Emergency Dental Procedures

Complaints pertaining to the teeth and supporting maxillofacial structures are common, and patients frequently go to the emergency department (ED) for evaluation. Complaints may range in scope from a simple chipped tooth to an odontogenic deep space infection or a maxillofacial injury. Treating these patients can be challenging and frustrating for busy emergency clinicians. Many emergency clinicians and other acute care providers do not receive specific training in dental emergencies during their training, yet it is important for them to be able to recognize and treat a wide range of dental and related maxillofacial problems. Some dental emergencies can lead to significant morbidity such as loss of teeth, chronic pain, infection, and craniofacial abnormality, whereas others can lead to life-threatening airway compromise.

Management of specific dental emergencies requires a thorough understanding of adult and pediatric dentition. The relevant anatomy of both populations is outlined. The techniques described for management of the various traumatic and infectious problems are, in most cases, temporizing until definitive dental or maxillofacial surgery referral can be obtained. Conditions that require emergency consultation are discussed. Topical, local, and regional anesthesia are of particular importance and utility in the management of odontogenic emergencies, so the clinician should be very familiar with these techniques.

Although this chapter describes the diagnosis and treatment of dental injuries that may confront emergency clinicians, no standard of care mandates that complex dental problems (e.g., replacement of avulsed teeth, drainage of infection) be definitively handled in the ED setting. Advances in ED equipment and clinician training, as well as the introduction of dental skills laboratories into the resident curriculum, are gradually raising the existing standard of care. The initial stabilization of fractured, subluxed, luxated, and avulsed teeth, as well as bleeding and dry sockets, is now within the treatment realm of the emergency clinician. Likewise, abscesses and infections should be properly identified and drained if necessary. It is appropriate to refer all significant dental pathology to a dentist or oral surgeon.

Teeth

The adult dentition normally consists of 32 teeth: 8 incisors, 4 canines, 8 premolars, and 12 molars. From the midline to the back of the mouth on each side, there is a central incisor, a lateral incisor, a canine (cuspid), two premolars (bicuspids), and three molars, the last of which is called the wisdom tooth ( Fig. 64.1 ). The 20 primary or deciduous (baby) teeth include 8 incisors, 4 canines, and 8 molars. From the midline to the back of the mouth, there is a central incisor, a lateral incisor, a canine, and two molars ( Fig. 64.2 ). There are no premolars in the primary dentition. Agenesis, or lack of proper formation of a tooth or teeth, is not uncommon, especially in the maxilla. Likewise, supernumerary, or extra, teeth may also occur. The adult teeth are numbered from 1 to 32, with the first tooth being the right upper third molar and the 16th tooth being the left upper third molar. The left lower third molar is the 17th, and the 32nd tooth is the right lower third molar. Numerous classification and numbering systems of the teeth exist; however, it is best for clinicians to simply describe the location and type of tooth in question (e.g., upper left second premolar, lower right canine). This removes any question when discussing a case with a consultant.

Figure 64.2, Identification of teeth, adult and child. Each tooth has a number assigned to it. By 14 years of age, all primary teeth should normally be lost. Do not reimplant an avulsed primary tooth; rather, refer to a dentist to prevent future misalignment of the permanent teeth.

A tooth consists of the central pulp, the dentin, and the enamel ( Fig. 64.3 ). The pulp contains the neurovascular supply of the tooth, which is responsible for carrying nutrients to the dentin, a microporous substance that consists of a system of microtubules. The dentin makes up the majority of the tooth, is a primary determinant of tooth color, and cushions the tooth during mastication. The enamel is the relatively translucent, outermost portion of the tooth and the hardest part of the body. The tooth may also be described in terms of the crown (coronal portion) and the root (apex portion). The crown is the portion covered in enamel; the root is the part that serves to anchor the tooth in the alveolar bone.

