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ORAL MEDICINE Dr Sam Shaikh, DO PGY-II Sinai-Grace Emergency Medicine Slide 2 Disclosures None Slide 3 Slide 4 Slide 5 Caries Oral flora develop Dental Bacterial Plaque Metabolize carbohydrates acids Erode enamel After enamel eroded Microporous dentin Pulp Pulp hyperemia & Inflammation Degeneration & necrosis Slide 6 Slide 7 Periapical Abscess Pus leaks from apex of root Abscess confined within alveolar bone May erode cortical plate mandible/maxilla subperiosteal spread If spread through muscle attachments facial planes of head & neck Slide 8 Complications of Periapical Abscess Submaxillary, sublingual & submental spaces Ludwig's Angina Anterior maxillary teeth Periorbital infection Cavernous Sinus Thrombosis Slide 9 A 45 year old male with poor dentition presents with submandibular swelling and crepitus. Which of the following spaces are involved in Ludwigs angina? Canine space Parapharyngeal space Pterygomandibular space Submandibular space Slide 10 A 45 year old male with poor dentition presents with submandibular swelling and crepitus. Which of the following spaces are involved in Ludwigs angina? Canine space Parapharyngeal space Pterygomandibular space Submandibular space Slide 11 Cavernous sinus thrombosis most commonly results from which teeth? Mandibular anterior teeth Mandibular posterior teeth Maxillary anterior teeth Maxillary posterior teeth Slide 12 Cavernous sinus thrombosis most commonly results from which teeth? Mandibular anterior teeth Mandibular posterior teeth Maxillary anterior teeth Maxillary posterior teeth Slide 13 Ideal Dental Exam HOB at 45 degree angle Overhead light preferred Adjuncts: 2x2, Tongue depressor Soft tissue, tongue, base of tongue, milk Whartons duct, Stensens duct, percussing teeth Consider panoramic radiograph Periapical (dental) films not available in ED Slide 14 or just wing it in The Chairs. Slide 15 Slide 16 Methods ED made Guidelines for management of non-emergent dental pain Excluded patients admitted/transferred, receiving I&D, or IV antibiotics Encouraged non-opiates, nerve blocks, and immobilization Slide 17 Results Opioid prescribing in ~17k visit per year ED for dental pain went from 59% 42% Dental pain visits from 26/1000 21/1000 Annals Reply Tramadol was not included as opiate Slide 18 A 24 year old female is examined for concerns of sialolithiasis. Which gland(s) does Whartons duct empty saliva from? A collection of minor salivary glands Parotid gland Sublingual gland Submandibular gland Slide 19 A 24 year old female is examined for concerns of sialolithiasis. Which gland(s) does Whartons duct empty saliva from? A collection of minor salivary glands Parotid gland Sublingual gland Submandibular gland Slide 20 A 24 year old female is examined for concerns of sialolithiasis. Where is the opening of Stensons duct located? Floor of the mouth inferior to ventral surface of the tongue Papilla on buccal mucosa adjacent to mandibular first molar Papilla on buccal mucosa adjacent to maxillary first molar Posterior dorsal surface of tongue Slide 21 A 24 year old female is examined for concerns of sialolithiasis. Where is the opening of Stensons duct located? Floor of the mouth inferior to ventral surface of the tongue Papilla on buccal mucosa adjacent to mandibular first molar Papilla on buccal mucosa adjacent to maxillary first molar Posterior dorsal surface of tongue Slide 22 A 34 yo male presents to the ED with CC-I have an abscessed tooth and Im in pain. He states the pain wakes him up at night and it is constant and throbbing. You see a grossly decayed tooth but no evidence of generalized or localized swelling, and no signs of an abscess. What do you do? Analgesics, refer to dentist Analgesics and antibiotics, refer to dentist I & D and admit I & D with IV antibiotics Slide 23 A 34 yo male presents to the ED with CC-I have an abscessed tooth and Im in pain. He states the pain wakes him up at night and it is constant and throbbing. You see a grossly decayed tooth but no evidence of generalized or localized swelling, and no signs of an abscess. What do you do? Analgesics, refer to dentist Analgesics and antibiotics, refer to dentist I & D and admit I & D with IV antibiotics Slide 24 A 34 yo male presents to the ED with CC-I have an abscessed tooth and Im in pain. He states the pain wakes him up at night and it is constant and throbbing. You