March 2007

MANAGING DENTAL EMERGENCIES

Kathy Wilson

(South Tyneside PCT & Newcastle Dental School & Hospital)

Aims of Presentation

Basic dental anatomy Diagnosis and treatment planning Pulpitis Dental abscess and cellulitis Trauma to teeth Anaesthesia for dental procedures Extraction Drugs in dentistry Emergency dental kit

Dental Emergencies

In remote or under-developed regions where the nearest dentist may be many days journey, doctors and nurses frequently find themselves required to deal with pain, infection and trauma in the mouth.
Dental conditions are not usually dangerous to life, but they are often exceedingly painful
J.N.W. McCagie, Oral Surgeon

BASIC DENTAL ANATOMY

Dentition
Soft tissues Blood and nerve supply Lymphatic drainage

Anatomy of the Tooth

Nerve & Blood Supply

Maxilla

Mandible

Red - Blood Supply

Yellow - Nerve supply

Buccal region

Buccal region

Blue - Areas where local analgesic can be delivered

Palatal region

Lingual region

Lymphatic Drainage
Lymphatic drainage is to the submental,
sublingual and deep cervical nodes.

DIAGNOSIS & TREATMENT PLANNING

HISTORY TAKING
Dental History
Ask the client to voice their complaint or point to
area which is hurting

Onset and duration of complaint Relieving or initiating factors Type of pain sharp or dull; moderate or severe

HISTORY TAKING
Medical History General state of health Current medication & why Particular conditions
Rheumatic fever Drug allergy (penicillin) Bleeding tendency

CLINICAL EXAMINATION
General State
Temperature Fatigue

Extra oral examination

Swellings of face Palpate lymph nodes Examine for fractures

CLINICAL EXAMINATION
Intra oral
A good light is essential

Mirror and probe

CLINICAL EXAMINATION
Intra oral
Inspect soft tissues: Inflammation swelling Tenderness ulceration
Inspect the teeth Decay Mobility Fractured teeth

DIAGNOSIS & TREATMENT PLANNING

Make a diagnosis
Treatment planning for:
Relief of pain Treatment of pathology Long term view

COMMON CONDITIONS
Dental caries Pulpitis Dental Abscess Facial swelling and cellulitis Dry socket, Osteomyelitis Fractured teeth Fractured jaw

DENTAL CARIES
One of the most common diseases

Starts in enamel, extends to dentine and if

not treated into pulp

DENTAL CARIES Management

Remove decay using an excavator

Place temp filling Using a flat plastic

DENTAL CARIES
Filling Materials

Cavit (temporary filling)

Glass Ionomer Cement (semi-permanent filling)

PULPITIS
Inflammation of the pulp
Dental caries extending into dentine
causes a sharp pain with hot and cold

Early stages reversible Remove decay Cavit dressing When pain settled permanent filling
placed

DENTAL ABSCESS
Periapical abscess
Result of decay and infection
extending into pulp of tooth

Pain is severe, persistent,

& throbbing

Tooth is tender to touch

If not treated pus tracks to surface

inside or outside the mouth

DENTAL ABSCESS Treatment

Periapical abscess drainage
1. Open tooth into pulp chamber using excavator (if possible) and dressing 2. Antibiotics (Amoycillin 250mg TDS / 5 days) 3. Extraction of tooth

DENTAL ABSCESS
Extra oral Swelling
Can spread into the tissues Leading to cellulitis Systemic involvement Drainage required

DENTAL ABSCESS

Treatment

Extra oral Swelling

Antibiotics

Excision and drainage

Anaesthesia with topical paste or ethyl chloride Number 11 blade for incision extra orally

Open tissues using mosquitos

Allow pus to drain/insert rubber drain
suture to keep patent

Ultimately extract tooth under LA

DRY SOCKET
Dry Socket
Localised osteitis Severe pain 2 -4 days post extraction TREATMENT LA Debride socket Dressing Alvogel

DENTAL TRAUMA
Fractured front tooth
Dentine Dentine/Enamel Dentine/Enamel/Pulp

Before

After Treatment with Glass Ionomer Cement

DENTAL TRAUMA
Avulsed Tooth
A good chance of the tooth
re-implanting into the socket successfully if done within an hour.