The following descriptive terminology is used for the different anatomic surfaces of the tooth. These terms are useful when describing the specific tooth injury to a consultant or colleague:

Facial : the part of the tooth that faces the opening of the mouth. This is the part that you see when somebody smiles. It is a general term applicable to all teeth.
Labial : the facial surface of the incisors and canines.
Buccal : the facial surface of the premolars and molars.
Oral : the part of the tooth that faces the tongue or the palate. This is a general term applicable to all teeth.
Lingual : toward the tongue; the oral surface of the mandibular teeth.
Palatal : toward the palate; the oral surface of the maxillary teeth.
Approximal/interproximal : the contacting surfaces between two adjacent teeth.
Mesial : the interproximal surface facing anteriorly or closest to the midline.
Distal : the interproximal surface facing posteriorly or away from the midline.
Occlusal : biting or chewing surface of the premolars and molars.
Incisal : biting or chewing surface of the incisors and canines.
Apical : toward the tip of the root of the tooth.
Coronal : toward the crown or the biting surface of the tooth.

The Periodontium

The periodontium, also known as the attachment apparatus, consists of two major subunits and is necessary for maintaining the integrity of the normal dentoalveolar unit.

The gingival subunit consists of the junctional epithelium and gingival tissue. Gingival tissue is composed of keratinized, stratified squamous epithelium; it can be divided into the free gingival margin and the attached gingiva. The free gingiva is the cuff of tissue formed around the neck of the tooth. The gingival sulcus is the space between the free gingiva and the tooth. It is rarely greater than 2 to 3 mm in depth in normal healthy dentition. The attached gingiva is the portion of gingiva attached to alveolar bone and extends apically (away from the tooth) to the mucogingival junction (or the mucobuccal fold). At this point the tissue, loose and nonkeratinized, is called the alveolar mucosa (or buccal mucosa).

The periodontal subunit includes the periodontal ligament, alveolar bone, and the cementum of the root of the tooth. The periodontal ligament consists of collagen that extends from the alveolar bone to the root of the tooth. One end of the periodontal ligament inserts into the alveolar bone and the other end into the cementum.

The gingival subunit is primarily responsible for maintaining the integrity of the periodontal subunit. Certain disease states such as gingivitis weaken the attachment apparatus and can result in loss of a tooth.

Acute Toothache in the ED

Patients with an acute toothache (odontalgia) often come to the ED for dental evaluation and relief of symptoms. Although multiple problems can initially cause pain in the area of the teeth, the cause is usually pulpitis, abscess, or dental trauma. Pulpitis can be either acute or chronic and the physiology, treatment, and prognosis are different for each patient. Unfortunately, many patients have irreversible pulpitis by the time they seek emergency care.

Pain in a tooth when exposed to hot liquids usually indicates pulpal inflammation. Sensitivity to cold can signify simple sensitivity or gum recession but can also indicate decay. Pain while biting down or to percussion can indicate a fractured tooth, abscess, or decay.

Many fillings can leak and cause pain, and microcracks can occur and not be readily apparent to someone who is not a dentist. One cause of microcracks, or even a totally fractured tooth, is constant trauma from the metal balls implanted with tongue piercing.

Referral to a dentist is the logical definitive course of action for odontalgia, but pain relief can be initiated in the ED. Nonsteroidal antiinflammatory drugs (NSAIDs), acetaminophen, opioids, and local nerve blocks can all provide relief of pain, depending on the scenario. Hile and Linklater reported significant pain relief in a fractured tooth by applying 2-octylcyanoacrylate tissue adhesive (Super Glue) directly to the tooth. This intervention is currently anecdotal but may also provide temporary pain relief for patients with open decay when air and temperature exacerbate the pain. Dry the tooth thoroughly with gauze, and generously apply a few layers of the product to the affected area. This intervention lasts less than 24 hours before enzymatic breakdown occurs. Note that the use of skin adhesives has not been approved for intraoral use; they tend to break down quickly in the oral cavity.

For years, clove oil (containing eugenol) has been a popular and reasonably effective short-term home remedy for an acute toothache or inflamed gingiva. For a cavity or gingiva pain, saturate a piece of cotton in clove oil and place the cotton directly in the cavity or along the gum. This will provide relief for a few hours. Clove oil should not be used more than a few times because of irritation and possible nerve damage. Another simple method of pain management is to apply viscous lidocaine directly onto the tooth or saturate a small cotton ball with the gel and place it in a cavity. This treatment is temporary, and caution should be exercised if reapplication is considered. Do not exceed the total recommended dosage of lidocaine.

