sfl_4_acutedentalproblems

7/27/2019 SFL_4_AcuteDentalProblems

http://slidepdf.com/reader/full/sfl4acutedentalproblems 1/48

www.smilesforlifeoralhealth.org

Copyright STFM 2005-2010

Third Edition June 2010



Course Steering Committee EditorsRussell Maier, M.D.

Alan B. Douglass, M.D.

Dental Consultant

Joanna M. Douglass, B.D.S., D.D.S.

Smiles for Life Editor

Alan B. Douglass, M.D.

Funded By



Educational Objectives

• Understand the nature of oral pain.

• Recognize the importance of a thorough history and

examination in developing a differential diagnosis for oral

pain.• Identify the best analgesia choices for oral pain.

• Learn how to properly diagnose, manage, and refer patients

suffering from oral infections.

• Develop familiarity with antibiotic options.• Understand the epidemiology of dental trauma

• Perform extraoral and intraoral exams to assess for injuries.



Educational Objectives

• Diagnose, initially manage, and appropriately refer patients

suffering from common dental trauma.

• Develop familiarity with dental trauma terminology in order

to accurately describe injuries for referral.• Understand how trauma to primary teeth can affect

permanent teeth.

• Recognize the different types of dental trauma and how to

appropriately treat and refer patients.• Implement strategies aimed at the prevention of oral

injuries.



Oral Pain

Photo: Joanna Douglass, BDS, DDS

Chapter Objectives

• Understand the nature of

oral pain• Recognize the importance of a

thorough history and examination

in developing a differential

diagnosis for oral pain• Identify the best analgesia

choices for oral pain



Oral Pain


Frequency and Nature

• Oral pain is common, with 22% of

adults reporting oral pain in the

past six months.

• Oral pain can be difficult to

localize and diagnose.

• Pain may be referred to the ear.

• Diagnosis in children is

particularly challenging.

• Children may present with

behavioral problems rather than

specific oral complaints.

6



Diagnosing Oral Pain

Diagnosis Requires

• A history that includes

̶ How long the pain has been present

̶ Whether there is pain with chewing, temperature change,

and sweet foods

• A head and neck examination that includes

̶ Extraoral examination for swellings and external masses

̶ Teeth

̶ Intraoral soft tissues

7



Oral Pain Etiologies

Dental

• Caries and its sequellae

• Eruptions problems (e.g.,

pericoronitis)

•Periodontal problems• Trauma

Nondental

• Sinusitis

• Otitis media/ otitis externa

• Oral ulcerations

• Temporomandibular joint

The differential diagnosis should include sources of

referred pain and pain of nondental origin.

8



Analgesia for Oral Pain

Nonsteroidal Inflammatory Drugs (NSAIDS)

• Typically highly effective for oral pain and should be

the first line of choice

• Relatively well tolerated

• No potential for abuse

Opioids

• May occasionally be required for severe pain

• Have potential for abuse

• Care should be taken when evaluating the need for opioids as drug seekers often complain of oral pain



Analgesia for Oral Pain

Oil of Cloves (Eugenol) and Other Topical Agents

• Although often used topically for oral pain, have not been

shown to be effective

• FDA reclassification of eugenol indicates insufficient data to

support efficacy

• Topical local anesthetics have little effect on dental pain and

should not be used in young children

10



Oral Infections

Photo: ICOHP

Chapter Objectives

• Understand the pathogenesis of oral

infections• Learn how to appropriately

diagnose, manage, and refer

patients suffering from oral

infections

• Develop familiarity with antibiotic

options



Reversible Pulpitis


Symptoms • Pain with hot, cold, and sweet

• Resolves spontaneously

Etiology

• Carious lesion approaching the

pulp removes insulating dentin

Treatment • Filling insulates the pulp causing

symptoms to disappear

• Analgesics are not generally necessary

12



Irreversible Pulpitis

Graphic: AAFP Home Study Program- with permission

Symptoms • Tooth is often sensitive to

percussion

• Pain is severe, spontaneous,

persistent, and poorly localized

Etiology• As carious lesion progresses, the

pulp becomes infiltrated with

bacteria and inflamed.

