Emergency Physician's Guide to Dental Care 9781512814354

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Emergency Physician's Guide to Dental Care

Healthy Iboth and Supporting Structures

Enamel Gingiva (gums) Dentin Pulp (includes the nerve) Cementum Jawbone Periodontal Ligament

*

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Emergency Physician's Guide to Dental Care HARRISON M. BERRY, JR., D.D.S., M.Sc., Editor Emeritus Professor of Radiology, School of Dental Medicine, University of Pennsylvania

University of Pennsylvania Press

Philadelphia

The frontispiece and Appendix A are copyright by the American Dental Association. Reprinted by permission. Reproductions for figures 8-2, 8-3A, B, and C, 8-4A and B, 8-5, 86A and Β, 8-7A and Β, 8-8A and Β, 8-9A and Β, 8-10A and B, 811A and B, and 8-12A and Β are provided through the courtesy of Cook-Waite Laboratories, Inc., 90 Park Avenue, New York, NY 10016. Copyright © 1983 by the University of Pennsylvania Press All rights reserved

Library of Congress Cataloging in Publication Data Main entry under title: Emergency physician's guide to dental care. Includes bibliographical references. 1. Dental emergencies. I. Berry, Harrison M. [DNLM: 1. Dentistry—Methods. 2. Emergencies. WU 100 E535] RK305.E45 1983 617.6Ό26 83-3455 ISBN 0-8122-1149-9 |pbk.)

Printed in the United States of America

To our partners in the alleviation of suffering

Contents

List of C o n t r i b u t o r s

xi

List of Illustrations

xiii

Foreword by }. A r t h u r Steitz, M . D .

xvii

Preface

xix

Introduction

xxi

H o w t o U s e T h i s Book

xxiii

Complaint Locator

Section 1

xxv

Ibothache and Iboth-Related Problems

1

TOOTHACHE—INTRINSIC ETIOLOGY (Odontalgia), 3

Cavity in tooth, 3 Toothache under existing restoration (filling), 9 Loss of permanent filling or crown, 9 Toothache following recent treatment of a tooth, 10 Split or cracked tooth syndrome, 12

TOOTHACHE—EXTRINSIC ETIOLOGY, 13

Maxillary sinusitis, 13 Imbalance in occlusal relations, 14 Trauma resulting in a chipped or fractured tooth, 14 Fractured root, 16

TEETHING PAIN, 17 UNSPECIFIED DENTAL PAIN, 18

Sensitivity to cold, heat, chewing, reclining, jogging, air travel, 18

DON'TS, 18

Section 2

Bleeding

21

BLEEDING FOLLOWING TOOTH EXTRACTION, 23 MINOR BLEEDING FOLLOWING PERIODONTAL SURGERY OR DEEP SCALING, 24 SIGNIFICANT BLEEDING AFTER PERIODONTAL SURGERY, 25

(Bleeding From Lacerations—see

Section 4, pages

54-56)

vii

vili Section 3

CONTENTS

Generalized Mouth (Soft Tissue) Pain

ACUTE NECROTIZING ULCERATIVE GINGIVITIS (Vincent's I n f e c t i o n Trench Mouth), 29 ACUTE HERPETIC STOMATITIS, 30 ALLERGIC STOMATITIS, 31 ULCERS, 31

27

Aphthous ulcer (Canker Sore), 32 Traumatic ulcers, 33 Denture sore, 33

ACUTE SOFT TISSUE SWELLING, 34

Allergic edema, 34 Subcutaneous emphysema,

Section 4

34

DON'TS, 3 5

Trauma to Ifeeth, Jaws, and Soft Tissues

37

TRAUMA TO TEETH, 3 8

Luxation, Avulsion, Traumatic (Fractured

38 39 impaction, 41 tooth crown or root, see Section 1, pages

14-16)

TRAUMA TO JAWS, 42

Alveolar fracture, 42 Mandibular fracture, 43 Condylar fracture, 46 Dislocation (anterior) of Condyles, 47 Maxillary fractures, 49 LeFort I fracture, 49 LeFort II fracture, 50 LeFort III fracture, 51

MALAR BONE—ZYGOMATIC ARCH FRACTURES, 52 LACERATION OF ORAL SOFT TISSUES, 53

Lip laceration, 54 Cheek laceration, 55 Tongue laceration, 56 Palate laceration, 56

Section 5

Face and Jaw Pain and Swelling

57

TIC DOULOUREUX, 5 9 TEMPOROMANDIBULAR JOINT, 60

Sprain, 60 Myofacial Pain Dysfunction, Degenerative arthritis, 61 Rheumatoid arthritis, 62

60

EXTRACTION SOCKET—PAIN, 6 3 ALVEOLAR OSTEITIS—"DRY SOCKET", 6 3 ABSCESSED TOOTH, 64

Periapical abscess, 64 Pericoronitis, gingival, and periodontal Spreading dentoalveolar abscess, 68

Section 6

Periodontal Emergencies

POSTPERIODONTAL SURGERY, 71

abscesses,

65

69

ix

CONTENTS (Bleeding, see Section 2, page 24) Pain, 71 Loss of periodontal dressing or pack, 72

Section 7

Orthodontic Appliance Problems

75

LOOSE BANDS OR BONDED ATTACHMENTS, 77 SOFT TISSUE DAMAGE, 78

Ligature wires, 79 Coil springs, 80 Overextension of archwire, 80

BROKEN OR BENT APPLIANCES, 81

Section 8

Local Anesthetic Techniques

83

ANESTHETIC AGENTS USED, 84 ARMAMENTARIUM, 84 CONTRAINDICATIONS AND PRECAUTIONS, 85 ANATOMICAL REVIEW, 86

Maxillary division of trigeminal nerve, 86 Mandibular division of trigeminal nerve, 87

INJECTION TECHNIQUES, 88

Anterior superior alveolar nerve infiltration, Infraorbital nerve block, 88 Maxillary supraperiosteal infiltration, 91 Posterior superior alveolar nerve block, 92 Nasopalatine nerve block, 93 Greater palatine nerve block, 93 Mandibular and lingual nerve blocks, 94 Mental nerve block, 96 Long buccal nerve injection, 98 Mandibular supraperiosteal injection, 100

88

ANESTHESIA FOR LACERATIONS, 100

Section 9

Radiography

INTRAORAL OCCLUSAL PROJECTIONS, 106

Films, 106 Processing, 106 Exposure techniques,

103

106

Appendix A

D e v e l o p m e n t of the H u m a n D e n t i t i o n

114

Appendix Β

Tooth Terminology and Identification

116

Appendix C

M e d i c a m e n t s to Have on Hand

118

Appendix D

M a t e r i a l s and I n s t r u m e n t s to Have on H a n d

119

Appendix E

References for the E m e r g e n c y R o o m Bookshelf

120

Glossary

121

List of Contributors

LESTER W. BURKET, D.D.S., M.D. Dean Emeritus, and Emeritus Professor of Oral Medicine, School of Dental Medicine, University of Pennsylvania ROBERT E. DeREVERE, D.D.S. Emeritus Professor of Restorative Dentistry, School of Dental Medicine, University of Pennsylvania EDWARD P. HENEFER, D.D.S. Professor of Oral Surgery and Anesthesiology, School of Dental Medicine, University of Pennsylvania ROBERT L. VANARSDALL, D.D.S. Associate Professor of Orthodontics and Periodontics, School of Dental Medicine, University of Pennsylvania

Editorial Consultants ROBERT C. EMLING, M.S., Ed.D. Assistant Dean of Academic Affairs and Admissions, School of Dental Medicine, University of Pennsylvania ALVIN L. MORRIS, D.D.S., Ph.D. Professor of Dental Care Systems and Oral Medicine, School of Dental Medicine, University of Pennsylvania

xi

List of Illustrations

Frontispiece Table 1-1A Table 1-1B Table 1-1C Table 1-1D Table 1-1E Table 1 -1F Table 1 -1G Tablel-2 Fig. 1-1 Fig. 4-1 Fig. 4-2 Fig. 4-3 Fig. Fig. Fig. Fig.

4-4A 4-4B 4-5 4-6

Fig. 4-7 Figs. 4-8A and Β Fig. 4-9 Fig. 4-10 Fig. 4-11 Fig. 4-12 Fig. 4-13 Fig. 4-14 Fig. 4-15 Figs. 5-1A and Β

Healthy tooth and supporting structures Stage I in dental caries: precavity plaque formation Stage II in dental caries: initiation of cavity Stage III in dental caries: superficial dentin involvement Stage IV in dental caries: deep dentin cavity; no pulp exposure Stage V in dental caries: superficial invasion of pulp Stage VI in dental caries: extensive pulpal involvement Stage VII in dental caries: pulpal death, localized periapical abscess Diagnostic Tests for Toothache Enamel fragments of maxillary incisor traumatically embedded in lower lip Luxation, displacing incisor palatally Essig-type wiring to support a luxated incisor Luxated and extruded incisor being intruded by ligating an arch bar to adjacent teeth with cervical wiring Traumatic impaction of a permanent incisor Traumatic intrusion of a deciduous (primary) incisor Maxillary alveolar fracture causing extrusion of the segment Displaced compound fracture accurately reduced by restoring the dental occlusion Displaced condylar fracture Repositioning a dislocated mandible LeFort I fracture LeFort II fracture Recognition of a LeFort II fracture LeFort III fracture Depressed fracture of the zygoma Repair of laceration of the lip Repair of laceration of the cheek Pericoronitis: inflamed gingival tissue overlying a partially erupted third molar

xiii

xiv Fig. 5-2 Fig. 6-1 Fig. 6-2A Fig. 6-2B Fig. 8-1 Fig. 8-2 Fig. 8-3A Figs. 8-3B and C Fig. 8-3D Figs. 8-4A and Β

LIST OF ILLUSTRATIONS

Periodontal abscess Occlusal view of a periodontal dressing covering the facial and palatal aspects of the upper teeth Periodontal sutures between teeth Periodontal dressing does not extend over the occlusal portion of the tooth. Dental carpule syringe and needles Maxillary and mandibular distribution of the trigeminal nerve Anterior superior alveolar nerve branches Injection technique for anterior superior alveolar nerve infiltration Area of anesthesia from anterior superior alveolar nerve infiltration injection Infraorbital injection technique

Fig. 8-4C Fig. 8-5

Area of anesthesia from infraorbital nerve block injection Injection site for maxillary supraperiosteal infiltration

Figs. 8-6A and Β Fig. 8-6C

Injection technique for posterior superior alveolar nerve block

Figs. 8-7A and Β Fig. 8-7C Figs. 8-8A and Β Fig. 8-8C Figs. 8-9A and Β Fig. 8-9C Fig. 8-10A and Β Figs. 8-11A and Β Fig. 8-11C Fig. 8-12A Fig. 8-12B Fig. 9-1 Fig. 9-2A Fig. 9-2B

Area of anesthesia from posterior superior alveolar nerve block injection Injection site for nasopalatine nerve block Area of anesthesia of tissues of hard palate from nasopalatine nerve block injection Injection technique for greater palatine nerve block Area of anesthesia of tissues of hard palate from greater palatine nerve block injection Injection technique for mandibular and lingual nerve blocks Area of anesthesia from mandibular and lingual nerve blocks Injection technique for mental nerve block Long buccal nerve injection technique Area of anesthesia of gingival and buccal soft tissues from long buccal nerve injection Inferior dental nerve distribution Mandibular supraperiosteal injection technique Method of attaching an occlusal film to a 14 χ 17 film for processing in an X-Omat automatic processor Mandibular symphysis occlusal projection, patient seated Mandibular symphysis occlusal projection, patient lying on table

LIST OF ILLUSTRATIONS

Fig. 9-3 Fig. 9-4A Fig. 9-4B Fig. 9-5A Fig. 9-5B Fig. 9-5C Fig. 9-5D Appendix A Appendix Β

XV

Mandibular floor-of-mouth occlusal projection Maxillary midline occlusal projection, patient seated Maxillary midline occlusal projection, patient lying on table Maxillary molar occlusal projection, front view, patient seated View of top of the head of projection in Figure 9-5A Maxillary molar occlusal projection, patient lying on table View of top of the head of projection in Figure 9-5C Development of the human dentition Tooth terminology and identification

Foreword

Any physician who has served in an emergency department knows well that dental emergencies are very much a part of the scenario. And, it seems, they somehow manage to present themselves after hours—nights, weekends, holidays—when full dental resources are not at hand. It is also well known that even the best trained individuals may have a lesser acquaintance with dental emergencies. This has been a neglected area in our training, and I and many of my colleagues have commented that we lack full preparation for such problems. One wears many hats during the daily emergency department tour ; each requires a full supply of accurate facts for prompt application. Frequently this does not apply for dental problems. While there is an abundance of written material for most areas of emergency medicine, I have not seen a source that deals adequately with or covers the full scope of dental problems in the emergency department context. I had commented on this situation on several occasions in conversation with Dr. Berry. He and his distinguished colleagues rose to the challenge, and this publication is the result. It is apparent that careful thought has gone into the planning and writing of the Guide. There is full coverage of the range of problems that may present from the painful cavity to major traumatic injuries. All the material that formerly was found only in scattered areas now is logically combined in one well organized source. The novel use of the Complaint Locator gives one ready access to the appropriate information without resorting to a cumbersome index. The text material is concise, yet covers topics thoroughly. The diagrams and illustrations are skillfully and accurately presented and well explained. All the necessary information concerning terms, supplies, instruments, anesthesia, and the do's and don'ts of management is here in a very usable format. The University of Pennsylvania Press should be proud, and justly so, of this addition to their distinguished catalogue of publications. I am extremely pleased with the results and feel that a long-awaited need has been filled. The emergency physician now has an excellent new resource and our patients should benefit greatly. /. Arthur Steitz, M.D. xvii

Preface

In a lecture on scientific writing, a wise medical newswriter once said, "Never underestimate your readers' intelligence, nor overestimate their knowledge." We recognize that users of this book are highly intelligent, skilled physicians and nurses, experienced in the primary care of medical emergencies, but it is possible that they are less knowledgeable of dental and oral diseases and their treatment requirements. For this reason, we have included illustrations of the component parts of a tooth and its supporting structures (Frontispiece), the developmental stages of the primary, mixed, and permanent dentitions (Appendix A), and the names of the teeth as well as the accepted system for their numerical designation (Appendix B); the latter should prove useful in record keeping. We have also included a brief glossary of common dental terminology. Appendices C and D list medicaments, materials, and instruments that an emergency room might not routinely contain. In the process of selecting from the multitude of mouth-oriented complaints those which conceivably could cause persons to seek care at hospital emergency departments, the authors have consulted not only with dental colleagues but with emergency physicians as well. We realize that some conditions may have been omitted that should have been included, and we will welcome suggestions from our readers. Our objective is two-fold: to present pertinent material concisely, and to make it readily accessible. We have attempted to avoid textbook-like discussions of etiology, theory, and definitive treatment that a dentist ultimately would render. For additional information, Appendix E lists several reference books recommended for the emergency department bookshelf. To facilitate rapid access to each dental emergency condition, we have compiled a Complaint Locator, which lists complaints as patients might express them, translates them into professional terminology, and identifies the sections and pages where the information is to be found. The special binding permits the book to lie open. The authors wish to express their gratitude to Pat McHugh for manuscript preparation, Elissa Berardi for artwork, and David Sullivan for photography. We also thank Cook-Waite Laboratories for permitting use of their illustrations on local anesthetic techniques. Finally, we wish to thank Dr. J. Arthur Steitz, EP, for the idea that this information could be useful in the field of emergency medicine.

xix

Introduction

Just as practicing dentists occasionally are confronted with unexpected medical problems in their dental offices, so too are physician members of hospital emergency teams often faced with dental problems that were not a specific part of their medical training. As far back as 1851, "S.S. Hornor, Practical Dentist" wrote a book entitled The Medical Student's Guide in Extracting Teeth: with Numerous Cases in the Surgical Branch of Dentistry. With Illustrations, published by Lindsay and Blakiston, Philadelphia. This 76-page book offered advice to fledgling physicians who might be confronted with dental problems when no dental practitioners were nearby. The Latin phrase, "primum nocere non," the by-word upon which all health care is predicated, probably comes from Hippocrates' Epidemic Diseases, Book 1, Section 2: "as to diseases make a habit of two things—to help or at least to do no harm." When no dental clinicians are present or on call, today's emergency physicians may be faced with unfamiliar problems of diagnosis, palliative treatment, and advice; above all it is imperative that they do no harm. This book was written to enable emergency physicians to help in the administration of palliative and supportive dental care, "or at least to do no harm," and to share our expertise with our medical colleagues when they are confronted with problems of mutual interest. This book will help the emergency staff to meet the JCAH's Principle for Emergency Services, as stated in the 1980 Accreditation Manual for Hospitals: "Any individual who comes to the hospital for emergency medical evaluation or initial treatment shall be properly assessed by qualified individuals, and appropriate services shall be rendered within the defined capability of the hospital." Today some hospitals have dental medicine departments or oral surgical services, with residents on call for the treatment of such emergencies. Most of these are located in large urban medical centers, but it is apparent that many smaller community hospitals do not enjoy the ready availability of dental personnel. The American Hospital Association 1979 Annual Survey reports that 81 percent of hospitals had emergency departments/services, and 41 percent of hospitals have "dental services," ranging from a low of 19.6 percent in hospitals with 2 5 - 4 9 beds to a high of 83 percent in hospitals with 500 or more beds. Only 35.5 percent of those identified as community hospitals have dental

xxi

xxii

INTRODUCTION

services. The Survey did not indicate whether panels of dentists were available on an "on call" basis. The American Dental Association's most recent Survey of Hospital Dental Departments (1977) published data from questionnaires received from 5,365 (75.2 percent) of all the 7,157 hospitals on file at the American Hospital Association. Of the responding hospitals, 52.9 percent reported dental services (indicating at least one dentist member of the medical staff). Of that 52.9 percent (2,838 hospitals), 62.3 percent (1,768 hospitals) had dentists "on call" in the emergency room. This would appear to indicate that perhaps as many as 5,000 hospitals in this country have no staff dentists available for emergency room service. It has long been recognized that provision for emergency dental care is basically the problem of the dental profession, for in 1962 the House of Delegates of the American Dental Association passed the following resolution: Resolved, that in the interest of the public and the profession, all dental societies be urged to survey the facilities for dental care in their communities, and be it further Resolved, that the societies take any necessary steps to assure that dental service is available to any person faced with a dental emergency, regardless of the hour of the day or the day of the week. (Trans. 1962:289) A number of dental society emergency dental-care programs, some associated with hospitals, have appeared in the literature.* Dental society response has been commendable, but the availability of complete emergency coverage is not yet perfect. E. W. Small reported in the North Carolina Dental Journal (1975) that 58 percent of hospitals within the state "have a dental presence"; that only 27 percent of dentists responding to a survey stated that their local dental societies had an emergency call list, and a mere 50 percent responded that their local hospitals maintained an emergency call list of dentists. Thus, much more cooperative medical-dental effort is needed at the local level. Regardless of the organization, situations do occur when the emergency physician is called upon to render immediate palliative care to make the patient comfortable until he or she can receive more definitive treatment from a dental practitioner. Today's hospital emergency service has become the "family doctor" for many persons, and they present with a wide variety of complaints. And many times patients do not realize that their problems are dentally related, that actually they should have sought the services of a dentist; but there they are, at 2:00 A.M., and something must be done—even if only reassurance and referral to a dentist. This book has been prepared to guide the physician in meeting such emergencies. "See, for example, R. R. Thompson, "A Local Dental Emergency Program." /. Calif. Dent. Assn. 3 (June 1975): 40-43; and E. W. Lentchner, "Emergency Dental Care for the Community." Ν. Y. State Dent. /. 42 (Apr. 1976): 213-17.

