Dental Emergencies: Management Strategies That Improve Outcomes

Table of Contents

 

It’s become a common ED occurrence: patients with dental emergencies, either traumatic or nontraumatic. The number of patients presenting with dental problems has almost doubled in the past 10 years. But many emergency physicians may still be unsure whether their treatment decisions will result in the best cosmetic as well as functional outcomes. Uncertainty about the best storage methods for avulsed teeth, and how and when they remain viable for replantation, can lead to unnecessary tooth loss. Although many diagnoses involve painful or cosmetically challenging yet harmless conditions, some can be life-threatening. Correctly managing the special needs of patients with HIV or diabetes, and determining the origin and seriousness of odontogenic infections, is crucial. This article makes management of most dental emergencies easier by providing recommendations for replanting avulsed teeth, the use of imaging to identify suspected deep neck infections (especially in high-risk immunocompromised or diabetic patients), appropriate use of antibiotics, and familiarity with orofacial nerve blocks to deliver safe and effective pain relief.

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Anatomy
6. Etiology and Pathophysiology
   1. Dentoalveolar Trauma
   2. Atraumatic Dental Emergencies
   3. Odontogenic Abscesses and Deep Neck Infections
7. Differential Diagnosis
8. Prehospital Care
   1. Storage Media
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Pediatric Patients
10. Diagnostic Studies
    1. Imaging Studies
    2. Laboratory Studies
11. Treatment
    1. Analgesia
       1. Supraperiosteal Nerve Block
       2. Inferior Alveolar Nerve Block
       3. Mental Nerve Block
       4. Infraorbital Nerve Block
    2. Antibiotic Treatment
    3. Concussion, Subluxation, and Luxation Injuries
    4. Tooth Avulsion
    5. Dental Fractures
       1. Fractures Involving the Enamel Only (Ellis I)
       2. Fractures Involving the Enamel and Dentin (Ellis II)
       3. Fractures Involving the Enamel, Dentin, and Pulp (Ellis III)
       4. Alveolar Ridge Fractures
    6. Alveolar Osteitis
    7. Mandibular Dislocation
12. Controversies and Cutting Edge
13. Disposition
14. Summary
15. Key Points
16. Risk Management Pitfalls for Dental Emergencies in the Emergency Department
17. Time- and Cost-Effective Strategies
18. Case Conclusions
19. Clinical Pathway for Approach to the Patient With Dental Trauma
20. Tables and Figures
    1. Table 1. Differential Diagnosis of Orofacial Pain
    2. Table 2. Length of Periodontal Ligament Cell Viability, Based On Storage Medium
    3. Table 3. Recommended Antimicrobials for Severe Periodontal Disease, Severe Pericoronitis, and Simple Odontogenic Infections
    4. Table 4. Dental Equipment Needed in the Emergency Department
    5. Figure 1. Age of Tooth Eruption for Deciduous (Primary) and Permanent (Secondary) Teeth
    6. Figure 2. Classification of Teeth
    7. Figure 3. Periodontium
    8. Figure 4. Luxation of Teeth
    9. Figure 5. Alveolar Ridge Fracture
    10. Figure 6. Dental Fracture Classification
    11. Figure 7. Necrotizing Stomatitis
    12. Figure 8. Operculum and Pericoronitis
    13. Figure 9. Alveolar Osteitis ('Dry Socket')
    14. Figure 10. Submental Space Infection
    15. Figure 11. Submandibular Space Infection
    16. Figure 12. Supraperiosteal Nerve Block
    17. Figure 13. Inferior Alveolar Nerve Block
    18. Figure 14. Mental Nerve Block
    19. Figure 15. Infraorbital Nerve Block
    20. Figure 16. Traditional Method of Reducing a Mandibular Dislocation
    21. Figure 17. 'Unified Hands' Technique
21. References

Abstract

Acute dental emergencies are a common chief complaint presenting to emergency departments, and they are increasing substantially in frequency. The diagnosis and management of dental emergencies is a core competency of the emergency clinician, and proper therapeutic strategies can significantly improve cosmetic and functional outcomes for patients. This issue provides a systematic review of the literature on common acute traumatic and atraumatic dental emergencies with a focus on the historical and physical examination findings that must be understood to identify life-threatening infections, relieve pain, salvage natural teeth, and communicate with specialists in the further management of patients after emergency treatment.