Acute dental pain may also be referred pain, so a complete evaluation should be conducted if the anatomy in question appears to be normal ( Fig. 64.4 ). For example, acute sinusitis can cause tooth pain and vice versa. Obvious dental infection should be treated with antibiotics (e.g., penicillin, clindamycin, erythromycin, metronidazole, amoxicillin-clavulanate) while awaiting dental evaluation. Chronic acetaminophen overdose is a known complication of overaggressive use of analgesics by patients unable to obtain dental care for an acute toothache.

Figure 64.4, This physician had severe pain in his jaw thought to be related to a dental problem. Two days after onset of the pain, the rash of herpes zoster appeared, which was the cause of the pain.

Antibiotics provide no benefit for pain from a simple toothache, dental cavity, or pulpitis, although some clinicians prescribe them because follow-up dental care may be delayed or difficult to obtain. The emergency clinician, likewise, doesn't know whether a periapical abscess exists and so if definitive care is likely to be delayed, antibiotics are a reasonable choice.

Individual teeth (except the posterior molars) can be temporarily anesthetized with total pain relief by simply giving a supraperiosteal injection of a local anesthetic (see Chapter 30 ). Bupivacaine has a long duration of action (4 to 12 hours) and has been shown to decrease the narcotic requirement of postoperative oral surgery patients even after the anesthetic properties of the medication have worn off. Molars, which are more difficult to anesthetize with supraperiosteal injections, can be anesthetized via different nerve block techniques, such as the inferior alveolar nerve block.

Dentoalveolar Trauma

Dental Fractures

Dentoalveolar trauma is a common reason for ED visits. Injury to the maxillary central incisors accounts for between 70% and 80% of all fractured teeth. Acute trauma to the teeth is not usually life-threatening; however, the morbidity associated with poorly managed dental fractures can be significant and includes failure to complete eruption, change in color of the tooth, abscess, loss of space in the dental arch, ankylosis, abnormal exfoliation, and root resorption. Dental injuries are often associated with intraoral lacerations. When a tooth is chipped or missing and there is a concomitant intraoral laceration, there is a risk that the missing portion of the tooth is embedded in the depths of the laceration ( Fig. 64.5 ).

Figure 64.5, A chipped front tooth after a punch to the mouth can result in a piece of tooth being aspirated or embedded in the laceration. When this lip laceration was explored, a piece of tooth was found embedded within the laceration. If this foreign body is not removed, an infection is certain to occur within a few days. Note the obvious chipped upper tooth, the source of the piece found in the upper lip laceration.

Some general principles apply to the evaluation and management of dental trauma. First, identify all fracture fragments and mobile teeth. Percuss each tooth surface for mobility and sensitivity. If a tooth is missing, it cannot always be assumed that it has been avulsed. Teeth can be aspirated into the respiratory tract, swallowed into the gastrointestinal tract, or fully intruded into the maxillary sinus, alveolar bone, or nasal cavity. Take radiographs if there is any suspicion of aspiration of tooth fragments or intrusion of fragments into the gingiva or alveolar bone. Second, the dentition is much more easily manipulated if the patient is not in significant discomfort. Tooth injection and common dental blocks should be part of the emergency clinician's armamentarium. Third, topical tooth remedies and analgesics, both over-the-counter and prescribed, should be discouraged because their long-term use can lead to the development of sterile abscesses and soft tissue irritation. Fourth, administer tetanus vaccine if needed.

Management of fractured teeth depends on the extent of fracture with regard to the pulp, the degree of development of the apex of the tooth, and the age of the patient. Dentoalveolar injuries and, in particular, tooth fractures can be classified in many ways. The Ellis classification is one system often cited in the emergency medicine literature; however, many dentists and maxillofacial surgeons do not use this nomenclature, thus making it less than ideal when discussing these types of injuries with specialists ( Fig. 64.6 ). The most easily understood method of classification is one based on a description of the injury.