How to Use This Book

1. After ascertaining the patient's complaint, refer to the Complaint Locator, pages xxvii-xxxii. 2. Locate that complaint in the alphabetical listing in the left-hand column. 3. Listed to the right of the complaint (center column) are specific dentomedical conditions suggested by that complaint. 4. The information on the pertinent condition will be found in the section and page number listed in the right-hand column. The sections have been numerically coded to provide quick access. 5. If the patient's complaint is not specific, or cannot be found in the Complaint Locator, consult the contents pages for the appropriate section. 6. So that the proper medicaments, materials, and instruments will be available when needed, Appendices C and D have been provided, pages 118-119. 7. For information on tooth development and eruption, terminology used to identify teeth by name, number and/or letter, and for in-depth reference books, Appendices A, B, and E have been provided, pages 114, 116, and 120. 8. Should the dental terms used in the text be unfamiliar, consult the Glossary, pages 121-122.

xxiii

Complaint Locator

PATIENT S COMPLAINT

SUGGESTS

SEE SECTION

PAGES

ABSCESS

1. Periapical abscess 2. Periocoronal abscess 3. Periodontal abscess

5 5 5

64 65 65

APPLIANCE hurts, loose

1. Orthodontic bands or wires loose, impinging on soft tissues 2. Crown anchoring fixed bridge is loose 3. Sore spot under denture

7

77

1

9

3

33

BAND cutting cheek

Orthodontic band or wire sticking out

7

80

BAND loose

Orthodontic band loose

7

77

BIT my cheek

Cheek laceration

4

55

BIT my tongue

Tongue laceration

4

56

BITE (can't bite properly; it hurts to bite)

1. High filling

1

9

2. Split tooth 3. Imbalance in occlusal relationship 4. Trauma to teeth 5. Jaw fracture(s) 6. Temporomandibular joint dysfunction 7. Orthodontic appliance loose 8. Condylar dislocation

1 1

12 14

4 4 5

38 42 60

7

81

4

47

1. After extraction 2. After periodontal surgery 3. From trauma; fractures 4. From lacerations 5. Gums

2 2

23 24--25

4 4 3

42--52 53--56 29, 33

BLOOD BLISTER

1. Hematoma

2

24

BOIL, on gum

1. Periapical abscess 2. Periodontal abscess

5 5

64 65

BRACES, broken, loose

Loose or broken orthodontic band or wire

7

77

BLEEDING

xxvii

xxviii

COMPLAINT LOCATOF SEE SECTION

PATIENT'S COMPLAINT

SUGGESTS

PAGES

BRACES, cutting gum

Loose or broken orthodontic band or wire

7

77, 81

BROKE a tooth

Fractured, chipped tooth

1

14

BROKE my jaw

Fractured jaw

4

42-52

BURNED tongue, palate

1. "Pizza palate" 2. Aspirin burn

3 3

33 33

BURNING gums, lip

Acute herpetic stomatitis

3

30

CANKER SORE

Aphthous ulcer

3

32

C A N ' T CLOSE M O U T H

1. Condylar dislocation 2. Jaw fracture

4 4

47 42-52

CAP loose, lost

Crown loose, lost

1

9

CAVITY

Dental caries

1

3

CHEEK cut, bit

Lacerated cheek

4

55

CHEEK battered

Zygomatic fracture

4

52

CHIPPED T O O T H

Fractured crown, root

1

14

CROWN loose, lost

Crown loose, lost

1

9

CUTS, lips, tongue, cheek, gums

1. Lacerations 2. From orthodontic bands, wires

4 7

53-56 78

DENTURE hurts

Denture sore

3

33

DISLOCATED JAW

Condylar dislocation

4

47

DOUBLE VISION

Maxillary fracture

4

49

DRESSING painful, lost

Periodontal pack

6

72

DRY SOCKET

Alveolar osteitis

5

63

FACE hit

1. Fractured tooth 2. Fractured jaw

1 4

14 42

FACE swollen

1. Allergic edema 2. Subcutaneous emphysema 3. Spreading dentoalveolar abscess 4. "Dry socket" 5. Periodontal abscess 6. Fractures

3 3

34 34

5

68

5 5 4

63 65 42-52

COMPLAINT LOCATOR

xxix SEE SECTION

PATIENT'S COMPLAINT

SUGGESTS

FILLING high

High restoration

1

FILLING loose, lost

Restoration loose, lost

1

FRACTURE

1. Tooth 2. Jaw

1

PAGES

11 9-11

4

14 42

GROUND tooth

Rough tooth after dentist ground tooth

1

12

GUM boil

1. Periapical abscess 2. Periodontal abscess

5 5

64 65

1. Acute necrotizing ulcerative gingivitis 2. Orthodontic band cuts 3. After periodontal surgery 4. From lost periodontal pack

3

29

7 2

78, 79 24, 25

6

72

GUM packing (dressing) lost

Lost perio pack

6

72

GUMS painful

1. Acute necrotizing ulcerative gingivitis 2. Acute herpetic stomatitis 3. Aphthous ulcer

3

29

3

30

3

4. Denture sore

3

32 33

1. Acute necrotizing ulcerative gingivitis 2. Apical abscess 3. Pericoronitis 4. Periodontal abscess

3

29

5

64 65 65

GUMS bleed

GUMS swollen

HIT in mouth, face

5 5

1. Chipped, fractured tooth 2. Fractured jaw

4

14 42-52

JAW broken

Fractured jaw

4

42-52

JAW joint hurts

Temporomandibular joint sprain; myofacial pain dysfunction; arthritis

5

60-62

JAW out of joint

Condylar dislocation

4

47

JAW swollen

Abscess(es)

5

64-68

1

HURTS (See PAIN)

XXX

COMPLAINT LOCATOR

PATIENT'S COMPLAINT

SUGGESTS

SEE SECTION

KNOCKED tooth out

Avulsion

4

39

LIP cut

Lacerated lip

4

54

LIP swollen

1. Allergic edema 2. Trauma, fractured tooth crown

3 1

34 14

LOOSE braces

Loose orthodontic band, wires

7

77

LOOSE cap, crown

Loose crown

1

9

LOOSE tooth

1. Split tooth 2. Trauma

1 1

12 14

LOST cap, crown

Lost crown

1

9

LOST filling

Lost restoration

1

9

LOST packing

Lost periodontal pack

6

72

MOUTH burns

Acute herpetic stomatitis

3

30

MOUTH hit

1. Fractured tooth 2. Fractured jaw

1 4

14 42--52

1. Acute necrotizing ulcerative gingivitis 2. Aphthous ulcer 3. Denture sore 4. Burns, chemical, thermal 5. Lacerations

3

29

3 3 3

32 33 34

4

53--56

NUMBNESS chin, lip infraorbital rim

1. Jaw fractures 2. Zygomatic fracture

4 4

42--52 52

PAIN, face gums

Tic douloureux 1. Acute necrotizing ulcerative gingivitis 2. Acute herpetic stomatitis 3. Aphthous ulcers 4. Denture sore 5. From orthodontic appliance 6. Periodontal, pericoronal (abscess)

5 3

59 29

3

30

3 3 7

32 33 77--81

5,6

65, 71

PAGES

MOUTH PAIN (See PAIN) MOUTH SORES

COMPLAINT LOCATOR PATIENT'S COMPLAINT

jaws teething tooth toothache

xxx: SUGGESTS

SEE SECTION

PAGES

Fractures Teething pain Trauma 1. Toothache 2. Sinusitis

4

PAIN, postoperative extraction gum surgery root canal

Alveolar osteitis Periodontal pain Post-root canal pain

5

PERIODONTAL pain bleeding dressing

Abscess, pericoronitis Postperiodontal surgery Periodontal pack

5 6

65 24, 25 72

PLATE hurts

Denture sore

3

33

PUSHEDTN tooth

Traumatic impaction, luxation

4

41, 38

ROOT CANAL pain

Root canal treatment pain

1

11

ROUGH T O O T H

1. Chipped, fractured 2. Ground tooth

1

14 12

SENSITIVITY, tooth

Tooth sensitivity

1

4-8, 18

SORE gums, mouth (SORES in mouth)

1. Acute necrotizing ulcerative gingivitis 2. Acute herpetic stomatitis 3. Allergic stomatitis 4. Aphthous ulcers 5. Aspirin burn 6. "Pizza palate" 7. Abscesses

3

29

3

30

3

31 31 33 33 64-68

SWELLING, face

gums

1. Allergic edema 2. Subcutaneous emphysema 3. Spreading dentoalveolar abscess 4. Trauma 1. Acute necrotizing ulcerative gingivitis

1 1 1 1

6 1 2

1

3 3 3 5

42-52 17 14 3 13 63 71 11

3

34 34

4

68

4

41

3

29

3

xxxii

COMPLAINT LOCATOR SUGGESTS

SEE SECTION

2. Abscesses

5

64-68

jaw

1. Abscesses 2. Fractured jaw 3. Hematoma

5 4 2

64-68 42 24

lips

1. Allergic edema 2. Trauma

3 1,4

34 15,54

neck

1. Spreading dentoalveolar abscess 2. Allergic edema 3. Subcutaneous emphysema

5

68

3 3

34 34

TONGUE, cut, sore

1. Aphthous ulcer 2. Laceration 3. Ulcer

3 4 3,4

32 56 33,57

TRENCH MOUTH

Acute necrotizing ulcerative gingivitis

3

29

ULCERS

1. 2. 3. 4.

Aphthous ulcers Traumatic ulcers Aspirin burn "Pizza palate"

3 3 3 3

32 33 33 33

PATIENT'S COMPLAINT

PAGES

1 Toothache and Iboth-related Problems

Toothache—Intrinsic Etiology (Odontalgia) CAVITY IN TOOTH Dental caries, a ternary disease of tooth surfaces exposed to the oral environment, requires the interaction of ( 1 ) microbial plaque material, (2) suitable substrate, and (3) a susceptible tooth surface. microbial plaque

+

suitable substrate

demineralizing byproducts

+

susceptible tooth

çavjty

The distress associated with dental caries generally occurs when the decay activity reaches the dentin, which is physiologically connected to the pulp of the tooth. The distress becomes more severe as the pulp of the tooth is approached and the pulp becomes infected. The swelling and inflammation of pulp tissue and the accumulation of putrefactive products in the confined space of the pulp chamber cause the patient to experience one of the most excruciating pains known to mankind. The stages in the development and progression of a carious lesion, diagrammatically illustrated in Table 1-1, provide a convenient portrayal of the stages of disease involvement, pulpal response, symptoms, and palliative treatment. The treatment is not necessarily that which would be provided by a dentist with his more extensive armamentarium and practice experience. Rather, the procedures suggested here are ones which can be carried out in a hospital emergency facility where the equipment and materials are limited, as well as the dental expertise of the providers. 3

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TOOTHACHE AND TOOTH-RELATED PROBLEMS

9

TOOTHACHE UNDER EXISTING RESTORATION (FILLING) Patients may experience pain in teeth that have sound fillings of long standing. Some patients may recall a comment by the attending dentist regarding proximity of cavity depth to pulp or whether the pulp was exposed and treated before placement of the restoration.

EXAMINATION

• Radiographs are most helpful in these situations to determine the proximity of the restoration to pulp. • Percussive, thermal, and electrical pulp tests (Table 1-2) are helpful in identifying the tooth involved and determining the state of the pulp.

TREATMENT

Once it has been established that the pain is associated with a filling, the treatment requires removal of the filling. It is unlikely that this condition can be treated directly in the hospital emergency room. Therefore, the emergency treatment is palliative. • Although heat seldom relieves most types of toothache, in this case heat applied intraorally (warm saline rinse) or cold externally may provide relief. • Prescribe an analgesic-sedative at a level commensurate with the degree of pain.

LOSS OF PERMANENT FILLING OR CROWN The loss of a filling or crown may result in the exposure of sensitive dentin to oral irritation, causing the patient to seek relief. Unless the patient can positively state or demonstrate the whereabouts of the restoration, it is advisable to rule out the possibility of having swallowed or aspirated it (particularly if lost during sleep) by chest and/or abdominal radiographs. The decision to order such radiographs should be based first upon knowledge of the probable composition of the missing object, for most plastic—methylmethacrylate—fillings and crowns are radiolucent and would not be discernible. Whereas aspirated objects usually cause a significant problem, those entering the stomach normally pass through the GI tract without complication. Their passage may be facilitated by the ingestion of applesauce or mashed banana into which a few wisps of cotton or wool ravelings have been mixed, thus forming a cocoon-like wrapping around any sharp edges.

10

SECTION 1

TREATMENT (LOSS OF FILLING)

• The sensitivity of the dentin may be relieved by wedging a cotton pledget dampened with eugenol into the cavity left by the lost filling, if it is sufficiently retentive, or by the placement of a putty-like mix of zinc oxide and eugenol in the cavity. • If the remaining edges of the cavity are sharp or pointed, causing laceration of contacting soft tissues, these sharp areas can be relieved with an emery board (fingernail file type), in the absence of appropriate dental equipment (sandpaper disc in a rotary dental instrument). TREATMENT (LOSS OF CROWN)

The loss of a crown results in a larger surface area of exposed dentin that is more difficult to protect. The primary objective is to shield the exposed dentin from thermal, chemical, and mechanical irritants. • Recovered inlays, onlays, or crowns can be recemented temporarily with a creamy mix of zinc oxide and eugenol. • In the event of a nonrecovered crown loss the treatment of choice would be to make a new temporary methylmethacrylate (plastic) replacement or to adapt a preformed acrylic crown over the prepared tooth. Either procedure requires appropriate materials and expertise not likely to be readily available, and the infrequent demand would not justify maintaining the inventory of materials or keeping current on the techniques. A simpler interim procedure is to soften in warm water (120° F.) a piece of base plate wax that is the same width and half the length of a stick of chewing gum. Adapt this over the exposed tooth and each adjacent tooth, locking the wax into the spaces between the teeth. (NOTE: These wax protective coverings can be more effective and more readily retained if they are first coated with a puttylike mixture of zinc oxide (powder) and eugenol, which will eventually harden and adhere to the teeth.) • The loss of a temporary filling or crown is managed as described above for the loss of a permanent restoration.

TOOTHACHE FOLLOWING RECENT TREATMENT OF A TOOTH AFTER A RESTORATIVE PROCEDURE FOR A FILLING, CROWN, OR INLAY

This toothache likely results from pulpal trauma associated with a restorative procedure for a filling, crown, or inlay. Or, in the case of a final restoration, the filling or crown may be "high," as revealed by the patient's complaint that it is painful to touch or bite upon. The tooth

TOOTHACHE AND TOOTH-RELATED PROBLEMS

11

may be responsive to percussion, reflecting irritation of the supporting tissue of the tooth. TREATMENT

• If it is a "high" filling, simply reduce it or the opposing cusp tip with a fingernail emery board or file until a dentist can adjust the filling with appropriate rotary instruments. • Pulpal irritation may require complete removal of the restoration and the placement of an obtundent (zinc oxide-eugenol mix) in the cavity preparation. This is best achieved by a dentist with appropriate equipment; otherwise, one can only prescribe general palliative medication commensurate with the degree of distress. • Instruct the patient to avoid all irritating stimulants, hot, cold, or both. • Occasionally a patient may experience a sharp electric-type shock (galvanism) when teeth containing fillings with dissimilar metals make contact. Such shock may be relieved by tightly knotting a piece of dental floss around the contacting area between the offending teeth, or by drying the offending teeth thoroughly and coating the fillings with copal resin dental varnish, if available, or clear nail polish. Such coating is also indicated if the galvanic reaction is between two teeth in opposite arches. In time (a few days) an insulating oxide microfilm will form over the filling, providing permanent relief. It is advisable to refer the patient to a dentist to ascertain that galvanism was, indeed, the cause of the pain. • Severe throbbing pain following the recent restoration of a tooth indicates pulpal involvement, necessitating removal of the restoration and placement of a sedative dressing (zinc oxide and eugenol), if possible; otherwise prescribe a general palliative medication with the recommendation to see a dentist as soon as possible. AFTER ROOT CANAL FILLING

The treatment involving removal of the contents of the pulp (nerve) chamber and canals can result in severe pain after the anesthetic wears off. Endodontists (specialists in root canal therapy) are generally on call to relieve their patients of this distress. Usually, the pain is the result of the build-up of gases in the sealed canal. Generally there is an outer temporary cementing material, which can be dug out with a suitable hand instrument such as a dental pick (explorer or curette), and an inner cotton spacer to prevent the sealant from penetrating into the canal. Pain may also be periapical in origin, resulting from the trauma of the instrumentation to remove the canal contents and enlarge the canal.

12

SECTION 1

TREATMENT

• The only local treatment is to remove the sealant from the pulp access cavity and from the pulp chamber. Just breaking the seal often relieves the pain. • If removing the seal does not relieve the pain, then it could be of traumatic origin, and can only be relieved immediately by general palliative drug therapy. • The final permanent filling of the root canals may likewise result in a painful tooth, generally due to periapical irritation. Again, the pain is usually transient and is relieved by general drug therapy. In all such cases, it is best to consult with the treating endodontist, if at all possible. PAIN FOLLOWING OCCLUSAL ADJUSTMENT

Grinding away a superficial portion of the tooth to provide a more efficient and less traumatic intermeshing of opposing teeth seldom results in pain. Usually, the only discomfort is the presence of sharp or rough surfaces. The teeth may "grit" or "grab" or "squeak." Occasionally, the grinding may have exposed sensitive dentin, causing sensitivity. TREATMENT

• Rough or sharp surfaces may be relieved by smoothing with an emery board or sandpaper disc mounted in rotary dental instrument. • Sensitivity from exposed dentin can be alleviated by avoiding contact with irritating substances. The patient's dentist will be able to apply desensitizing agents. The discomfort is not of such severity that emergency level treatment is indicated.

SPLIT OR CRACKED TOOTH SYNDROME Severe, difficult-to-diagnose dental pain makes the cracked tooth syndrome a prime consideration. The pain is severe because the hairline crack extends into or through the pulp chamber. A history of pain— initially from hot and cold, subsequently from biting pressure, and eventually spontaneous—is often indicative of a cracked tooth, particularly in the absence of more obvious clinical findings. EXAMINATION

• Careful questioning and diagnostic tests (hot, cold, percussion, probing cracks and fissures with a sharp explorer) may lead to the offending tooth.