Case Presentations

Your first patient of the shift is a 20-year-old man who was involved in an altercation. On physical examination, you note that he is missing 2 teeth and has chipped another. EMS found 1 of the teeth on the scene and has stored it in milk. You wonder, “Was milk the best storage medium? Do I need to worry about the missing tooth or other injuries? How do I replant a tooth? Does the chipped tooth need any specific intervention?”

As you ponder these questions, your next patient arrives. She is an 18-year-old woman complaining of severe, dull pain 3 days after wisdom-tooth removal. Upon inspection, the socket that previously held her right mandibular third molar is devoid of any blood clot. You recognize this as “dry socket,” or alveolar osteitis, but think, “What can I even do about this?”

Later that day, you see yet another patient with a dental complaint: a 60-year-old homeless man with fever, malaise, and severe gingival pain and bleeding. On examination, he has a temperature of 38.1°C and has submandibular lymphadenopathy as well as gingiva that are friable, with exudates and blunted papillae. You are dumbfounded at what this represents and how to treat it, and ask yourself, “Why didn’t I read that dental emergencies article that arrived in the mail...?”

Introduction

Dental complaints present frequently to the emergency department (ED), yet studies show that emergency clinicians have a low level of comfort in managing them.^1,2 The number of dental visits to EDs nearly doubled from 2000 to 2010 and continues to rise. In 2012, there were 2.18 million ED visits for dental complaints,³ underscoring the importance of expertise with the diagnosis and management of these conditions. Often, complications from dental procedures will first present to the ED and must be initially managed by an emergency clinician. Dental problems can range from benign and bothersome, such as localized tooth pain, fracture, or avulsion, to oropharyngeal cancer, deep-tissue infection, or facial trauma with emergent potentially life-threatening sepsis or airway compromise. Early recognition and treatment can decrease mortality, morbidity, and poor cosmetic outcome. This issue of Emergency Medicine Practice reviews important issues involving teeth, gingiva, periodontium, and mandible, and more serious infections that extend into the deep spaces of the neck.

Critical Appraisal of the Literature

PubMed was searched for articles published in English in the last 5 years; references from these articles were then used to identify additional articles and guidelines. The search identified 171 articles related to tooth avulsion; 469 articles related to tooth fracture; 36 articles related to alveolar osteitis; 54 articles related to pericoronitis; and 26 articles related to necrotizing periodontitis/periodontal infections. Recommendations from the International Association for Dental Traumatology and the Cochrane Database of Systematic Reviews were also reviewed.

Data on tooth avulsion are generally strong, with studies assessing storage media and periodontal cell viability as well as some in vivo data. There is a lack of high-quality data to assess deciduous tooth replantation; for example, a systematic review that suggested a high negative consequence rate reviewed only 41 teeth in the study.⁴ Management of dental fractures is guided mostly by expert opinion, and ED-based randomized trials do not exist; emerging data in case reports of using tissue adhesive glue have been described, but no high-quality studies exist. Splinting of luxated teeth has good data to support use, but data are scarce regarding types of splints and fixation periods.⁵ Data on treatment of alveolar osteitis are poor, with a recent Cochrane review citing insufficient evidence to recommend any specific treatment for established alveolar osteitis. Studies on mandibular dislocation are not randomized compared to standard reduction techniques.

Risk Management Pitfalls for Dental Emergencies in the Emergency Department

1. “The patient had an open femur fracture; I didn’t think to check his mouth for injuries.”