$Figure 64.6, A, The Ellis classification for fractured alveolar teeth. The easiest method to classify fractured teeth is by description (e.g., fracture through the dentin of the first upper right molar). B, Ellis class I: only the enamel is fractured. These fractures pose no threat to the dental pulp and are not sensitive to temperature or forced air. C, Ellis class II: the crown fracture demonstrates involvement of the enamel and dentin, without exposure of the pulp. Immediate dental referral is necessary to prevent contamination of the pulp through the dentinal tubules. D, This crown fracture involves enamel, dentin, and the soft tissue of the pulp as well. Immediate dental referral is mandatory to save the tooth.$

Crown fractures may be divided into uncomplicated and complicated categories. Uncomplicated crown fractures result from injuries to the enamel alone or to a combination of the enamel and dentin. Complicated crown fractures extend into the pulp.

Ellis Class I Fractures

Uncomplicated crown fractures through only the enamel are known as Ellis class I fractures (see Fig. 64.6 B ). They are not usually sensitive to either temperature or forced air. These fractures generally pose minimal threat to the health of the dental pulp. They may feel sharp to the patient's tongue, lips, or buccal mucosa. Immediate treatment is not necessary but may consist of smoothing the sharp edge of the tooth with an emery board or rotary disk sander. The patient should be reassured that a dentist can restore the tooth to its normal appearance with composite resins and bonding material. Follow-up is important with these injuries because pulp necrosis and color change can occur in some cases (< 3%).

Ellis Class II Fractures

Uncomplicated fractures through the enamel and dentin are called Ellis class II fractures . Fractures that extend into the dentin are at higher risk for pulp necrosis and therefore need more aggressive treatment by the emergency clinician (see Fig. 64.6 C ). The risk for pulp necrosis in these patients is less than 10%, but it increases as treatment time extends beyond 24 hours. These patients often complain of sensitivity to heat, cold, or forced air. Physical examination reveals the yellow tint of the dentin in contrast to the white hue of the enamel. With fractures closer to the pulp cavity, the dentin will have a pink tinge. The tooth is usually sensitive to percussion with a tongue blade. The porous nature of dentin allows passage of bacteria from the oral cavity to the pulp, which may result in inflammation and infection of the pulp chamber. This is more likely to occur after 24 hours of dentin exposure but occurs sooner if the fracture site is closer to the pulp. Likewise, patients younger than 12 years have a pulp-to-dentin ratio larger than that in mature adults and are at increased risk for pulp contamination. For this reason, younger patients should be treated aggressively and be seen by a dentist within 24 hours.

The goal of treating dentin fractures is twofold: to cover the exposed dentin and thus prevent secondary contamination or infection and to provide relief of the pain. After the tooth is covered, the dentist, using modern composites, can often rebuild the tooth directly over the calcium hydroxide (CaOH) cap that was placed in the ED. Perform supraperiosteal injection or a regional tooth block before any manipulation of the tooth. This will make application of the dressing easier because manipulation of the tooth will not cause discomfort. Dressings that may be applied to the surface of the tooth include CaOH, zinc oxide, skin adhesives, and glass ionomer composites. Some literature suggests that glass ionomer may be superior to other coverings; however, the difference is probably slight, and the increased cost of glass ionomer is not justified for routine use in the ED at this time. Certain composites may be cured with a bonding light. This is routinely done in the dentist's office and is beyond the scope of most emergency practice. Bone wax and skin glue such as the cyanoacrylates are not recommended as dressings. Many dressings come as a base and a catalyst which require mixing, but are often available in premixed formulations as well. This is easily accomplished with a dental spatula and a mixing pad, which can be obtained from any dental supply house. A commonly used ED dressing is CaOH (Dycal [Dentsply Sirona, York, PA], Preline [Henry Schein, Melville, NY], or other similar products). Mix the catalyst and the base in equal portions, and place a small amount on the exposed area with an applicator such as a dental spatula or another appropriate instrument ( Fig. 64.7 ). The fracture site must be dry before application of the CaOH to ensure adherence.