TOOTHACHE AND TOOTH-RELATED PROBLEMS

13

• The independent movement of two segments of the same tooth with attendant pain is an obvious confirmation of this syndrome. • The controlled application of a dye such as gentian violet, followed by a water rinse, may help to reveal the crack. TREATMENT

• Treatment requires the services of a dentist, and usually involves removal of the nerve, if the tooth is restorable, or of the entire tooth. • Emergency room treatment might consist of removal of a loose fragment, possibly requiring a topical or local anesthetic. More often, a general drug administered for relief of pain is indicated to hold the patient over comfortably until a dentist can be consulted.

Tbothache—Extrinsic Etiology MAXILLARY SINUSITIS It is not unusual for a patient to complain of a toothache, particularly in the upper posterior quadrants, when there is maxillary sinus congestion or inflammation. This sinus involvement need not be more involved than that associated with the common cold. Dental innervation arises within the thin walls forming the sinus. Irritation of the sinus membrane may reach these nerve pathways, and the patient may be misled into believing the cause of discomfort is dental rather than sinus. In fact, the patient may claim that the dental response is more severe than that attributable to the sinusitis. DIAGNOSIS

An obvious dental cause of the ache must be ruled out before pursuing the sinusitis diagnosis. In the absence of intrinsic dental etiology, the patient should be questioned regarding recent colds, sinus congestion, and sinus fullness. The latter is aggravated when the patient bobs the head as in going up or down stairs. TREATMENT

This discomfort is more in the realm of the physician than the dentist and it would be presumptuous to indicate here how the physician should diagnose and treat the condition. The only point to be made here is that a patient's complaint of dental pain can often be traced to a sinus problem, even to the extent that "all the teeth, upper and lower, are aching."

14

SECTION 1

IMBALANCE IN OCCLUSAL RELATIONS Imbalance in occlusal relations simply means that the upper and lower teeth are not intermeshing properly when the patient bites, particularly in lateral movements of the mandible. More specifically, one or more cusps of one or two opposing teeth may be hitting before the rest of the teeth are able to be brought together with maximum interdigitation, resulting in a "prematurity" of the occlusion as it relates to the offending tooth. This can cause a most painful response in a single tooth as a result of inflammation of the supporting structures of that tooth, especially when under pressure. DIAGNOSIS

Obvious intrinsic causes should be ruled out first, such as caries, split tooth, etc. If a prematurity is suspected, it is more likely to be painful if it is the result of a lateral movement of the mandible rather than a centric or "normal" closure of the teeth. The culprit is easily identified by the patient. Inflammation of the supporting structures can be confirmed by percussing the tooth sharply with the end of a tongue blade. Compare the response with a noninvolved tooth. TREATMENT

• Reduction of the offending cusp tips usually provides immediate relief, with the patient responding most favorably to the freedom of movement of the mandible; however, cusp reduction is best left to the dentist. • Immediate relief under emergency room conditions is best limited to general medication for relief of pain.

TRAUMA RESULTING IN A CHIPPED OR FRACTURED TOOTH Chipped Tboth This generally involves a corner of an incisor or cusp of a molar and is limited to one or two millimeters of the tooth. The problem is mostly one of annoyance to the patient because the sharp, jagged edge catches the soft tissue of the tongue, lip, or cheek. Smoothing the sharp edge with a fingernail emery board will usually provide sufficient relief until a dentist can be consulted for more permanent restorative treatment.

TOOTHACHE AND TOOTH-RELATED PROBLEMS

15

Fractured Iboth (Crown) This is a more serious condition, since trauma of sufficient magnitude to fracture the crown could result in one or more of the following serious consequences not immediately evident: 1. Aspiration of the fragment 2. Embedding of the fragment in nearby soft tissue (Fig. 1-1) 3. Fracture of the root of the tooth 4. Exposure of the pulp Fig. 1-1. Trauma to the mouth has fractured the crowns of several incisors, driving enamel fragments into the lower lip. Lips that are lacerated and swollen from trauma make detection of embedded enamel fragments difficult. The radiopaque border of the bony profile is seen on the right, from chin to maxillary alveolar process. An occlusal film (see Section 9) was employed in this case for an extraoral profile projection, with the patient holding the packet parallel with the midsagittal plane, behind the lips and incisor teeth; an SSD of 24", 65 kVp and 4 MAS were employed for the exposure.

DIAGNOSIS

Appropriate radiographs are required to rule out 1, 2, and 3. Exposure of the pulp can be determined visually by flushing the site with warm water, gently drying with warm air, and examining for a red spot, possibly as tiny as a pin point. TREATMENT

The exposed dentin of a fractured tooth can be painfully responsive, even to the passage of air across its surface when breathing. Exposure of the pulp exacerbates this pain. The sooner the patient can be treated by a dentist, the better the prognosis for both the tooth and the pulp. • In the meantime, the immediate relief of this pain depends upon protection of the exposed surface from external stimuli. First, smooth the jagged edge with an emery board, or suitable dental rotary abrasive if available, to reduce the irritation to contacting soft tissue—lip, tongue, cheek.

16

SECTION 1

• Gently irrigate exposed dentin and/or pulp with warm water. Warmed dental local anesthetic solution is good for this purpose, since it is sterile and isotonic as well as mildly anesthetic to the exposed pulp. • Gently dry the surface with warmed air or cotton pledgets. • Gently tease a thin layer of calcium hydroxide paste (Dycal®), mixed as per manufacturer's instructions, over the exposed dentin and pulp. The humidity of the oral environment will cause this to set into a hard film. • Calcium hydroxide is very vulnerable to displacement, and should itself be protected by a more permanent covering such as a temporary acrylic crown, orthodontic band, or composite resin restoration, all of which are generally beyond the scope of the emergency clinic unless dental personnel and armamentarium are available. In the absence of such more appropriate coverings, the tooth can be protected with a wax covering as described on page 9, under "Loss of Crown"; this will suffice for a few hours until the services of a dentist are available. • A small wisp of cotton dampened with eugenol can be substituted for the calcium hydroxide if the latter is unavailable. Then the wax covering can be sealed to the tooth with a creamy mix of zinc oxideeugenol, preferably a fast-setting variety (Caulk's 2200 zinc oxideeugenol temporary cement). Prescribe a suitable analgesic and sedative.

FRACTURED ROOT The root of the tooth may be fractured in the apical, middle, or coronal third. Apical third fractures have the best prognosis, coronal third fractures the poorest due to contamination from the oral cavity as well as the mechanical disadvantage of a short root supporting the crown. DIAGNOSIS

Definitive diagnosis of root fracture is from a radiograph. TREATMENT

The decision to provide root canal therapy or to extract the tooth is best left to the dentist. • If it is obvious that the fractured tooth must be extracted and such procedure is within the scope of the emergency room armamentarium and the ability of the personnel, administer a local anesthetic (see Section 8) and proceed. • Otherwise, administer medication for pain relief and advise the patient to see a dentist at the earliest opportunity.

TOOTHACHE AND TOOTH-RELATED PROBLEMS

17

Table 1-3. Toothache, Extrinsic SINUSITIS

OCCLUSAL IMBALANCE

CHIPPED, FRACTURED TOOTH CROWN

Does patient have: a cold? allergy? sinus congestion?

Does patient: hit one tooth hard? have pain in one tooth?

Small chip: Smooth with emery board

Diagnosis: Rule out intrinsic causes (cavity, etc.) Do percussion test Treatment: 1. No hard chewing or biting 2. $ general medication for relief of pain 3. See dentist

Fractured crown: Where is fragment? —aspirated? —in soft tissue? Is root fractured? Is pulp exposed? Treatment: 1. Smooth sharp edges with emery board 2. Cover surface with calcium hydroxide or small piece of gauze dampened with eugenol 3. Cover with wax (see "Lost Crown," page 10)

Teething Pain Discomfort presumed to be associated with the eruption of the primary teeth of children can be very real but all too frequently is the "catch all" diagnosis for less easily identifiable causes of a child's irritability and/ or malaise. Teething does not cause a fever unless there is definite evidence of a local inflammatory condition, and even then a fever of teething origin is most unusual. Consequently, it is very important to rule out other etiological factors before assuming that it is "just a teething problem." TREATMENT

General palliative treatment is probably more effective than local treatment. • The administration of an analgesic commensurate with the age and weight of the child may be indicated. • The massaging of eruption sites with salves and lotions is probably more of a psychological benefit for the parent than a physiological benefit for the infant, but if it helps to pacify either or both, then a topical obtundent such as Anbesol® or a topical anesthetic such as 5% Xylocaine® ointment may be gently massaged upon the site by the parent.

18

SECTION 1

Unspecified Dental Pain Sensitivity to Cold: Tooth discomfort due to cold is generally indicative of exposed hypersensitive dentin or recent metallic restorations. See Tables 1-1, 1-2. Sensitivity to Heat: Tooth discomfort due to heat is not only indicative of exposed hypersensitive dentin, but may also be a symptomatic manifestation of pulp involvement, from hyperemia to suppurative pulpitis. See Tables 1-1, 1-2. Chewing: Pain or discomfort during chewing generally reflects an involvement of the periapical tissues or tooth-supporting structures. Reclining: Dental pain or discomfort on reclining or lying down is the result of the transfer of additional body fluids to an already inflamed or suppurative site, usually in a confined area such as within a tooth or the alveolar bone. See Table 1-1, Stages V, VI, and VII. Jogging or Going Up and Down Stairs: Dental discomfort as a result of this type of activity is usually a manifestation of congestion in a confined area such as the sinus, alveolar bone, or even a large attenuated soft tissue abscess. Air Havel: Discomfort due to air travel, while not very common in modern pressurized aircraft cabins, can still be a real problem during periods of ascent, and, to a lesser degree, descent. Pressure changes similar to those experienced in one's ears can adversely affect the pulps of teeth that are already in a hyperemic or more advanced state of inflammation. While not generally sufficiently severe to require emergency treatment, a dental examination is indicated.

Don 'ts DON'T place aspirin or other counterirritants on mucous membrane next to the tooth or between cheek and gum. DON'T place heat on the face if confined suppuration is suspected. DO use warm saline mouthwashes. DON'T use a heat test on a tooth suspected to have suppurative pulpitis.

TOOTHACHE AND TOOTH-RELATED PROBLEMS

19

DON'T seal sedative dressings (cements) into a cavity when suppurative pulpitis, a necrotic pulp, or alveolar abscess is suspected. DON'T suggest that the patient lie down or go to bed in a reclining position when a suppurative pulpitis is suspected. DON'T probe depths of cavities with instruments without local anesthetic. DON'T place loose or displaced fillings, crowns, inlays, or temporaries back on the tooth without cementation. DON'T replace (even with cement) poorly fitting, loose, temporary fillings, crowns, inlays, etc. DON'T seal penicillin or other antibiotics in cavities of teeth or mix with temporary filling materials. DON'T rely on radiographs to diagnose a pulp exposure: superimpositions and morphological variations are misleading. DON'T condemn a tooth for extraction without confirming positively that the pulp is exposed and involved beyond salvage. DON'T forcibly spray a water stream into the root canals of a tooth. DON'T forcibly flow compressed air into the root canals of a tooth. DON'T probe the length of a root canal without the aid of a radiograph. DON'T wedge an instrument between fragments of a cracked tooth. DON'T lance gums to relieve "teething" pain or discomfort. DON'T attempt to grind or reduce dentures to relieve sore spots. DON'T place any medications on dentures before returning dentures to mouth of patient. DON'T attempt to adjust partial denture clasps.

2

Bleeding

Equipment and supplies for control of persistent dental bleeding should include: 1. Good lighting 2. Good suction with size 10-12 Frazier tips 3. Dental mirror and college pliers 4. Local anesthetic syringe with 2% lidocaine with epinephrine 1:100,000 5. Needle holder, scissors, and 3 - 0 silk suture 6. Curved mosquito hemostats 7. 2 χ 2 or 3 χ 3 gauze packs 8. Hemostatic agents, including surgical gauze, Avitene®, 'A-inch iodoform gauze or Vaseline® gauze.

Bleeding Following Tooth Extraction One commonly seen bleeding problem is the persistently oozing socket following tooth extraction. Although most of these respond to properly applied pressure from a gauze pack, some will persist in bleeding. A stepwise approach to treatment would include: • Remove any large liver-like clots that prevent adequate inspection: these may be readily wiped away with a 3 χ 3 gauze pad. • With good lighting and suction, inspect the wound to determine the source of the bleeding. Usually it is from the soft tissue margin and will be oozing in nature. This will often respond to a well-placed gauze pressure pad. The use of a local anesthetic with vasoconstrictor infiltrated into the area will promote hemostasis and provide improved patient comfort while the pressure pad is in place. • If bleeding persists, or if one wishes to provide more security against hemorrhage recurring later, a snug suture across the socket mouth or a horizontal mattress suture through the gingival margin will help. • Persistent bleeding from the depths of the wound usually has its origin in deep infected granulation tissue and this may require the use of an 23

24

SECTION 2

absorbable packing to promote clot formation in addition to the above measures. Oxidized cellulose gauze (Surgicel®) or microfibrillar collagen (Avitene®) may be used. • If this fails, or if there is significant spurting bleeding from the socket depths, a Vaselined pack of V^-inch plain or iodoform gauze strip can be packed into the socket and sutured over. This is to be used as a last resort, since it will result in a wound that must heal by granulation tissue over a period of weeks. However, it rarely fails to arrest a case of persistent bleeding. • After bleeding has been arrested, the patient should be advised against vigorous physical activity, as this promotes fibrinolysis, and should be told to select a liquid-to-soft diet for 36 to 48 hours. • Analgesics are often necessary and efforts should be made to maintain good oral hygiene without vigorous rinsing. Post-extraction bleeding can be an alarming experience for the patient, although total blood loss is not usually excessive. In older patients, particularly those who have been bleeding for several hours, dehydration combined with blood loss can result in hypotension, which may require intravenous support and monitoring. Closed bleeding within the looser tissues of the oral cavity, such as the cheeks, may follow vascular rupture from local anesthetic needles or trauma and punctures of these tissues, producing a hematoma. These are usually self-limiting and do not lead to significant complications. The collected blood may become infected, particularly the postsurgical hematoma, and the physician may choose to prescribe an antibiotic prophylactically.

Minor Bleeding Following Periodontal Surgery or Deep Scaling CAUSE

Good medical history usually rules out patients with bleeding disorders (hemophilia, thrombocytopenia, platelet deficiency, etc.). However, the patient may have acquired bleeding problems from heavy aspirin intake or systemic drugs. The average blood loss during a quadrant of periodontal surgery has been reported to be around 37 ml.

BLEEDING

25

SYMPTOMS

Slow oozing, with large, dark, exophitic clots that have formed around the teeth. EXAMINATION

All clots should be removed from around the teeth and the mouth should be cleaned with surgical suction. Locate the bleeding point or area that is hemorrhaging. TREATMENT

• Place a moist (saline solution) gauze pad over the bleeding site and hold it firmly in position for 3 to 5 minutes. • Since placing pressure between the teeth is difficult, it may be necessary to inject local anesthetic (lidocaine) with 1:50,000 vasoconstrictor between the teeth (interproximally) to control bleeding and establish a new clot. • Once the bleeding has been controlled, place a periodontal dressing to stop the bleeding (see page 73). An instrument can be used to adapt the dressing between the teeth. If using the Coe-Pak® dressing, Vaseline® should be placed on the fingers before handling the material. The dressing should not cover the biting surfaces (occlusal) of the teeth nor extend beyond the depth of the vestibule. • The patient should be instructed not to manipulate the dressing with the tongue or fingers. • The patient should be reassured, and any emotional concern should be alleviated.

Significant Bleeding After Periodontal Surgery SYMPTOMS

After having temporarily stopped, significant hemorrhage may reoccur following periodontal surgery. EXAMINATION

• All clots should be removed from around the teeth and the mouth should be cleaned with surgical suction. • Locate the bleeding point or area that is hemorrhaging. • Determine whether sutures have been placed.

26

SECTION 2

• Sometimes during periodontal surgery tissue from the roof of the mouth is removed to graft around the teeth: vessels here may have been severed and arterial bleeding may occur. TREATMENT

• Though pressure dressings work well over de-epithelialized gingiva, it may be necessary to remove clots from the margins of soft tissue flaps. • Absorbable gut sutures can be used to tie around bleeding vessels (usually always palatal). Electrocautery can be used to cauterize the area, as well. • A hemostatic agent (Surgicel®, Gelfoam®) can be sutured in position to act as a sponge, establishing a framework for clot formation. • For milder problems, patients can moisten a tea bag (tannic acid) and place pressure on the area for up to fifteen minutes to promote clot formation. • Periodontal dressing is helpful. • To prevent recurrence of bleeding, the patient should be cautioned to remain quiet (no talking) and not to spit or suck.

3

Generalized Mouth (Soft Tissue) Pain

A patient may come to the hospital emergency room with systemic symptoms of fever, maliase, or dehydration, but whose primary symptom is an extremely painful mouth.

Acute Necrotizing Ulcerative Gingivitis (Vincent's Infection—Drench Mouth) SYMPTOMS

This condition occurs most often in the teenager, although its presence in younger and older patients is not uncommon. Marked local symptoms overshadow systemic findings, with the oral pain frequently so intense that the patient will hold a handkerchief over the mouth to avoid the passage of air over the involved tissues. • The principal finding is ulceration of the marginal gingivae, particularly of the interdental papillae (projections of the gum tissue between the teeth). • Localized lesions are most commonly found in the upper incisor or lower molar regions, but the condition is often generalized. • The ulcerations bleed easily, sometimes spontaneously, and the margins are often covered by a yellowish-grey pseudomembrane. • Ulcers of the buccal mucosa are occasionally present. If they are a prominent part of the clinical picture, systemic conditions must be ruled out (see Ulcers, page 31). • A metallic odor to the breath is a characteristic feature and profuse salivation is common. TREATMENT

• Treatment requires local debridement of the areas of ulceration. Although painful to the patient, this must be accomplished by cleansing with a cotton applicator soaked in one-half strength U.S.Ρ hydrogen peroxide. Rinsing with a 2% warm hydrogen peroxide mouthwash will also be helpful. 29

30

SECTION 3

• If lymphadenopathy and prominent systemic signs are present, systemic antibiotic therapy should be considered. • Medication for pain is indicated. • The patient should be dismissed with instructions to continue the mouth rinse and to visit a dentist immediately. Although improvement of acute symptoms will be dramatic, unless the lesions are completely debrided by a dentist, the condition will become chronic, with extensive tissue destruction.