All traumatic injury patients should be evaluated in a systematic manner, including for dental injuries. Unrecognized dental injuries or unrecognized aspiration of teeth can lead to unnecessary morbidity.

2. “They didn’t find the tooth at the scene, but I assumed it was just left on the pavement some-where.”

All teeth must be accounted for. If all teeth are not accounted for, consider intrusive luxation mimicking avulsion, aspiration of teeth, swallowing of teeth, or the possibility that a tooth is embedded in a laceration.

3. “The patient required a lot of work, so I just left the tooth on the table.”

More than 60 minutes of extraoral dry time makes replantation almost always unsuccessful. If not immediately replanted, teeth should be stored in an appropriate storage medium.

4. “The patient’s tooth was fractured, but he said he could follow up with his dentist in a few days, so I let him go.”

Failure to appropriately manage dental fractures that involve the dentin or pulp with calcium hydroxide coverage and failure to obtain consultation or prompt follow-up can lead to unnecessary morbidity.

5. “I put that patient’s tooth back in, splinted it, and he came back 2 days later after it came out while eating a steak!”

All patients who have subluxation, luxation, or avulsion injuries should be advised to maintain a soft diet and be prescribed chlorhexidine rinses. For avulsion injuries, prescribe antibiotics, such as doxycycline.

6. “That patient’s neck was pretty full, but I never would have guessed there was a big abscess there.”

The clinical examination has relatively limited sensitivity for detection of deep neck infections or to fully describe their extent based on physical examination findings alone. Liberal usage of contrast-enhanced CT scan should be considered for any patient suspected of having a deep neck infection.

7. “The patient desaturated after I had to give him 6 doses of morphine for his mandibular fractures; there was nothing I could do to get him comfortable!”

Regional anesthesia is very effective for dentoalveolar trauma. Always consider whether an orofacial nerve block is indicated when managing these patients.

8. “The patient had diabetes and HIV, but it seemed to just be an infected tooth. I didn’t think she would come back needing surgery.”

Have a high index of suspicion for patients in an immunocompromised state, as the incidence and the severity of deep neck infections is much higher in these populations.

9. “The patient had 3 mobile teeth, but I didn’t know how to splint them, so I let her go.”

Become comfortable and familiar with usage of calcium hydroxide paste for fractures and with periodontal splinting material for luxation and avulsion injuries, as they can improve outcomes in patients with traumatized teeth.

10. “I told him to follow up with a dentist. I assumed he understood to see the dentist the next day.”

It is important to provide appropriate and feasible dental follow-up for many of these patients with acute dental emergencies, as many of the ED treatments are only temporizing.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

