DENTAL EMERGENCIES

DR O.G. OGBEBOR(BDS,MPH,FMCGDP)

NIGER STATE 2012 AGM/CME

DECEMBER, 2012

OUTLINE

DEFINITION INTRODUCTION CAUTION SOURCES OF DENTAL EMERGENCIES TYPES OF DENTAL EMERGENCIES HANDLING OF COMMON DENTAL

EMERGENCIES CONCLUSION

DEFINITIONS Emergency means sudden occurrence or

unplanned negative or positive event.

Dental emergency is therefore dental conditions that may occur suddenly and requires dental professional intervention.

Illinois State Dental Society defined dental emergency as an oral condition that occurs suddenly and creates an urgent need for professional consultation and or treatment. These clinical conditions may include haemorrhage, infection, pain, and trauma

However, for the topic we are concerned with today; Dental emergencies, will be tailored to the emergencies associated with dental profession.

By this it will be all encompassing i.e. Dental emergency as may occur in the dental clinic or outside the Dental clinic as may be explained latter.

INTRODUCTION Dental emergencies though relatively rare,

are very important because precise and adequate handling is very essential to avoid severe complications and mortality.

The relatively rarity of dental emergencies is due to the ambulatory nature of dentistry so dental surgeons could be caught unawares esp. those that occur on the dental chair.

Hence adequate preparations and high index of suspicion on every patient during practice is very important and recommended.

Thorough assessment of every patient and taken into cognizance the relevant findings before treatment is commenced will reduce incidence to the barest minimum.

The goals of the dental practitioner is to develop a sense of vigilance and anticipation to enable one respond to an urgent medical or dental needs in a reasonably confident and efficient fashion when it occurs as prevention is far better and cheaper than cure.

CAUTION It is estimated that about 90% of

emergencies can be prevented. This means that 10% will occur in spite of our best efforts!!!

SOURCES OF DENTAL EMERGENCIES

This can be grouped into three major groups for the purpose of this discussion.

Arising from: 1. Patients 2. Dental Treatment 3. Trauma

THOSE ARISING FROM PATIENTS:

(a) Attitude to dental care – Late, poor or never dental attendance (b) Application of self medications eg Toxins (touch and go, battery acids, aspirin, etc).

(c) Exercepated patients’ dental conditions eg toothache from untreated diseased tooth or teeth, cancers, abscesses etc.

THOSE ARISING FROM PATIENTS:

(d) Unidentified or poorly managed medical conditions• Diabetes mellitus(Hyper/Hypo glycaemia), • Hypertension, • Ischaemic Heart disease (Angina pectoris/myocardial

infarction)• Cardiac Arrest, • Cerebrovascular Accident, • Fits/seizures, • Anaphylaxis, • Adrenal insufficiency, • orthostatic hypotension{dizzyness in upright position}, • Asthmatic attack.• Psychiatric conditions

THOSE ARISING FROM DENTAL TREATMENT:

Broken tooth/teeth(retained roots) Post extraction haemorrhage Foreign bodies (swallowed denture), fish bones, broken fillings Post extraction trauma/swellings Endodontics Periodontal diseases(gingivitis) Others emanating from reaction of patient to treatment Fears and apprehensions – Fainting/ vasovagal syncope.

THOSE ARISING FROM TRAUMA:

Maxillofacial Injuries/FracturesLacerations - Avulsion - Tooth displacement - Fracture of teethThese could be from RTA, domestic violence, playground or sports injury etc.

TYPES OF DENTAL EMERGECIESThis can be grouped into two major parts: (a)Emergency occurring within the clinic: (i) Loss of consciousness(LOC) in the Dental Clinic; This could be as a result of

fainting/vasovagal syncope. Starvation(hypoglycaemia) – as a result

of Patient not taken meals at home before coming for dental treatment.

TYPES OF DENTAL EMERGECIES Fit/seizures Anaphylaxis Adrenal Insufficiency Asthmatic attack Inhaled foreign bodies Psychiatric(Hyperventllation Syndrome)

Fear/anxiety as a result of the sight of

dental gadgets and presumed fear of dental pain.

Diabetes Mellitus(hypoglycaemia/hyperglycaemia)

Ischaemic Heart disease(Angina pectoris/myocardial infarction).

Cardiac Arrest. Cerebrovascular Accident.

FAINTING/VASOVAGAL SYNCOPY Defined as sudden loss of consciousness(LOC) due

to cerebral hypoperfusion. It is most common of LOC in the Dental Clinic. Patient is usually a fit able bodied young Man! Causes: Anxiety,pain,fatigue,high temperature and

humidity.

Presentation: Premonitory dizziness,weakness,nausea, Pallor, cold moist skin and then LOC.

MANAGEMENT:

Lay patient on the dental chair and elevate the chair downwards to allow easy blood flow to the brain.

Loosen tight fittings, clothings. Lay Patient flat or in Trendelenborg

position. Recovery occurs within 3 minutes

otherwise consider other likely cause of LOC.

May need to reschedule appointment.

