FCEM Preparation: HAP9 Dental Emergencies

1. Dental Infections

Dental infections usually arise from pulpitis and associated necrotic dental pulp that initially begins on the tooth’s surface as dental caries. The infection may remain localised or quickly spread through various fascial planes.

Odontogenic infection may be primary or secondary to periodontal, pericoronal, traumatic, or postsurgical infections. A typical odontogenic infection originates from caries, which decalcify the protective enamel.

Once enamel is dissolved, the infectious caries can travel through the dentinal tubules and gain access to the pulp. In the pulp, the infection may develop a track through the root apex and burrow through the medullar cavity of the mandible or maxilla. The infection then may perforate the cortical plates and drain into the superficial tissues of the oral cavity or track into deeper fascial planes. If the infection does not drain, it will remain localised and develop into a periapical or periodontal abscess.

Serotypes of Streptococcus mutans (cricetus, rattus, ferus, sobrinus) are primarily responsible for causing oral disease.[1] Although lactobacilli are not primary causes, they are progressive agents of caries because of their great acid-producing capacity.

Dental caries is not a life-threatening disease; however, if an odontogenic infection spreads through fascial planes, patients are at risk for sepsis, airway compromise (eg, Ludwig angina, retropharyngeal abscess).

Symptoms and Signs:

Patients with superficial dental infections may complain of localised pain, oedema, and sensitivity to temperature and air. Patients with deep infections or abscesses that spread along the fascial planes may complain of fever and difficulty swallowing, breathing, and opening the mouth.

Local infections

Typically, the tooth is grossly decayed, although it may be normal with cavitated lesions that may have a surrounding chalky demineralised area and swollen erythematous gingiva. Affected teeth generally are tender to percussion and temperature.

Mandibular infections

Submental space infection is characterised by a firm midline swelling beneath the chin and is due to infection from the mandibular incisors.

Sublingual space infection is indicated by swelling of the mouth’s floor with possible tongue elevation, pain, and dysphagia due to anterior mandibular tooth infection.

Submandibular space infection is identified by swelling of the submandibular triangle of the neck around the angle of the jaw. Tenderness to palpation and mild trismus is typical. Infection is caused by mandibular molar infections.

Retropharyngeal space infection is identified by stiff neck, sore throat, dysphagia, hot potato voice, and stridor with possible spread to the mediastinum. These infections are due to infections of the molars.

With spread to the deeper areas of the neck, signs and symptoms of vagal injury, Horner syndrome, and lower cranial nerve injury may be seen.

Infection in this space is more common in children younger than 4 years.

Etiology usually is due to an upper respiratory infection (URI) with spread to retropharyngeal lymph nodes.

Because of high potential for spread to the mediastinum, retropharyngeal space infection is a serious fascial infection.

Ludwig angina (name derived from sensations of choking and suffocation) is characterised by brawny board like swelling from a rapidly spreading cellulitis of the sublingual, submental, and submandibular spaces with elevation and oedema of the tongue, drooling, and airway obstruction.The condition is odontogenic in 90% of cases and arises from the second and third mandibular molars in 75% of cases.

Middle and lateral facial oedema

Buccal space infection is typically indicated by cheek oedema and is due to infection of posterior teeth, usually premolar or molar.

Masticator space infection always presents with trismus manifestation and is due to infection of the third molar of the mandible. Large abscesses may track toward the posterior parapharyngeal spaces. Patients may require fiberoptic nasoendotracheal intubation while awake.

Canine space infection is evidenced by anterior cheek swelling with loss of the nasolabial fold and possible extension to the infraorbital region. This is due to infection of the maxillary canine and potentially may spread to the cavernous sinus.

Gingivitis

Acute narcotising ulcerative gingivitis (Vincent angina, trench mouth) is a condition in which patients present with edematous erythematous gingiva with ulcerated, interdental papillae covered with a gray pseudomembrane.

Patients may have fever and lymphadenopathy and may complain of metallic taste. The condition is caused by invasive fusiform bacteria and spirochetes but is not contagious.

Causative agents:

Serotypes of S mutans are thought to cause initial caries infection. Infections through the fascial planes usually are polymicrobial (average 4-6 organisms). Dominant isolates are anaerobic bacteria.

Anaerobes (75%) – Peptostreptococci, Bacteroides and Prevotella organisms, and Fusobacterium nucleatum

Aerobes (25%) – Alpha-hemolytic streptococci

Investigations:

In dental infection, a FBC count with differential is not mandatory, but a large outpouring of immature granulocytes may indicate the severity of the infection.

Blood cultures in patients who are toxic may help guide management if the course is prolonged.

X-rays to identify involvement of tooth and surrounding bone in the infectious process.

Treatment:

Analgesics and antibiotics may be given if the patient is not systemically ill and appears to have a simple localised odontogenic infection or abscess.