Acute Herpetic Stomatitis This condition, resulting from a primary infection with the Herpes simplex virus, usually occurs in children before the age of 12 but may also be seen in young adults. These young adult patients should have no past history of recurrent Herpes labialis (cold sores). Such history would rule out the diagnosis.

SYMPTOMS

Systemic symptoms are a prominent feature. • There is a history of generalized prodromal symptoms that may include fever, malaise, and nausea and that precede oral symptoms by 1 or 2 days. • Lymphadenopathy and high fever (104° F.) are common presenting symptoms, along with multiple, shallow, round, discrete ulcers surrounded by a red halo of inflammation that may be present on all portions of the oral mucosa. • An important diagnostic criterion of this disease is the appearance of a generalized, acute inflammation of the gum tissue surrounding the teeth. • Although the entire gingivae is edematous and inflamed, bleeding is rare and ulceration of the gingiva is not common. • This disease is self-limiting, with loss of fever within 3 or 4 days and healing or oral ulcers within a week or 10 days. TREATMENT

• Treatment is primarily supportive, including aspirin for fever and fluids to maintain hydration. • If the patient has difficulty eating and drinking, a topical anesthetic may be administered before meals. A 0.5% solution of Dyclonine Hydrochloride is an excellent topical anesthetic for the oral mucosa.

GENERALIZED MOUTH (SOFT TISSUE) PAIN

31

If this medication is not available, a solution of Benadryl® (5 mg/ml, mixed with an equal amount of milk of magnesia) also has satisfactory topical anesthetic properties.

Allergic Stomatitis Antibody-antigen reactions may cause clinical signs and symptoms in the mouth. Sometimes they result in ulcerations (see Ulcers, below), but, like other allergic reactions, they can be caused by a wide variety of substances and produce a broad range of tissue responses. Fixed drug eruptions are not common in the mouth. Contact allergic manifestations in oral tissues, however, are commonly observed and are referred to as stomatitis venenata. DIAGNOSIS

• If a patient presents with a chief complaint of sore mouth in the absence of systemic symptoms, an allergic reaction must be considered. • The complaint may be burning of oral tissues with little or no visible changes in oral tissues. • Localized or generalized swelling and inflammation may be evident. • The clinical appearance of stomatitis venenata may be difficult to differentiate from trauma. • A careful history must be taken, with emphasis on recent use of new products such as toothpaste, mouthwash, or chewing gum. TREATMENT

In the absence of tissue ulceration, no treatment is indicated other than medication for pain, reassurance, and instructions to limit the use of all oral products until the patient is seen by a dentist.

Ulcers Oral ulcers are painful and may cause sufficient distress to stimulate a visit to a hospital emergency room. They present diagnostic challenges because there are many systemic conditions that manifest themselves as ulcerations of oral tissues. DIAGNOSIS

The first lesions of pemphigus, erythema multiforme, lichen planus, and oral herpes zoster may appear in the mouth. Whenever the physician

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SECTION 3

encounters unexplained oral ulcers, he/she must take a careful history and examine the skin and genitalia to rule out such diseases. Patients suffering from leukemia, agranulocytosis, or those receiving chemotherapeutic drugs frequently experience a breakdown of the oral tissues. All such patients may require attention in the emergency room for oral pain ; however, the important role of the emergency physician lies in diagnosis and referral for the underlying cause. TREATMENT

Emergency treatment consists primarily of control of pain through systemic medication and topical administration of anesthetic solutions (0.5% aqueous solution of Dyclonine Hydrochloride, or 5 mg/ml. solution of Benadryl®. The following ulcerative conditions are limited primarily to the oral cavity. APHTHOUS ULCER (CANKER SORE) Perhaps as many as one-third of all men and women experience two or more lifetime episodes of aphthous ulcers. Half of these may develop ulcers at least annually, and a significant number are bothered by the condition six or more times each year. These common ulcers of unknown etiology are not usually of significance to emergency physicians. When multiple lesions occur (aphthous stomatitis), or an isolated ulcer reaches unusual size, however, a visit to a hospital emergency room might result. SYMPTOMS

• Individual ulcers are usually 0.5 to 1.0 cm. in diameter; however, they may reach three times this size. They are round, symmetrical, and shallow, and are covered by a yellowish exudate with a red halo at the margins. • The ulcers are extremely painful and, when located on the soft palate or tonsillar area, cause difficulty in swallowing. • A history of recurrence supports the diagnosis. TREATMENT

The patient may be reassured that the ulcer will no longer be acutely painful after the third or fourth day and will heal without scarring in ten to fourteen days. Symptoms may be relieved through the use of topical anesthetic agents such as 0.5% Dyclonine Hydrochloride, 5 mg./ ml. solution of Benadryl®, or Lidocaine Viscous (Xylocaine® Viscous) applied with a cotton swab or, in the case of multiple lesions, used as a

GENERALIZED MOUTH (SOFT TISSUE) PAIN

33

mouth rinse. Triamcinolone acetonide in an emollient dental paste (Kenalog® in Orabase®) applied to an individual ulcer will also relieve pain.

TRAUMATIC ULCERS Due to the rich blood supply to oral tissues and the abundant oral bacterial flora, lacerated oral tissues quickly become inflamed ulcerated lesions and are treated as such. DIAGNOSIS

A history of trauma will often establish the cause of an isolated oral ulcer. The clinical appearance will vary according to the nature of the trauma. • Bites of the tongue, some of which may be severe, are commonly associated with convulsive seizures and should prompt a careful history. • Emergency physicians may well be called upon to treat severe palatal lesions caused by thermal trauma. The "pizza palate," created by hot cheese sticking to the palate, results in an extremely painful condition. • The ulceration caused by chemical trauma that is most likely to be encountered by the emergency physician is the aspirin burn. It is a common practice for patients to dissolve one or more aspirin tablets in the mucobuccal fold adjacent to an aching tooth. The resulting chemical burn, which can be quite severe in some patients, is usually covered by a grey exudate. TREATMENT

• Treatment for all traumatic ulcers consists of reassuring patients that oral tissues heal rapidly and applying topical anesthetic solutions as indicated: 0.5% Dyclonine Hydrochloride; 5 mg./ml. solution of Benadryl®; Xylocaine® Viscous; or Kenalog® in Orabase®. • Warm saline mouth rinses provide comfort during the four- to fiveday healing period.

DENTURE SORE It is not unusual for recently inserted dentures to cause sore spots where they contact the soft tissues. These are generally manifested by localized areas of inflammation that, if permitted to persist, may progress to ulcerous lesions.

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SECTION 3

TREATMENT

• The obvious treatment is to remove the denture pending adjustment of the offending area on the denture by a dentist. • Benzodent® or Orabase® with Benzocaine applied to the sore spot will provide temporary relief of pain.

Acute Soft Tissue Swelling ALLERGIC EDEMA A localized anaphylactic reaction involving the rich blood supply of the oral tissues can produce massive swelling in a short period of time. The lips and the tongue are the most common sites for the reaction. Usually a history can be elicited that includes recent consumption of a food or drug not commonly used by the patient. Although the distended tissues are uncomfortable, they usually are not painful, and the patient's primary complaint is distress and alarm over the condition. TREATMENT

Unless enlargement of the tongue is compromising the airway, the patient is in no danger and should be treated with 50 mg. of Benadryl® four times a day until the swelling diminishes. If the tongue swelling is so extensive that the airway is compromised, the condition can be life-threatening. However, even in such cases, it is possible to establish and maintain a patent airway mechanically. If, when first observed, the patient is comatose due to airway obstruction, a tracheotomy should be performed in order that the patient may receive oxygen while other emergency procedures are pursued.

SUBCUTANEOUS EMPHYSEMA Introduction of air into tissues beneath the oral mucosa during operative dental procedures may produce rapid, dramatic (and frightening) swelling of the face and neck.

CAUSES

• Air introduced beneath mucosa by use of an air turbine handpiece in preparing a cavity or sectioning a tooth or bone ; use of an air syringe; use of H 2 0 2 or air blown through root canals during root canal (endodontic) treatment.

G E N E R A L I Z E D M O U T H (SOFT TISSUE) PAIN

35

• The patient may raise intra-oral pressure by coughing, sneezing, blowing the nose, vomiting, or playing a wind instrument following tooth extraction. Trauma (fractures), accidental puncture of mucosa, LeFort I osteotomy, or surgical opening of paranasal sinuses are additional causes. SYMPTOMS

Rapid swelling of face and/or neck, crepitus, dysphagia, dyspnea, and, in a few cases, temperature elevation. TREATMENT

• • • • •

Explain the problem and reassure the patient. Prescribe an antibiotic as a precaution against infection. Prescribe an analgesic. Apply moist heat or ice packs to the face and neck. Consider hospitalization for observation.

COURSE

Although death from an air embolus has been produced in dogs (via root canals of teeth), no case approaching this severity has been reported in humans. In nearly all cases, swelling and other symptoms will regress over a 2- to 10-day period with no after-effects.

Dont's DON'T—use silver nitrate or any tissue coagulant to cauterize any oral lesion. DON'T—relate pain of oral soft tissue lesions with their significance; squamous cell carcinoma of oral tissues is a relatively painless lesion! DON'T—relate the size of oral soft tissue lesions with their significance. The twenty-four month survival rate of patients with an oral carcinoma one cm. in diameter is little better than 5 0 % !

4 Trauma to Tfeeth, Jaws, and Soft Tissues

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SECTION 4

Sudden and forcible injuries to the teeth and jaws that do not produce fractures can result in loss of pulp vitality, which is not evident at the time of the initial examination. It often becomes apparent weeks later, with the loss of normal tooth color and translucency. Therefore, when teeth have been traumatized but not obviously damaged, the patient should be advised to have pulp vitality (see Table 1-2, page 8) evaluated over a period of time by his dentist. An undetected nonvital pulp can lead to development of a cyst or infection in the apical region of the tooth. (When a traumatized pulp fails to respond to appropriate vitality testing within a 3- to 6-month period, particularly when radiographs reveal periapical disturbances, root canal therapy is usually instituted by the dentist). When the injuring force is adequate in amplitude and direction to fracture the tooth or displace it partially or totally from its usual position in the alveolar bone, it may be considered to be luxated, avulsed, traumatically impacted, or fractured, or it may be a combination of several of these. Management of chipped or fractured teeth is discussed on pages 14-15.

Trauma to Teeth LUXATION Luxation is typically caused by a blunt impact, such as a blow from another player's elbow while jumping for a basketball, which displaces the upper incisor palatally (Fig. 4-1). Fig. 4-1. Luxation, displacing incisor palatally. Fractured labial alveolar bone may be molded closely to tooth with fingers. (Copyright School of Dental Medicine, University of Pennsylvania. Reproduced with permission of Dr. Ronald Johnson.)

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SYMPTOMS

• The tooth is out of line in the arch and seems longer than it should be, since partial avulsion usually accompanies luxation. • Swelling, discoloration, and often laceration of the gingival tissues can be seen. • The patient may be unable to close his back teeth together due to premature contact of his lower incisors on the extruded tooth. TREATMENT

• Slowly and firmly reposition the tooth with the fingers under locally infiltrated anesthetic solution. • Fractured alveolar bone can be detected by the fingers and should be molded closely about the root of the tooth to minimize bacterial contamination and provide the best conditions for healing of the torn periodontal ligament. • The repositioned tooth may tend to relapse to its displaced position when released and may require temporary wire support to the adjacent teeth (Fig. 4-2). • A liquid or very soft diet for a week or so is desirable and early dental consultation is appropriate. • The patient should be advised that the risk of eventual pulp death is high. Fig. 4-2. Essig-type wiring for supporting a luxated tooth that can be manually repositioned into a proper relation. Twisted wire ends may be tucked as shown or toward the gingivae.

AVULSION The complete loss of periodontal ligament attachment between the tooth and the alveolar bone results in partial or total avulsion of the tooth. In those cases in which a tooth has been lost and could not be located at the scene of the accident, the possibility that it may have been either aspirated or ingested must be considered, and the necessary radiographic surveys should be made.

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PARTIALLY AVULSED TOOTH—TREATMENT

• Reposition the tooth with firm gradual finger pressure under local anesthesia; usually it can be completely or almost completely replaced into the socket. • The alveolar bone should be molded about the root to provide greater stability. • Additional support by wiring or similar techniques is usually necessary (Fig. 4-3).

Fig. 4-3. A luxated and extruded tooth that resists repositioning can often be intruded by ligating an arch bar to adjacent teeth with cervical wiring and then ligating the displaced tooth with its wire above the cingulum.

TOTALLY AVULSED TOOTH

The totally avulsed tooth may be replaced with the expectation that it may provide useful service for a reasonable length of time if the following conditions are met: • If it is a permanent tooth—deciduous teeth are rarely replanted; • If its root is not badly damaged or fractured; • If it has not been out of the socket for over 2 hours; • If it has not been subjected to treatment with strong antiseptics or allowed to dry out excessively. DON'T discard the tooth that has been out of the mouth longer than 2 hours if the patient accepts the reduced chances for its prolonged retention.

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The cells of the residual periodontal ligament on the root surface should be viable when the tooth is replanted to minimize the occurrence of early and rapid resorption of the root by osteoclasts from the alveolar bone, resulting in premature loss of the tooth. TREATMENT

• Irrígate the root and the socket with saline to remove debris and clotted blood. • Replant the tooth promptly under local anesthesia. • Splinting will usually be necessary (Fig. 4-3). DON'T tighten wires on the cervical portion oí the root of an avulsed tooth because this will usually tend to extrude the tooth as the wire moves apically along the conical root.

• Root canal therapy will be necessary in most cases, but can usually be deferred for at least 2 weeks to allow for reattachment of the tooth to the alveolus ; meanwhile, a soft diet is advisable. • Ifetanus prophylaxis and antibiotic therapy are essential in these cases.

TRAUMATIC IMPACTION The tooth is forcibly intruded into the alveolar socket in an apical direction, resulting in irreversible pulp damage and expansion deformity of the alveolus (Fig. 4-4A). In some instances, the incisai edge of the crown may still be visible, but often the entire tooth is lost from view. If it is a deciduous tooth (Fig. 4-4B), it may re-erupt, but its apical displacement may have injured the permanent successor beneath it. If the impacted tooth is a permanent tooth, it will most often require mechanical or orthodontic repositioning into the arch.

TREATMENT

• Immediate repositioning can be deferred for a day or less and is probably best performed by the family dentist or oral surgeon. • Emergency care usually consists of medication to control pain and to minimize infection until dental help is obtained. • Root canal treatment will probably be required, eventually.

Fig. 4-4A. Traumatic impaction of the permanent incisor destroys pulpal vitality and results in fracture and expansion of the alveolar bone. Repositioning the tooth and molding the alveolar bone more closely to the root will aid healing. B. Forcible intrusion of the deciduous incisor can result in displacement or deformity of the permanent tooth bud.

Trauma to Jaws ALVEOLAR FRACTURE Alveolar fracture often occurs when the teeth have been luxated or partially avulsed and the displacing force has caused fracture and displacement of a variably-sized segment of the alveolar process that does not extend completely through adjacent basal bone. One or more teeth may be fractured and displaced and have a poor individual prognosis, but if they are firmly attached to the loosened alveolar process

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43

they may be repositioned under local anesthesia and supported by wiring, thus providing reduction and fixation of the attached alveolar bone until it heals (Fig. 4-5). These teeth may be removed later, and most of the healed bone can be preserved, which can be very important to subsequent prosthetic replacement of the missing teeth. Alveolar fracture is usually associated with soft tissue laceration and ecchymosis, involving gingival and vestibular tissues. Fig. 4-5. Alveolar fracture often causes extrusion of the segment with premature bite on that side and open bite on the stable side. Use of a single mandibular arch bar with a segmented maxillary arch bar and elastic traction between the arches will usually reduce the occlusal discrepancy.

TREATMENT

• Carefully explore lacerations under local anesthesia and remove bone fragments that lack soft tissue attachments. • Irrigate the wound thoroughly with sterile normal saline and repair it with 3-0 silk suture. • Prescribe an antibiotic such as penicillin, Declomycin®, or cephalosporin. • Mold the fractured alveolar bone with firm gradual finger pressure under local anesthesia. • Fixation by wiring should be accomplished by an oral surgeon.

MANDIBULAR FRACTURE Most fractured mandibles are the result of significant trauma to the jaw: a blow strong enough to fracture the jaw must be considered potentially strong enough to cause head injury with intracranial edema and bleeding. Injury to the cervical spine must also be considered.

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SYMPTOMS

• The fractured mandible is usually marked by significant pain and local swelling. • The patient is usually unable to occlude the teeth normally (Fig. 4-6), and swallowing may be painful due to resulting muscular stresses on the broken bone. • The patient may report numbness in the lip and chin, indicating damage to the inferior alveolar nerve passing through the mandibular canal. • Ecchymosis in the floor of the mouth is a sign of mandibular fracture, until proven otherwise.

Fig. 4-6. A displaced compound fracture is accurately reduced by restoring occlusion (inset diagram shows ideal occlusion). A single upper arch bar and a lower arch bar segmented into two at the fracture site provide useful mechanical aids in reducing and stabilizing the fracture with interarch elastics or wires. Improved results can often be gained by placing a transosseous or transcortical wire intraorally near the lower border of the jaw. EXAMINATION

It is very common to find a second or third site of fracture in the broken jaw. An example is the epileptic injury, which is produced by falling on the point of the chin, resulting in fracture of both condyles and fracture at the midline symphysis.

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• Gently palpate the jaw from the condyles downward along the inferior border of the jaw to the chin, looking for step defects, altered contours, crepitus, and excessive tenderness. • Ask the patient to bring his back teeth together and note any obvious discrepancies in the occlusion. The patient can often advise you as to whether his teeth occlude as they did prior to the injury. • The patient should not be transferred for x-ray studies until intracranial and cervical spine injuries have been ruled out. • Radiographs should include PA and right and left oblique lateral views of the mandible and a reverse Towne's view for the condylar necks. • Panographic radiography and intraoral occlusal and periapical films are very helpful (see Section 9). • Temporomandibular joint films may be required for complete diagnosis.

TREATMENT

• Maintain an airway. Disruption of muscle attachments of the tongue and bleeding and swelling of the tissues of the floor of the mouth constitute a risk to the patency of the upper airway. This is particularly true with bullet wounds of these structures. Nasal and oral airways, endotracheal intubation, cricothyrotomy, or tracheotomy may be required where trauma is severe. The airway and oral secretions are generally most manageable when the patient is in a sitting or semi-supine position—the semi-Fowler position, for example—if his circulation and neurological conditions are stable. • Clear the mouth and oropharynx of any clots, fragments of tooth, or denture or filling material. A good suction and good light are essential. • Temporarily support the fractured jaw to reduce pain and local bleeding. A Barton-type dressing, which supports the jaw and brings the teeth together, may help, but in some cases it may only aggravate the problems of the patient. Temporary intermaxillary wiring of the teeth to achieve immobility of the fractured parts will help (Fig. 4-6). • Provide intravenous hydration if the patient experiences marked dysphagia. • If severe bleeding is a problem, reduction of the fracture and temporary immobilization will usually suffice to arrest the bleeding. Repair of lacerated soft tissue aids in minimizing further contamination of the fracture site and aids hemostasis. • Fractures of the tooth-bearing portion (or body) of the mandible are almost always compounded into the oral cavity. Antibiotic therapy for the compound fracture and strong analgesics are essential.