1. Ulusoy AT, Onder H, Cetin B, et al. Knowledge of medical hospital emergency physicians about the first-aid management of traumatic tooth avulsion. Int J Paediatr Dent. 2012;22(3):211-216. (Survey; 69 emergency physicians)
2. Needleman HL, Stucenski K, Forbes PW, et al. Massachusetts emergency departments’ resources and physicians’ knowledge of management of traumatic dental injuries. Dent Traumatol. 2013;29(4):272-279. (Survey; 74 physicians)
3. Wall T, Vujicic M. Emergency department use for dental conditions continues to increase. Health Policy Resources Center Research Brief. American Dental Association. April 2005. Available at: http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0513_1.ashx Accessed May 1, 2017. (ADA report)
4. * Martins-Junior PA, Franco FA, de Barcelos RV, et al. Replantation of avulsed primary teeth: a systematic review. Int J Paediatr Dent. 2014;24(2):77-83. (Systematic review; 891 papers screened and 19 reviewed)
5. Kahler B, Heithersay GS. An evidence-based appraisal of splinting luxated, avulsed and root-fractured teeth. Dent Traumatol. 2008;24(1):2-10. (Systematic review; 12 studies)
6. Herrera D, Alonso B, de Arriba L, et al. Acute periodontal lesions. Periodontol 2000. 2014;65(1):149-177. (Review)
7. Magraw CB, Golden B, Phillips C, et al. Pain with pericoronitis affects quality of life. J Oral Maxillofac Surg. 2015;73(1):7-12. (Survey; 113 patients)
8. Klasser GD, Kugelmann AM, Villines D, et al. The prevalence of persistent pain after nonsurgical root canal treatment. Quintessence Int. 2011;42(3):259-269. (Survey; 250 patients)
9. Schott CK, Counselman FL, Ashe AR. A pain in the neck: non-traumatic adult retropharyngeal abscess. J Emerg Med. 2013;44(2):329-331. (Case report)
10. Huang TT, Tseng FY, Liu TC, et al. Deep neck infection in diabetic patients: comparison of clinical picture and outcomes with nondiabetic patients. Otolaryngol Head Neck Surg. 2005;132(6):943-947. (Retrospective; 185 patients)
11. Liu CF, Weng SF, Lin YS, et al. Increased risk of deep neck infection among HIV-infected patients in the era of highly active antiretroviral therapy--a population-based follow-up study. BMC Infect Dis. 2013;13:183. (Retrospective case-control study; 9888 HIV patients matched with 49,440 controls)
12. Noy D, Rachmiel A, Levy-Faber D, et al. Lemierre’s syndrome from odontogenic infection: Review of the literature and case description. Ann Maxillofac Surg. 2015;5(2):219-225. (Literature review)
13. * Karkos PD, Asrani S, Karkos CD, et al. Lemierre's syndrome: a systematic review. Laryngoscope. 2009;119(8):1552-1559. (Systematic review; 84 studies)
14. Patel SB, Boros AL, Kumar SK. Atypical odontalgia--an update. J Calif Dent Assoc. 2012;40(9):739-747. (Review)
15. Hiremath G, Kidiyoor KH. Avulsion and storage media. J Investig Clin Dent. 2011;2(2):89-94. (Review)
16. * Poi WR, Sonoda CK, Martins CM, et al. Storage media for avulsed teeth: a literature review. Braz Dent J. 2013;24(5):437-445. (Literature review; 234 papers screened and 39 reviewed)
17. de Souza BD, Bortoluzzi EA, da Silveira Teixeira C, et al. Effect of HBSS storage time on human periodontal ligament fibroblast viability. Dent Traumatol. 2010;26(6):481-483. (In vitro study)
18. Mousavi B, Alavi SA, Mohajeri MR, et al. Standard oral rehydration solution as a new storage medium for avulsed teeth. Int Dent J. 2010;60(6):379-382. (In vitro study; 75 teeth)
19. Oleszkiewicz I, Emerich K. How to proceed in case of tooth avulsion: state of student knowledge. Eur J Paediatr Dent. 2015;16(2):103-106. (Survey; 356 senior-level university students)
20. Namdev R, Jindal A, Bhargava S, et al. Awareness of emergency management of dental trauma. Contemp Clin Dent. 2014;5(4):507-513. (Survey; 1500 parents of children)
21. Cardoso Lde C, Poi WR, Panzarini SR, et al. Knowledge of firefighters with special paramedic training of the emergency management of avulsed teeth. Dent Traumatol. 2009;25(1):58-63. (Survey; 110 firefighters)
22. * Malmgren B, Andreasen JO, Flores MT, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 3. Injuries in the primary dentition. Dent Traumatol. 2012;28(3):174-182. (Review, IADT guidelines for primary dentition trauma)
23. Miller WD, Furst IM, Sandor GK, et al. A prospective, blinded comparison of clinical examination and computed tomography in deep neck infections. Laryngoscope. 1999;109(11):1873-1879. (Prospective blinded comparison; 35 patients)
24. Caputo ND, Raja A, Shields C, et al. Re-evaluating the diagnostic accuracy of the tongue blade test: still useful as a screening tool for mandibular fractures? J Emerg Med. 2013;45(1):8-12. (Prospective trial; 190 patients)
25. Peretz B, Kharouba J, Somri M. A comparison of two different dosages of oral midazolam in the same pediatric dental patients. Pediatr Dent. 2014;36(3):228-232. (Non-blinded study; 23 pediatric patients)
26. Sunbul N, Delvi MB, Zahrani TA, et al. Buccal versus intranasal midazolam sedation for pediatric dental patients. Pediatr Dent. 2014;36(7):483-488. (Randomized controlled crossover trial; 25 patients)
27. Chayra GA, Meador LR, Laskin DM. Comparison of panoramic and standard radiographs for the diagnosis of mandibular fractures. J Oral Maxillofac Surg. 1986;44(9):677-679. (Retrospective; 88 fractures comparing Panorex^® versus hospital mandibular series)