$Figure 64.7, Calcium hydroxide application for the treatment of dentin fractures.$

To dry the surface of the tooth, have the patient bite into gauze pads or mouth breathe. Likewise, connecting a nasal cannula to high-pressure wall O ₂ and aiming it at the tooth will facilitate drying. CaOH will dry within minutes after being exposed to the moist environment of the mouth. Although placing dental foil over the CaOH dressing is recommended in some texts, it is not necessary if the patient plans to follow up with a dentist within 24 to 36 hours. It is also not technically easy to perform. To prevent dislodgment of the CaOH dressing, instruct the patient to eat only soft foods until seen by a dentist. Although there is no evidence to support antibiotic therapy for fractured teeth in the ED, many consultants recommend initial treatment with penicillin or clindamycin until definitive dental care can be obtained.

Many patients who sustain a fracture through the dentin will require a root canal or other definitive endodontic treatment. Timely application of an appropriate dressing in the ED, however, may prevent contamination of the pulp and make root canal therapy unnecessary. As with any trauma to the anterior teeth, explain to the patient that disruption of the neurovascular supply is possible and that long-term complications such as pulp necrosis, color change, and resorption of the root might occur.

Ellis Class III Fractures

Complicated fractures involving the pulp are also known as Ellis class III fractures (see Fig. 64.6 D ). Complicated fractures of the crown that extend into the pulp of the tooth are true dental emergencies. These fractures result in pulp necrosis in 10% to 30% of cases even with appropriate treatment, so the vast majority of these injuries end up with root canal therapy. They may be distinguished from fractures of the dentin by the pink color of the pulp. Wipe the fractured surface of the tooth with gauze and observe for frank bleeding or a pink blush, which indicates exposure of the pulp. Fractures through the pulp are often excruciatingly painful, but occasionally there is lack of sensitivity secondary to disruption or concussion of the neurovascular supply of the tooth.

Immediate management includes referral to a dentist, oral surgeon, or endodontist. The patient usually requires pulpectomy (complete removal of the pulp) or, in the case of primary teeth, pulpotomy (partial removal of the pulp) as definitive treatment. The longer the pulp is exposed, the greater the likelihood of contamination and abscess formation. If a dentist cannot see the patient immediately, attempt to relieve the pain and cover the exposed pulp ( Fig. 64.8 ). If significant pain is present, perform a supraperiosteal injection. Subsequently, cover the tooth with one of the dressings described earlier. The bleed can be brisk at times. Control such bleeding by having the patient bite onto a gauze pad that has been soaked with a topical anesthetic containing a vasoconstrictor such as epinephrine. Alternatively, inject a small amount of anesthetic/vasoconstrictor into the pulp to control bleeding. After the covering is applied, instruct the patient to follow up as soon as possible with a dentist. Antibiotics with coverage directed at oral flora (e.g., penicillin, metronidazole, or clindamycin) should be considered, with recommendations to eat only soft food and to avoid mastication on the affected side. Removal of the pulp with specialized instruments by the emergency clinician is not recommended, although some authors have advocated this in the past. This procedure is the realm of the dental professional and is likely to result in complications if not done properly.

$Figure 64.8, Application of periodontal calcium hydroxide paste to the fractured surface of the tooth. The paste hardens quickly in the moist environment of the mouth.$

Luxation, Subluxation, Intrusion, and Avulsion

Luxation and Subluxation

Subluxation refers to teeth that are mobile but not displaced. Luxation refers to teeth that are displaced, either partially or completely, from their sockets. Luxation injuries are divided into four types ( Fig. 64.9 ):

1.
Extrusive luxation is an injury in which the tooth is forced partially out of the socket in an axial direction (see Fig. 64.9 A ).
2.
Intrusive luxation , or intrusion, occurs when the tooth is forced apically. It may be accompanied by crushing or fracture of the tooth apex (see Fig. 64.9 B ).
3.
Lateral luxation occurs when the tooth is displaced either facially, lingually, mesially, or distally (see Fig. 64.9 C ). This injury is often associated with injuries to the alveolar wall.
4.
Complete luxation , also known as complete avulsion, results in loss of the entire tooth from the socket.