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• Definitive treatment of the fractured mandible consists of either closed reduction alone, using intermaxillary wiring, or a combination of closed reduction with intraoral or extraoral open reduction with restoration of proper occlusion and uncomplicated healing as the primary goals. It can be anticipated that swallowing may be difficult and painful until the definitive reduction and fixation has been accomplished.

CONDYLAR FRACTURE Fractures of the mandible frequently involve the weakest and most vulnerable part of the jaw, the condylar neck. The condyle may be the only part fractured, but it usually accompanies fractures elsewhere in the jaw. Many condylar fractures go undetected in hospital emergency rooms because personnel fail to appreciate how frequently these injuries occur with only modest trauma to the jaws. It is particularly important to detect these injuries in children to minimize subsequent facial deformity and possible ankylosis, since the condylar head is an important growth center. EXAMINATION

• On examination and palpation over the joint there is swelling, increased tenderness, and, as the jaw opens, the condylar head cannot be felt to move. • The range of motion of the jaw on opening is reduced, opening and lateral movements are usually painful, and the jaw usually deviates on opening toward the side of the condylar fracture. • The teeth often fail to occlude, meeting prematurely on the fractured side and failing to meet on the opposite side (Fig. 4-7). Fig. 4-7. Displaced condylar fracture. Note characteristic deviation of the jaw with midline discrepancy, and premature molar bite with open bite on the opposite side. These findings result from loss of vertical support and elevator muscle activity at the ramus, producing a decreased vertical height posteriorly and a shift of the jaw toward the fractured side. Reduction to correct occlusion is mandatory and is usually accomplished with intermaxillary traction and fixation for two weeks.

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47

• If both condyles are fractured and displaced, an anterior open bite will be evident due to a loss of vertical support and premature posterior contact and the jaw will be somewhat retruded. • Confirmation of the above evidence by careful radiographic examination is essential. DON'T discharge a patient with a significant blunt trauma to the jaw without a careful clinical and radiographic assessment for condylar fractures. This is especially important in children.

TREATMENT

Not all condylar fractures must be treated: however, if the patient cannot easily achieve his usual centric occlusion or if significant pain persists beyond the first 48 hours following fracture, intermaxillary fixation by an oral surgeon for a period of 2 to 3 weeks, followed by active therapy to insure good function, is indicated. Deviation of the jaw on opening is not an indication for treatment because this will tend to persist even following adequate treatment for a period of time. • Temporary relief and limited function of the part may be obtained through the use of analgesics. • A liquid to soft diet should be recommended.

DISLOCATION (ANTERIOR) OF CONDYLES— DISLOCATED JAW The dislocated jaw, resulting from a forward displacement of the condyles out of their glenoid fossae, accompanied by laxity and rupture of capsular ligaments and spasm of the protractor muscles of the jaw, usually requires forceful manipulation to reduce the dislocation. The patient will complain of severe discomfort and being unable to close his jaws together. This may be an initial episode related to an injury or to wide yawning, or it may be a recurring problem. One or both condyles may be involved. TREATMENT

• Manually reduce the dislocation by placing the thumbs laterally to the molars and the fingers beneath the mandible, drawing the jaw initially forward and forcibly rocking the back of the jaw down while rotating the chin up to clear the articular eminence and gain the fossa (Figs. 4-8A and B). • Reduction may be difficult and can be aided by local anesthetic infiltration of the tissues around the joint.

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• Occasionally a general anesthetic with muscle relaxants may be required. • On discharge, the patient can anticipate a painful joint and must avoid a recurring dislocation by minimizing jaw excursions such as wide yawning. • Analgesics and a soft diet are recommended. Recurring dislocation usually requires surgical correction by one of several methods: the currently popular method is reduction of the articular eminence to remove the obstruction to self-reduction of the forwardpositioned condyle.

Figs. 4-8A and B. Mandibular dislocation. Standing either behind or in front of the patient, the operator places his thumbs laterally adjacent to the second molars and his fingers beneath the jaw anteriorly. The jaw is then forcibly rotated about an axis at the thumbs. This depresses the condyle below the articular eminence and a backward force relocates the condyles in their fossae. Local anesthetics infiltrated into the tissues about the condyle may reduce muscle spasm and aid reduction.

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49

MAXILLARY FRACTURES Fractures of the mid-face are termed LeFort I, LeFort II, and LeFort III fractures, in order of increasing severity (Figs. 4-9, 4-10, and 4-12). All of these fractures alter the way the teeth meet, usually resulting in a bite kept open anteriorly by premature contact of the molars. SYMPTOMS

• Bleeding from the nose, antral cavities, and lacerated vessels can be severe and persistent. • Ecchymosis and edema of local soft tissues is rapid and extensive. • The displacement of the upper jaw downward and posteriorly, combined with bleeding and edema of tissues, produces a serious risk of airway obstruction.

LEFORT I FRACTURE LeFort I is a horizontal segmented fracture of the alveolar process of the maxilla in which the teeth are usually contained in the detached portion of the bone. The highly mobile segment comprises the entire alveolus and palate, suspended solely by periosteum and soft tissues.

Fig. 4-9.

LeFort I—Horizontal

TREATMENT

• Establish and maintain an airway, including forcible forward repositioning of the bony structures. • Control active bleeding by packs and ligatures. • Replace circulatory volume losses. • Assess the patient for neurological damage. • Definitive treatment by the dentist will restore the correct occlusal relationship to the intact mandible through intermaxillary wiring for a period of 5 to 6 weeks. The continuity of periosteum across the fracture lines prevents significant movement of the fractured bone during this period of fixation.

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LEFORT II FRACTURE LeFort II is a pyramidal fracture separating the maxillae and the nasal bones from orbital bone structures and the cranial base.

DIAGNOSIS

• The nasal skeleton moves in conjunction with the maxilla when the maxilla is grasped anteriorly by the thumb and forefinger and moved back and forth while supporting the forehead with the other hand (Fig· 4-11). • Other diagnostic features include numbness of the upper lip, nose, and labial gingiva (from fractures extending through the infraorbital canals), diplopia, cerebrospinal rhinorrhea, and orbital and periorbital edema and ecchymosis. Fig. 4-11. Recognition of LeFort II fracture (see text)

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TREATMENT

• Establish and maintain an airway, including forcible forward repositioning of the bony structures. • Control active bleeding by packs and ligatures. • Replace circulatory volume losses. • Perform closed reduction with intermaxillary fixation to the intact mandible. • Manual reduction may be necessary to improve mobility and correct the posterior and inferior displacement that frequently accompanies this fracture. • The closed reduction may require further refinement and stabilization through open reduction at one or more fracture lines and internal wire ligation and suspension to adjacent stable facial or cranial structures. • Antral packing may be required for support of the fractured and depressed orbital floor or after evacuation of an antral hematoma.

LEFORT III FRACTURE LeFort III is a severe horizontal fracture in which the entire maxilla and one or more facial bones are completely separated from the craniofacial skeleton. These fractures are usually accompanied by multiple fractures of the facial bones.

Fig. 4-12.

LeFort III—Craniofacial dysjunction

DIAGNOSIS

The LeFort III fracture results in most or all of the features enumerated for the LeFort II fracture, but ocular disturbances are more frequent and severe and facial edema is more pronounced. TREATMENT

• Establish and maintain an airway, including forcible forward repositioning of the bony structures.

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• Control active bleeding by packs and ligatures. • Replace circulatory volume losses. • Perform open reduction of fracture lines at lateral and inferior orbital rims and reposition displaced nasal bones. • Manual reduction of the maxilla with intermaxillary fixation to the intact mandible in a good occlusal relation is essential. • Ruptured medial canthal ligaments require early repair and the continuity of the nasolacrimal apparatus should be established. This injury is very complex; it involves many structures and requires detailed preoperative analysis and a variety of surgical approaches.

Malar Bone—Zygomatic Arch Fractures Malar bones are subject to depression from direct trauma. Because the extent of depression is often masked by rapid soft tissue swelling, the displaced fractures are frequently not recognized and are not treated early with resultant facial deformity. Late repair may require extensive surgery, including osteotomy of the healed bones, bone grafting, and implants to restore contours. Fig. 4-13. A depressed fracture of the zygoma reduced and supported by direct bone wiring at the zygomatico-frontal and infraorbital fracture sites. An additional wire is less often needed posteriorly. Inset shows the usual antral wall relationship after fracture. Reduction of the body of the zygoma should restore continuity here. Occasionally, antral packing may be required.

EXAMINATION

• Carefully palpate orbital rims and zygomatic arches for step defects (Fig. 4-13). • Radiographic studies should include a Waters view and a submento· vertex projection.

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• Deformity of the orbital rims, zygomatic arches, and fluid levels in the maxillary sinus as seen on the radiographs will indicate malar/orbital fracture. • Numbness in the distribution of the infraorbital nerve is commonly found. • Depression of the zygomatic arch may impede the opening movement of the mandible through impingement on muscle and bone. TREATMENT

• Provide analgesics for pain and antibiotics to prevent infection of the antral hematoma. • Ice packs will help hold swelling to a minimum. Definitive care will consist of reduction of the displacement, usually by open surgical approach, and often with support maintained by antral packing, direct bone wiring, or both.

Laceration of Oral Soft Tissues The oral soft tissues may be lacerated by blunt trauma, which impacts these tissues against the cusps and edges of the teeth, or, occasionally, by penetrating foreign bodies. These injuries may extend through to involve the skin and intervening tissues, including salivary ducts, nerves, arteries, and veins, which may also require identification and repair. TREATMENT

• A wound of any reasonable size should be irrigated, explored for foreign materials embedded in the depths of the wound, and repaired. • Facial skin has a superior blood supply, and lacerated and partially avulsed skin should be conserved, even tissue with a small pedicle. • Severely contused and macerated skin may be conservatively excised to yield a finer scar. • Unfortunately, the mucosal side of a lacerated lip or cheek is often left unrepaired to heal secondarily. Repair by primary closure of mucosa will provide vastly superior results with less bacterial contamination, less necrosis, less pain, and more rapid healing. • Antibiotic coverage and oral irrigations of warm dilute saline or baking soda will reduce secondary infection. • A mouthwash consisting of a l/i- to '/2-strength solution of 2% hydrogen peroxide in warm water will aid in cleansing the sutures of food debris and may be followed by a dilute proprietary mouthwash. • With oral soft tissue injuries, oral hygiene will be difficult, but it

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should be stressed to the patient that a clean mouth will heal faster and that, when comfort permits, brushing the teeth and rinsing the mouth after eating are desirable. • With large intraoral lacerations, the use of a clear liquid diet for the first 24 hours contributes to fewer complications in healing.

LIP LACERATION A principle of wound repair is the need to reapproximate anatomical landmarks. This is particularly important in repair of the lacerated lip. • Where the laceration extends through the junction of vermillion and skin, the first suture should be applied to this junction to provide a continuous vermillion edge (Fig. 4-14). • Subsequent sutures are of 3-0 chromic gut, placed subcutaneously in an inverted fashion, followed by repair of the skin with 5-0 monofilament sutures such as nylon. • The vermillion area of the lip is repaired with absorbable suture for muscle layers and 3-0 silk for mucosal repair, leaving one or more long sutures to assist in everting the lip. • With the lip everted, exposing the oral side of the wound, the muscular and mucosal tissues are repaired. • In tying sutures, provision should be made for swelling. Only the knots and not the sutures themselves should be tied tightly. • Surface silk sutures should be given a third throw on the knot, and gut sutures should have four squared knots laid down to prevent premature loss of the sutures. • When adequate suture repair is provided in the subcutaneous and muscular layers of the lip, surface sutures may be removed in 5 to 7 days. Steri Strips® may be applied for an additional 5 days to reduce tension on the healing wound. Fig. 4-14. Repair of laceration of the lip. Following adequate hemostasis, the initial suture is placed to accurately align the junction of lip vermillion and skin. This avoids a step defect that would produce a poor cosmetic result. Repair of the muscular layer, subcutaneous tissue, and skin precedes mucosal suturing.

TRAUMA TO TEETH, JAWS, AND SOFT TISSUES

55

CHEEK LACERATION Deep lacerations of the cheek may result in division of Stenson's duct from the parotid gland. If this is not recognized and the tissues are repaired over it, saliva will spill into the loose tissues of the cheek, forming a large fluid accumulation or sialocoele, which will require surgical fistulation at a later date. • Duct laceration may be diagnosed by passing a fine polyethylene catheter into the parotid duct orifice opposite the upper first molar: if the tube appears in the wound, the duct is severed. • If the proximal end of the duct can be located, it should be threaded over the catheter and the duct wall repaired with fine sutures of 6-0 silk. • If the proximal end cannot be located, the wound should be drained intraorally in an effort to create a permanent fistula for escape of saliva into the mouth. Deep lacerations of the cheek that fall between the stylomastoid foramen and a vertical line dropped from the lateral canthus of the eye can sever major branches of the facial nerve (Fig. 4-15). Fig. 4-15. Laceration of the cheek may transect a major branch of the facial nerve and the parotid duct. Nerve repair should be performed on branches behind a line dropped from the lateral canthus of the eye. The parotid duct is cannulated with a polyethylene tube and the duct repaired directly.

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• Severence of main branches of the facial nerve necessitates primary nerve repair during wound closure (Fig. 4-15). • Fine branches anterior to this line are rarely repaired because innervation returns either by nerve regeneration or by supplemental nerve supply from other main branches. When there is a high laceration in the posterior cheek, the buccal fat pad may extrude through it. • The buccal fat pad should generally be repositioned into the wound rather than be removed, because loss of major amounts of this fat may result in loss of facial contour and eventual restriction of mandibular motion. • When this fat is contaminated, antibiotic prophylaxis against infection is desirable.

TONGUE LACERATION Small puncture wounds of the tongue such as those from a single tooth need not be repaired surgically. (See Ulcers, page 31.) • When laceration involves the muscular layer of the tongue, muscle repair is indicated using 3-0 chromic gut suture. • The mucosal layer is best repaired with 3-0 silk in adults, with a third suture knot carefully tied to avoid early loss of the suture. • Young children are best managed by inverting 3-0 sutures of chromic gut so that the knots are buried and unlikely to come undone.

PALATE LACERATION Palatal lacerations usually result from children running and falling with sticks and other objects in their mouths. These injuries will almost always benefit from primary repair. • The wound must be carefully inspected and foreign bodies must be removed from the tissues. • Absorbable sutures are usually adequate when tied with extra throws. • Swallowing may be difficult and painful for several days post-injury. DON'T leave mucosal lacerations unrepaired: to do so invites infection, necrosis, and delayed, painful healing. Primary suture repair almost always gives superior results.

5 Face and Jaw Pain and Swelling

Tic Douloureux Tic Douloureux results in intense and searing recurrent paroxysms of pain that are distributed unilaterally in the more superficial tissues of one side of the face. DIAGNOSIS

• The pain has a sudden onset and is provoked by motion or light touch to a part of the face (the trigger zone). • The pain is described as lightning-like and lasts briefly. • If it is accompanied by objective loss of the sensory components of the trigeminal nerve, a more extensive examination must be performed to rule out the possibility of tumor formation. TREATMENT

Emergency treatment is by medication. Surgery may be required for cases that do not respond to medication. • Carbamazepine (Tegretol®) may be tried initially at a dosage of 200 mg two or three times a day and may be increased to 800 mg or more per day, although side effects become a real concern at these higher levels. • Monitoring is essential. • Anticonvulsants such as phenytoin and mephenesin have been used with less success. • Medication is continued for weeks or months, as necessary to obtain freedom from attacks, and the patient should continue the medication for about 2 months after relief from pain has been achieved. If the problem does not respond to medical therapy, a variety of surgical treatments are available, including microsurgical decompression of the fifth cranial nerve root entry zone (Janetta procedure) and destruction of the gasserian ganglion by controlled thermocoagulation. 59

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Temporomandibular Joint SPRAIN A patient may present with a complaint of sudden onset of tenderness and pain in the temporomandibular joint that may result in limitation of motion and inability to bring the teeth together on the affected side. This may follow a blow to the jaw or an episode of anterior dislocation of the condyle, or it may result from continuous pressure on joint structures due to a faulty sleeping position. These various traumatic factors produce inflammation and edema within the soft structures of the joint, resulting in swelling, which prevents the proximal seating of the condylar head in the glenoid fossa. As a result, the molars on that side fail to meet. DIAGNOSIS

• Pressure applied over the joint during palpation will produce pain, as will certain movements of the jaw that compress inflamed tissues. • Radiographs of the joints in the open position reveal little evidence of a problem, but in the closed position they reveal a widened joint space with the condyle positioned downward and forward due to swelling of tissues above and behind the condyle. TREATMENT

• Recommend the use of a heating pad over the affected area and recommend aspirin, to be taken at 4-hour intervals, for its analgesic and anti-inflammatory properties. • A liquid or soft diet will reduce trauma to the joint from chewing. • The joint should respond favorably within 48 hours. No long-term damage is to be anticipated, although the patient may experience a temporary increase in the frequency of clicking during function.

MYOFACIAL PAIN DYSFUNCTION Pain that occurs unilaterally around the temporomandibular joint and has a gradual onset may be due to muscle spasms. This occurs predominantly in young females. SYMPTOMS

• The patient complains of persistent dull, aching pain, sometimes severe, aggravated by chewing.

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61

• Pain is often diffuse in the preauricular region and may radiate to the temple, angle of the mandible, or lateral cervical region. • On examination, it may be noted that opening is limited or is accompanied by lateral deviation due to spasm of the elevator muscles of the mandible. • An important diagnostic feature is the lack of significant tenderness of joint structures to palpation, while point tenderness may be detected when muscles are palpated, as for example at the mandibular angle, the temporal crest, and above and behind the maxillary tuberosity. • Radiographs are negative for any specific changes. TREATMENT

Therapy consists of: • Resting the jaw muscles by selecting a soft diet • Avoidance of clamping the teeth together or grinding the teeth. • Avoidance of yawning. • Relaxant therapy with Valium® or similar agents. • Use of a heating pad. • Analgesics as needed. Additional therapy may include: • Use of plastic occlusal wafers to disengage the bite. • Myotherapy with reflex relaxation exercises and/or psychotherapy. It is rarely necessary to resort to surgical intervention.

