Dental

Rapid Review

• Background
  • Avulsed teeth are those that are completely dislodged from the socket. An avulsed tooth should be manually reinserted into it’s socket and immobilized with a temporary splint in order to promote restoration of the periodontal ligament. Every minute that the tooth is not reimplanted, viability reduces by 1%.
• Indications
  • Avulsed permanent tooth.
• Contraindications
  • Primary tooth involvement, significant socket damage, grossly decayed tooth, intruded tooth (pushed deeper into socket)
• Complications
  • Unsuccessful reimplantation, tooth contaminated with dirt may cause tetanus.

Pearls

• When reimplanting a tooth, avoid touching the root to minimize damage to the periodontal ligament.
• Keeping the gingiva and surrounding teeth dry during splinting is key for getting the Coe-Pak to adhere to the structures.

Deep Dive

• How To Replace and Splint an Avulsed Tooth (Merck Manual)

Rapid Review

• Background
  • Dental abscesses may be periapical (root of the tooth) or periodontal (in the gum). Incision and drainage helps provide analgesia and limit deeper spread of the infection.
• Indications
  • Periapical or periodontal abscess
• Contraindications
  • Airway obstruction, infection spreading to skin surface (needs oral and maxillofacial surgeon). Relative contraindications include coagulopathy and pregnancy.
• Complications
  • Inadequate drainage, spread of infection, local anesthetic complications.

Pearls

• Be generous with the depth of the incision. If the incision is not deep enough (at least 1-2 cm), this will prevent effective drainage. 
• Provide adequate anesthesia with nerve blocks, but only if you can do it without passing the needle through the track of the infection. If unable, apply topical anesthetics. 

Deep Dive

• How To Drain a Tooth Abscess (Merck Manual)

Rapid Review

• Background
  • Alveolar osteitis, also known as “dry socket”, is inflammation of the alveolar bone that typically occurs when a blood clot fails to form or is lost following tooth extraction. Management in the ED typically includes analgesia, irrigation, and application of iodoform gauze soaked in anesthetic ointment (lidocaine, tetrocaine, eugenol) or application of dental paste, such as Coe-pak.
• Indications
  • Dry socket
• Contraindications
  • None
• Complications
  • Inadequate analgesia, infection

Pearls

• Excessive irrigation or curretting may worsen dry socket by dislodging remaining blood clots.
• After packing the socket, the dressing will need to be removed within 2 days and ideally changed every other day for the next 3-5 days by a dentist/oral surgeon.

Deep Dive

• Alveolar Osteitis: A Comprehensive Review of Concepts and Controversies (PubMed)

Rapid Review

• Background
  • Dental fractures can be classified as Ellis I (Involving only enamel), Ellis II (involvement of enamel and dentin), and Ellis III (involvement of enamel, dentin, and pulp). Treatment involves covering the exposed dentin with zinc oxide or calcium hydroxide and ensuring follow-up with dentist within 24 hours.
• Indications
  • Ellis II or Ellis III fractures; fractures involving only the enamel can be repaired cosmetically at the patient’s convenience. 
• Contraindications
  • None
• Complications
  • Long-term calcium hydroxide dressings may cause cervical root fractures

Pearls

• The fractured tooth must be completely dry prior to applying the zinc oxide or calcium hydroxide past. Have the patient keep their mouth open for approximately 10-15 immediately following application.
• If you don’t have zinc oxide or calcium hydroxide, you can use dermabond instead.

Deep Dive

• Mastering Minor Care: Dental Fractures (Taming the SRU)

Rapid Review

• Background
  • Displacement of the mandibular condyle from the articular groove in the temporal bone. Dislocation may be anterior (most common), posterior, lateral, or superior. Most dislocations can be managed in the emergency department with manual reduction.
• Indications
  • Acute TMJ dislocations (unilateral or bilateral
• Contraindications
  • Dislocations associated with fractures or chronic dislocations
• Complications
  • Mandibular fracture, injury to clinician, injury to facial nerve or external carotid artery (rare).

Pearls

• The extraoral approach has the benefit of avoiding the risk of getting bit during the procedure.
• Analgesics and/or muscle relaxants can help facilitate reduction. If dystonia was the underlying cause of the dislocation, be sure to treat first with diphenhydramine or benztropine.

Deep Dive

• Temporomandibular Joint Dislocation (emDocs)