March 2007

MANAGING
DENTAL EMERGENCIES

Kathy Wilson
(South Tyneside PCT & Newcastle Dental School & Hospital)
 Aims of Presentation
• Basic dental anatomy
• Diagnosis and treatment planning
• Pulpitis
• Dental abscess and cellulitis
• Trauma to teeth
• Anaesthesia for dental procedures
• Extraction
• Drugs in dentistry
• Emergency dental kit
 Dental Emergencies

“In remote or under-developed regions where

the nearest dentist may be many days’ journey,
doctors and nurses frequently find themselves required
to deal with pain, infection and trauma in the mouth.”

“Dental conditions are not usually dangerous to life,

but they are often exceedingly painful”

J.N.W. McCagie, Oral Surgeon

 BASIC DENTAL ANATOMY

• Dentition

• Soft tissues

• Blood and nerve supply

• Lymphatic drainage
Anatomy of the Tooth
 Nerve & Blood Supply
Maxilla Mandible

Red - Blood Supply

Yellow - Nerve supply

Buccal region Buccal region

Blue - Areas where local

analgesic can be
delivered

Palatal region Lingual region

 Lymphatic Drainage

• Lymphatic drainage is to the submental,

sublingual and deep cervical nodes.
 DIAGNOSIS
&
TREATMENT PLANNING
 HISTORY TAKING

• Dental History

• Ask the client to voice their complaint or point to area

which is hurting

• Onset and duration of complaint

• Relieving or initiating factors

• Type of pain – sharp or dull; moderate or severe

 HISTORY TAKING
• Medical History

• General state of health

• Current medication & why

• Particular conditions
– Rheumatic fever
– Drug allergy (penicillin)
– Bleeding tendency
 CLINICAL EXAMINATION

• General State
– Temperature
– Fatigue

• Extra oral examination

– Swellings of face
– Palpate lymph nodes
– Examine for fractures
 CLINICAL EXAMINATION
• Intra oral
– A good light is essential

– Mirror and probe

 CLINICAL EXAMINATION
• Intra oral
– Inspect soft tissues:
• Inflammation
• swelling
• Tenderness
• ulceration

– Inspect the teeth

• Decay
• Mobility
• Fractured teeth
 DIAGNOSIS &
TREATMENT PLANNING

• Make a diagnosis

• Treatment planning for:

– Relief of pain
– Treatment of pathology
– Long term view
 COMMON CONDITIONS

• Dental caries
• Pulpitis
• Dental Abscess
• Facial swelling and cellulitis
• Dry socket, Osteomyelitis
• Fractured teeth
• Fractured jaw
 DENTAL CARIES
• One of the most common diseases

• Starts in enamel, extends to dentine and if

not treated into pulp
DENTAL CARIES
Management

Remove decay
using an excavator

Place temp filling

Using a flat plastic
 DENTAL CARIES

Filling Materials

“Cavit” “Glass Ionomer Cement”

(temporary filling) (semi-permanent filling)
 PULPITIS
• Inflammation of the pulp

• Dental caries extending into dentine

causes a sharp pain with hot and cold

• Early stages reversible

• Remove decay
• Cavit dressing

• When pain settled permanent filling

placed
 DENTAL ABSCESS
• Periapical abscess

• Result of decay and infection

extending into pulp of tooth

• Pain is severe, persistent, &

throbbing

• Tooth is tender to touch

• If not treated pus tracks to surface

inside or outside the mouth
 DENTAL ABSCESS
“Treatment”

• Periapical abscess – “drainage”

1. Open tooth into pulp chamber using

excavator (if possible) and dressing

2. Antibiotics (Amoycillin 250mg TDS / 5 days)

3. Extraction of tooth
 DENTAL ABSCESS

• Extra oral Swelling

– Can spread into the tissues

– Leading to cellulitis
– Systemic involvement
– Drainage required
 DENTAL ABSCESS
“Treatment”
• Extra oral Swelling

– Antibiotics

– Excision and drainage

• Anaesthesia with topical paste or ethyl chloride

• Number 11 blade for incision extra orally

• Open tissues using mosquitos

• Allow pus to drain/insert rubber drain suture to keep

patent

– Ultimately extract tooth under LA

 DRY SOCKET
• Dry Socket
– Localised osteitis
– Severe pain 2 -4 days post extraction

– TREATMENT
• LA
• Debride socket
• Dressing – Alvogel
 DENTAL TRAUMA
• Fractured front tooth
• Dentine
• Dentine/Enamel
• Dentine/Enamel/Pulp

After Treatment
Before with Glass Ionomer
Cement
 DENTAL TRAUMA
• Avulsed Tooth

• A good chance of the tooth

re-implanting into the socket
successfully if done within an hour.