DEGENERATIVE ARTHRITIS The temporomandibular joint is one of the most active joints in the body and is subject to the same effects from wear and tear as are other joints: this sometimes leads to changes in the articulating surfaces of the bony parts and the articular disc, with resultant production of pain. DIAGNOSIS

• Typically the pain involves one joint only, and is worse after function, although initial stiffness improves with function. • On palpation there is usually tenderness over and behind the joint and down the posterior surface of the condylar neck. • Muscles are usually not tender, but muscle spasm and tenderness may accompany degenerative changes within the joint. • Radiographs may reveal one or more of a variety of degenerative changes, including loss of joint space, flattening and erosion of the articular surface of the condyle, productive changes that form osteophytes on

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the condylar surface, and deformation of the glenoid fossa. • Special radiographic studies such as tomography may be required for complete diagnosis. TREATMENT

Emergency treatment consists of conservative efforts to permit the patient reduced function with diminished pain. • Selection of a soft diet. • Application of heat to the joint. • Use of analgesics. • Correction of bite abnormalities. • Selected exercises may be prescribed. When the conservative approach fails, surgery of the joint may be necessary.

RHEUMATOID ARTHRITIS The patient stricken with rheumatoid arthritis usually has multiple joint involvement prior to extension of the disease to the temporomandibular joint, making diagnosis of the complaint simpler and more acccurate. SYMPTOMS

• Bilateral temporomandibular joint involvement is the rule and stiffness and pain are typically more marked after rest. • Pain generally diminishes with function. • The patient experiences acute phases and remissions: during the acute periods the joint is often warm and swollen and tender to palpation. • Degenerative changes will take place and there may be crepitant noises during motion. • Demineralization and eventually loss of condylar height can occur, with production of an anterior open bite. • Some affected joints can progress to fibrosis and ultimately to fusion, with true bony ankylosis. TREATMENT

• Medication—such as aspirin, indomethacin, and phenylbutazone— reduces inflammation and pain. • Graded exercises help to maintain mobility. • Intracapsular injections of steroids have been employed with some success, particularly methylprednisolone, which shows less tendency to promote subsequent degenerative changes than some of the other steriods that were used in the past.

FACE AND JAW PAIN AND SWELLING

63

• Rarely is operative intervention necessary unless pain is intractable or adhesions and bony fusion prevent function. • Advise the patient to rest jaw activity during acute phases.

Extraction Socket—Pain The removal of an impacted tooth or a surgical extraction involving dissection of soft tissues and bone often results in a significant degree of postoperative pain within the first 24 hours. Codeine-type postoperative analgesics, which are usually prescribed by dentists, are not universally effective in relieving the pain, and the patient may visit the emergncy room "after hours" seeking something more effective. TREATMENT

• Demerol®—up to 150 mg orally—every 4 hours, or 75 mg intramuscularly; or Dilaudid® tablets—2 mg every 4 to 6 hours—will usually relieve the most severe postextraction pain during the first 12 to 14 hours. • Beyond the first 24 hours, there should be little need for strong analgesics; if healing is progressing normally, codeine preparations or "over the counter" analgesics should be adequate.

Alveolar Osteitis—"Dry Socket" In some cases the clot that should form in the postextraction surgical defect forms poorly and undergoes early liquefaction and dissolution. The result is exposure of bony socket walls: the socket becomes partially filled with necrotic clot, putrefying food debris, and florid anaerobic bacterial growth. This combination results in marked irritation to the bone and severe pain, which is typically worse in the evening and upon arising in the morning: it usually interferes with sleep. TREATMENT

• A simple and often effective treatment consists of repeated irrigation of the socket with warm saline solution and placement into the socket of a Winch iodoform gauze dressing that has been saturated with eugenol, or oil of cloves. This must be replaced within 24 hours because its effectiveness declines rapidly. • Narcotic analgesics should be provided in case relief from local treatment is only partial.

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• Antibiotics are not indicated unless infection of adjacent tissues is significant. • Caustic preparations such as phenol or crushed aspirin tablets placed in the socket will relieve pain but are to be avoided because they destroy healing tissues and lead to marked delay in healing. • Continued treatment is often necessary for 7 to 10 days and is best provided by the dentist.

Abscessed Iboth When pathogenic microbial organisms reach the connective tissues of the mouth, they invade and cause inflammation and pain. The enamel of the teeth and the intact epithelium of the gingival and mucosal tissues provide a continuous natural barrier to invasion of underlying connective tissues. • The carious process destroys the enamel, exposing the dentin, and subsequently the dental pulp, to infection, resulting in pulpal and periapical necrosis and abscess formation. • A deep periodontal pocket may also permit a retrograde infection of the pulp. • Trauma and ulceration of the epithelial layers of oral soft tissues exposes the deeper layers to microbial invasion, with resultant abscess and cellulitis. All of these processes are initially localized, but, depending on the pathogenicity of the organisms and local and systemic resistance factors, the infection may rapidly spread to adjacent tissues and spaces, with more serious sequellae.

PERIAPICAL ABSCESS DIAGNOSIS

• In the very early stages of pulpal death, the pain can be persistent and severe, but difficult to localize. The pain may be referred to any area served by the trigeminal nerve on that side, including other teeth, the other jaw, the sinus, the ear, etc. • The tooth responsible for the pain will be on the same side as the pain, as the pain never crosses the midline. • When the abscess develops in the region of the tooth apex, it can be more readily located because the inflammatory changes cause local tenderness during chewing and this may be elicited by light perçus-

FACE A N D JAW PAIN AND SWELLING

65

sion of the teeth with the handle of an instrument such as a dental mirror. In the dentist's office, selective application of electric currents, cold and heat to the teeth, and diagnostic injection of local anesthesia all supplement information provided by accurate dental x-ray studies in determining the source of the pain. TREATMENT

• Antibiotics will promote patient comfort and early resolution of soft tissue abscess formation. The most effective antibiotics are currently felt to be penicillin, doxycycline (Vibramycin®), cephalosporin, and erythromycin, in that order. • Incision and drainage provide relief when vestibular tissues are painfully distended by purulent collections. • The patient should be referred to a dentist immediately for endodontic therapy or tooth extraction.

DON'T depend on antibiotics alone for control of significant dental abscesses. Early incision and drainage are generally rewarded by relief from pain and rapid resolution of swelling.

PERICORONITIS, GINGIVAL, AND PERIODONTAL ABSCESSES The gingival or periodontal abscess is caused by bacteria, a foreign object, or both, becoming lodged below the gingiva or deeper periodontal tissues. Objects such as popcorn kernels, nuts, seeds, or other debris may become trapped below the tissue and serve as a substrate for bacteria. The acute periodontal abscess is usually an exacerbation caused by the inability of the entrapped object and infected tissue to establish drainage for a local accumulation of pus, which occurs beneath the tissue. Pericoronitis is infection of the soft tissue around the crown of a partially erupted tooth. It is most frequently seen as inflamed tissue overlying the partially erupting third molar (wisdom tooth) (Figs. 5-1A and B); it is also commonly found on the last molar in the lower arch. In children it may be seen on erupting permanent teeth: as the tooth first penetrates the oral tissues, debris can become trapped beneath the gingival tissue. As the flap of tissue over the crown begins to swell, mandibular movement is limited and temperature may be elevated.

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Fig. 5-lA. Occlusal view illustrating gum tissue as it typically covers a portion of the crown of the last molar in the lower arch. B. Pericoronitis on the distal portion of the partially erupted molar as indicated by the dark area

The periodontal abscess involves a localized inflammation that invades the periodontal tissues and may extend deeply into the supporting bone along the root (pocket) of a tooth (Fig. 5-2). The periodontal abscess is frequently encountered after a patient has been to the dentist for subgingival scaling; dislodged calculus may become trapped below the gum tissue. SYMPTOMS

• A painful lesion, involving one tooth, will usually be sensitive to percussion, to chewing, or even to closure of the teeth. • A localized, reddish, marginal swelling will appear adjacent to or between the teeth. DIAGNOSIS

• The involved tooth will show mobility and be sensitive to percussion. • The reddened edematous tissue becomes tender upon palpation and may exhibit suppuration. • A periapical radiograph can be helpful in locating any radiopaque objects

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67

that may be present; discernible bone loss may be detected. • The tooth will respond to testing with ice. If there is no response to placement of ice, the problem may require endodontic therapy by a dentist. • Lymphodenopathy is common in the mandible and the patient may have a fever.

Fig. 5-2. Representation of a periodontal abscess that has become sealed off in the gingival sulcular area (above), spread into the periodontal ligament, and extended through the buccal plate of bone, causing enlargement of the vestibular tissue

TREATMENT

• Administer local infiltration anesthetic to the area around the lesion. • Establish drainage of the purulent exudate by moving a curette along the soft tissue around the crown or root to remove the mechanical lock, or penetrate the surface of the abscess with a needle or a # 11 scalpel blade. Attempt to locate the foreign object or particle that may be present. • With the aid of college pliers, place Iklbot's Iodine solution into the pocket or between the tissue flap and the tooth to help reduce the local bacteria. With pericoronitis, swelling will reduce quickly with drainage and with the Talbot's Iodine application. • Leave the area open to drain. Instruct the patient to rinse with warm water after each meal and an additional 4 to 5 times a day. • Give the patient enough pain medication (Tylenol® # 3 q.6h) for one day. • The patient should be instructed to see a dentist within 24 hours. • Systemic antibiotics (penicillin, erythromycin) are not usually given unless the patient has a fever or other general health considerations.

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SPREADING DENTOALVEOLAR ABSCESS When an abscess of dentoalveolar origin spreads beyond the early confines of the vestibular tissues, it extends into various tissue planes and potential spaces for localization of infection. Most of these fascial spaces communicate with one another, and after early localization in one space, the abscess eventually spreads to adjacent spaces. The most significant spaces to be affected are those that relate to the muscles and other tissues involved in functions such as swallowing and respiring, particularly tissues of the floor of the mouth and the neck. A febrile patient unable to swallow cannot take fluids for hydration or oral medications such as antibiotics and analgesics, and his general condition can deteriorate rapidly. When swelling begins to obstruct the free and easy passage of air, his condition is seriously compromised. Hospitalization and emergency care are essential. TREATMENT

• The patient may urgently require intubation or emergency tracheostomy. • Meanwhile, intravenous hydration and massive antibiotic therapy, such as 3 - 5 million units of crystalline penicillin G every 4 to 6 hours, are necessary, along with very close observation for airway distress.

6

Periodontal Emergencies

Postperiodontal Surgery It is normal to have slight bleeding, swelling, and tenderness immediately following periodontal surgery. To relieve pain the patient is usually given pain medication (Tylenol® #3, Demerol®, Percodan®) for the first 24 to 36 hours. Some practitioners administer prophylactic systemic antibiotics (tetracycline) to prevent infection by the oral microbiota that invade the surgical wound or injection sites. • A periodontal dressing is closely adapted around the teeth to hold the tissue flaps in position, protect the operated area, and provide patient comfort. • The patient is instructed not to chew on the surgical side or use a toothbrush in the area of the dressing. • The biting (occlusal) surfaces of the teeth should not be covered by the periodontal dressing itself; however, thin tinfoil is occasionally placed over the dressing to help hold it in place and allow the dressing material to "set up."

PAIN • After the first 24 hours, a patient should experience only minimal pain unless bone surgery was involved, particularly in the mandibular molar areas. Inquire as to whether the patient has been taking the prescribed pain medication. • Impingement from the periodontal dressing upon mucosal tissue, frenum areas, tongue, or floor of the mouth can cause severe ulcerations and discomfort. The dressing may interfere with chewing, and bruxism could create further problems. • Pain related to infection does not start until several days after the surgical procedure. Infection is also accompanied by lymphadenopathy, elevated temperature, and malaise. 71

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DIAGNOSIS

• Look for ulceration in the mucosal tissue around the margins of the dressing. • Palpate for lymphadenopathy. • Perform a percussion test on the teeth in the surgical area. TREATMENT

• Carefully remove the dressing from the surgical area by teasing it away from the teeth on the cheek and tongue sides separately (with college pliers or a curette) (Figs. 6-1, 6-2A, B). • If the patient has an infection, a systemic antibiotic (penicillin, erythromycin) should be prescribed for a m i n i m u m of 10 days. • Place a new dressing (Coe-Pak®) [see page 73) that will not interfere with the bite (occlusion) or soft tissues. Check for impingement by manipulating the lips and cheeks. • The patient should be instructed to consult his dentist for follow-up care as soon as possible.

¿sfyiwà—-

Fig. 6-1. Occlusal view of the periodontal dressing covering the facial and palatal aspects of the upper teeth. Note that it does not, and must not, cover the occlusal surfaces of the teeth. Dashed area outlined on the palatal aspect of the molars indicates a free gingival graft wound area beneath the dressing that m u s t be covered as indicated

LOSS OF PERIODONTAL DRESSING OR PACK Following surgery on the tissues surrounding the teeth, a dressing or pack is usually placed to cover and protect the surgical wound and provide patient comfort. Most dressings consist of zinc oxide and eugenol, with additional ingredients. There are rare reports of contact allergy from eugenol or dressings containing rosin. Noneugenol dressings have also been known to produce allergic responses. A popular noneugenol dressing that is well-accepted by patients is Coe-Pak® (Coe Laboratories,

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PERIODONTAL EMERGENCIES

Chicago). It is supplied in two tubes so that equal lengths of paste can be mixed and used immediately. Trauma to the surgical site, due to manipulation by the tongue, excessive expectoration, bleeding, and the like, may cause the periodontal dressing to be removed or lost by the patient. SYMPTOMS

• The patient may complain of irritation and sensitivity in response to foods, thermal changes, air, or tongue movements. EXAMINATION

• Make sure that no foreign objects or food debris have become wedged between teeth or under the tissue flaps. • The area can be syringed with warm water to remove oral debris. • Determine whether there are any signs of infection. TREATMENT

• Place equal lengths of Coe-Pak® paste on a sheet of mixing paper and mix until it begins to thicken. • Place Vaseline® on the fingers to prevent the paste from sticking, and mix the Coe-Pak® paste until a putty-like consistency is achieved; from this material, make two small strips equal to the length of the surgical site. , / x

A

Fig. 6-2A. Note sutures located between the teeth which should not be removed when replacing the dressing. B. Note that the periodontal dressing does not extend over the occlusal portion of the tooth or beyond the depth of the facial vestibule.

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• Apply the first strip to the cheek side and then one to the tongue side of the teeth: gently press the material with the fingers on both sides of the teeth to join the pack between each tooth. • The pack should not be extended into the mucosa or onto the top of the teeth (Fig. 6-1, 6-2A, B). • Thin tinfoil can be placed over the dressing to allow it to harden without interference. • Instruct the patient to return to his dentist.

7

Orthodontic Appliance Problems

Orthodontic appliances are used to position the teeth in order to achieve esthetic and functional alignment of the dentition. These appliances may be either fixed to the teeth or removable. Only the dentist can remove the fixed appliance. The patient may accidently distort or break an appliance. The fixed appliance usually consists of metal tubes and brackets (attachments) welded to metal bands that are cemented to the teeth, or attachments directly bonded to the teeth. The attached brackets have a slot or slots into which archwires are placed, which provide the force to move the teeth. Although there are over 120 different types of brackets available, the most popular appliances are variations of the Edgewise and Begg appliances. Removable appliances are usually made of acrylic and wire: these appliances can create gingival (gum) injuries as a result of tissue impingement. Should a removable orthodontic appliance cause problems, it can be removed until the patient can see his orthodontist. During orthodontic treatment, there are few, if any, life threatening emergencies, but there are situations that can create significant discomfort for the patient if they occur. Whether a fixed or a removable appliance is involved, immediate and effective relief of the oral irritation can be provided.

Loose Bands or Bonded Attachments Stainless steel bands may work themselves loose, either because of chewing on hard objects or due to functional forces. Once the band is loose, the cement washes out rather quickly. Bonded attachments that separate from the tooth slip around on the arch wire and may irritate the gingiva as well as the cheek and lips. 77

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SYMPTOMS

• A loose band can collect food and debris that can be forced into the gingival area around the crown. • The tissue may be lacerated. The tissue will be reddened, sore to palpation, and damage to the enamel surfaces can occur if the condition is uncorrected for a long period of time. • Should caries develop under the band, it may cause sensitivity and pain from sweets, cold liquids, or air. EXAMINATION

• A loose band may look normal, clinically: place a curette at the band margin to test for movement when pressure is exerted: any movement of the band away from the tooth means that the band is loose. • Force air into the area of the band margin to check for sensitivity. • Move an explorer or curette under the band from its margin to check for caries. • Injured gingiva may apear swollen and red around the individual tooth. • A loose attachment can usually be identified by the patient; the attachment will slide along the archwire to which it is attached. TREATMENT

• Bands and bonded brackets are attached to the archwire by steel ligature wires, lock pins, or elastics: these can be removed by scissors or a small wire cutter to allow the band to be removed from the tooth or to allow a loose bonded bracket to be removed from the arch. • Gently curette inflamed gingival tissues to make sure that no foreign objects (cement, for example) remain lodged beneath the marginal tissue around the tooth. • Instruct the patient to rinse the area with warm water several times a day and after each meal, and not to chew in the area of the traumatized tissue. • Do not adjust the existing wire or appliance. • Instruct the patient to see his orthodontist as soon as possible.

Soft Tissue Damage Appliances can damage or impinge upon the soft tissue surrounding the teeth. Wires that contain looped configurations frequently irritate the cheeks or gingival tissue.

ORTHODONTIC APPLIANCE PROBLEMS

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SYMPTOMS

• The wire loops may become completely submerged beneath the gingival tissue. • Lacerations in the cheek may become infected and swollen. • Lymph nodes may become enlarged and tender. • Inflammatory redness, pain, and swelling may appear, especially if the area becomes superinfected. TREATMENT

• Administer local infiltration anesthetic around the involved area. • Cut the archwire several millimeters from where it enters the tissue as well as where it extends from beneath the tissue. • Remove the section of wire from the gingival tissue or mucosa. Usually sutures will not be necessary. • Remove the remaining two segments of the archwire from the brackets. • The need for analgesics and antibiotics should be determined by the severity of the infection. • Cheek and gingival lesions can be made comfortable by limited application of Negatan® to the ulcerated area with a cotton swab for 30 seconds to a minute. • Instruct the patient to return to his orthodontist for placement of a new archwire as soon as possible.

LIGATURE WIRES Ligature wires are thin, soft stainless steel wires used to secure attachments to archwires. The ligature wire is twisted around the bracket, leaving a 2 - 3 mm. excess "pigtail" that should be tucked under the archwire next to the wing of each bracket. If the pigtail is dislodged, it will protrude and irritate the cheeks, causing severe pain. SYMPTOMS

• Whitish, raised laceration or ulceration of the mucosa of the lips or cheeks. • Severe pain in the area of tissue irritation. EXAMINATION

• Run a finger along the main archwire to locate the protruding ligature wire. • Isolate the adjacent mucosal lesion with gauze.

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TREATMENT

• With a metal instrument, tuck the pigtail back under the archwire to prevent further irritation. • Use a cotton swab to place Negatan® on the cheek lesion to aid in patient comfort and healing.