DIABETES MELLITUS INDUCED LOC Usually occurs in known DM patient; Either due to a missed meal or poorly

controlled condition.Presentation: Drowsiness, disorientation or

aggressiveness could suggest hypoglycaemia.

There is dry mouth, dry skin and deep breathing in hyperglycaemia.

MANAGEMENT Give oral glucose if patient is conscious

and I/V if unconscious (irrespective of whether is hypo or hyper) since you may not be able to differentiate.

1mg glucagon can be given in hypoglycaemia.

ISCHAEMIC HEART DISEASEAngina Pectoris: Presenting with central crushing chest

pain usually precipitated by exertion. No physical sign associated. Relieved by rest and GTN.Myocardial infarction: Ischaemic necrosis of the cardiac musles. Pain more severe than AP and not

relieved by rest or GTN.

CARDIAC ARREST Characterized by sudden pallor,

respiratory arrest, loss of pulse and LOC.Causes: Myocardial infarction(Asystole and

ventricular fibrillation, analphylaxis)Management: Cardiopulmonary resuscitation.

CEREBROVASCULAR ACCIDENT (STROKE)

Presentation: Patient is usually a known hypertensive Severity depends on site and size of the

brain involved. Loss of consciousness. Weakness of limbs on one side. Facial dropping Speech affection.Management: Maintain airway and observe.

FITS/SEIZZURES Known Epileptics Can occur in hypoglycaemia, drug

overdose(LA),may follow LOC. Presentation: LOC with rigid extended body. Jerking movements Incontinence may follow.Management: Most fits terminate spontaneously; just

prevent damage to Patient.

FITS/SEIZURES 10mg I/V Diazepam can be given if

fitting does not end within 5minutes. Give oxygen. Avoid forcing mental or wooden objects

into patient’s mouth.

ANAPHYLAXIS Type I hypersensitivity reaction. Usually a reaction to the fixative in local

anaesthetic(LA) called methyl paraben and I/V penicillin.

There could be facial flushing, itching,paraesthesia and peripheral coldness.

Rapid and weak pulse, cold clammy skin. LOC.

MANAGEMENT Patient is laid flat; administer oxygen. Give I/V 100- 2OOmg hydrocortisone. 10 – 20mg chropheniramine I/V And if need be 1ml of 1:1000 adrenaline

i/m.

ASTHMATIC ATTACK Usually a known asthmatic.Causes: Anxiety, infection or exposure to

allergens.Presentation: Breathlessness Expiratory wheezes Tachypnoea Use of accessory muscles of respiration

MANAGEMENT Reassure and give inhaler 0.3cc of 1000 adrenaline may be

required Administer oxygen and I/V

hydrocortisone Avoid barbiturates, NSAID and narcotics

in Asthmatics. May need to see his Physician.

INHALED FOREIGN BODY Usually a tooth or endodontic instrument Could result in respiratory obstruction,

lung abscess or death. Management: Heimlich manauver(not slapping the

patient on the back. Failing, an endoscopy will be needed. Also X- Ray usually needed for

localisation.

INHALED FOREIGN BODY

HYPERVENTILATION SYNDROME

Patient is usually an anxious or hysterical woman

Overbreathing until carbon dioxide washes out resulting in tetany and paraesthesia

Palpitations, breathlessness and dizziness often associated.

Causes: Organic cause include pain.

HYPERVENTILATION SYNDROME

It could be a response to acidosis or poor ventilatory exchange(compensatory physiological response).

Management: Reassurance Re- breathing into a bag to overcome

alkalosis. May require I/V diazepam.

ADRENAL INSUFFICIENCY

Manifest as inability to cope with stress.

Causes: Include: Addison’s disease, acute

withdrawal of corticosteriods, pituitary or adrenal diseases or damage.

Likely when corticosteroid > 20mg daily for two weeks in the last two years.

Prevention: Preoperative steroids

ORTHOSTATIC HYPOTENSION

Dizziness in upright position or sudden change in posture.

Causes include anti BP, tricyclics, Narcotics, poor postural reflex, pregnancy.

Management: Prevent by gradual change in position.Treatment: As in vasovagal syncope.

Note: ONLY FEW EMERGENCIES CAN BE

TREATED DEFINITIVELY IN THE DENTAL SURGERY.

THE IDEA IS TO BE ABLE TO CARRY OUT LIFE SAVING GENERAL MEASURES: ENSURING PATIENT AIRWAY,

BREATHING AND MAINTENANCE OF CIRCULATION.

TAKE HOME MESSAGE

Anticipation, Prevention and planning. Anticipation: what type of emergency

can you anticipate with this patient? Prevention: what can you do to

decrease the risk of occurrence? Planning: what would you do if the

problem occur?

PULPITIS FROM DENTAL CARIES

ACUTE PERIAPICAL PERIODONTAL FROM DENTAL CARIES

THOSE ARISING FROM DENTAL TREATMENT: Broken tooth/teeth(retained roots) Treatment depend on the type of fracture Enamel fracture- round off rough edges Dentine

fracture-composite/GIC/amalgam filling Fracture involving pulp- RCT Cervical root fracture -extraction Sagittal split - extraction

THOSE ARISING FROM DENTAL TREATMENT:

THOSE ARISING FROM DENTAL TREATMENT:

THOSE ARISING FROM DENTAL TREATMENT:

THOSE ARISING FROM DENTAL TREATMENT: Post extraction haemorrhage Assess source of bleeding Give I.M vitamin K If soft tissue, compress with guaze and

put horizontal matress suture If bone, apply haemostatic agent like

surgicel, bone wax, gel foam. If haematological issues are detected

from blood test refer to the haematology.

