Third Edition June 2010

www.smilesforlifeoralhealth.org
Copyright STFM 2005-2010

Course Steering Committee Editors Russell Maier, M.D. Alan B. Douglass, M.D. Dental Consultant Joanna M. Douglass, B.D.S., D.D.S. Smiles for Life Editor Alan B. Douglass, M.D. Funded By

Educational Objectives
Understand the nature of oral pain. Recognize the importance of a thorough history and examination in developing a differential diagnosis for oral pain. Identify the best analgesia choices for oral pain. Learn how to properly diagnose, manage, and refer patients suffering from oral infections. Develop familiarity with antibiotic options. Understand the epidemiology of dental trauma Perform extraoral and intraoral exams to assess for injuries.

Educational Objectives
Diagnose, initially manage, and appropriately refer patients suffering from common dental trauma. Develop familiarity with dental trauma terminology in order to accurately describe injuries for referral. Understand how trauma to primary teeth can affect permanent teeth. Recognize the different types of dental trauma and how to appropriately treat and refer patients. Implement strategies aimed at the prevention of oral injuries.

Oral Pain
Chapter Objectives Understand the nature of oral pain Recognize the importance of a thorough history and examination in developing a differential diagnosis for oral pain Identify the best analgesia choices for oral pain

Photo: Joanna Douglass, BDS, DDS

Oral Pain
Frequency and Nature
Oral pain is common, with 22% of adults reporting oral pain in the past six months. Oral pain can be difficult to localize and diagnose. Pain may be referred to the ear. Diagnosis in children is particularly challenging. Children may present with behavioral problems rather than specific oral complaints.

Photo: Joanna Douglass, BDS, DDS

Diagnosing Oral Pain

Diagnosis Requires
A history that includes How long the pain has been present Whether there is pain with chewing, temperature change, and sweet foods A head and neck examination that includes Extraoral examination for swellings and external masses Teeth Intraoral soft tissues

Oral Pain Etiologies

The differential diagnosis should include sources of referred pain and pain of nondental origin. Dental
Caries and its sequellae Eruptions problems (e.g., pericoronitis) Periodontal problems Trauma

Nondental
Sinusitis Otitis media/ otitis externa Oral ulcerations Temporomandibular joint

Analgesia for Oral Pain

Nonsteroidal Inflammatory Drugs (NSAIDS)
Typically highly effective for oral pain and should be the first line of choice Relatively well tolerated No potential for abuse

Opioids
May occasionally be required for severe pain Have potential for abuse Care should be taken when evaluating the need for opioids as drug seekers often complain of oral pain

Analgesia for Oral Pain

Oil of Cloves (Eugenol) and Other Topical Agents
Although often used topically for oral pain, have not been shown to be effective FDA reclassification of eugenol indicates insufficient data to support efficacy Topical local anesthetics have little effect on dental pain and should not be used in young children

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Oral Infections
Chapter Objectives Understand the pathogenesis of oral infections Learn how to appropriately diagnose, manage, and refer patients suffering from oral infections Develop familiarity with antibiotic options
Photo: ICOHP

Reversible Pulpitis
Symptoms
Pain with hot, cold, and sweet Resolves spontaneously

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Etiology
Carious lesion approaching the pulp removes insulating dentin

Treatment

Filling insulates the pulp causing symptoms to disappear Analgesics are not generally necessary

Photo: Joanna Douglass, BDS, DDS

Irreversible Pulpitis
Symptoms
Tooth is often sensitive to percussion Pain is severe, spontaneous, persistent, and poorly localized

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Etiology
As carious lesion progresses, the pulp becomes infiltrated with bacteria and inflamed. Ultimately pulp necrosis results
Graphic: AAFP Home Study Program- with permission

Irreversible Pulpitis
Treatment
Root canal treatment or tooth extraction Root canal removes the pulp and fills the residual space followed by a crown. Analgesics often necessary If untreated, inflammation will reach the apex of the tooth, eventually leading to periapical periodontitis (inflammation of the apical area of the periodontal ligament and subsequent periapical abscess or cellulitis)
Photo: Joanna Douglass, BDS, DDS