28. Roth FS, Kokoska MS, Awwad EE, et al. The identification of mandible fractures by helical computed tomography and panorex tomography. J Craniofac Surg. 2005;16(3):394-399. (Retrospective; 80 patients)
29. Pollack CV Jr. Coagulation assessment with the new generation of oral anticoagulants. Emerg Med J. 2016;33(6):423-430. (Review)
30. Pollack CV Jr, Reilly PA, Eikelboom J, et al. Idarucizumab for dabigatran reversal. N Engl J Med. 2015;373(6):511-520. (Prospective cohort study; 90 patients)
31. Becker DE. Pain management: part 1: managing acute and postoperative dental pain. Anesth Prog. 2010;57(2):67-78. (Review)
32. * Van Dyke T, Litkowski LJ, Kiersch TA, et al. Combination oxycodone 5 mg/ibuprofen 400 mg for the treatment of postoperative pain: a double-blind, placebo- and active-controlled parallel-group study. Clin Ther. 2004;26(12):2003-2014. (Prospective double-blind study; 498 patients)
33. Forbes JA, Kehm CJ, Grodin CD, et al. Evaluation of ketorolac, ibuprofen, acetaminophen, and an acetaminophen-codeine combination in postoperative oral surgery pain. Pharmacotherapy. 1990;10(6 (Pt 2)):94S-105S. (Double-blind randomized trial; 206 patients)
34. Syverud SA, Jenkins JM, Schwab RA, et al. A comparative study of the percutaneous versus intraoral technique for mental nerve block. Acad Emerg Med. 1994;1(6):509-513. (Prospective crossover trial; 10 patients)
35. Lynch MT, Syverud SA, Schwab RA, et al. Comparison of intraoral and percutaneous approaches for infraorbital nerve block. Acad Emerg Med. 1994;1(6):514-519. (Prospective randomized crossover; 12 patients)
36. Agnihotry A, Fedorowicz Z, van Zuuren EJ, et al. Antibiotic use for irreversible pulpitis. Cochrane Database Syst Rev. 2016;2:CD004969. (Cochrane review)
37. Shahakbari R, Eshghpour M, Rajaei A, et al. Effectiveness of green tea mouthwash in comparison to chlorhexidine mouthwash in patients with acute pericoronitis: a randomized clinical trial. Int J Oral Maxillofac Surg. 2014;43(11):1394-1398. (Randomized trial; 97 patients)
38. Cope A, Francis N, Wood F, et al. Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults. Cochrane Database Syst Rev. 2014(6):CD010136. (Cochrane review)
39. Ellison SJ. An outcome audit of three day antimicrobial prescribing for the acute dentoalveolar abscess. Br Dent J. 2011;211(12):591-594. (Prospective study; 188 patients)
40. Kouassi YM, Janvier B, Dufour X, et al. Microbiology of facial cellulitis related to dental infection. Med Mal Infect. 2011;41(10):540-545. (Prospective observational study; 100 patients)
41. Tsilingaridis G, Malmgren B, Andreasen JO, et al. Intrusive luxation of 60 permanent incisors: a retrospective study of treatment and outcome. Dent Traumatol. 2012;28(6):416-422. (Retrospective; 60 intruded teeth)
42. Andersson L, Andreasen JO, Day P, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol. 2012;28(2):88-96. (Review, IADT guidelines for tooth avulsion)
43. Trope M. Avulsion of permanent teeth: theory to practice. Dent Traumatol. 2011;27(4):281-294. (Review)
44. Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011;57(4):375-377. (Case report)
45. Ritter AL, Ritter AV, Murrah V, et al. Pulp revascularization of replanted immature dog teeth after treatment with minocycline and doxycycline assessed by laser Doppler flowmetry, radiography, and histology. Dent Traumatol. 2004;20(2):75-84. (Canine trial; 38 teeth)
46. Tsilingaridis G, Malmgren B, Skutberg C, et al. The effect of topical treatment with doxycycline compared to saline on 66 avulsed permanent teeth--a retrospective case-control study. Dent Traumatol. 2015;31(3):171-176. (Retrospective case-control study; 66 teeth in 50 patients)
47. Hile LM, Linklater DR. Use of 2-octyl cyanoacrylate for the repair of a fractured molar tooth. Ann Emerg Med. 2006;47(5):424-426. (Case report)
48. Daly B, Sharif MO, Newton T, et al. Local interventions for the management of alveolar osteitis (dry socket). Cochrane Database Syst Rev. 2012;12:CD006968. (Cochrane review)
49. Jesudasan JS, Wahab PU, Sekhar MR. Effectiveness of 0.2% chlorhexidine gel and a eugenol-based paste on postoperative alveolar osteitis in patients having third molars extracted: a randomised controlled clinical trial. Br J Oral Maxillofac Surg. 2015;53(9):826-830. (Randomized trial of chlorhexidine vs eugenol vs control; 270 patients)
50. Cheng D. Unified hands technique for mandibular dislocation. J Emerg Med. 2010;38(3):366-367. (Case report)
51. Gorchynski J, Karabidian E, Sanchez M. The “syringe” technique: a hands-free approach for the reduction of acute nontraumatic temporomandibular dislocations in the emergency department. J Emerg Med. 2014;47(6):676-681. (Prospective convenience sample, multicenter study)
52. Torabinejad M, Dinsbach NA, Turman M, et al. Survival of intentionally replanted teeth and implant-supported single crowns: a systematic review. J Endod. 2015;41(7):992-998. (Meta-analysis and systematic review)
53. * Andreasen JO, Lauridsen E, Gerds TA, et al. Dental trauma guide: a source of evidence-based treatment guidelines for dental trauma. Dent Traumatol. 2012;28(2):142-147. (Review)

