no sensitivity to hot/cold/sweet stimuli
Management of non-viable tooth
Simple analgesia
Urgent dental review
Likely cause of dental pain with associated pressure tenderness
Likely early abscess
Likely cause of dental pain with swelling in area of recent toothache
Dental abscess
Likely cause of tooth pain that is worsened when leaning forward
Likely sinusitis and not dental at all
Likely cause of dental pain persisting in days after dental extraction
Alveolar osteitis AKA “dry socket”
- temporary exposed jawbone following extraction
Management of alveolar osteitis
NO ANTIBIOTICS
flush socket with sterile saline
Apply sedative dressing if available
Urgent review by dentist
Local analgesia options for dental pain
Cover any cavity (eg. with chewing gum)
Nyal toothache drops (contain benzocaine) apply via cotton bud for 1 minute
Signs that may indicate dental or orofacial pain in a patient with demetia/unable to communicate
- resistance to oral hygiene cares
- having difficulty with eating or maintaining weight
- behavioural change, agitation, unsettled without explanation
Most likely sign is treating for dental pain and seeing that behaviours change
Management of tooth socket bleeding
Local pressure with gauze (+/- adrenaline soaked) for 30 minutes
Assessment of post-dental surgery swelling
Swelling may take 3 days to develop fully
Check for demonstrable signs of infection
Check for any high risk features in patient (e.g. immunocompromised)
Generally need no antibiotics
Check that patient has post-op instructions and ability to contact treating dentist