I&D may be required if a periapical or periodontal abscess is identified – Maxfax referral

In deep fascial infections of the neck, an airways assessment might be necessary before the Maxfax referral. If they are systemically unwell, prompt use of IV antibiotics and other measures necessary for a septic patient.

2. Dental Fractures

Types	Clinical Features	ED Treatment	Referral
Infraction	● An incomplete fracture of the enamel without loss of tooth structure.● Not tender. If tenderness is observed evaluate the tooth for a possible luxation injury or a root fracture.	Reassurance	Own dentist
Enamel Fracture $Enamel fracture$	● A complete fracture of the enamel.● Loss of enamel. No visible sign of exposed dentin. ● Not tender. If tenderness is observed evaluate the tooth for a possible luxation or root fracture injury. ● Normal mobility.	ReassuranceDentist treatment ● If the tooth fragment is available, it can be bonded to the tooth.	Own dentist or Emergency Dentist
Enamel-Dentin-Fracture	● A fracture confined to enamel and dentin with loss of tooth structure, but not exposing the pulp.● Percussion test: not tender. If tenderness is observed, evaluate the tooth for possible luxation or root fracture injury. ● Normal mobility.	ReassuranceDentist treatment ● If the tooth fragment is available, it can be bonded to the tooth.	Own Dentist or Emergency Dentist
Enamel-Dentin-Pulp-Fracture	● A fracture involving enamel and dentin with loss of tooth structure and exposure of the pulp.● Normal mobility ● Percussion test: not tender. If tenderness is observed, evaluate for possible luxation or root fracture injury. ● Exposed pulp sensitive to stimuli.	AnalgesiaReassurance	Dentist
Crown Root Fracture without Pulp Exposure	● A fracture involving enamel, dentin and cementum with loss of tooth structure, but not exposing the pulp.● Crown fracture extending below gingival margin. ● Percussion test: Tender. ● Coronal fragment mobile.	● As an emergency treatment a temporary stabilisation of the loose segment to adjacent teeth can be performed until a definitive treatment plan is made.	Dentist or Emergency Dentist
Root Fracture	● The coronal segment may be mobile and may be displaced.● The tooth may be tender to percussion. ● Bleeding from the gingival sulcus may be noted. ● Sensibility testing may give negative results initially, indicating transient or permanent neural damage.	● Reposition, if displaced, the coronal segment of the tooth as soon as possible. ● Check position radiographically. ● Stabilise the tooth with a temporary splint ● Referral to Maxfax or Emergency Dentist	Maxfax or Emergency Dentist
Alveolar Fracture	● The fracture involves the alveolar bone and may extend to adjacent bone.● Segment mobility and dislocation with several teeth moving together are common findings. ● An occlusal change due to misalignment of the fractured	● Reposition any displaced segment and then temporary splint.	Urgent Maxfax referral
Concussion	● The tooth is tender to touch or tapping; it has not been displaced and does not have increased mobility.	Reassurance	Dentist check up
Subluxation	● The tooth is tender to touch or tapping and has increased mobility; it has not been displaced.● Bleeding from gingiva may be noted.	ReassuranceMight need a splint for few weeks through dentist.	Dentist
Extrusive Luxation	● The tooth appears elongated and is excessively mobile.	● Reposition the tooth by gently re-inserting it into the tooth socket. ● Stabilise the tooth for using a temporary splint.	Dentist
Lateral Luxation	● The tooth is displaced, usually in a palatal/lingual or labial direction.● It will be immobile ● Fracture of the alveolar process present.	● Reposition the tooth digitally or with forceps to disengage it from its bony lock and gently reposition it into its original location.● Temporary splint if it is loose.	Maxfax
Intrusive Luxation	● The tooth is displaced axially into the alveolar bone.● It is immobile	● Primary teeth: to allow spontaneous re-eruption except when displaced into the developing successor. Extraction is indicated when the apex is displaced toward the permanent tooth germ.● Permanent teeth: to reposition passively (allowing re-eruption to its preinjury position), actively (repositioning with traction), or surgically and then to stabilise the tooth with a splint for up to 4 weeks in its anatomically correct position	Maxfax / Dentist
Avulsion	● Complete displacement of tooth out of socket.	● Primary teeth: to prevent further injury to the developing successor. Avulsed primary teeth should not be replanted because of the potential for subsequent damage to developing permanent tooth germs.● Permanent teeth: to replant as soon as possible and then to stabilise the replanted tooth in its anatomically correct location to optimise healing of the periodontal ligament and neuromuscular supply while maintaining aesthetic and functional integrity.If replantation of tooth is not possible in the ED, it should be kept in saline, milk or inside of patients mouth moistened by saliva.	Maxfax