• The tooth should be located

& picked up by the crown or
enamel portion NOT the root.

• If the tooth is dirty/contaminated,

it should gently be placed in whole
cold milk, saline, or
saliva.
 DENTAL TRAUMA

• Place tooth back into

socket.

• Splint the tooth to stabilize

– Wire and glass ionomer
cement.

– Dental wax and foil

• Antibiotics - Amoxycillin
 FACIAL TRAUMA

• Injuries to the face and jaws can occur

Mandibular Fractures
Maxillary Fractures
 FACIAL TRAUMA
• Emergency Management of Facial Fractures

• Attempt to stabilize the jaw

• Give Antibiotics

• Soft foods

• Get to hospital ASAP

 ADMINISTERING
LOCAL ANAESTHESTIC
• 2% Lignocaine +/- Adrenaline

• Syringe

– Dental syringe and needle

– 5 ml syringe and needle

 ADMINISTERING
LOCAL ANAESTHETIC
Maxilla Mandible

Blue - Areas where

Buccal region local anaesthetic Buccal region
can be delivered

Palatal region Lingual region

 INFILTRATION

• Maxilla • Mandible
 INFILTRATION

• Should achieve anaesthesia within 5 minutes

• Can be safely repeated is unsuccessful

• Do not give where there is grossly infected tissue

 INFERIOR DENTAL NERVE
BLOCK
• Mandible
– Palpate the anterior ramus border at the coronoid notch.

– Slide the finger or thumb posteriorly

and medially until a ridge of bone is
palpated.
This is the internal oblique ridge.

– Insert until bone is contacted

then withdraw ~1 mm. The depth
of insertion is approximately 25 mm.
 DENTAL EXTRACTIONS

• Indications

• Severe pulpitis

• Periapical abscess

• Tooth fracture

• Severe periodontal disease

 DENTAL EXTRACTIONS

• Basic Instruments

Upper Forceps

Elevators Lower Forceps

 DENTAL EXTRACTIONS
• How to hold the instruments

Lower Forceps Upper Forceps

Elevators
 DENTAL EXTRACTIONS
• Upper Extractions

Incisors, Canines & Premolars – Push up, rotate, pull down

Molars – Push up, ease tooth buccally

 DENTAL EXTRACTIONS
• Lower Extractions

Incisors, canines & premolars – Push down, rotate, pull up

Molars – Push down, figure of eight, pull up

 DENTAL EXTRACTIONS

• Post operative instructions

– Pressure on socket
– No rinsing for 24 hours
– Cold food and drink for 24 hours
– No smoking for 24-48 hours
– HSMW after 24 hours
– If bleeding pressure pack for 20 minutes
 DENTAL EXTRACTIONS

• Complications

• Fractured tooth
• Bleeding
• Swelling
• Bruising
• Pain
• Trismus
• Dry Socket
 DENTAL EXTRACTIONS

• Complications – Bleeding

– Apply Pressure

– Pack with haemostatic agent

– Suture
 COMMONLY USED DRUGS
• Analgesics for toothache
• Paracetamol
• Co-Codamol
• NSAID

• Antibiotics
• Amoxycillin
• Erythromycin/Clindamycin
• Metronidazole
 EMERGENCY DENTAL
KIT

• Dental Mirror
• Tweezers
• Excavator and Flat plastic
• Cotton pellets & Rolls
• Extraction forceps
• Syringe & needle
• Sterile Dressings
• 11 Blade Scalpel
• Gloves
EMERGENCY DENTAL
KIT
• Cavit/Temp dressing
• Eugenol/Oil of cloves
• Glass ionomer cement
• Dental Wax/Wire
• Topical anaesthetic
• Local anaesthetic
• Amoxyl/Metronidazole
• Paracetamol/Co-codamol
 EMERGENCY DENTAL
KIT

• Life Systems Dental First Aid Kit

– www.travel-stuff.com

• Nitro-pak dental First-Aid Kit

– www.nitro-pak.com

• Dentanurse
– www.dentanurs.com