The tooth should be located

& picked up by the crown or enamel portion NOT the root.

If the tooth is dirty/contaminated,

it should gently be placed in whole cold milk, saline, or saliva.

DENTAL TRAUMA
Place tooth back into
socket.

Splint the tooth to

stabilize
Wire and glass ionomer cement.

Dental wax and foil

Antibiotics - Amoxycillin

FACIAL TRAUMA
Injuries to the face and jaws can occur

Maxillary Fractures

Mandibular Fractures

FACIAL TRAUMA
Emergency Management of Facial Fractures
Attempt to stabilize the jaw Give Antibiotics Soft foods Get to hospital ASAP

ADMINISTERING LOCAL ANAESTHESTIC

2% Lignocaine +/- Adrenaline
Syringe
Dental syringe and needle

5 ml syringe and needle

ADMINISTERING LOCAL ANAESTHETIC

Maxilla

Mandible

Buccal region

Blue - Areas where local anaesthetic can be delivered

Buccal region

Palatal region

Lingual region

INFILTRATION
Maxilla
Mandible

INFILTRATION
Should achieve anaesthesia within 5 minutes
Can be safely repeated is unsuccessful Do not give where there is grossly infected tissue

INFERIOR DENTAL NERVE BLOCK

Mandible
Palpate the anterior ramus border at the coronoid notch.

Slide the finger or thumb posteriorly and medially until a ridge of bone is palpated. This is the internal oblique ridge.

Insert until bone is contacted then withdraw ~1 mm. The depth of insertion is approximately 25 mm.

DENTAL EXTRACTIONS
Indications
Severe pulpitis Periapical abscess Tooth fracture

Severe periodontal disease

DENTAL EXTRACTIONS
Basic Instruments

Upper Forceps Elevators Lower Forceps

DENTAL EXTRACTIONS
How to hold the instruments

Lower Forceps

Upper Forceps

Elevators

DENTAL EXTRACTIONS
Upper Extractions

Incisors, Canines & Premolars Push up, rotate, pull down Molars Push up, ease tooth buccally

DENTAL EXTRACTIONS
Lower Extractions

Incisors, canines & premolars Push down, rotate, pull up

Molars Push down, figure of eight, pull up

DENTAL EXTRACTIONS
Post operative instructions
Pressure on socket No rinsing for 24 hours Cold food and drink for 24 hours No smoking for 24-48 hours HSMW after 24 hours If bleeding pressure pack for 20 minutes

DENTAL EXTRACTIONS
Complications
Fractured tooth Bleeding Swelling Bruising Pain Trismus Dry Socket

DENTAL EXTRACTIONS
Complications Bleeding
Apply Pressure Pack with haemostatic agent

Suture

COMMONLY USED DRUGS

Analgesics for toothache
Paracetamol Co-Codamol NSAID

Antibiotics

Amoxycillin Erythromycin/Clindamycin Metronidazole

EMERGENCY DENTAL KIT

Dental Mirror Tweezers Excavator and Flat plastic Cotton pellets & Rolls Extraction forceps Syringe & needle Sterile Dressings 11 Blade Scalpel Gloves

EMERGENCY DENTAL KIT

Cavit/Temp dressing Eugenol/Oil of cloves Glass ionomer cement Dental Wax/Wire Topical anaesthetic Local anaesthetic Amoxyl/Metronidazole Paracetamol/Cocodamol

EMERGENCY DENTAL KIT

Life Systems Dental First Aid Kit
www.travel-stuff.com

Nitro-pak dental First-Aid Kit

www.nitro-pak.com

Dentanurse
www.dentanurs.com