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Periapical Abscess
Periapical abscess is a localized, purulent form of periapical periodontitis. Symptoms
Pain is well localized Tooth is typically percussion sensitive Pain may be severe, spontaneous, and persistent If the abscess is draining, pain may be less severe
Graphic: AAFP Home Study Programwith permission

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Abscess may track through bone to form a localized fluctuant swelling, fistulize, or spread to surrounding tissues causing cellulitis

Periapical Abscess Treatment

Arrange urgent dental referral for root canal or extraction If not done, abscess is likely to recur. Incision and drainage can provide temporary relief if not fistulized Analgesics are necessary. Only use antibiotics if concurrent cellulitis is present

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Photo: Donald Greiner, DDS, MS

Photo: Joanna Douglass, BDS, DDS

Facial Cellultis
Facial cellulitis secondary to a dental abscess is a true dental emergency! Symptoms
Pain, often with fever Facial swelling Trismus, dysphagia, or airway obstruction

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Treatment
Localized cellulitis in compliant patients: Photo: ICOHP Outpatient oral antibiotics and analgesics Prompt dental referral Extraction or root canal treatment to prevent recurrence Severe cellulitis involving deep spaces or sepsis requires CT scan and hospitalization

Pericoronitis
Pericoronitis is an infection of the gum flap overlying partially erupted molars. Symptoms
Patients complain of pain, gum swelling, and inability to bite down on the affected side

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Etiology
Food and plaque are trapped under the gum causing inflammation, swelling, and pain Secondary cellulitis of the surrounding soft tissues can develop
Graphic: AAFPwith permission

Pericoronitis
Treatment
Mild cases can be managed with irrigation under the flap Cellulitis should be treated with antibiotics Administer analgesics as needed Recurrent cases may require removal of tooth or gum flap
Photo: Joanna Douglass, BDS, DDS

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Periodontal Abscess
Periodontal abscess is a deep infection of the tooth supporting structures Symptoms
Patient my experience continuous localized pain Tooth is loose and sensitive to touch Overlying gum may be red or swollen Fistulized abscesses may drain through the periodontal pocket or through the gum Cellulitis may also occur

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Treatment
Analgesics Antibiotics if concurrent cellulitis is present Dental referral for deep scaling and periodontal treatment

Antibiotic Options
The following antibiotics can be used to treat oral infections:
Penicillin VK, 2550 mg/kg/day, divided four times daily Amoxicillin, 3550 mg/kg/day, divided three times daily

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For penicillin allergic patients use:

Clindamycin, 1025 mg/kg/day, divided three times daily

For severe infections consider broad spectrum agents:

Ampicillin-sulbactam Cefotaxime Ceftizoxime Clavulanate Piperacillin-tazobactam Imipenem-cilastatin

Dental Trauma
Chapter Objectives Understand the epidemiology of dental trauma. Perform extraoral and intraoral exams to assess for injuries. Diagnose, initially manage, and appropriately refer patients suffering from common dental trauma. Develop familiarity with dental trauma terminology in order to accurately describe injuries for referral.

Epidemiology of Dental Trauma The peak incidence of dental injury occurs between ages 1
and 2 years as infants are becoming more mobile and peak a second time at 8 to 10 years. Preschoolers
At least 30% of preschoolers have had a dental injury of some kind. Falls are the most common source of oral injury.

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School-aged Children
Bikes, falls, sports injuries, automobile accidents, and violence are common causes of dental trauma Twenty-five percent of 12-year-olds have injured permanent teeth. Anterior maxillary incisors are most often injured Trauma to permanent teeth can have life-long consequences

Patient History Requirements Ask

When the injury occurred Where the injury occurred How the injury occurred If there are any associated injuries

Assess Symptoms
Pain patient is experiencing Change in occlusion

Determine Tetanus Status

Consider prophylaxis for intrusion, avulsion, deep laceration, or contaminated wound if not updated in past five years

