dr o.g. ogbebor (bds,mph,fmcgdp) niger state 2012 agm/cme december, 2012
TRANSCRIPT
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DENTAL EMERGENCIES
DR O.G. OGBEBOR(BDS,MPH,FMCGDP)
NIGER STATE 2012 AGM/CME
DECEMBER, 2012
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OUTLINE
DEFINITION INTRODUCTION CAUTION SOURCES OF DENTAL EMERGENCIES TYPES OF DENTAL EMERGENCIES HANDLING OF COMMON DENTAL
EMERGENCIES CONCLUSION
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DEFINITIONS Emergency means sudden occurrence or
unplanned negative or positive event.
Dental emergency is therefore dental conditions that may occur suddenly and requires dental professional intervention.
Illinois State Dental Society defined dental emergency as an oral condition that occurs suddenly and creates an urgent need for professional consultation and or treatment. These clinical conditions may include haemorrhage, infection, pain, and trauma
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However, for the topic we are concerned with today; Dental emergencies, will be tailored to the emergencies associated with dental profession.
By this it will be all encompassing i.e. Dental emergency as may occur in the dental clinic or outside the Dental clinic as may be explained latter.
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INTRODUCTION Dental emergencies though relatively rare,
are very important because precise and adequate handling is very essential to avoid severe complications and mortality.
The relatively rarity of dental emergencies is due to the ambulatory nature of dentistry so dental surgeons could be caught unawares esp. those that occur on the dental chair.
Hence adequate preparations and high index of suspicion on every patient during practice is very important and recommended.
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Thorough assessment of every patient and taken into cognizance the relevant findings before treatment is commenced will reduce incidence to the barest minimum.
The goals of the dental practitioner is to develop a sense of vigilance and anticipation to enable one respond to an urgent medical or dental needs in a reasonably confident and efficient fashion when it occurs as prevention is far better and cheaper than cure.
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CAUTION It is estimated that about 90% of
emergencies can be prevented. This means that 10% will occur in spite of our best efforts!!!
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SOURCES OF DENTAL EMERGENCIES
This can be grouped into three major groups for the purpose of this discussion.
Arising from: 1. Patients 2. Dental Treatment 3. Trauma
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THOSE ARISING FROM PATIENTS:
(a) Attitude to dental care – Late, poor or never dental attendance (b) Application of self medications eg Toxins (touch and go, battery acids, aspirin, etc).
(c) Exercepated patients’ dental conditions eg toothache from untreated diseased tooth or teeth, cancers, abscesses etc.
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THOSE ARISING FROM PATIENTS:
(d) Unidentified or poorly managed medical conditions• Diabetes mellitus(Hyper/Hypo glycaemia), • Hypertension, • Ischaemic Heart disease (Angina pectoris/myocardial
infarction)• Cardiac Arrest, • Cerebrovascular Accident, • Fits/seizures, • Anaphylaxis, • Adrenal insufficiency, • orthostatic hypotension{dizzyness in upright position}, • Asthmatic attack.• Psychiatric conditions
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THOSE ARISING FROM DENTAL TREATMENT:
Broken tooth/teeth(retained roots) Post extraction haemorrhage Foreign bodies (swallowed denture), fish bones, broken fillings Post extraction trauma/swellings Endodontics Periodontal diseases(gingivitis) Others emanating from reaction of patient to treatment Fears and apprehensions – Fainting/ vasovagal syncope.
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THOSE ARISING FROM TRAUMA:
Maxillofacial Injuries/FracturesLacerations - Avulsion - Tooth displacement - Fracture of teethThese could be from RTA, domestic violence, playground or sports injury etc.
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TYPES OF DENTAL EMERGECIESThis can be grouped into two major parts: (a)Emergency occurring within the clinic: (i) Loss of consciousness(LOC) in the Dental Clinic; This could be as a result of
fainting/vasovagal syncope. Starvation(hypoglycaemia) – as a result
of Patient not taken meals at home before coming for dental treatment.
