In this part 2 of our 2-part podcast series on dental emergencies we cover traumatic dental emergencies. Dental trauma is common and often associated with facial trauma. In this episode Dr. Chris Nash and Dr. Richard Ngo answer questions like: At what age is it safe to attempt reimplantation of an avulsed tooth in the ED? What are the 3 most time-sensitive dental trauma emergencies? When is Panorex X-ray or CT indicated in dental trauma? What is the preferred solution to transport an avulsed tooth in? What are 3 dental splinting methods we should consider for dental subluxations and avulsions? How should we handle an avulsed tooth to maximize the chances of a successful reimplantation? When are antibiotics indicated after dental trauma? What role does chlorhexidine rinses play in preventing infection after dental trauma? What are the recommended first and second line treatments for persistent dental hemorrhage? and many more…

Podcast production, sound design & editing by Anton Helman; voice editing by Braedon Paul; background research by Ronak Saluja & Ryan O’Reilly

Written Summary and blog post by Anton Helman August, 2023

Cite this podcast as: Helman, A. Ngo, R. Nash, C. Traumatic Dental Emergencies. Emergency Medicine Cases. August, 2023. https://emergencymedicinecases.com/traumatic-dental-emergencies. Accessed September 14, 2023

Dental structures (superficial to deep) to know for dental trauma are enamel, dentin, pulp, alveolar bone:

Care of ALiEM Smiler series

Adults most commonly have 32 teeth (permanent dentition) divided into 4 quadrants: left and right mandibular dentition and maxillary dentition.

Care of ALiEM Smiler series

Children most commonly have 20 primary teeth, usually present by the age of 3 which gradually are replaced by permanent teeth usually between the ages of 6 and 12.

Pitfall: One pitfall is to attempt reimplantation of a primary tooth that has been avulsed. This may lead to ankylosis and prevention of permanent tooth eruption.

The most common traumatic dental injuries are uncomplicated fractures  of the enamel and/or dentin of crown of the tooth (do not extend to level of pulp) which require only observation and follow up with outpatient dentist for consideration of re-bonding. Re-bonding can be attempted in the ED.

Complicated dental fractures involve the pulp of the tooth resulting in exposure of the dental pulp to the oral cavity. Patients often experience severe pain and tooth sensitivity and will ultimately require either a root canal or tooth extraction as an outpatient to prevent infection. In the ED calcium hydroxide should be applied to the exposed pulp that is clearly seen as pink tissue within the tooth and arrangements for follow-up with a dentist should be made within 7 days.

Tooth subluxations should be treated with a dental splint (see below) for at least 2 weeks.

Tooth avulsions should be re-implanted and splinted (see below) ASAP in the ED whenever possible.

The most time sensitive traumatic dental emergencies include:

Consider a CXR to identify aspirated tooth fragments or whole tooth if these cannot be accounted for otherwise.

Panoramic x-ray (‘Panorex’ view) is indicated for all dental trauma according to the International Association of Dental Traumatology, however, the practical use of this x-ray in the ED is to rule out alveolar bone fracture, mandible or maxillary fractures when CT is not available or contra-indicated.

Panorex view showing right undisplaced mandible fracture

Pre- and post-procedural imaging is important to ensure improved positioning after a dental fracture, subluxation or intrusion has been reduced.

CT is generally reserved for suspected mandibular or maxillary fractures and are usually not helpful for isolated  tooth fractures.

Mandible fracture should be suspected if the patient is unable to open their mouth >5cm and/or has a positive tongue blade bite test)

Pitfall: one common pitfall is the failure to consider an aspirated tooth or tooth fragment. If not all teeth/tooth fragments can be accounted for, obtain a CXR to rule out an aspirated tooth or tooth fragment.

For dental trauma in which the pulp is exposed, pain can be treated quickly and effectively with a calcium hydroxide cap application or surgical skin glue application (eg. Dermabond, Swiftset). Otherwise, for mild to moderate pain, acetaminophen and NSAIDs are recommended. For severe pain, whenever possible, avoid opioids or prescribed in short courses only in patients with low risk of dependence.

Consider a supraperiosteal nerve block for temporary relief of severe maxillary dental pain:

Consider an inferior alveolar nerve block for temporary relief of severe mandibular dental pain:

For tooth avulsions >20 mins from the time of injury, soak the tooth in saline for 30 minutes followed by a doxycycline solution (1mg doxy in 20mL of saline) for 5 minutes prior to reimplantation and splinting to maximize the chances of revascularization and reintegration of the tooth.

