Dental problems

Dentoalveolar Injuries

Tooth Fracture

1. Enamel (Ellis Class I)
   1. Routine f/u only; nothing to do
2. Enamel + dentin (yellowish) (Ellis Class II)
   1. Pts experience sensitivity to hot/cold stimuli and air passing over tooth during breathing
   2. Cover exposed dentin to decrease pulpal contamination
      1. Place dental cement over fracture site
      2. Next day f/u
3. Enamel + dentin + pulp (reddish) (Ellis Class III)
   1. On wiping fractured surface with gauze, blood is easily seen
   2. Immediate referral (dental emergency)
   3. If no dentist is available:
      1. Cover exposed pulp with calcium hydroxide base
      2. Cover this and the remaining exposed dentin with dental cement

Tooth Subluxation

1. Extrusive Luxation
   1. Reposition tooth
   2. F/u within 24hr for stabilization
   3. Temporizing measure: Periodontal pack in which tooth is bonded to its two neighboring teeth on both sides
2. Lateral Luxation
   1. More extensive injury than extrusive luxation
      1. Associated with cracking or fracture of the surrounding alveolar bone
   2. Treatment
      1. Attempt repositioning of tooth
      2. Apply temporary splinting with periodontal dressing
      3. F/u within 24hr for stabilization
3. Intrusive Luxation
   1. Most serious because of significant damage to alveolar socket and periodontal ligament
   2. Treatment
      1. Allow tooth to erupt on its own

Tooth Avulsion

1. Dental emergency
2. Often associated with alveolar ridge fracture

1. Where is the tooth?
   1. May be intruded, aspirated, swallowed, or embedded in the oral mucosa
      1. Consider facial films, CXR
2. Adult
   1. Replace avulsed tooth as soon as possible (as long as no alveolar ridge fx, no severe socket injury)
      1. If reimplanted within 1hr 66% chance of good outcome
      2. Rinse tooth in saline, suction socket (if necessary), reimplant tooth, bond tooth to neighboring teeth
      3. Manipulate tooth only by the crown
   2. Storage solution (in order of efficacy): Hank's balanced salt solution > Milk > saliva > saline
   3. Penicillin or clindamycin
3. Child
   1. Do not reimplant primary teeth
      1. Refer to pedodontist for space maintainer

[[Bleeding Tooth Socket]

1. Apply pressure by having pt bite on gauze or tea bag

Odontogenic Infections

Dental Caries/Pulpitis

1. Two types: reversible pulpitis and irreversible pulpitis
   1. Reversible Pulpitis
      1. Duration of pain is short (seconds)
      2. Associated with noxious stimuli (cold or heat)
   2. Irreversible Pulpitis
      1. Duration of pain is long (hours) and intense
      2. Associated with noxious stimuli or may occur spontaneously
      3. Tx = root canal or extraction

Periapical Abcess

1. Treatment
   1. I&D
   2. Penicillin VK 500mg PO QID OR Clindamycin 300mg PO QID
   3. Dental referral

Trench Mouth (Acute Necrotizing Ulcerative Gingivitis)

Background

1. Severe gingival disease
2. Must distinguish from herpes gingivostomatitis
   1. Herpes has more systemic signs, less bleeding, lack of interdental papilla involvement
3. Associated with immunosuppression, especially HIV

Clinical Features

1. Triad of:
   1. Pain
   2. Ulcerated or "punched out" interdental papillae
   3. Gingival bleeding
2. Secondary signs:
   1. Fetid breath
   2. "Wooden teeth" feeling
   3. Teeth mobility
   4. Fever
   5. Malaise

Treatment

1. Chlorhexidine 0.01% oral rinse BID
2. Metronidazole 500mg PO TID
3. Dental debridement and scaling

See Also

• Acute Alveolar Osteitis (Dry Socket)
• Dental Numbers

Source

• ER Atlas
• Tintinalli
• UpToDate