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TYPES OF DENTAL EMERGECIES Fit/seizures Anaphylaxis Adrenal Insufficiency Asthmatic attack Inhaled foreign bodies Psychiatric(Hyperventllation Syndrome)
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Fear/anxiety as a result of the sight of
dental gadgets and presumed fear of dental pain.
Diabetes Mellitus(hypoglycaemia/hyperglycaemia)
Ischaemic Heart disease(Angina pectoris/myocardial infarction).
Cardiac Arrest. Cerebrovascular Accident.
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FAINTING/VASOVAGAL SYNCOPY Defined as sudden loss of consciousness(LOC) due
to cerebral hypoperfusion. It is most common of LOC in the Dental Clinic. Patient is usually a fit able bodied young Man! Causes: Anxiety,pain,fatigue,high temperature and
humidity.
Presentation: Premonitory dizziness,weakness,nausea, Pallor, cold moist skin and then LOC.
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MANAGEMENT:
Lay patient on the dental chair and elevate the chair downwards to allow easy blood flow to the brain.
Loosen tight fittings, clothings. Lay Patient flat or in Trendelenborg
position. Recovery occurs within 3 minutes
otherwise consider other likely cause of LOC.
May need to reschedule appointment.
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DIABETES MELLITUS INDUCED LOC Usually occurs in known DM patient; Either due to a missed meal or poorly
controlled condition.Presentation: Drowsiness, disorientation or
aggressiveness could suggest hypoglycaemia.
There is dry mouth, dry skin and deep breathing in hyperglycaemia.
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MANAGEMENT Give oral glucose if patient is conscious
and I/V if unconscious (irrespective of whether is hypo or hyper) since you may not be able to differentiate.
1mg glucagon can be given in hypoglycaemia.
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ISCHAEMIC HEART DISEASEAngina Pectoris: Presenting with central crushing chest
pain usually precipitated by exertion. No physical sign associated. Relieved by rest and GTN.Myocardial infarction: Ischaemic necrosis of the cardiac musles. Pain more severe than AP and not
relieved by rest or GTN.
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CARDIAC ARREST Characterized by sudden pallor,
respiratory arrest, loss of pulse and LOC.Causes: Myocardial infarction(Asystole and
ventricular fibrillation, analphylaxis)Management: Cardiopulmonary resuscitation.
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CEREBROVASCULAR ACCIDENT (STROKE)
Presentation: Patient is usually a known hypertensive Severity depends on site and size of the
brain involved. Loss of consciousness. Weakness of limbs on one side. Facial dropping Speech affection.Management: Maintain airway and observe.
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FITS/SEIZZURES Known Epileptics Can occur in hypoglycaemia, drug
overdose(LA),may follow LOC. Presentation: LOC with rigid extended body. Jerking movements Incontinence may follow.Management: Most fits terminate spontaneously; just
prevent damage to Patient.
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FITS/SEIZURES 10mg I/V Diazepam can be given if
fitting does not end within 5minutes. Give oxygen. Avoid forcing mental or wooden objects
into patient’s mouth.
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ANAPHYLAXIS Type I hypersensitivity reaction. Usually a reaction to the fixative in local
anaesthetic(LA) called methyl paraben and I/V penicillin.
There could be facial flushing, itching,paraesthesia and peripheral coldness.
Rapid and weak pulse, cold clammy skin. LOC.
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MANAGEMENT Patient is laid flat; administer oxygen. Give I/V 100- 2OOmg hydrocortisone. 10 – 20mg chropheniramine I/V And if need be 1ml of 1:1000 adrenaline
i/m.
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ASTHMATIC ATTACK Usually a known asthmatic.Causes: Anxiety, infection or exposure to
allergens.Presentation: Breathlessness Expiratory wheezes Tachypnoea Use of accessory muscles of respiration
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MANAGEMENT Reassure and give inhaler 0.3cc of 1000 adrenaline may be
required Administer oxygen and I/V
hydrocortisone Avoid barbiturates, NSAID and narcotics
in Asthmatics. May need to see his Physician.