This month's episode of EMplify, a podcast corollary to the Emergency Medicine Practice journal, focuses on management strategies that improve dental emergency outcomes. Hosts Jeff Nusbaum, MD, and Nachi Gupta, MD, cover all aspects of the diagnosis and management of this condition, from initial diagnosis and treatment in the emergency department to controversies and cutting-edge strategies.

This podcast is based on the full-length review published in the June 2017 issue of Emergency Medicine Practice. In it, author Ryan Pedigo, MD, Director of Undergraduate Medical Education at Harbor-UCLA Medical Center and Assistant Professor of Emergency Medicine at the David Geffen School of Medicine, cover evidence published in more than 700 articles and reviewed recommendations from the International Association for Dental Traumatology and the Cochrane Database.

Topics covered in this episode of EMplify include

• Case Presentations
• Dental Anatomy
• Traumatic Dental Emergencies
  • Concussion
  • Subluxation
  • Luxation
  • Avulsion
  • Fracture
• Ellis classification system
• Atraumatic dental emergencies
• Dental Infections
• Dental Disease
• Prehospital Care
• Imaging
• Nerve blocks
• Antibiotics
• Management of tooth trauma
• Treatment for dental fractures
• Summary of key points

Links and resources:

• Tables referenced in this podcast episode
• Dental Emergencies: Management Strategies That Improve Outcomes
• Clinical Decision Making in Emergency Medicine