Triage & Extraoral Exam Triage Procedure

1. 2. 3. 4. 5. 6. 7. 8. 9. Check airway, breathing, and circulation Determine if other life-threatening injuries are present Perform a neurologic exam Assess the cervical spine Check for skull, orbit, zygomatic, ormandibular fractures Evaluate extraoral soft tissue injuries Conduct intraoral examination Determine if injury is to primary or permanent teeth Assess availability of dental care

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Intraoral Exam
Procedure
Irrigate to remove blood, clots, and debris Examine mouth, including soft tissues, teeth, and bony structures Assess the injured area for Tenderness and swelling Damaged or mobile teeth Occlusion Mobile jaw segments Pain or limitation on opening, which can indicate trauma to the TMJ or condyles

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Photo: ICOHP

Alveolar Bone Fracture Symptoms & Findings

Localized tenderness "Steps" in the occlusion or alveolar bone although displacement may not be present Movement of segmental alveolar fractures when tooth mobility assessed Gingival laceration

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Referral
Image with CT See dentist or oral surgeon emergently Reduction is easier before swelling occurs
Photo: ICOHP

Chin Trauma & Condylar Fracture Symptoms & Findings

Preauricular swelling Pain Limited ability to open mouth Deviation on opening Palpable movement of condylar heads Altered occlusion Posterior tooth fracture (may not be evident)

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Photo: Jared Sorenson DDS

Referral
See oral surgeon emergently

Definitions
Concussion: Tooth is tender but not displaced or mobile Subluxation: Tooth is mobile with no displacement, though it may have hemorrhage from the gingival crevice Luxation: Tooth is loose with some degree of lateral displacement Intrusion: Tooth is pushed deeper into its socket Extrusion: Tooth is partially displaced axially from its socket Avulsion: Tooth has been completely displaced or knocked out of its socket

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Definitions
Tooth Fractures

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Graphic: ICOHP

Trauma to Primary Teeth

Chapter Objectives Understand how trauma to primary teeth can affect permanent teeth. Recognize the different types of dental trauma and how to appropriately treat and refer patients.

Photo: ICOHP

Trauma to Primary Teeth

Characteristics
Alveolar bone is more pliable in children Intrusion and luxation injuries of primary teeth more common Intrusion or subluxation of primary teeth may damage adjacent developing permanent dentition
Photo: ICOHP

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Intrusion
An intruded tooth is driven into its socket crushing surrounding alveolar bone Treatment
Do not attempt to remove intruded tooth Administer analgesics and recommend good oral hygiene Refer patient for dental evaluation in one day to one week based on symptoms

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Dental Care & Expected Outcome

The dentist will take a radiograph Extraction is indicated if the intruded tooth is impinging on a developing permanent tooth bud

Photos: ICOHP

Luxation
A luxated tooth is loose and has some lateral displacement though it is still in its socket. Treatment
Management depends on mobility and displacement Highly mobile teeth or teeth interfering with child's occlusion require immediate dental referral Less traumatized teeth require good oral hygiene, a soft diet, and dental referral in one day to one week based on symptoms

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Dental Care & Expected Outcome

The dentist will take a radiograph Highly mobile teeth or teeth interfering with occlusion may be treated by extraction, repositioning, and splinting

Avulsion of Primary Teeth An avulsed tooth has been completely displaced or knocked
out of its socket. Treatment
Avulsed primary teeth are NOT reimplanted to prevent further injury to the adjacent developing successor Locate the teeth to ensure it is not intruded, aspirated, or swallowed Take appropriate radiographs if aspiration is suspected Refer patient to dentist in one day to one week

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Dental Care & Expected Outcome

Dentist will take radiograph to ensure tooth is not intruded and rule out injuries to adjacent teeth Effect on permanent teeth cannot accurately be predicted

Fractures of Primary Teeth Simple Crown Fracture

Involves only enamel and dentin Routine dental referral for smoothing or restoration

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Crown Fracture with Pulp Involvement

Involves enamel, dentin, and pulp and can extend below the gumline Urgentone day referral for pulp treatment or extraction
Photo: Joanna Douglass, BDS, DDS