THOSE ARISING FROM DENTAL TREATMENT: Foreign bodies (swallowed denture), fish

bones, broken/fillings Fish bone can be removed using artery

forcep and open flap to visualise it Swallowed denture will be retrieved

through endoscopy by Otorhinolaryngologist or Cardiothoracic Surgeon after having barium swallow or barium meal radiograph.

Broken filling may occur from improper use of elevator and this have to be replaced

THOSE ARISING FROM DENTAL TREATMENT: Abscess: Dentoalveolar, palatal and

fascial space abscess, etc.

DENTOALVEOLAR ABSCESS

PALATAL ABSCESS

SUBMANDIBULAR ABSCESS

BUCCAL SPACE ABSCESS

SUBMASSETERIC ABSCESS

LUDWIG ANGINA

THOSE ARISING FROM DENTAL TREATMENT: Endodontic emergencies may arise at the

preoperative, intraoperative and postoperative stages of dental care

Preoperative occurs from pulpitis, acute apical periodontitis. RCT will suffice for them except in reversible pulpitis where temporary dressing with dycal and ZOE is necessary

Intraoperative like flare up - do more biomechanical cleaning and dress root canal with non setting Ca(OH)2

Postoperative like high spots - grinding the high spots after detecting with articulating paper.

THOSE ARISING FROM ORTHODONTIC TREATMENT:

Orthodontic wires can cause injuries. The wire will be adjusted or cut

THOSE ARISING FROM DENTAL TREATMENT:

PERIODONTAL ABSCESS

ANUG

THOSE ARISING FROM DENTAL TREATMENT: Periodontal diseases in form of

periodontal abscess, acute necrotizing ulcerating gingivitis (ANUG)

Periodontal abscess-incision and drainage, treat the casuative agent like periodontal pocket.

ANUG- gross scaling, diluted hydrogen perioxide mouth wash, antibiotics-amoxil and flagyl,

Diagnosis Definition Presentation Complications Treatment Reversible pulpitis

Pulpal inflammation Pain with hot, cold, or sweet stimuli

Periapical abscess, cellulitis

Filling

Irreversible pulpitis

Pulpal inflammation Spontaneous, poorly localized pain

Periapical abscess, cellulitis

RCT, extraction

Abscess Localized bacterial infection

Localized pain and swelling

Cellulitis I & D and RCT or extraction

Cellulitis Diffuse soft tissue bacterial infection

Pain, erythema, and swelling

Regional spread Antibiotics and RCT or extraction

Pericoronitis Inflamed gum over partially erupted tooth

Pain, erythema, and swelling

Cellulitis Irrigation, antibiotics if cellulitis also present

Tooth fracture Broken tooth Clinical examination and radiography

Pulpitis and sequelae

Fillings, with or without RCT, extraction

Tooth luxation

Loose tooth Clinical examination and radiography

Aspiration, pulpitis, and sequelae

Splinting, with or without RCT, extraction

Tooth avulsion

Missing tooth Clinical examination

Ankylosis, resorption

Reimplantation and splinting

THOSE ARISING FROM TRAUMA:Lacerations- remove debris and foreign bodies, arrest haemorrhage, finally suture it

THOSE ARISING FROM TRAUMA:- Avulsion if the tooth is whole, hold the crown and replant into the cleaned socket and splint with composite reinforced with stainless steel wireDisplaced tooth- Splint

MANDIBULAR FRACTURE

THOSE ARISING FROM TRAUMA:Mandibular Fractures Principles and practice of fracture

management as reduce, stabilize and fix, apply here.

For bilateral parasymphyseal mandibular fracture, the lack of tongue support will lead to it falling back and patient suffocating. Emergency measures like applying suture on the tongue and tying it to the patients apron.

THOSE ARISING FROM TRAUMA:Maxillary Fractures: Lefort I, II and III

THOSE ARISING FROM TRAUMA:Lefort I

THOSE ARISING FROM TRAUMA:Lefort II

THOSE ARISING FROM TRAUMA:Lefort III

THOSE ARISING FROM TRAUMA:Maxillary Fractures: Lefort I, II and III Principles and practice of fracture

management as reduce, stabilize and fix, apply here.

Lefort II fracture will cause backward slide of the segment which will occlude the airway. Emergency measures is to do manual or mechanical reduction.

CONCLUSION Dental emergencies which arises from dental

and medical conditions needs urgent and precise care to prevent complications.

Proper history and clinical examination will help in reducing the prevalence of preventable dental emergencies in the dental clinic.

Training and retraining of dentist will help reduce dental emergencies associated with dental treatment.

Patient education to heighten awareness will help reduce dental emergencies associated with poor dental awareness and personal care.

THANK YOU