• Ultimately pulp necrosis results

13



Irreversible Pulpitis

Treatment

• Root canal treatment or tooth

extraction

• Root canal removes the pulp and fills

the residual space followed by a

crown.• Analgesics often necessary

• 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)


14



Periapical Abscess

Periapical abscess is a localized,

purulent form of periapicalperiodontitis.

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 severeGraphic: AAFP Home Study Program—with permission

Abscess may track through bone to form a localized fluctuant

swelling, fistulize, or spread to surrounding tissues causing

cellulitis

15



PeriapicalAbscessTreatment

• Arrange urgent dental referral for rootcanal or extraction

̶ If not done, abscess is likely to

recur.

• Incision and drainage can providetemporary relief if not fistulized

• Analgesics are necessary.

• Only use antibiotics if concurrent

cellulitis is present

Photo: Donald Greiner, DDS, MS


16



Facial Cellultis

Symptoms • Pain, often with fever

• Facial swelling

• Trismus, dysphagia, or airway obstruction

Treatment • Localized cellulitis in compliant patients:

̶ Outpatient oral antibiotics and analgesics

̶ Prompt dental referral• Extraction or root canal treatment to prevent recurrence

• Severe cellulitis involving deep spaces or sepsis requires

CT scan and hospitalization

Photo: ICOHP

Facial cellulitis secondary to a dental

abscess is a true dental emergency!

17



Pericoronitis

Pericoronitis is an infection of the

gum flap overlying partially eruptedmolars.

Symptoms • Patients complain of pain, gum

swelling, and inability to bite down onthe affected side

Graphic: AAFP—with permission

Etiology

• Food and plaque are trapped under

the gum causing inflammation,

swelling, and pain

• Secondary cellulitis of the surrounding

soft tissues can develop

18



Pericoronitis

Treatment

• 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


19



Periodontal Abscess

Symptoms

• Patient my 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 gum

• Cellulitis may also occur

Treatment

• Analgesics

• Antibiotics if concurrent cellulitis is present

• Dental referral for deep scaling and periodontal treatment

Periodontal abscess is a deep infection of the tooth

supporting structures

20



Antibiotic Options

The following antibiotics can be used to treat oral

infections:• Penicillin VK, 25–50 mg/kg/day, divided four times daily

• Amoxicillin, 35–50 mg/kg/day, divided three times daily

For penicillin allergic patients use:

• Clindamycin, 10–25 mg/kg/day, divided three times daily

For severe infections consider broad spectrum agents:

• Ampicillin-sulbactam

• Cefotaxime

• Ceftizoxime• Clavulanate Piperacillin-tazobactam

• Imipenem-cilastatin

21



Dental TraumaChapter Objectives

• Understand the epidemiology of dental trauma.

• Perform extraoral and intraoral exams to assess for injuries.

• Diagnose, initially manage, and appropriately refer patients suffering from common dental trauma.

• Develop familiarity with dental trauma terminology inorder to accurately describe injuries for referral.



Epidemiology of Dental TraumaThe peak incidence of dental injury occurs between ages 1

and 2 years as infants are becoming more mobile and peak asecond time at 8 to 10 years.

Preschoolers

• At least 30% of preschoolers have had a dental injury of some kind.• Falls are the most common source of oral injury.

School-aged Children

• Bikes, falls, sports injuries, automobile accidents, and violence are

common causes of dental trauma

• Twenty-five percent of 12-year-olds have injured permanent teeth.