Use teeth occlusion as a guide to positioning of the tooth during reimplantation.

Hold avulsed teeth by the crown of the tooth only; avoid handling the root of the tooth whenever possible to maintain the vitality of the periodontal ligament cells.

Pitfall: one pitfall in the management of an avulsed tooth is handling the root of the tooth; this may obfuscate tooth vitality. Always handle the tooth from the crown.

Using the wires supplied in your ED dental kit, place wire across the tooth in question as well as the 2 adjacent teeth use the curing light to convert the liquid composite material into a solid material to adhere the wires to the teeth, as described in this video:

Care of Core EM https://coreem.net/core/dental-trauma/

If a dental kit is not available in your ED, an N95 respiratory mask nose bridge with surgical skin glue is a recognized alternative. N95 mask metal nose bridge dental splint technique.

Care of ALiEM https://www.aliem.com/trick-of-trade-dental/

Antibiotics are generally not indicated for isolated dental avulsions or fractures, and should be reserved for open dental alveolar fractures, however chlorhexidine mouth washes twice daily for 7 days have been recommended to prevent infectious complications.

Do not attempt reimplantation of a complicated crown fracture, fractured root or dental injury with alveolar fracture.For complicated dental fractures involving exposed pulp (pink dot on exam), calcium hydroxide should be applied in the ED by mixing the catalyst and the base in an equal ratio, drying the surface of the tooth with gauze or air and applying a small amount to cover the exposed pulp. Follow up with a dentist is recommended for consideration of root canal.

Pearl: If calcium hydroxide is not available in your ED, surgical skin glue (eg. Dermabond, Swiftset) is a reasonable alternative for covering exposed pulp in a complicated dental fracture

First line: Soak gauze with tranexamic acid (500mg in 10mL) and apply pressure by instructing the patient bite down hard continuously for 30 minutes.

Second line: If the above method fails, consider injection of 2% xylocaine with epinephrine into the source of bleeding and the surrounding gingiva until blanching of the tissue is visible, followed by repeated pressure by biting down on gauze for the 30 minutes. The analgesia provided allows the patient to apply adequate pressure without causing pain.

At ED discharge is important to set expectations about possible post dental trauma risks that include:

The post PODCAST: Traumatic Dental Emergencies part II first appeared on האיגוד הישראלי לרפואה דחופה.

Here’s the problem: About 1% of all visits to the ED are for dental complaints, yet most of us have little training on how to recognize and manage dental emergencies. There are a multitude of reasons to explain the hoards of dental patients showing up in our EDs, not to mention the cost of seeing a dentist. Regardless, we need to know how to recognize and manage dental emergencies to best take care of our patients. After some suggestions from listeners and various colleagues to do an episode on dental emergencies, and learning more about dental emergencies myself, I realized, that the simple algorithm I apply to most patients I see in the ED with atraumatic dental pain  – doesn’t look like deep space infection or something I can drain -> analgesics + antibiotics -> send to dentist, was inadequate. In this Part 1 of our 2-part podcast series on dental emergencies, with the help of Dr. Chris Nash and Dr. Richard Ngo, we tackle these atraumatic dental emergencies: infections ranging from dental caries to pulpitis and gingivitis to dental abscess, cellulitis and deep space infection, as well as acute necrotizing gingivitis, pericoronitis and dry socket. These all have specific clinical characteristics and require specific management…

Podcast production, sound design & editing by Anton Helman; voice editing by Braedon Paul.

Background research by Ronak Saluja & Ryan O’Reilly

Written Summary and blog post by Anton Helman August, 2023

Cite this podcast as: Helman, A. Ngo, R. Nash, R. Atraumatic Dental Emergencies. Emergency Medicine Cases. August, 2023. https://emergencymedicinecases.com/atraumatic-dental-emergencies. Accessed September 14, 2023

It is important to understand the usual progression of dental infections as the management changes as the infection progresses. Simple dental anatomy helps to understand this progression.

Dental anatomy

Dental cary: a bacterial disease of teeth that demineralizes tooth enamel and dentine by acid produced during the fermentation of dietary carbohydrates by oral bacteria. It is characterized by loss of enamel and discoloration of the tooth.