COIL SPRINGS Coil springs are small sections of coil wire that are placed on the main archwire to close or open space between adjacent teeth. The ends of the coil may roll out and irritate the cheek. SYMPTOMS

• There will be soreness in the area of the ulceration. The patient may not be able to tell you exactly what is causing the problem, but will be able to locate the sharp wire. • The protruding portion of the coil may not be visible to the eye: a small whitish lesion will appear on the cheek. TREATMENT

• Place soft wax over the protruding coil wire. • Use a cotton swab to place Negatan® on the ulcerated cheek. • Instruct the patient to see his orthodontist as soon as possible.

OVEREXTENSION OF ARCHWIRE Chewing and bruxism can cause the archwire to work around the arch and protrude from the last tooth into the cheek in the back of the mouth. SYMPTOMS

• The archwire will extend several millimeters beyond the last molar tube and a whitish lesion will appear in the cheek. • There will be considerable pain and there may be limitation upon opening. The damaged tissue may even become infected. TREATMENT

• Cut off the offending end of wire. • Place soft wax over minimally extended wires. • The ulcerated area can be medicated with Negatan® to make the lesion less painful during healing.

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• The patient should be instructed to see his orthodontist immediately to prevent improper forces from being delivered by the shifted wire.

Broken or Bent Appliances Occasionally a patient may receive trauma to the mouth that will deform or distort the archwires. SYMPTOMS

• The main arch may be broken, deformed, or protruding into the cheek and gingival tissues. • There will be soreness and pain in the areas of wire impingement. TREATMENT

• Remove the remaining portions of the archwire, if it is broken. A distorted wire should be removed, as well, to prevent adverse forces to the dentition. • If the archwire cannot be removed, protruding portions should be bent back toward the teeth to prevent further soft tissue injury. • Irritated areas can be medicated with Negatan®. • The patient should be instructed to see his orthodontist immediately for a new archwire placement.

Local Anesthetic Techniques

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The ability to use local anesthetics effectively will materially improve the treatment of emergencies of the mouth and related structures. The following list gives some examples of the diverse procedures in which good local anesthesia is an important element of patient care. • Exploration and repair of lacerations of soft tissues of the lips, cheeks, and other oral soft tissues. • Replacement and stabilization of displaced teeth and alveolar process. • Placement of arch bars for intra-arch and inter-arch stabilization. • Provision of temporary relief for acute toothache pain. Incision and drainage of localized abscesses. • Procedures in the arrest of persistent bleeding following tooth extraction or periodontal surgery. • Reduction of stubborn condylar dislocation.

Anesthetic Agents Used For effective and safe local anesthetics, most dentists prefer either 2% lidocaine (Xylocaine®) with 1:100,000 epinephrine or 2% mepivacaine (Carbocaine®) with 1:20,000 Neo-Cobefrin®. When they need agents without a vasoconstrictor, they most often select 3% mepivacaine or 4% prilocaine (Citanest®). The added vasoconstrictor (epinephrine, NeoCobefrin®) delays vascular absorption of the agent, thereby reducing toxicity and improving the depth and duration of infiltration anesthesia. The attendant reduction in local bleeding is often valuable in improving operating conditions or controlling persistent bleeding. The accepted safe dosage of lidocaine, for example, is 400-500 mg., which would be the equivalent of 20 to 25 ml. of the 2% solution given subcutaneously at any one time. When large amounts of solution must be injected, it is best to spread the injections out over a period of time and include the vasoconstrictor if there are no contraindications to its use. The dosage for children is proportionately less, according to body weight.

Armamentarium The dental carpule syringe is useful for intraoral work: it is long and slim and permits easy access for angulation of the needle and for the deeper injections (Fig. 8-1). Larger syringes, up to a 10 cc. Luer-Lok syringe, can be used with reasonable facility, but injection into dense fibrous tissues becomes increasingly difficult with larger bore syringes. Needles used are generally 25- to 27-gauge, approximately 1 inch and

LOCAL ANESTHETIC TECHNIQUES

1 Vi inches Carpules 50 carpules in multiple

85

long; the latter is useful for deeper block injections. with 1.8 ml. of anesthetic solution are available in cans of for use with the carpule syringe. Several agents are available dose vials and ampules.

Fig. 8-1. Dental aspirating syringe with carpules of local anesthetic solution. The needles shown are 25 gauge short and long disposable dental needles.

Contraindications and Precautions Certain circumstances may preclude the use of local anesthetics or require modification of usual drugs and techniques. • Patients too young to accept local anesthetic injections. • Uncooperative patients of any age. • Injuries too extensive for repair under local anesthesia. In the above instances, general anesthesia would be desirable. • Patients with a history of allergy to local anesthetics or the methylparaben preservative used with most local anesthetics. Mepivacaine does not contain methylparaben. • Patients with a history of frequent angina, significant arrhythmias, or thyrotoxicosis, who may be adversely affected by the epinephrine contained in local anesthetic solutions. In these instances, we suggest the use of agents without the vasoconstrictor; or the addition of NeoSynephrine®, which has no significant cardiac effects, although a large amount may raise blood pressure and result in reflex bradycardia. • Infected tissues that require minor surgical procedures. Anesthesia by local infiltration will probably be unsatisfactory and result in spreading infection: block anesthesia is preferred in most cases. Local infil-

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tration of tissues overlying an abscess cavity is often useful prior to incision and drainage.

Anatomical Review (Refer to Fig. 8-2) MAXILLARY DIVISION OF TRIGEMINAL NERVE The maxillary division of the trigeminal nerve provides sensory nerve supply to the maxilla and its associated structures, including the maxillary sinuses, hard and soft palate, teeth, alveolar bone and mucoperiosteum, lower eyelid, anterior cheek and upper lip, and the skin along the side of the nose. • Leaving the cranium via the foramen rotundum, the maxillary division passes across the sphenopalatine fossa. • While the nerve is within the fossa, it gives off branches to the sphenopalatine ganglian (Meckel's ganglion), from which the major nerves continue to the hard and soft palate: included in these nerves is the nasopalatine nerve, which passes forward within the nasal cavity and enters the oral cavity, passing down through the nasopalatine canal, palatal to the central incisor teeth, to supply the mucosa of the hard palate from canine to canine. • The anterior or greater palatine nerve passes downward through the posterior palatine canal to exit through the greater palatine foramen and turns forward to supply the mucoperiosteum and gingival tissues on the palatal aspect of the molar and bicuspid teeth. • Other smaller branches, the lesser palatine nerves, follow a similar path downward, but exit through minor foramina behind the greater palatine foramen to distribute sensory fibers to the soft palate. • While still in the sphenopalatine fossa, the maxillary division gives rise to posterior superior alveolar branches, which enter the maxillary bone above the tuberosity, innervating the three upper molar teeth and their bony and soft tissue investments. • Having given rise to the above-described branches from within the sphenopalatine fossa, the main branch of the nerve passes forward through the inferior orbital fissure and enters the infraorbital canal, running along the orbital floor. • Middle and anterior superior alveolar nerves, which provide innervation to the premolar and anterior teeth respectively, run within the lateral and anterior walls of the maxillary sinus. • Finally, the infraorbital nerve exits through the infraorbital foramen, and its terminal distribution is to the upper lip, cheek, nose and lower eyelid. An overlapping of contralateral sensory nerve supply to bone and soft tissues occurs as the midline is approached.

LOCAL ANESTHETIC TECHNIQUES

Fig. 8-2.

87

Maxillary and mandibular distribution of the trigeminal nerve

MANDIBULAR DIVISION OF TRIGEMINAL NERVE

The mandibular division exits from the cranium through the foramen ovale, and in addition to motor branches to numerous muscles, it gives rise to four main sensory branches: buccal, lingual, inferior alveolar, and auriculotemporal. • The long buccal nerve passes forward in the substance of the cheek, and its branches perforate the buccinator muscle to supply the entire mucosa of the cheek forward to the region of the commissure of the lips. Here it supplies sensory fibers to the skin, as well. In addition, the mandibular molar gingivae are supplied in the molar region. • The lingual nerve passes forward in the floor of the mouth along the lingual aspect of the second and third molar teeth. Here it is quite superficially located beneath the mucosa. Passing forward, it innervates the tissues of the floor of the mouth and the lingual gingival tissues. It passes in a medial direction beneath the submaxillary duct to reach the tongue, where it provides sensory supply to the mucous

88

SECTION 8

membrane and substance of the tongue forward of the circumvallate papillae. • The inferior alveolar nerve enters the mandibular foramen on the medial surface of the ramus and runs forward within the inferior alveolar canal. From within the canal it gives origin to sensory fibers passing to the dental pulps, alveolar bone, and gingival tissues. A branch, the mental nerve, exits at the mental foramen to supply the skin and mucous membrane of the lower lip and branches to the labial alveolar mucosa. • The auriculotemporal nerve enters the parotid gland and divides into two branches. One branch supplies innervation to the region of the temporomandibular joint, the outer ear, and the skin in the greater posterior part of the temple. The other branch distributes filaments to the skin of the posterior cheek.

Injection Techniques ANTERIOR SUPERIOR ALVEOLAR NERVE INFILTRATION (FIGS. 8-3A, B, C, AND D) The anterior superior alveolar nerve may be infiltrated to produce anesthesia of the dental pulps, the supporting alveolar bone, and labial soft tissues of the anterior teeth. In addition, the mucosa and skin of the upper lip will be anesthetized. As the midline is approached, there will be overlapping innervation from the contralateral side. TECHNIQUE

• Using a short needle and a puncture point just mesial to the bulge of the canine root, 1 - 2 ml. of the solution is deposited close to bone near the canine apex. • This injection may be given bilaterally to effect anesthesia for the six anterior teeth and supporting structures, or it may be supplemented at the midline if only one side is to be subjected to a surgical procedure. • Alternatively, each tooth may be infiltrated close to its apex using 0.75 to 1.0 cc. for each. • The palatal mucosa will require a separate block of infiltration anesthesia if it will be involved in the surgical procedure.

INFRAORBITAL NERVE BLOCK (FIGS. 8-4A, B, AND C) When inflammation or infection precludes effective infiltration in the region of the anterior maxillary alveolar bone, the infraorbital block

89

LOCAL ANESTHETIC TECHNIQUES

A

Fig. 8-3A. Anterior superior alveolar nerve branches. B. and C. Injection technique for anterior superior alveolar nerve infiltration. D. Approximate area of anesthesia of facial soft tissues and dentoalveolar structures

Β

90

SECTION 8

A

Β

Fig. 8-4A and Β. Infraorbital injection technique. C. Approximate area of anesthesia of facial soft tissues and dentoalveolar structures

LOCAL ANESTHETIC TECHNIQUES

91

injection will be valuable. If the solution is deposited within the canal, the anterior and middle superior alveolar nerves will be blocked and there will be anesthesia of the tissues of the lower eyelid, anterior cheek, upper lip, and ala of the nose. TECHNIQUE

• The infraorbital foramen is located below the infraorbital rim directly beneath the palpable rough suture line joining maxilla to zygoma, or directly below the pupil of the eye as the patient looks straight ahead. A palpating finger is kept over the foramen while the lip is lifted. • Puncture is made with a long needle opposite the apex of the second premolar tooth and 5 mm. out into the mucobuccal fold so that the needle will bridge the canine fossa in its path to the foramen. • Depositing the solution in short bursts helps to locate the needle beneath the tip of the palpating finger, and when the tip of the needle is located at the foramen, pressure is maintained with the palpating finger as 1.5 cc. of solution is deposited. • Should surgery involve structures close to the midline, overlapping innervation must be blocked, and if palatal soft tissue is involved, it must also be anesthetized.

Fig.8-5. Injection site for maxillary supraperiosteal infiltration

MAXILLARY SUPRAPERIOSTEAL INFILTRATION (FIG. 8-5) Supraperiosteal injections may provide adequate pulpal anesthesia for procedures involving incisor, premolar, and molar teeth in the maxilla. If

92

SECTION 8

palatal mucosa is to be involved in the surgery, it must also be anesthetized. Occasionally, bone constituting the zygomatic process of the maxilla and overlying the roots of the upper first molar is too dense and prominent to permit effective supraperiosteal infiltration anesthesia. In these cases, the posterior superior alveolar nerve is blocked at the tuberosity (see the following section, Posterior Superior Alveolar Nerve Block).

POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK (FIGS. 8-6A, B, AND C) This injection places the anesthetic solution in direct contact with the nerve trunks before they enter the bone to form the nerve plexus supplying the maxillary molars. This usually provides a depth and duration of anesthesia superior to that gained by diffusion of the solution after simple supraperiosteal infiltration over molar apices.

Figs. 8-6A and B. Injection technique for posterior superior alveolar nerve block. C. Approximate area of anesthesia of dentoalveolar structures and cheek tissues (by diffusion)

LOCAL ANESTHETIC TECHNIQUES

93

TECHNIQUE

• The puncture is made with a 1-inch needle in the mucobuccal fold opposite the distobuccal root of the second molar, directing the needle approximately 45° medially and upward to a depth of about 2 cm. • Staying close to the bone of the posterolateral surface of the maxilla, 1.5 cc. may be deposited. • A deeper injection angled slightly more medially may provide a complete block of the second division of the trigeminal nerve. • With the posterior superior alveolar injection, supplemental anesthesia will be required for surgical procedures involving the palatal mucosa, and infiltration will be necessary over the mesiobuccal root of the first molar.

NASOPALATINE NERVE BLOCK (FIGS. 8-7A, B, AND C) The nasopalatine nerve supplies palatal soft tissues and bone approximately anterior to a line drawn from the distal aspect of one canine to the distal aspect of the other canine. At these margins, supplemental innervation usually comes from branches of the greater palatine nerves, requiring additional anesthetic infiltration to cover the overlap. TECHNIQUE

The nasopalatine nerves may be blocked as they exit the foramen by slowly injecting 0.25 cc. of solution alongside and slightly behind the incisive papilla located in the midline behind the central incisor teeth. • Alternatively, tissues on either side of the midline may be infiltrated as needed. • Blanching of the tissues should be evident.

GREATER PALATINE NERVE BLOCK (FIGS. 8-8A, B, AND C) The posterior two-thirds of the soft tissue and bone of the hard palate is innervated by the greater palatine nerves, which run forward after exiting from the greater palatine foramen. The foramen is in a recess of the palatal vault located about one-half of the distance from the gingival margin of the second molar to the palatal midline. Here it is surrounded by glandular and fatty tissues. Lesser foramina located posteriorly transmit other palatine nerve filaments to innervate the soft palate.

TECHNIQUE

• About 0.25 cc. of solution is deposited well beneath palatal mucosa at the foramen or at any point along the course of the nerve proximal to the field of operation. • Excessive solution deposited posteriorly may produce anesthesia of the soft palate and gagging. • The foramen may be entered with the long needle, passing up the pterygopalatine canal with the intent to anesthetize the entire second division of the trigeminal nerve in the pterygopalatine fossa.

MANDIBULAR AND LINGUAL NERVE BLOCKS (FIGS. 8-9A, B, AND C) Because of the dense, nonporous nature of the buccal bone in the molar and premolar regions of the mandible, supraperiosteal infiltration is inadequate, particularly for the molar teeth. The mandibular block

LOCAL ANESTHETIC TECHNIQUES

95

injection is an effective procedure that provides anesthesia of dental pulps to the midline of the mandible and, in combination with long buccal and lingual nerve blocks, provides anesthesia of the soft tissues and bone almost to the midline. The lingual nerve is commonly blocked during administration of the mandibular block injection, while the long buccal injection is usually given separately. The cheeks, lower lip and chin, anterior twothirds of the tongue, floor of the mouth, mandibular teeth, bone, and gingival tissues may be anesthetized by use of bilateral mandibular, lingual, and long buccal nerve blocks, which makes these valuable injection techniques.

96

SECTION 8

TECHNIQUES

• With the jaw opened maximally, the deepest concavity on the anterior lateral border of the ramus of the mandible, termed the coronoid notch, is palpated with the index finger. The midpoint of this notch, approximately 1 cm. above the occlusal level of the molar teeth, is at the same level as the mandibular foramen and constitutes the vertical reference for the injection. • The syringe should lie approximately over the contralateral canine tooth, and the 1.5-inch long needle enters the tissue close to the nail of the palpating finger and lateral to a vertical soft tissue elevation, the pterygomandibular raphe. • Early contact should be made with bone at the internal oblique ridge, and some anesthetic fluid deposited in its vicinity will reduce injection discomfort and diffuse to block the nearby lingual nerve. • The needle is then advanced, staying close to the medial surface of the ramus for an additional 1 5 - 2 0 mm., at which time two-thirds— about 1 inch—of the needle is buried in the tissues. • Approximately 1.5 cc. of anesthetic solution is deposited at this point and this will usually provide profound mandibular block anesthesia. • The patient will be aware of loss of sensation in the lip and chin on that side and the teeth will feed "wooden" as they are brought together. • Objective testing for response to pressure from the edge of an instrument or fingernail in the sensitive mental foramen area will provide information about the depth of anesthesia. • About 5 minutes should pass before assessing depth, and if subjective and objective signs of anesthesia are developing poorly, the block should be repeated, perhaps at a slightly higher level with attention to detail. • Children who have received a mandibular block should be warned against biting the numb lip.

MENTAL NERVE BLOCK (FIGS. 8-10A AND B) This injection, given at the mental foramen, provides anesthesia of the pulps and supporting structures of the premolar and anterior teeth by blocking the incisive branch of the inferior alveolar nerve. By blocking the other terminal branch of the inferior alveolar nerve—the mental nerve, anesthesia of the lip and chin also results. While the latter invariably occurs, anesthesia of the incisive branch can only be dependably obtained by entering the foramen for a short distance. Supplemental

LOCAL ANESTHETIC TECHNIQUES

97

A Figs. 8-9A and B. Injection technique for mandibular and lingual nerve blocks. C. Approximate area of anesthesia of lip, chin, tongue, and dentoalveolar structures

Β

98

SECTION 8

A

Β

Figs. 8-10A and B. Injection technique for mental nerve block

infiltration of the lingual nerve in the floor of the mouth near the alveolar bone will be necessary when the surgical procedure involves the lingual gingival tissues. As the midline of the mandible is approached, there is a crossing-over of innervation to bone and soft tissues both labially and lingually, often requiring supplemental injections. TECHNIQUE

• Drawing the cheek laterally, the 1-inch needle penetrates the vestibular tissues about 8 - 1 0 mm. from the lateral bony surface and is advanced at about a 45° angle downward and somewhat forward until it contacts the bone just below the apex of the second premolar. • The position of the foramen is variable and may not always be detected by palpation prior to injection. Therefore, after depositing a small amount of solution to reduce pain, carefully explore with the needle tip to try to enter the foramen. • Depositing about 1 cc. of solution within the mental foramen should provide profound anesthesia of the two terminal branches of the inferior alveolar nerve.