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INHALED FOREIGN BODY Usually a tooth or endodontic instrument Could result in respiratory obstruction,
lung abscess or death. Management: Heimlich manauver(not slapping the
patient on the back. Failing, an endoscopy will be needed. Also X- Ray usually needed for
localisation.
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INHALED FOREIGN BODY
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HYPERVENTILATION SYNDROME
Patient is usually an anxious or hysterical woman
Overbreathing until carbon dioxide washes out resulting in tetany and paraesthesia
Palpitations, breathlessness and dizziness often associated.
Causes: Organic cause include pain.
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HYPERVENTILATION SYNDROME
It could be a response to acidosis or poor ventilatory exchange(compensatory physiological response).
Management: Reassurance Re- breathing into a bag to overcome
alkalosis. May require I/V diazepam.
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ADRENAL INSUFFICIENCY
Manifest as inability to cope with stress.
Causes: Include: Addison’s disease, acute
withdrawal of corticosteriods, pituitary or adrenal diseases or damage.
Likely when corticosteroid > 20mg daily for two weeks in the last two years.
Prevention: Preoperative steroids
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ORTHOSTATIC HYPOTENSION
Dizziness in upright position or sudden change in posture.
Causes include anti BP, tricyclics, Narcotics, poor postural reflex, pregnancy.
Management: Prevent by gradual change in position.Treatment: As in vasovagal syncope.
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Note: ONLY FEW EMERGENCIES CAN BE
TREATED DEFINITIVELY IN THE DENTAL SURGERY.
THE IDEA IS TO BE ABLE TO CARRY OUT LIFE SAVING GENERAL MEASURES: ENSURING PATIENT AIRWAY,
BREATHING AND MAINTENANCE OF CIRCULATION.
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TAKE HOME MESSAGE
Anticipation, Prevention and planning. Anticipation: what type of emergency
can you anticipate with this patient? Prevention: what can you do to
decrease the risk of occurrence? Planning: what would you do if the
problem occur?
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PULPITIS FROM DENTAL CARIES
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ACUTE PERIAPICAL PERIODONTAL FROM DENTAL CARIES
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THOSE ARISING FROM DENTAL TREATMENT: Broken tooth/teeth(retained roots) Treatment depend on the type of fracture Enamel fracture- round off rough edges Dentine
fracture-composite/GIC/amalgam filling Fracture involving pulp- RCT Cervical root fracture -extraction Sagittal split - extraction
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THOSE ARISING FROM DENTAL TREATMENT:
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THOSE ARISING FROM DENTAL TREATMENT:
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THOSE ARISING FROM DENTAL TREATMENT:
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THOSE ARISING FROM DENTAL TREATMENT: Post extraction haemorrhage Assess source of bleeding Give I.M vitamin K If soft tissue, compress with guaze and
put horizontal matress suture If bone, apply haemostatic agent like
surgicel, bone wax, gel foam. If haematological issues are detected
from blood test refer to the haematology.
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THOSE ARISING FROM DENTAL TREATMENT: Foreign bodies (swallowed denture), fish
bones, broken/fillings Fish bone can be removed using artery
forcep and open flap to visualise it Swallowed denture will be retrieved
through endoscopy by Otorhinolaryngologist or Cardiothoracic Surgeon after having barium swallow or barium meal radiograph.
Broken filling may occur from improper use of elevator and this have to be replaced
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THOSE ARISING FROM DENTAL TREATMENT: Abscess: Dentoalveolar, palatal and
fascial space abscess, etc.
