240. Oral and Dental Emergencies

Anatomy

Diseases/Disorders

Teething: either primary or deciduous teeth. Irritability, drooling, decreased oral intake. Fever/diarrhea not necessary associated with it.

Pericoronitis: infection/inflammed operculum (gingiva above erupting third molar/wisdom tooth). Tx like most dental abscess: PCN VK or clindamycin.

Dental caries: enamel breakdown; cold/sweet sensivity. If deep enough into the dentin, can get into pulp and cause irreversible damage. Tx for irreversible pulpitis or pulpal necrosis is root canal or extraction.

Periodonitis: extension of infection into surrounding gingiva/tissue. Can form dental abscesses. Tx: PCN VK 500mg QID/Clindamycin 300mg QID.

Dry Socket: postextraction pain (usually lasts 12-24 hrs with ice/NSAIDs) or postextraction alveolar osteitis – second/third day postoperative day – usually due to clot displacement. Xray may show retained root tip. Tx: irrigate socket, dry area with dry gauze and eugenol ribbon gauze. Should have immediate pain relief. Tx: PCN VK or Clindamycin, daily packing changes.

Postextraction Bleeding: usually just needs firm packing for 20 minutes. If not, apply surgicel or can consider suture to loosely close gingiva. Consider lido/epi or silver nitrate as well.

Periodontal Abscess: infection between tooth and socket. Tx: I&D if necessary, abx, warm saline rinses.

Acute Necrotizing Ulcerative Gingivitis: “Vincent dx/trench mouth”. gingiva ulceration that can lead to bone and tissue destruction. Triad: pain, ulcerated/punched-out papillae, gingiva bleeding. Similiar presentation to herpes gingivostomatitis. Usually anaerobic bacteria. RF: HIV. Tx: chlorhexidine 0.1% oral rinses BID, debridement, metronidazole 500mg TID.

Trigenimal neuralgia: age 30-60yo, primarily women, maxillary branch of CNV. Severe electric shock-like paroxysmal pain, short duration. Unilateral. Can be triggered by touching point. Consider ruling out: acoustic neuroma, cerebral aneurysm, nasopharyngeal carcinoma. Tx: carbamazepine 100mg BID (up to 1200mg daily). Also can receive phenytoin,gabapentin, oxcarbazepine, baclofen. Neurology referral. Surgery for refractory cases.

Trigenimal Nerve

Oral Candidiasis: white pseudomembranous curd-like plaques that can be scraped off to show red base. RF: extremes of age, dentures, antibiotics, AIDS. Tx: nystatin oral suspension 500k units swillow and swallow QID, clotrimazole 10mg troches 5x/daily, or fluconazole 100mg PO daily.

Aphthous Stomatitis: “canker sores”, labial/buccal mucuosa, erythematous macule that ulcerates and forms central fibropurulent eschar. Self-limited, usually resolves in 10-14 days. Major/minor forms – major is deeper. Due to unknown trigger: could be immune, breach to mucosal barrier, allergic reaction. Tx: Fluoconionide 0.05% gel applied topically; can also do betamethasone syrup of 0.01% dexamethasone elixir as mouth risnse. Resistane can require steroid injection.

Herpes Simplex: type 1/2 indistinguishable. Fever/adenopathy a few days before it occurs; burning/tingling can occur as well prior to vesicles erupt.  Painful,  ulcers that rupture over 1-2 days, then heal over 1-2 weeks. Kids: acyclovir 75mg/kg/day divided into 5x daily (max 2g/daily) x 7 days. Adults: acyclovor 400mg TID/5x daily x 5 days or valacyclovir 2g PO daily x 1 day.

Varicella-Zoster: unilateral, can present as headache/toothache. 15-20% shingles present as trigenimal distribution. Ophthalmic branch requires urgent optho consult.

Herpangina: coxsackievirus group A; usually summer/fall, presents with fever, sore throat, headache, fatigue and oral vesicles in back of mouth sparing the tongue, bucca, gingiva. Lasts 10 days.

Pyogenic granuloma: increase in granulation tissue usually due to trauma/irritation. Can occur in pregnancy and usually resolves post-partum.

Gingival hyperplasia: medication reaction, well known to phenytoin. Also: cyclosporine, CCB. Can bleed easily if inflamed. Worse with poor hygiene.

 Benign Migratory Glossitis: “geographic tongue”, affects 1-3% of population, usually females. Multiple, well demarcated zones of erythema on tongue caused by atrophy. Benign, self-limited. Usually asymptomatic, can be related to stress/menses.

Oral cancer: 90% squamous cell cancer. RF: tobacco use, alcohol use, sunlight. MC site posterolateral border of tongue. Floor of the mouth is 35%. Usually painless. Fixed, adenopathy.

Dental fractures: Ellis classification (most dentists don’t use): I: enamel portion only, no tx necessary. II: dentin involved, requires intervention. 70% of fractures. Patients usually have hot/cold stimuli – look for exposed dentin – creamy yellow color. If not treated, can lead to pulp necrosis. Needs dental cement. Can also consider using dermabond. III: pulp exposure – blood present. Tx: cover pulp with calcium hydroxide base and then cover with dental cement. Most unless very small will require endodontic or root canal therapy. Root fractures – place in splint and refer.

Tooth concussion: tenderness with percussion. No stabilization needed.

Tooth luxation: subluxation is mobility without any displacement. Luxation is displacement requiring splinting. Splinting: firm, gentle pressure will reposition tooth. Flexible wire splint or temporarily splint with noneugenol zinc oxide peridontal dressing (Coe-Pak, ZONE periopak). Need to see dentist or oral surgeon within 24 hours.

Tooth avulsion: Permanent teeth need to be reimplanted ASAP (within 2-3 hrs). Rinse with sterile water, replace into socket. If need to transport, place in Hank’s solution, sterile saline, milk, or saliva. Consider looking for aspirated tooth that was swallowed. Do not scrub the tooth. Prepare socket by removing clot and irrigating. Local anesthesia usually required. All patients need abx: doxycycline 100mg PO or PCN VK. Do not reimplant avulsed primary tooth in kids.

Tongue lacerations: approximate wound edges on the dorsum of the tongue very precisely – may result in epithelial cleft and bifid appearance.

Lip lacerations: through lip border need to have vermillion border sutured first. Sutures usually removed in 5 days.

Frenulum lacerations: maxillary labial frenulum or lingual frenulum do not require sutures.

References

Tintinalli, Seventh Edition, Chapter 240: Oral and Dental Emergencies

Crashingpatient.com, Scott Weingart, Oral Medicine and Denistry

240. Oral and Dental Emergencies

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