Dental Emergencies in Urgent Care: Management Strategies That Improve Outcomes (Trauma CME, Pain Management CME, Infectious Disease CME, and Pharmacology CME)

Table of Contents

 

About This Course

Patient presentations to urgent care with dental trauma and other dental emergencies are increasingly common. However, urgent care clinicians may be unsure of the best treatment options to achieve optimal cosmetic and functional outcomes. While many dental presentations require simple management and referral for dental follow-up, some dental problems can represent dangerous etiologies. In this issue, you will learn:

The most effective options for management of dental pain, including orofacial nerve blocks

How to determine the origin and severity of odontogenic infections

When emergent imaging is indicated in dental conditions

Indications for use of oral antibiotics and recommendations for antibiotic regimens

Recommendations for replanting avulsed teeth

Treatment strategies and urgency of referral for dental fractures based on the depth and location of the fracture

Options for management of mandibular dislocations

The dental supplies that every urgent care clinic needs

CHARTING & CODING: Learn how to select the appropriate level of service for encounters with patients who present with dental emergencies

1. About This Course
2. Abstract
3. Case Presentations
4. Introduction
5. Anatomy
6. Etiology and Pathophysiology
   1. Dentoalveolar Trauma
   2. Atraumatic Dental Emergencies
   3. Odontogenic Abscesses and Deep Neck Infections
7. Differential Diagnosis
8. Preclinic Care
   1. Storage Media
9. Urgent Care 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. Management of Concussion, Subluxation, and Luxation Injuries
    4. Management of Tooth Avulsion
    5. Management of 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. Management of Alveolar Osteitis
    7. Mandibular Dislocation Management
12. Controversies and Cutting Edge
13. Disposition
14. Time- and Cost-Effective Strategies
15. Summary
16. Risk Management Pitfalls for Dental Emergencies in Urgent Care
17. 5 Things That Will Change Your Practice
18. Critical Appraisal of the Literature
19. Case Conclusions
20. Charting & Coding: What You Need to Know
    1. Medical Decision Making for Dental Emergencies in Urgent Care
       1. Problems Addressed Category
       2. Complexity of Data Category
       3. Risk of Complications Category
    2. Summary
21. Clinical Pathway for Urgent Care Management of Dental Emergencies
22. References

Abstract

Acute dental emergencies are a common chief complaint presenting to ambulatory healthcare settings, and they are increasing substantially in frequency. The diagnosis and management of dental emergencies is a core competency of frontline clinicians, 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; it focuses on the historical and physical examination findings that must be uncovered to identify dangerous infections, relieve pain, salvage natural teeth, and communicate with the specialists who will assume care of these patients at follow up.

Case Presentations

A 20-year-old man presents to the urgent care clinic following a physical altercation...

• On physical examination, you note that in addition to a small lower lip laceration, he has subluxation of the left lateral maxillary incisor and a chipped left central maxillary incisor.
• You wonder if either the mobile tooth or the chipped tooth need any specific urgent interventions…

An 18-year-old woman presents with a complaint 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.
• You consider what, if anything, you can do about this condition in the urgent care setting...

A 60-year-old man presents with lower jaw pain and swelling, malaise, and trouble fully opening his mouth...

• On examination, he has a temperature of 37.8°C, trismus, fullness and tenderness of the gingiva of the left first mandibular molar, and left submandibular swelling and tenderness to palpation.
• You wonder if it’s safe to treat him with antibiotics and instruct him to urgently follow up with a dentist...

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Urgent Care Management of Dental Emergencies

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

3. Wall T, Vujicic M. Emergency department use for dental conditions continues to increase. April 2015. (Research brief)

12. * Karkos PD, Asrani S, Karkos CD, et al. Lemierre's syndrome: a systematic review. Laryngoscope. 2009;119(8):1552-1559. (Systematic review; 84 studies) DOI: 10.1002/lary.20542

15. * 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) DOI: 10.1590/0103-6440201302297

18. * 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. (Guidelines) DOI: 10.1111/edt.12576

23. * Christensen BJ, Park EP, Suau S, et al. Evidence-based clinical criteria for computed tomography imaging in odontogenic infections. J Oral Maxillofac Surg. 2019;77(2):299-306. (Prospective cohort study; 129 patients) DOI: 10.1016/j.joms.2018.09.022

27. * 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) DOI: 10.1016/j.clinthera.2004.12.002

31. * Agnihotry A, Thompson WF, Z, van Zuuren E, et al. Antibiotic use for irreversible pulpitis. Cochrane Database Syst Rev. 2019;5(5):CD004969. (Cochrane review) DOI: 10.1002/14651858.CD004969.pub4

36. * Day PF, Duggal M, Nazzal H. Interventions for treating traumatised permanent front teeth: avulsed (knocked out) and replanted. Cochrane Database Syst Rev. 2019;2(2):CD006542. (Systematic review; 4 studies, 183 patients) DOI: 10.1002/14651858.CD006542.pub3

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Keywords: dental emergency, dentoalveolar, tooth, tooth fracture, periodontium, periodontal, alveolar ridge, alveolar osteitis, subluxation, luxation, avulsion, Ellis, gingiva, gingivitis, necrotizing stomatitis, pericoronitis, operculum, wisdom teeth, alveolar osteitis, dry socket, odontogenic abscess, Ludwig angina, Hanks' balanced salt solution, HBSS, mandibular dislocation, nerve block, syringe technique