• Anterior maxillary incisors are most often injured

• Trauma to permanent teeth can have life-long consequences

23

i i



Patient HistoryRequirementsAsk

• When the injury occurred• Where the injury occurred

• How the injury occurred

• If there are any associated injuries

Assess Symptoms

• Pain patient is experiencing

• Change in occlusion

Determine Tetanus Status • Consider prophylaxis for intrusion, avulsion, deep laceration, or

contaminated wound if not updated in past five years

i & l



Triage & ExtraoralExamTriage Procedure

1. Check airway, breathing, and circulation

2. Determine if other life-threatening injuries are present

3. Perform a neurologic exam

4. Assess the cervical spine5. Check for skull, orbit, zygomatic, ormandibular fractures

6. Evaluate extraoral soft tissue injuries

7. Conduct intraoral examination

8. Determine if injury is to primary or permanent teeth

9. Assess availability of dental care

25

I l E



Intraoral ExamProcedure

• Irrigate to remove blood, clots, anddebris

• Examine mouth, including soft tissues,

teeth, and bony structures

• Assess the injured area for

̶ Tenderness and swelling ̶ Damaged or mobile teeth

̶ Occlusion

̶ Mobile jaw segments

̶ Pain or limitation on opening, whichcan indicate trauma to the TMJ or

condyles

Photo: ICOHP

26

Al l B



Alveolar BoneFractureSymptoms & Findings

• Localized tenderness• "Steps" in the occlusion or alveolar bone

although displacement may not be present

• Movement of segmental alveolar fractures

when tooth mobility assessed

• Gingival laceration

Referral

• Image with CT

• See dentist or oral surgeon emergently

• Reduction is easier before swelling occurs

Photo: ICOHP

27

Chi T & C d l

http://bmj.com/cgi/content/full/321/7260/559/Fu12



Chin Trauma & CondylarFractureSymptoms & Findings

• Preauricular swelling• Pain

• Limited ability to open mouth

• Deviation on opening

• Palpable movement of condylar heads

• Altered occlusion

• Posterior tooth fracture (may not be

evident)

Referral

• See oral surgeon emergently

Photo: Jared Sorenson DDS

28

D fi iti



Definitions

• 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 knockedout of its socket

29

D fi iti



Definitions

Tooth Fractures

Graphic: ICOHP

30



Trauma to Primary Teeth

Photo: ICOHP

Chapter Objectives

• Understand how trauma

to primary teeth can affect

permanent teeth.

• Recognize the different types of

dental trauma and how

to appropriately treat and refer patients.

T t P i T th



Trauma to Primary Teeth

Characteristics

• Alveolar bone is more pliablein children

• Intrusion and luxation injuries

of primary teeth more

common

• Intrusion or subluxation of primary teeth may damage

adjacent developing

permanent dentition

Photo: ICOHP

32

I t i



Intrusion

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

• The dentist will take a radiograph

• Extraction is indicated if the intruded

tooth is impinging on a developing

permanent tooth bud

Photos: ICOHP

An intruded tooth is driven into its socket crushing surrounding

alveolar bone

33

L ti



Luxation

A luxated tooth is loose and has some lateral displacement

though it is still in its socket.

Treatment

• Management depends on mobility and displacement

• Highly mobile teeth or teeth interfering with child's occlusion requireimmediate dental referral

• Less traumatized teeth require good oral hygiene, a soft diet, and

dental referral in one day to one week based on symptoms


• The dentist will take a radiograph

• Highly mobile teeth or teeth interfering with occlusion may be treated

by extraction, repositioning, and splinting

34

A l i f P i



Avulsion of Primary Teeth An avulsed tooth has been completely displaced or knocked

out of its socket.

Treatment

• Avulsed primary teeth are NOT reimplanted to prevent further injury

to the adjacent developing successor

• Locate the teeth to ensure it is not intruded, aspirated, or swallowed

• Take appropriate radiographs if aspiration is suspected

• Refer patient to dentist in one day to one week


• Dentist will take radiograph to ensure tooth is not intruded and rule

out injuries to adjacent teeth

• Effect on permanent teeth cannot accurately be predicted

35

F t f P i



Fractures of Primary Teeth

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 and canextend 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