see a grossly decayed tooth with swelling, fluctuance, and purulent drainage. What do you do? Analgesics, refer to dentist Analgesics and antibiotics, refer to dentist I & D and admit I & D and discharge with PO antibiotics Slide 25 A 34 yo male presents to the ED with CC-I have an abscessed tooth and Im in pain. He states the pain wakes him up at night and it is constant and throbbing. You see a grossly decayed tooth with swelling, fluctuance, and purulent drainage. What do you do? Analgesics, refer to dentist Analgesics and antibiotics, refer to dentist I & D and admit I & D and discharge with PO antibiotics Slide 26 CHIEF COMPLAINT: Toothache MCC = Dental caries Pulpitis temperature or air Pain refers to ear, temple, eye, neck, opposite side Exam: Look, palpate, utilize ice TTP w/o temperature sensitivity suggest underlying abscess ED Management NSAIDS Dental block Opiates for acute presentation Be careful to evaluate for abscess which may be need I&D Slide 27 Draining Periapical Abscess Dental Block Incise express purulence Penrose drain or Iodoform gauze secured with 4-0 silk Penicillin V or Erythromycin f/u with Dentist or OMFS for reeval and drain removal Slide 28 Facial Cellulitis PCN VK 250-500 mg QID Airway: CT, early intubation, ENT, anesthesia Admit: suggested spread into facial planes, fever, toxic, trismus, immunocompromised Slide 29 Trismus Irritation of internal pterygoid or masseter Inability to open mouth due to muscle spasm Muscular in origin Not relieved by paralytics All patients with trismus should be presumed difficult Attempt awake intubation Slide 30 Facial Cellulitis IV Penicillin 15-20m U daily B fragillis cephalosporin, clinda, flagyl Surgical exploration for causative & loculations Remove necrotic tissue Slide 31 A 30 year old schizophrenic with present with complaints of foul odor in her mouth. Your physical exam reveals the following. What is your diagnosis Abscess Beriberi HSV Periodontitis Slide 32 A 30 year old schizophrenic with present with complaints of foul odor in her mouth. Your physical exam reveals the following. What is your diagnosis Abscess Beriberi HSV Periodontitis Slide 33 Periodontal Disease Gingivitis - Inflammatory response to irritation inflammation Alveolar Bone loss = Periodontitis Periodontitis Gingival resorption Slide 34 Periodontitis Rarely present to ED. Bloody toothbrush, sensitivity, loose dentition Periodontal Abscess food trapped in pocket Stab incision, irrigate, analgesics, ABX Dental follow-up Tetracycline preferred if > 8 yo for G- & Anaerobes Slide 35 Types of Dental Abscess Slide 36 Acute Necrotizing Ulcerative Gingivitis (ANUG) Bacteria invade non-necrotic tissue - Fusobacteria & Spirochetes Fever, malaise, lymphadenopathy Painful edematous papillae w gray- pseudomembrane Risks: immunocompromised, stress, trauma, smoking Trench Mouth Tx: Saline/H2O2 rinses, hygiene, analgesics, ABX PCN, Erythro, Tetra Slide 37 OTHER CAUSES OF DENTALGIA Slide 38 Slide 39 Dentalgia, continued Cracked Tooth & Split Root Syndrome worse w chewing, history of trauma or previous endodontic. Tx like caries Maxillary Sinusitis can present as dentalgia with negative oral exam, pain on percussion over sinus, rhinorrhea Slide 40 A 24 year old female presents with worsening pain after wisdom teeth extraction. She is a heavy smoker and has continued to smoke despite her dentists instructions, although she "really cut down". What is the appropriate treatment Blood patch Extraction Packing Zygomatic arch ORIF Slide 41 A 24 year old female presents with worsening pain after wisdom teeth extraction. She is a heavy smoker and has continued to smoke despite her dentists instructions, although she "really cut down". What is the appropriate treatment Blood patch Extraction Packing Zygomatic arch ORIF Slide 42 Acute Alveolar Osteitis aka Dry Socket Premature loss of healing blood clot from socket localized infection of bone Treatment Anesthetic nerve block, irrigation, packing socket with iodoform gauze saturated in Sed-A-Dent or Euginol Oral ABX PCN, erythromycin, NSAIDs Slide 43 A 19 yo male presents with localized pain that he believes is coming from his third molar. Upon examination you see this: Dental caries Normal eruption pattern Periodontitis Pericoronitis Slide 44 A 19 yo male presents with localized pain that he believes is coming from his third molar. Upon examination you see this: Dental