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Description : Check out this medical presentation on Dental Abrasion, which is titled "Dental Emergencies and Common Dental Blocks", to understand that teething does not cause fever, define, recognize, and treat pericoronitis, periapical abscess, and alveolar osteitis, describe treatment for ANUG, and, state three ways to treat bleeding gums.

Tags : Dental Abrasion, Dental Emergencies, Common Dental Blocks, teething, treat pericoronitis, periapical abscess, alveolar osteitis, treatment, ANUG, bleeding gums

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Slide 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: http://creativecommons.org/licenses/by-sa/3.0/ 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 open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. 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
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Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy 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
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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
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Disclosure No conflicts of interest 4
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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 Learn 5
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Teeth 6 Vlad2i (Wikimedia Commons)
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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 Teeth 7
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How to Name the Teeth 8 Gray's Anatomy (Wikipedia)
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How to Number the Teeth 9
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11 Permanent Teeth Permanent maxillary Right first molar Permanent mandibular right third molar Permanent maxillary Left second premolar Permanent mandibular left canine Kaligula (Wikipedia)
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Definitions Interproximal: surfaces between two adjacent teeth Mesial: interproximal surface facing toward midline Distal: interproximal surface facing away from midline Occlusal: chewing surface Teeth 12
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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 Teeth 13
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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 Teeth 14
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Teeth 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
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16 Sam Fentress (Wikipedia)
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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 Teeth 17
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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 Teeth 18
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Healthy teeth Dozenist (Wikipedia) 19
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Healthy teeth Source Undetermined 20
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Teething Mathowie (Flickr) ratterrell (Flickr) 21
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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
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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 Teeth 23
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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 Teeth 24
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Teething Capital M (Flickr) 25
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Teething Boston Public Library (Flickr) 26
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Toothache 27
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Impacted Wisdom Teeth 28 Source Undetermined
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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
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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 Teeth 30
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Operculum = lid Pericoronitis 31 Source Undetermined
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Pericoronitis 32 Source Undetermined
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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 Teeth 33
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Dental Caries 34 Source Undetermined
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Dental Caries Source Undetermined 35
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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 Teeth Acad Emerg Med. 2004 Dec;11(12):1268-71. 36
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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 Teeth Acad Emerg Med. 2004 Dec;11(12):1268-71. 37
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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.” Teeth Acad Emerg Med. 2004 Dec;11(12):1268-71. 38
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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) Teeth 39
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Widened periodontal ligament space 40 Source Undetermined
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Periapical lucency Source Undetermined 41
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Periapical abscess 42 Source Undetermined
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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 Teeth 43
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Parulis = Fistula = Gum Boil 44 Source Undetermined
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Parulis = Fistula Source Undetermined 45
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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 Teeth 46
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Dry Socket 47 Source Undetermined
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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 Teeth 48
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www.nysora.com/techniques/oral_maxilla/ 49
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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
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Upper Incisors & Canines Dozenist (Wikipedia) 51
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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
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Upper Incisors & Canines 53 Source Undetermined
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Infraorbital Nerve Block Area of Anesthesia Infraorbital N. Barry Langdon- Lassagne (Wikimedia Commons) 55
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Infraorbital Nerve Block 57 Source Undetermined
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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
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Upper Premolars Infiltrate buccal fold next to tooth 1.0 – 1.5 ml at apex 62 Source Undetermined
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Supplemental Palate Injection Use small volume (~0.5 ml) – hurts like crazy 63 Source Undetermined
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Palatal Nerve Block 64 Source Undetermined
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Upper Molars 69 Source Undetermined
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Upper Molars Buccal infiltration: puncture mesial fold close to tooth Advance upward and backward until bone felt Inject 1 – 2 ml solution 70
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Upper Molars 71 Source Undetermined
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So for most upper teeth… Local infiltration is sufficient 73
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Lower Incisors & Canines 75 Source Undetermined
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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
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Lower Incisors & Canines Buccal soft tissue: mental nerve Lingual gingiva & periosteum: sublingual nerve 78
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Lower Incisor Block Patient supine Inject through buccal fold near tooth 79
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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
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Mental Nerve Block Area of Anesthesia Nerve Block Barry Langdon- Lassagne (Wikimedia Commons) 82
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Mental Nerve Block 84 Source Undetermined
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Supplementary Lingual Nerve Block Use 0.5 – 1 mL Source Undetermined 85
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Lower Molars Apices embedded in thick compact bone Local blocks don't work Inferior alveolar nerve 87
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Inferior Alveolar Nerve Block 91 Source: NYSORA.com
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Inferior Alveolar Nerve Block Source: NYSORA.com 92
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Inferior Alveolar Nerve Block Source Undetermined 93
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Facial Landmarks 95 Gray's Anatomy (Wikipedia)
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www.nysora.com/techniques/oral_maxilla/ 96
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Frenum Diastema i.e., gap-toothed 97 Source Undetermined
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Tetracycline Staining 98 Source Undetermined
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Gums Source Undetermined 99
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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 Gums 100
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Periodontal Disease 101 Source Undetermined
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Periodontal Disease Source Undetermined 102
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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 Gums 103
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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 Gums 104
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ANUG 105 Source Undetermined
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ANUG 106 Source Undetermined
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ANUG Source Undetermined 107
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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 Gums 108
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Gingival Hyperplasia 109 Source Undetermined
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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 Gums 110
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Bleeding Gums 111 Source Undetermined
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Bleeding Gums Source Undetermined 112
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Post-Extraction Bleeding Usually a dislodged clot Firm pressure usually adequate: folded 2 × 2 gauze pad placed over extraction site, then firm pressure by clenching teeth for 20 minutes Tea bag: tannic acid is hemostatic Gel-Foam, Avitene, or Instat sutured snugly into socket Infiltrate lidocaine with epinephrine Gums 113
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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 Gums 114
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Pyogenic Granuloma 115 Source Undetermined Source Undetermined
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Pyogenic Granuloma Source Undetermined 116
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I got a tooth knocked out Mouth msspider66 (Wikimedia Commons) 117
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I got a tooth knocked out Mouth 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
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I got a tooth knocked out Mouth 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
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I got a tooth knocked out Mouth 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
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I got a tooth knocked out Mouth 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
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I got smacked in the mouth 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
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I got smacked in the mouth Mouth Tongue cuts: rarely need repair Potter BC. Amer Fam Phys 18(5):96,1978 123 Source Undetermined
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I got smacked in the mouth Mouth Cheek / lip cuts: close to prevent food entrapped Frenulum cut: let heal on own Source Undetermined Source Undetermined 124
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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