Root Fracture
Often not detectable clinically unless mobile Routine referral for diagnosis and extraction of mobile fragment

Trauma to Permanent Teeth

Chapter Objective Recognize the different types of dental trauma and how to appropriately treat and refer patients
Photo: ICOHP

Intrusion of Permanent Teeth Treatment

Do not attempt to remove intruded tooth Refer patient to dentist immediately for evaluation and possible repositioning

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Photo: ICOHP

Dental Care & Expected Outcome

Dental care may include allowing for spontaneous eruption (preferable in immature teeth), or active repositioning (orthodontic or surgical with splinting) Root canal treatment, especially in mature permanent teeth is often required Risk for complications is high and includes tooth death, root resorption, and tooth ankylosis

Avulsion of Permanent Teeth Procedure at Time of Accident

Locate the tooth If you can't find it, consider aspiration, ingestion, or intrusion Hold the tooth by the crown (not the root) Rinse off any debris gently with saline or milk DO NOT touch, rub, or scrub the root Replace the tooth in the socket. Be careful not to reverse it! Bite down on a gauze or handkerchief for stabilization while going to the dentist Best outcome if reimplanted within 5 minutes

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Photo: ICOHP

Avulsed permanent teeth are a true dental emergency!

Avulsion of Permanent Teeth

Treatment by Clinician
If the tooth cannot be reimplanted at the scene, it should be transported in Hank's solution, milk, buccal sulcus, or saline to the clinician for reimplantation Antibiotic prophylaxis with penicillin or doxycycline for seven days is recommended Determine tetanus status. Consider prophylaxis if not updated in past five years Immediate referral to a dentist for splinting and follow-up

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Photo: Joanna Douglass, BDS, DDS

Avulsed permanent teeth are a true dental emergency!

Crown Fractures
Simple Crown Fracture
Involves only enamel and dentin May be sensitive to hot and cold Routine dental referral for restoration Long-term follow-up needed to evaluate for complications, such as pulp death or root resorption

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Crown Fracture with Pulp Involvement

Involves enamel, dentin, and pulp and can extend below the gumline Urgentone day referral for pulp treatment and restoration
Photos: ICOHP

Root Fractures
Treatment
Root fractures should be suspected whenever teeth have been traumatized Urgentone day referral to dentist if tooth is mobile and root fracture suspected

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Dental Care & Outcome

Radiographs are necessary to complete diagnosis Treatment may involve reduction, splinting, root canal treatment, or extraction Long-term prognosis depends on how well segments can be approximated among other factors
Photos: ICOHP

Oral Piercing Possible Complications Complication

Tooth fracture or injury Stud aspiration Allergic reaction Nerve damage Speech impediment Gingival recession Infection

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Management of Complications
If inflammation present around a piercing, remove jewelry. Perform local debridement Start antibiotics and provide close follow-up
Photos: ICOHP

Injury Prevention
Chapter Objective Implement strategies aimed at the prevention of oral injuries.

Injury Prevention
Epidemiology and Prevention
Most trauma occurs in soccer, football, baseball, and hockey Injuries are also common in skateboarding, basketball, and bicycling. A well-fitting mouth guard can decrease risk of injury Putting corner protectors on furniture reduces risk for young children

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What Can Clinicians Do?

Tell patients to use a mouth guard. Any are good; however, the best are custom fitted A well fitting mouth guard is most likely to be used consistently Include review of mouth guards at adolescent well child checks or sports physicals Remove oral piercings before activity

Mouth Guards Prevent Injuries There are three types of commonly available mouth guards.
Custom made Boil and bite Stock

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Photos: ICOHP

Take Home Messages

Consider dental and nondental sources of pain Understand the disease progression from pulpitis to facial cellulitis Accurately assess and describe dental trauma for optimal triage and referral Identify the two true dental emergencies:
Facial cellulitis needs immediate antibiotic treatment and possible hospitalization Avulsed permanent teeth require immediate reimplantation

Clinicians should promote the use of mouth guards and other protective equipment to prevent oral injuries

Questions ?