Raymond Hinerman, MD, DDS Dental Emergencies in Emergency Medicine. Who am I? Who am I?(cont) 4/15/2014

Transcription

1 Raymond Hinerman, MD, DDS Dental Emergencies in Emergency Medicine Who am I? Obtained DDS from WVU Dental School 1993 Post graduate General practice residency ( Hospital based dentistry) General Dentistry at Huttonsville Correctional Center Graduate of WVU School of Medicine 2000 General Surgery Internship WVU Who am I?(cont) Otolaryngology Residency WVU Clinical professor WVU Department of Otolaryngology Board Certified in Otolaryngology 2006 Private practice Abingdon Va Currently private practice Wheeling WV 1

2 Background Incredibly common.incredible need : 3 million ED visits in the US for tooth related complaints. Today, 2-3% of all ED visits, higher in urban center Lack of ER support from general dentists and OMS Background ED providers should be equipped to triage, diagnose, provide basic treatment, and ensure appropriate follow up care for dental problems. Annals of EM, July % of Americans over 65 have lost all of their teeth. --- Bad dental health impacts overall health and increases the risk for diabetes, heart disease and poor birth outcomes million low-income children received no dental care in More Dentists leave the profession on a yearly basis than are replaced by dental school graduates 2

3 Anatomy 32 Teeth --from the midline: -- Incisors -- Canines -- Premolars -- Molars Right Left Anatomy Kids 20 Primary Teeth -- incisors -- canines -- molars 3

4 Tooth Surfaces Palatal Oral or (palatal / lingual) Lingual Occlusal Facial or (Buccal / Labial) Approximal Surface Labial Buccal 4

5 Components Enamel Dentin Pulp Periodontal ligament Alveolar Bone Pain Etiology Most common cause is pulpitis. Pulpitis--most commonly secondary to bacteria (caries), although can be traumatic and chemical in origin as well. 5

6 Pulpitis Acute Treatment what works? -- Dental Block--definitely -- NSAIDS--definitely -- Narcotics definitely -- Antibiotics???? Pulpitis Efficacy of penicillin for dental pain without overt infection. Acad Emerg Med patients with undifferentiated-dental pain. PRDBPCT. Half got penicillin, half did not. Each group at 5-7 day follow up had a ~10% infection rate. Author s Conclusions Penicillin is neither necessary nor beneficial in the treatment of undifferentiated dental pain in the absence of overt infection. Well, what do real dentists say? What does common sense say? 6

7 American Endodontic Society The vast majority of endodontic infections can be managed without antibiotics. Healthy patients without systemic signs or symptoms but with symptomatic pulpitis do not require antibiotics. Common Sense Says Antibiotics don t usually make a difference, but without good radiographic and pulpal evaluation, good follow up, and the potential of serious deep space infection risk, they should probably be prescribed for at-risk ED patients. 7

8 The Supraperiosteal Injection Used for 1 or 2 teeth. Caveats Bupivacaine/epi Pain/Pulpitis due to deep Caries IF the tooth is painful & has an obvious deep carie.. Block the tooth, dry the tooth & cover it! Options are several. --Temrex --Dentinal Sealers --Cavit --ZOE --Dermabond? --Dental/Bone Wax? Covering Deep Caries Apply Temrex, ZOE or Cavit over the affected carie after your injection. Bug Juice Soft diet until seen by dentist. 8

9 Covering Deep Caries D E N T A L T R A U M A Fractured Teeth mechanism (history), most important Age / Extent of fracture determines initial care & salvagability Classification Systems 9

10 Ellis System Best for us?..the easiest one. Fracture Classification Enamel Fractures Not Sensitive Smooth Reassure/restore 3-5% chance of pulp necrosis 10

11 Fxs thru the enamel & the dentin More serious Sensitive to percussion, temp, forced air. Dentin is visible as deep, golden yellow. 11

12 Dentin Fxs Younger patients have a growing tooth with more pulp and less dentin, therefore, treat more aggressively. Overall, pulp necrosis rate of 7-10% if not treated within a week. Dentin Fxs -- Treatment Block the tooth! Dry the fracture! Cover the tooth! (CaOH paste, dentinal sealers, ZOE, cyanoacrylates) Calcium Hydroxide Paste 12

13 Why calcium hydroxide? Fast & Easy Watertight seal Hardens on contact with saliva Stimulates dentin growth Easy for dentist Dentin Fractures D/C Instructions Follow up in less than a week with dentist if covered. ASAP if not. REMEMBER, Proper ED treatment of dentin fractures can prevent the need for root canals, so try and cover it with something! 13

14 What is a root canal? Other covering materials besides CaOH paste Composite Resin Restoratives Better Bond --acid etched & light cured --better integrity Downsides -- multiple steps and materials -- expensive Pulp Fractures Frank blood from pulp cavity or pink blush of dentin. May not be painful. Pulp necrosis likely. 14