LONG BUCCAL NERVE INJECTION (FIGS. 8-1 ΙΑ, B, AND C) Leaving the mandibular division of the trigeminal nerve, the buccal nerve passes from medial to lateral across the anterior margin of the

99

LOCAL ANESTHETIC TECHNIQUES

mandibular ramus at or slightly above the depth of the coronoid notch. It passes on the outer surface of the buccinator muscle with multiple branches perforating the muscle to supply cheek mucosa and molar gingiva. TECHNIQUE

• This nerve may be blocked by penetrating cheek mucosa and buccinator muscle and depositing 0.25 to 0.5 cc. of solution as the nerve crosses the ramus, or it may be infiltrated at any point along its course. • The tissues adjacent to the molar teeth are usually infiltrated to anesthetize nerve filaments locally for surgical procedures. In any event, the injection must always be proximal to the operative site.

A

Β

Figs. 8-11A and B. Long buccal nerve injection technique. C. Approximate area of anesthesia of gingival and buccal soft tissues

C

100

SECTION 8

MANDIBULAR SUPRAPERIOSTEAL INJECTION (FIGS. 8-12A, AND B) The mandibular anterior teeth, and in the younger patient even the mandibular first premolar or deciduous molar, may sustain adequate anesthesia of the dental pulp and supporting structures by depositing solution supraperiosteally in the vicinity of the individual root apex. TECHNIQUE

• The 1-inch needle penetrates the mucolabial fold, advancing at a tangent to the alveolar bone surface to glide over the periosteum with bevel facing the bone. • Close to the bone at the level of the root apex, 1 - 2 cc. of solution should provide good pulpal and labial alveolar anesthesia. • Lingual supplementation will be required if lingual soft tissues are involved, and this is best achieved by injecting 0.5 cc. into the floor of the mouth close to where it reflects upward onto the lingual surface of the mandible.

A

Β

Fig. 8-12A. Inferior dental nerve distribution. B. Mandibular supraperiosteal injection technique

Anesthesia for Lacerations A laceration located in tissues served by sensory nerves that can be effectively blocked at a distance from the laceration is often best handled initially in that manner. Subsequent to gaining regional anesthesia, the

LOCAL ANESTHETIC TECHNIQUES

101

injured tissues may be directly infiltrated without pain if local hemostasis is to be provided. Local infiltration does produce tissue distortion and where cosmetic results are important it is helpful to keep distortion of the wound to a minimum. Where regional nerve blocks cannot be obtained, it is desirable to anesthetize by infiltration or to field block the side of the wound closest to the regional nerve supply first for greatest patient comfort during subsequent injections. One should avoid puncturing the skin if access can be obtained via a wound margin to subepidermal layers. Injection into the dermis is to be avoided, as the subcutaneous tissues are looser and injection here is less painful. Slow injection is less painful and causes less disruption and distortion of tissues than does rapid injection. REFERENCE:

Bennet, R.C. Monheim's Local Anesthesia and Pain Control in Dental Practice, 6th ed. St. Louis: The C.V. Mosby Company, 1978.

9

Radiography

In 70 percent of automobile accidents there are facial injuries, and fractures occur in 10 percent of these injuries. Hospital emergency services, together with their radiology departments, have established a standard series of projections for certain suspected injuries. For example: SKULL SERIES

1. 2. 3. 4.

Lateral, stereo PA, stereo Towne Base view

MAXILLOFACIAL SERIES

1. 2. 3. 4. 5. 6.

Waters Lateral Caldwell Oblique views of both orbits Tangential zygomatic arch Tomograms, as indicated

TMJ SERIES

1. 2. 3. 4.

Transcranial Transpharyngeal Oblique AP Tomograms, lateral and/or PA To these we would add certain projections for injuries of the teeth and tooth-supporting regions of the maxilla and mandible: 1. Panoramic projection 2. For right and left body and ramus of mandible, and premolar and molar teeth: oblique lateral mandible projection 3. For mandibular symphysis bone and anterior teeth: symphysis occlusal projection 4. For floor of mouth and topographic view of dental arch, Wharton's 105

106

SECTION 9

duct, tongue, genial tubercle: floor-of-mouth occlusal projection 5. For roof of mouth and maxillary incisor teeth: maxillary midline occlusal projection 6. For maxillary molars and tuberosity: maxillary molar occlusal projection

Intraoral Occlusal Projections FILMS For adults, the Kodak Occlusal film, DF-45 feat. #1499482), is employed. For views of the incisor teeth of children, the maxillary midline and/or mandibular symphysis techniques are used with # 2 size periapical film packets (Kodak DF-58, Cat. #1491737). These are both intraoral type films, sealed in light-proof and moisture-proof packets. The occlusal film is about 2 Ά χ 3", while the periapical is 35 mm. size. Printing on the nontube side of the packet states "Opposite Side Toward Tube." They are ultra-speed, double emulsion films, 2 films in each occlusal packet, 1 film in each periapical packet. PROCESSING These films may be processed in dental automatic processors or may be hand developed in tanks, using dental film hangers, for 4lA to 5 minutes at 68°F. For processing in the RP X-Omat 90-second processor, the following technique is suggested. Tape the short end of the occlusal or periapical film to the 17" edge of a used 14" χ 17" film (Fig. 9-1). Overlap the edge of the intraoral films about lA" over the 14" χ 17" film, taping them with plastic electrical tape stretched tightly; edge-to-edge taping promotes jamming. Feed the large film into the processor with the dental filmjs) trailing. One transit will not clear the films; therefore, lift the processor cover and feed the film through the fixer a second time. EXPOSURE TECHNIQUES FILM PLACEMENT

For all techniques, maxillary and mandibular, the mouth is opened slightly ( W to Vi") and the packet is guided gently over the occlusal surfaces of the teeth as far back as possible, making certain that the tube side of the packet faces the tube. The patient closes the teeth to retain the film, or uses finger pressure. With children, the periapical packet is placed sideways with the outer edge under the biting edge of the incisors and the patient bites on the packet to immobilize it.

107

RADIOGRAPHY

•

Fig. 9-1. Attachment of periapical (p) and occlusal (o) films in darkroom to 14 χ 17 film. Note slight overlapping of dental films and tight taping with plastic electrical tape on 17" side. The opposite edge of the 14 χ 17 film feeds into the X-Omat. The projection techniques will be described for both the seated (in a dental-type chair, wheel chair,* or straight-backed chair, using a head rest or other firm support—a wall will do—for the head), and the supine table positions. MANDIBULAR SYMPHYSIS

Point of Entry: Midline, at lower border of mandible Exposure: 20 mAs, 65kVp, 16" source-skin distance (SSD) Seated Position: Tilt chin up until occlusal plane is 45° to floor Vertical tube angle: - 20° to a plane parallel with the floor (Fig 9 - 2 A ) " R . A . Carson, Stable head support for the wheelchair patient, f. Hosp. (Oct. 1970): 112.

Dent.

Pract.

4

108

SECTION 9

Supine Position: Occlusal plane 90° to table top Vertical tube angle: 25° to table top (Fig. 9-2B) Horizontal tube angle: Through midsagittal plane for both seated and supine positions

Β

Fig. 9-2A. Mandibular symphysis occlusal projection, plane of film ( f c e n t r a l ray is solid arrow. B. The same projection with patient lying on table (t) MANDIBULAR FLOOR-OF-MOUTH AND TOPOGRAPHICAL VIEW OF MANDIBLE (FIG. 9-3)

Point of Entry: Midline, 1" posterior to lower border of mandible Exposure: 20 mAs, 65kVp, 16" SSD

RADIOGRAPHY

109

Seated Position: Head tilted posteriorly until occlusal plane is 90° to floor Vertical tube angle: parallel with floor Supine Position: Occlusal plane 90° to table top Vertical tube angle: parallel with table Horizontal tube angle: Through midsagittal plane for both seated and supine positions

MAXILLARY MIDLINE

Point of Entry: Nasion (bridge of nose) Exposure: 16 mAs, 65 kVp, 16" SSD; (4mAs with 8" dental cone) Seated Position: Occlusal plane parallel with floor Vertical tube angle: 65° to floor (Fig. 9-4A)

film (f) parrallel with floor, CR 65° to film. B. Same projection for patient lying on table (t)

110

SECTION 9

Supine Position: Occlusal plane 90° to table Vertical tube position: 25° to table, caudally (Fig. 9-4B) Horizontal tube angle: Through midsagittal plane for both seated and supine positions MAXILLARY MOLAR

Point of Entry: Outer canthus Exposure: 20 mAs, 65 kVp, 16" TFD ; (4 mAs for 8" SSD) Seated Position: Occlusal plane parallel with floor Vertical tube angle: 65° to floor (Figs. 9-5A and B) Supine Position: Patient lies on (opposite) side, midsagittal plane parallel with table top Vertical tube angle: 25° to table caudally (Figs. 9-5C and D) Horizontal tube angle: 90° to midsagittal plane, 90° to table top

RADIOGRAPHY

Fig. 9-5A. Maxillary molar occlusal projection, frontal view of seated patient, CR enters at outer corner of eye. B. View of top of head showing horizontal projection of CR at 90° to midsagittal plane. C. Patient lying on (opposite) side on table (t). D. View from top of head showing CR

D

Appendices

Glossary

Appendix A Development of the Human Dentition

DECIDUOUS DENTITION

* »'

I

o

2 years ( ± 6 mos.)

5 months in utero 7 months in utero

PRENATAL

3 years ( ± 6 mos.) Birth « «e

r

'

^

6 mos. ( ± 2 mos.

4 years ( ± 9 mos.)

9 mos. ± 2 mos.) 5 years ( ± 9 mos.) 1 year ± 3 mos.

6 years ( ± 9 mos.)

18 mos. 3 mos.)

INEANCY

114

EARLY CHILDHOOD (PRE-SCHOOL AGE)

PERMANENT DENTITION

M I X E D DENTITION

%

11 years ( ± 9 mos.

7 years ( ± 9 mos.)

12 years ( ± 6 mos.) 8 years ( ± 9 mos.)

15 years ( ± 6 mos.)

9 years ( ± 9 mos.)

21 years

35 years

10 years ( ± 9 mos.)

LATE CHILDHOOD (SCHOOL AGE)

ADOLESCENCE and ADULTHOOD

115

Appendix Β Iboth Terminology and Identification

PERMANENT DENTITION: 32 teeth 1 Maxillary right third molar (wisdom tooth) 2 Maxillary right second molar (12-year molar) 3 Maxillary right first molar (6-year molar) 4 Maxillary right second premolar (bicuspid) 5 Maxillary right first premolar (bicuspid) 6 Maxillary right canine (cuspid) ("eye tooth") 7 Maxillary right second (lateral) incisor 8 Maxillary right first (central) incisor 9 Maxillary left first (central) incisor 10 Maxillary left second (lateral) incisor 11 Maxillary left canine (cuspid) ("eye tooth") 12 Maxillary left first premolar (bicuspid) 13 Maxillary left second premolar (bicuspid) 14 Maxillary left first molar (6-year molar) 15 Maxillary left second molar (12-year molar) 16 Maxillary left third molar (wisdom tooth) 17 Mandibular left third molar (wisdom tooth) 18 Mandibular left second molar ( 12-year molar) 19 Mandibular left first molar (6-year molar) 20 Mandibular left second premolar (bicuspid) 116

APPENDIX Β

21 22 23 24 25 26 27 28 29 30 31 32

Mandibular Mandibular Mandibular Mandibular Mandibular Mandibular Mandibular Mandibular Mandibular Mandibular Mandibular Mandibular

117 left first premolar (bicuspid) left canine (cuspid) ("stomach tooth") left second (lateral) incisor left first (central) incisor right first (central) incisor right second (lateral) incisor right canine (cuspid) ("stomach tooth") right first premolar (bicuspid) right second premolar (bicuspid) right first molar (6-year molar) right second molar ( 12-year molar) right third molar (wisdom tooth)

DECIDUOUS (PRIMARY, "BABY", "MILK" TEETH): 20 teeth A Β C D E F G H I J Κ L M Ν O Ρ Q R S Τ

Maxillary right deciduous second molar Maxillary right deciduous first molar Maxillary right deciduous canine Maxillary right deciduous second incisor Maxillary right deciduous first incisor Maxillary left deciduous first incisor Maxillary left deciduous second incisor Maxillary left deciduous canine Maxillary left deciduous first molar Maxillary left deciduous second molar Mandibular left deciduous second molar Mandibular left deciduous first molar Mandibular left deciduous canine Mandibular left deciduous second incisor Mandibular left deciduous first incisor Mandibular right deciduous first incisor Mandibular right deciduous second incisor Mandibular right deciduous canine Mandibular right deciduous first molar Mandibular right deciduous second molar

Appendix C Medicaments to Have on Hand

Benadryl®, 50 mg. tabs (Parke, Davis & Co.) Benadryl®, 5 mg/ml. (Parke, Davis & Co.) Diclonine Hydrochloride (Dyclone® Solution 0.5%—Dow) Triamcinolone acetonide in emollient paste (Kenalog® in Orabase®—Squibb) Xylocaine® Viscous (Astra) Xylocaine® Ointment, 5% Negatol 45%, astringent and hemostatic (Negatan®, Savage Labs.) Anbesol, over-the-counter at drug store Orabase® with benzocaine (Hoyt) Benzodent® (Vick) Dycal® kit, calcium hydroxide (L. D. Caulk Co., Division of Dentsply International, Inc.) Eugenol, U.S.P., 2 fl. oz. btls. (Moyco—}. Bird Moyer Co., Inc.) Zinc oxide powder, U.S.P. (J. Bird Moyer Co., Inc.) ZOE 2200, fast setting sedative dressing (L. D. Caulk Co., Division of Dentsply International, Inc.) Surgicel®, oxidized cellulose gauze Avitene®, microfibrillar collagen Iodoform gauze Talbot's iodine* TALBOT S IODO-GLYCEROL

zinc oxide water iodine glycerine

118

12 8 20 40

gm. cc. gm. cc.

Dissolve zinc oxide in the water, add iodine, and when completely dissolved, add the glycerine

Appendix D Materials and Instruments to Have on Hand

Mirrors; dental mouth mirrors with handles # 4 (American Dental Mfg. Co.) Explorers, # 2 3 (American Dental Mfg. Co.) Excavator, # 3 3 L (Star Dental Co.) Pliers, wire cutting Coe-Pak® (Coe Laboratories, Chicago) Base plate wax (Moyco #1—J. Bird Moyer Co., Inc.) Temporary stopping (J. Bird Moyer Co., Inc.) Orthodontic tray wax sticks, box 48 (Hygienic Dental Mfg. Co.) Vaseline® Tinfoil, adhesive, 100 sheet pkg. (Burlew DRYFOIL, Jelenko Division of Pennwalt) Cotton pellets, assorted sizes (Richmond Dental Cotton Co.) Cotton rolls, size # 2 , 1.5 in. (Richmond Dental Cotton Co.) Emery boards, fingernail (dime store, pharmacy) Clear nail polish (dime store) Plastic electrical tape (hardware store) Radiographic film, dental # 2 periapical—Kodak DF-58, cat. #1491737. Occlusal—Kodak DF-45, cat. #1499482. Wire, splinting; 25 or 26 gauge stainless. Obtainable from local dental supply stores.

119

Appendix E References for the Emergency Room Bookshelf

American Dental Association. Accepted Dental Therapeutics. 1982, ed. 39. 211 E. Chicago Ave., Chicago, IL 60611. Goldman, H. M., and Cohen, D. W. Periodontal Therapy. 6th ed. St. Louis: The C. V. Mosby Company, 1980. McCarthy, F. M. Management of Oral Emergencies. 3d ed. Philadelphia: W. B. Saunders Company, 1979. Waite, D. E. Textbook of Practical Oral Surgery. 2d ed. Philadelphia: Lea & Febiger, 1978. Wood, N. K., and Goaz, P. W. Differential Diagnosis of Oral Lesions. 2d ed. St. Louis: The C. V. Mosby Company, 1980. Wuehrmann, A. H., and Manson-Hing, L. R. Dental Radiology. 5th ed., 1981. St. Louis: The C. V. Mosby Company, 1977. Zook, E. G. The Primary Care of Facial Injuries. Littleton, MA: PSG Publishing Company, 1980.

120

Glossary

alveolar process (bone)—the bony processes of the maxilla and mandible in which the teeth are embedded alveolectomy—surgical removal or recontouring of the alveolar bone alveolus—tooth socket within the alveolar process amalgam—a dental restoration (filling) composed of a silver alloy and mercury apex, root—the end of a tooth root; nerves and vessels pass through the apical foramen into the dental pulp band—a metal band cemented to a tooth, used to anchor orthodontic archwires, coils, etc. braces—lay term for orthodontic appliances bruxism—grinding (gnashing) of the teeth, usually during sleep buccal—pertaining to the cheek (as buccal mucosa) calculus, salivary—calcified substances that build up on tooth surfaces. Also referred to as "tartar" caries, dental—tooth decay cementum—the thin calcified substance that coats the root surfaces of teeth crown, artificial—a metallic, porcelain, or plastic restoration that replaces a natural tooth crown crown, clinical tooth—the part of a tooth appearing in the oral cavity, composed of dentin and covered by enamel deciduous dentition—the primary dentition (baby teeth), 20 in number (8 incisors, 4 canines, 8 molars) dentin—the (tubular) calcified substance comprising the bulk of the crown and root(s) of a tooth dentition—the complement of natural teeth denture—artificial teeth replacing lost teeth. A full or complete denture replaces all natural teeth, while a partial denture replaces several lost teeth enamel—the hard outer substance of a tooth crown gingivae—the gum tissues inlay—a type (usually gold) of dental restoration (filling) labial—pertaining to the lips lamina dura—the hard lining of a tooth socket; it is perforated to hold the fibers of the periodontal ligament that suspend the tooth in the socket mandible—the lower jaw maxilla—the upper jaw mucobuccal fold—the sulcus between the gums and cheeks

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GLOSSARY

"nerve"—see pulp, dental odontalgia—toothache onlay—a type of dental restoration, usually gold, that protects the biting surface of a tooth orthodontic appliance—an assemblage of bands, archwires, wire ligatures, coils, and elastics used to achieve functional and esthetic alignment of the teeth papilla, inderdental, gingival—projection of gum tissue between the teeth periapical—around the apex (root end) periodontal ligament (membrane)—a network of fibers, vessels, and nerves surrounding the roots of teeth; the fibers attach in the cementum of the roots and the lining of the socket (lamina dura), and suspend the tooth in the socket periodontium—the supporting tissues of the teeth: gums, periodontal ligament, lamina dura, and periodontal bone plaque, microbial—a sticky mass of mucin, food debris, and microbes that builds up on tooth surfaces and initiates the carious lesion pocket, periodontal—a detachment of the gingival epithelium from the tooth root, together with resorption of periodontal bone, forming a deep crevice or envelope along the root of the tooth pulp, dental—the soft tissue that occupies a chamber (pulp chamber) within the crown of a tooth and the canals (pulp canals) within the root(s), comprised primarily of nerves, blood vessels, and connective tissue