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DENTOALVEOLAR ABSCESS
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PALATAL ABSCESS
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SUBMANDIBULAR ABSCESS
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BUCCAL SPACE ABSCESS
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SUBMASSETERIC ABSCESS
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LUDWIG ANGINA
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THOSE ARISING FROM DENTAL TREATMENT: Endodontic emergencies may arise at the
preoperative, intraoperative and postoperative stages of dental care
Preoperative occurs from pulpitis, acute apical periodontitis. RCT will suffice for them except in reversible pulpitis where temporary dressing with dycal and ZOE is necessary
Intraoperative like flare up - do more biomechanical cleaning and dress root canal with non setting Ca(OH)2
Postoperative like high spots - grinding the high spots after detecting with articulating paper.
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THOSE ARISING FROM ORTHODONTIC TREATMENT:
Orthodontic wires can cause injuries. The wire will be adjusted or cut
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THOSE ARISING FROM DENTAL TREATMENT:
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PERIODONTAL ABSCESS
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ANUG
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THOSE ARISING FROM DENTAL TREATMENT: Periodontal diseases in form of
periodontal abscess, acute necrotizing ulcerating gingivitis (ANUG)
Periodontal abscess-incision and drainage, treat the casuative agent like periodontal pocket.
ANUG- gross scaling, diluted hydrogen perioxide mouth wash, antibiotics-amoxil and flagyl,
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Diagnosis Definition Presentation Complications Treatment Reversible pulpitis
Pulpal inflammation Pain with hot, cold, or sweet stimuli
Periapical abscess, cellulitis
Filling
Irreversible pulpitis
Pulpal inflammation Spontaneous, poorly localized pain
Periapical abscess, cellulitis
RCT, extraction
Abscess Localized bacterial infection
Localized pain and swelling
Cellulitis I & D and RCT or extraction
Cellulitis Diffuse soft tissue bacterial infection
Pain, erythema, and swelling
Regional spread Antibiotics and RCT or extraction
Pericoronitis Inflamed gum over partially erupted tooth
Pain, erythema, and swelling
Cellulitis Irrigation, antibiotics if cellulitis also present
Tooth fracture Broken tooth Clinical examination and radiography
Pulpitis and sequelae
Fillings, with or without RCT, extraction
Tooth luxation
Loose tooth Clinical examination and radiography
Aspiration, pulpitis, and sequelae
Splinting, with or without RCT, extraction
Tooth avulsion
Missing tooth Clinical examination
Ankylosis, resorption
Reimplantation and splinting
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THOSE ARISING FROM TRAUMA:Lacerations- remove debris and foreign bodies, arrest haemorrhage, finally suture it
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THOSE ARISING FROM TRAUMA:- Avulsion if the tooth is whole, hold the crown and replant into the cleaned socket and splint with composite reinforced with stainless steel wireDisplaced tooth- Splint
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MANDIBULAR FRACTURE
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THOSE ARISING FROM TRAUMA:Mandibular Fractures Principles and practice of fracture
management as reduce, stabilize and fix, apply here.
For bilateral parasymphyseal mandibular fracture, the lack of tongue support will lead to it falling back and patient suffocating. Emergency measures like applying suture on the tongue and tying it to the patients apron.
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THOSE ARISING FROM TRAUMA:Maxillary Fractures: Lefort I, II and III
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THOSE ARISING FROM TRAUMA:Lefort I
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THOSE ARISING FROM TRAUMA:Lefort II
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THOSE ARISING FROM TRAUMA:Lefort III
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THOSE ARISING FROM TRAUMA:Maxillary Fractures: Lefort I, II and III Principles and practice of fracture
management as reduce, stabilize and fix, apply here.
Lefort II fracture will cause backward slide of the segment which will occlude the airway. Emergency measures is to do manual or mechanical reduction.
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CONCLUSION Dental emergencies which arises from dental
and medical conditions needs urgent and precise care to prevent complications.
Proper history and clinical examination will help in reducing the prevalence of preventable dental emergencies in the dental clinic.
Training and retraining of dentist will help reduce dental emergencies associated with dental treatment.
Patient education to heighten awareness will help reduce dental emergencies associated with poor dental awareness and personal care.