Simple dental cary characterized by loss of enamel and discoloration

Pulpitis: inflammation of the tooth pulp caused by a cary encroaching the pulp.

Gingivitis: inflammation of the gingiva (gum adjacent to the tooth) caused by plaque on tooth surface

*no antibiotics required

*no antibiotics required

*no antibiotics required except for Acute Necrotizing Gingivitis (see below)

(including Ludwig’s Angina & septic cerebral venous thrombosis)

2 physical findings that suggest deep space infection and the need to obtain a CT:

1. Blunting of the inferior border of the mandible at the body

2. Trismus <2.5cm of maximum mouth opening

Cerebral venous thrombosis – Episode 181

Pearl: Pulpitis can be differentiated from a periapical abscess by considering the duration of the pain and secondary signs such as tooth elevation, swelling, adjacent cellulitis and lymphadenopathy.

Pitfall: avoid the mental nerve when incising when I&D of anterior mandibular abscess

Mental nerve surface anatomy to be avoided in I&D of anterior mandibular dental abscess

Pearl: 2 physical findings that strongly suggest deep space infection and the need to obtain a CT scan: Blunting of the inferior border of the mandible at the body and trismus <2.5cm of maximum mouth opening

Pearl: abscesses outside of the vestibular area (space between the front teeth and the lips forms the anterior part of the oral vestibule) or buccal space are best left to specialists.

Observational data suggest that antibiotics are over-prescribed for dental pain. It is important to understand that simple dental caries, pulpitis and gingivitis generally do not require antibiotics. While antibiotics are generally prescribed for dental abscess, there is little evidence that this practice is beneficial unless there is an associated cellulitis or deep space infection.

Antibiotic suggestions for dental infections (cellulitis, abscess, deep space infections)

Pitfall: The most common pitfall in the ED management of atraumatic dental emergencies is the overuse of antibiotics and over-coverage when using antibiotics. Dental caries, pulpitis and gingivitis do not require antibiotic treatment unless they are complicated by cellulitis, abscess or deep space infection. Penicillin, Amoxicillin or Clindamycin are recommended first line agents for simple dental infections. If the infection is severe, consider adding metronidazole or else Amoxicillin-Clavulinic acid, and for systemically ill patients with complicated infection consider Piperacillin-tazobactam or Clindamycin plus Ceftriaxone.

Another of the important dental emergencies is Acute necrotizing gingivitis, otherwise known as “trench mouth” – as World War 1 soldiers in the trenches suffered this disease as a result of prolonged poor dental hygiene. It is characterized by painful, swollen, bleeding gums and ulceration of inter-dental papillae (ulcers between the teeth) and should be suspected in patients with a known immunocompromising state with painful bleeding gums. If this dental emergencies diagnosis is made in the ED, HIV testing should be considered.

Acute necrotizing gingivitis with swollen gingiva and ulcers in between the teeth

sPericoronitis is inflammation of the gum surrounding the crown of a partially erupted tooth, most commonly a wisdom tooth. Food gets caught under the flap of gum covering the tooth. Pus may ooze from the flap. Pericoronitis may be complicated by cellulitis, abscess and trismus, and may rarely progress to airway compromise if left untreated.

Pericoronitis (care of academic Life in EM) https://www.aliem.com/smiler-104/

Management includes irrigation under the gum flap with saline which resolves pain within minutes, and saltwater mouthwashes. Antibiotics are reserved for pericoronitis that is complicated by cellulitis or abscess. Urgent referral to a dentist for consideration of tooth extraction is prudent.

Pearl: saline irrigation of suspected pericoronitis resulting in resolution of pain within minutes confirms the diagnosis

Dry socket typically occurs 3-5 days after tooth extraction when the clot dislodges and exposes the bone and nerve causing pain. There is little to see on exam. Dry socket should be irrigated with saline, gently suctioned taking care not to dislodge any blood clot that might be developing, and then placement of a medicated dry socket dressing – usually iodoform gauze. Curetting should be avoided so as not to dislodge any clot that may be forming in the socket. Patients with dry socket should be followed up by a dentist or oral surgeon in 2 days.

Pitfall: Curreting a dry socket is a common pitfall. Curetting should be avoided as it may dislodge a developing clot that protects the socket and diminishes pain.

The post PODCAST: Atraumatic Dental Emergencies part I first appeared on האיגוד הישראלי לרפואה דחופה.