Even minor trauma to the oral cavity requires meticulous examination for loose or missing teeth. Examine each tooth for mobility by applying a back-and-forth motion on each side of the tooth surface with either the fingertips or two tongue blades. Any blood in the gingival crevice (area where the gingiva touches the tooth) suggests a traumatized tooth.

Figure 64.9, Classification of tooth trauma. A, Extrusive luxation occurs when the tooth is forced partially out of the socket in an axial direction. B, Intrusive luxation of a tooth compresses the periodontal ligament and vascular supply of the pulp. It may even crush the apical bone. C, Lateral luxation occurs when the tooth is displaced in a lingual, mesial, distal, or facial direction. Fractures of the alveolus frequently accompany lateral luxation injuries.

Teeth that are minimally mobile and are not displaced do very well with just conservative treatment. The tooth will tighten up in the socket if not retraumatized or reinjured in any way. Instruct patients to eat only a soft diet for 1 to 2 weeks and see their dentist as soon as possible. Note that a seemingly lost (avulsed) tooth may actually be deeply intruded into the soft tissue ( Fig. 64.10 ).

Figure 64.10, Intruded tooth secondary to trauma. A, On superficial examination it appears that the tooth was simply knocked out. This missing tooth could be simply lost, fully intruded, aspirated, or swallowed. B, In some cases a dental radiograph or computed tomography scan is necessary to determine intrusion or avulsion. Intruded teeth create the potential for infection or cosmetic deformities. Intrusion of an upper tooth into the maxillary sinus can cause recurrent sinusitis. Teeth can also intrude into the nasal cavity and cause infection or bleeding, or they can be aspirated into the airway. The incisors are the teeth most commonly intruded.

Grossly mobile teeth require some form of stabilization as soon as possible. It is important to note that in certain patients with poor gingival health, luxated teeth may not be salvageable because of preexisting disease of the attachment apparatus. Stabilization is best performed by a dental specialist with enamel bonding material or wire ligation. Although many different “home remedies” exist for splinting loosened teeth in the ED, the clinician must be aware of the possibility of aspiration if the splint fails. Avoid the use of unapproved medications in the mouth. Splinting techniques are suitable for the emergency clinician to perform as temporizing measures until definitive care can be arranged. One simple technique for emergency use is to apply periodontal paste, commercially available as Coe-Pak (GC America Inc., Alsip, IL) or other similar commercial products ( Fig. 64.11 ). These products usually consist of a base and a catalyst that when mixed, form a moderately sticky claylike dressing that becomes firm after application. It is applied over the enamel and gingiva, as well as the adjacent teeth, to splint the subluxed tooth into place. Although the splint performs best if placed on the facial and buccal surfaces of the teeth, it is usually sufficient to apply the paste only to the front (facial) surface of the teeth. Make sure that the gingiva and enamel are completely dry. Lubricate gloves with water or lubricating jelly before applying the dressing. Apply the dressing into the grooves between the teeth, as well as on the adjacent teeth. Remind the patient to eat a soft diet until seen in follow-up within 24 hours. Periodontal pastes are usually fairly simple for the dentist to remove during formal restoration. They are also useful in treating difficult-to-repair gingival lacerations which are not associated with alveolar ridge fractures. The laceration is covered with periodontal paste and removed in 5 to 7 days by the follow-up dentist.

Figure 64.11, Dental splint (Coe-Pak, GC America Inc., Alsip, IL) application.

Teeth that are luxated in either the horizontal or the axial plane or are slightly extruded can also be splinted with the techniques described earlier. It is important that the loosened tooth be in as perfect alignment as possible when the final adjustments are made at the dentist's office. However, the alignment does not need to be as precise when the tooth is splinted in the ED. The important point is that the tooth be splinted adequately and follow-up ensured.

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