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.
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...?”
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.
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.
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.
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.
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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
Links and resources:
Ryan Anthony Pedigo, MD
June 1, 2017
June 30, 2020
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME and 0.5 Pharmacology CME credits
Upon competion of this article, you should be able to:
Date of Original Release: June 1, 2017. Date of most recent review: May 10, 2017. Termination date: June 1, 2020.
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Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Medical Journal activity, Emergency Medicine Practice, has been reviewed and is acceptable for up to 48 Prescribed credits by the American Academy of Family Physicians per year. AAFP accreditation begins July 1, 2016. Term of approval is for one year from this date. Each issue is approved for 4 Prescribed credits. Credit may be claimed for one year from the date of each issue. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME and 0.5 Pharmacology CME credits, subject to your state and institutional approval.
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