15 ..most often, it s the incisors 15

16 Pulp Fxs -- Treatment Block the tooth. Dry the tooth (get help!) Cover the tooth. Immediate referral to Dentist. What does the Dentist Do? Are we making their job harder? Are we as state of the art as they are?..now, off to the dentist 16

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18 Fractured Teeth D/C instructions All fractures get follow up. Fxs thru the pulp--asap. Covering the tooth lengthens this window Fxs thru the dentin--asap. Fxs thru enamel only--within a week or two. Diet--soft diet. Difficult fractures? Periodontal Paste or Ortho Bands with CaOH Paste along the fx line 18

19 Orthodontic Bands Periodontal Paste Subluxation, Luxation & Avulsion Subluxation -- loosened tooth! Luxation -- displaced tooth! Avulsion -- missing tooth! 19

20 Subluxation (nondisplaced) The Tooth Moves Blood in gingival sulcus --Grossly unstablefix it --Minimally unstablesoft diet. Luxation (displaced) Extrusive luxation --displaced coronally (toward crown) Extrusive Luxation 20

21 Luxation Intrusive luxation --displaced apically (toward the roots) Intrusive Luxation Luxation Lateral Luxation --Displaced in the horizontal plane 21

22 Lateral Luxation Stabilization Arch bars/ligature wires Light cure composites Periodontal Pastes Self cure composites Stabilization 22

23 Stabilization Periodontal Paste -- Coe-Pak -- Easy, cheap, sticky -- Applied to dry enamel & gingiva Periodontal Paste Stabilization Works great for gingival & palatal lacerations!! Also, vertical fractures of teeth! 23

24 Perio-paste allows you to work on all the surfaces of the teeth and gingiva. Stabilization Self cure composites --Similar to perio paste --Applied to enamel only --Dries within Minutes --Drawback=Dries Hard, can affect occlusion Stabilization 24

25 Stabilization and Treatment of Dental Avulsions and Fractures by Emergency Physicians Using Just-in-Time Training Mcintosh, Mark et al. Annals of EM, October 2009 Light Cured Composite Resin 3 Dentist Evaluators preferred composites: -- sustainability, more permanent -- improved perception of patient comfort Physicians had no preference -- Disliked the multiple steps -- Steep learning curve Problems for us as EPs Multiple Steps Steep learning curve Multiple Substances Composite can be sharp Relatively little bang for the $ 25

26 Subluxation/Luxation D/C Instructions Minimally loose teeth: --Progressive diet. F/u non-urgent Teeth which are stabilized: --Liquid/soft diet. F/u urgent (within 48 hrs) Be careful with the stabilization materials. Avulsion True Dental Emergency Suspect aspiration or intrusion Management: time, age, gingival health, condition of tooth 26

27 Avulsion Don t keep the tooth waiting! DO NOT wipe off the roots. Place in Hank s solution or milk as soon as possible. 27

28 Avulsed Tooth what to do?? Transport in milk, saline or saliva, not water. Don t wipe off roots! Once in ED, rehydrate immediately in warm milk or Hank s (emt toothsaver or Sav-a-Tooth). You have minutes if tooth is kept dry, before dessication of the PDL begins. In 2 hrs, the entire PDL is shot. 28

29 Avulsion-- what to do?? Rehydrate. Supraperiosteal injection Suction Avulsion -- what to do?? Irrigate the tooth and the socket. Reimplant firmly Splint Avulsion --what to do?? Splint with: Periodontal paste or Self cure composite F/U Urgently < 1 wk 29

30 Avulsion--what to do?? Kids?? Avulsion--what to do?? Primary teeth are never replaced!! May fuse to secondary teeth causing facial deformities, infection, eruption problems, etc. 30

31 Intrusion Easily missed. X-ray if suspicious. Intruded permanent teeth are often associated with alveolar fractures Intrusion Primary intruded teeth are observed.. and observed.. and observed!! Intrusion 31

32 Intruded Teeth In adults, they almost always need to be repositioned and splinted by the dentist. Often assoc. with alveolar bone fracture. In kids, the primary teeth are allowed to re-erupt. They do, however, need dental follow up for xrays. Alveolar Osteitis (Dry Socket) Horrific pain 3-4 days post extraction. Loss of clot, possibly from anaerobic growth, results in exposed alveolar bone Usual teeth involved Risky people Dry Socket -- Treatment Block the tooth. Irrigate and gently suction the socket. Pack the socket: -- Dry Socket Paste/Gelfoam this is easiest! -- Anesthetic/saline soaked (iodoform) gauze 32

33 Dry Socket D/C instructions Gauze will need to be repacked in hours. Dry socket paste sometimes needs to be replaced. Return to ED if dentist visit impossible. 33

34 Bleeding Irrigate Lido/Epi & Pressure 1st Bleeding the next step depends Bleeding Gelfoam or Surgicel Works best if sewn Works even better if you soak them in topical thrombin 34

35 Bleeding Thermal Cautery vs. Electro cautery Make sure they are numb first!!!! Questions?? 35