caries Normal eruption pattern Periodontitis Pericoronitis Slide 45 A 19 yo male presents with localized pain that he believes is coming from his third molar. What is the appropriate management? Emergent extraction Irrigate with normal saline and extract Irrigate with normal saline, PO antibiotics, no extraction indicated Irrigate with normal saline, PO antibiotics, extract after course of antibiotics Slide 46 A 19 yo male presents with localized pain that he believes is coming from his third molar. What is the appropriate management? Emergent extraction Irrigate with normal saline and extract Irrigate with normal saline, PO antibiotics, no extraction indicated Irrigate with normal saline, PO antibiotics, extract after course of antibiotics Slide 47 Oral Manifestations of Systemic Disease Slide 48 .A 28 year old diabetic presents with glucose 1400, bicarb 10, anion gap 27. She is altered and unable to engage in conversation, but her mother states she has been compliant with her insulin. She has been complaining of dental pain. What is the appropriate management? Airway evaluation Bolus insulin Central line IV fluids Slide 49 .A 28 year old diabetic presents with glucose 1400, bicarb 10, anion gap 27. She is altered and unable to engage in conversation, but her mother states she has been compliant with her insulin. She has been complaining of dental pain. What is the appropriate management? Airway evaluation Bolus insulin Central line IV fluids Slide 50 Diabetes Periodontitis Acute Gingival Abscess Severity of disease correlates with glycemic control Dental infection can precipitate DKA Consider HIV in acute deterioration of periodontal health Slide 51 A 42 year old with a family history of SLE presents with complaint of painful gums. Furthur history reveals hemoptysis and his primary physician concerned regarding worsening renal failure. What is the likely diagnosis? AIDS ANUG HSV Wegener's Slide 52 A 42 year old with a family history of SLE presents with complaint of painful gums. Furthur history reveals hemoptysis and his primary physician concerned regarding worsening renal failure. What is the likely diagnosis? AIDS ANUG HSV Wegener's Slide 53 Collagen Vascular Disease SLE Intraoral ulcers w necrotic borders Slide 54 Upon oral examination you notice gingival hyperplasia on a 52 yo female. She states that she is currently taking amlodipine, HCTZ, low dose aspirin, and metformin. Which medication may be contributing to this condition? Amlodipine HCTZ low dose Aspirin Metformin Slide 55 Upon oral examination you notice gingival hyperplasia on a 52 yo female. She states that she is currently taking amlodipine, HCTZ, low dose aspirin, and metformin. Which medication may be contributing to this condition? Amlodipine HCTZ low dose Aspirin Metformin Slide 56 Gingival Hyperplasia Phenytoin, calcium channel blockers, cyclosporine, and phenobarbitol 40% of patients on phenytoin have some degree of hyperplasia Slide 57 Aphthous Stomatitis Canker Sore Recurrent small mucosal ulcers Stress, nutrition, trauma Self-limiting H2O2, Benzocaine, Kaopectate, Maalox, Kenalog, Sucralfate Slide 58 An 8 yo male presents with a low grade fever and multiple erythematous "ulcers on his lips and gingiva. Mom says he does not want to eat. What is your diagnosis? Acute herpetic gingivostomatitis ANUG Aphthous stomatitis Pemphigus Vulgaris Slide 59 An 8 yo male presents with a low grade fever and multiple erythematous "ulcers on his lips and gingiva. Mom says he does not want to eat. What is your diagnosis? Acute herpetic gingivostomatitis ANUG Aphthous stomatitis Pemphigus Vulgaris Slide 60 Dental Trauma Slide 61 Slide 62 Retrospective review of 264 pt/548 teeth over 56 months Mean age 8.2 years, 62% male Most common age for injuries 2-4 & 8-10 53% of effected teeth were permanent Slide 63 237 teeth (43%) presented for follow up Mean time to follow up 55 days 58% of documented/followed-up cases had uncomplicated retention of teeth at 6 months Slide 64 Dental Trauma Most Common = Anterior Complications Fracture Neurovascular Fractures of tooth Loss of tooth=Avulsion Subluxation Slide 65 A 33 year old male presents after getting hit in the face with a rock. Examination of tooth 6 reveals visible dentin, but no pulp or blood. What type of fracture is this? Ellis I Ellis II Ellis III Ellis IV Slide 66 A 33 year old male presents after getting hit in the face with a