36



Trauma to Permanent Teeth

Photo: ICOHP

Chapter Objective

• Recognize the different types of

dental trauma and how to

appropriately treat and refer

patients

Intrusion of Permanent



Intrusion of Permanent TeethTreatment

• Do not attempt to remove intrudedtooth

• Refer patient to dentist immediately

for evaluation and possible

repositioningPhoto: ICOHP


• Dental care may include allowing for spontaneous eruption

(preferable in immature teeth), or active

repositioning (orthodontic or surgical with splinting)

• Root canal treatment, especially in mature permanent teeth is

often required • Risk for complications is high and includes tooth death, root

resorption, and tooth ankylosis

38

Avulsion of Permanent



Avulsion of Permanent TeethProcedure at 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)

• 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

• Best outcome if reimplanted within 5

minutes

Avulsed

permanent teeth

are a true dental

emergency!

Photo: ICOHP

39

Avulsion of Permanent Teeth



Avulsion of Permanent Teeth

Treatment by Clinician

• If the tooth cannot be reimplanted at thescene, it should be transported in

Hank's solution, milk, buccal sulcus, or

saline to the clinician for reimplantation

• Antibiotic prophylaxis with penicillin or

doxycycline for seven days isrecommended

• Determine tetanus status. Consider

prophylaxis if not updated in past five

years

• Immediate referral to a dentist for splinting and follow-up

Avulsed permanent

teeth are a true

dental emergency!


40

Crown Fractures



Crown FracturesSimple Crown Fracture

•Involves only enamel and dentin

• May be sensitive to hot and cold

• Routine dental referral for restoration

• Long-term follow-up needed to evaluate

for complications, such as pulp death or

root resorption

Crown Fracture with Pulp

Involvement

• Involves enamel, dentin, and pulp and

can extend below the gumline

• Urgent—one day referral for pulp

treatment and restoration

Photos: ICOHP

41

Root Fractures



Root FracturesTreatment

•Root fractures should be suspectedwhenever teeth have been traumatized

• Urgent—one day referral to dentist if

tooth is mobile and root fracture

suspected

Dental Care & Outcome• Radiographs are necessary to

complete diagnosis

• Treatment may involve reduction,

splinting, root canal treatment, or

extraction• Long-term prognosis depends on how

well segments can be approximated

among other factorsPhotos: ICOHP

42

Oral Piercing



Oral PiercingComplicationPossible Complications

•Tooth fracture or injury

• Stud aspiration

• Allergic reaction

• Nerve damage

• Speech impediment

• Gingival recession

• Infection

Management of Complications

• If inflammation present around a

piercing, remove jewelry.• Perform local debridement

• Start antibiotics and provide close

follow-upPhotos: ICOHP

43



Injury PreventionChapter Objective

• Implement strategies

aimed at the preventionof oral injuries.

Injury Prevention



Injury Prevention

Epidemiology and Prevention

• Most trauma occurs in soccer, football, baseball, and hockey• Injuries are also common in skateboarding, basketball, and

bicycling.

• A well-fitting mouth guard can decrease risk of injury

• Putting corner protectors on furniture reduces risk for young children

What Can Clinicians Do?

• Tell patients to use a mouth guard. Any are good; however, the best

are custom fitted

• A well fitting mouth guard is most likely to be used consistently• Include review of mouth guards at adolescent well child checks or

sports physicals

• Remove oral piercings before activity

45

Mouth Guards Prevent



Mouth Guards PreventInjuriesThere are three types of commonly available mouth guards.

Boil and bite

Custom made

Stock

Photos: ICOHP

46



Take Home Messages• Consider dental and nondental sources of pain

• Understand the disease progression from pulpitis tofacial cellulitis

• Accurately assess and describe dental trauma for optimal triage and referral

• Identify the two true dental emergencies: ̶ Facial cellulitis needs immediate antibiotic treatment and

possible hospitalization

̶ Avulsed permanent teeth require immediatereimplantation

• Clinicians should promote the use of mouth guardsand other protective equipment to prevent oralinjuries



Questions?

sfl_4_acutedentalproblems

Documents