rock. Examination of tooth 6 reveals visible dentin, but no pulp or blood. What type of fracture is this? Ellis I Ellis II Ellis III Ellis IV Slide 67 Fractured Teeth Ellis I Enamel Ellis II Enamel & Dentin Ellis III Enamel, Dentin, Pulp Slide 68 A 33 year old male presents after getting hit in the face with a rock. Examination of tooth 6 reveals visible dentin and bleeding from the center of the tooth. What is the ideal management of this patient. Anticoagulants Blood patch Cover with cotton and aluminum foil and follow up in 48-72 hours Cover with cotton and aluminum foil and follow up immediately Slide 69 A 33 year old male presents after getting hit in the face with a rock. Examination of tooth 6 reveals visible dentin and bleeding from the center of the tooth. What is the ideal management of this patient. Anticoagulants Blood patch Cover with cotton and aluminum foil and follow up in 48-72 hours Cover with cotton and aluminum foil and follow up immediately Slide 70 Ellis I Slide 71 Ellis II Slide 72 Ellis III Blood = pathognomonic True Dental emergency Pulpectomy If no dentist moist cotton over pulp, cover with aluminum foil Slide 73 A frantic parent presents in with her 7 year old son saying that he knocked his front tooth out about 30 minutes ago. She hands you a cup of water with the tooth in it. What solution would have been best for preserving the tooth while out of the socket? Distilled water Hank's balanced salt solution Milk Saliva Slide 74 A frantic parent presents in with her 7 year old son saying that he knocked his front tooth out about 30 minutes ago. She hands you a cup of water with the tooth in it. What solution would have been best for preserving the tooth while out of the socket? Distilled water Hank's balanced salt solution Milk Saliva Slide 75 A frantic parent presents in with her 7 year old son saying that he knocked his front tooth out about 30 minutes ago. She hands you a cup of water with the tooth in it. What do you do next? Disinfect the tooth with a wipe and place back into the socket Gently rinse any debris with saline and place it back into the socket Sterilize tooth in an autoclave and place back into socket after it cools Thoroughly dry off the tooth and place it back into the socket Slide 76 A frantic parent presents in with her 7 year old son saying that he knocked his front tooth out about 30 minutes ago. She hands you a cup of water with the tooth in it. What do you do next? Disinfect the tooth with a wipe and place back into the socket Gently rinse any debris with saline and place it back into the socket Sterilize tooth in an autoclave and place back into socket after it cools Thoroughly dry off the tooth and place it back into the socket Slide 77 A frantic parent presents in with her 7 year old son saying that he knocked his front tooth out about 30 minutes ago. She hands you a cup of water with the tooth in it. After replantation, mother asks what is the chance of the tooth living "Absolutely, 100%" "For every minute the tooth is out there is a 1% loss of success rate, so it is difficult to say." "Let me call the dentist to find out" "Not a chance, but at least he will look normal for his party this weekend." Slide 78 A frantic parent presents in with her 7 year old son saying that he knocked his front tooth out about 30 minutes ago. She hands you a cup of water with the tooth in it. After replantation, mother asks what is the chance of the tooth living "Absolutely, 100%" "For every minute the tooth is out there is a 1% loss of success rate, so it is difficult to say." "Let me call the dentist to find out" "Not a chance, but at least he will look normal for his party this weekend." Slide 79 Remove from storage solution, rinse off gently Reimplant by manipulating crown Avoid damaging periodontal ligament fibers Stabilize with Coe-Pak Initiate PCN or Erythromycin. Check Tetanus. Liquid diet Follow up with dentist. May (likely) need revision Reimplantation Slide 80 Subluxed Teeth Subluxed = Loose in socket May have associated fracture May have ring of blood in gingival crevice Minimally mobile respond to soft diet Marked mobility stabilize within 10-14 days Arch bar, wire ligation, enamel Slide 81 Soft Tissue Injury Evaluation for tooth fragments Gaping wounds can become ulceration, infected, pain, need closure Mucosa - 4-0 absorbable or silk. Gingival or Tongue silk, less irritating material Small