Objectives

1. Understand that teething does

not cause fever
2. Define, recognize, and treat
pericoronitis, periapical abscess,
and alveolar osteitis
3. Describe treatment for ANUG
4. State three ways to treat bleeding
gums 5
 Teeth

Vlad2i (Wikimedia Commons)

6
 How Many Teeth?
32 permanent 20 primary or
• 8 incisors deciduous
• 4 canines • 8 incisors
(cuspids) • 4 canines
• 8 premolars • 8 molars
(bicuspids)
• 12 molars
(tricuspids)
7
How to Name the Teeth

8
Gray's Anatomy (Wikipedia)
How to Number the Teeth

9
 Permanent Teeth

Permanent maxillary
Right first molar Permanent maxillary
Left second premolar

Permanent mandibular
right third molar

Permanent mandibular
left canine

Kaligula (Wikipedia) 11
 Definitions
• Interproximal: surfaces between
two adjacent teeth
• Mesial: interproximal surface
facing toward midline
• Distal: interproximal surface
facing away from midline
• Occlusal: chewing surface
12
 Definitions
• Labial: toward the lips, specific to
anterior teeth
• Buccal: toward the cheek, specific
to posterior teeth
• Palatal: toward the palate, specific
to maxillary teeth
• Lingual: toward the tongue,
specific to mandibular teeth
13
 Definitions
• Apical: toward the tip of the root
of the tooth
• Radicular: associated with the
root, especially the apical region
• Coronal: toward the crown of the
tooth
• Incisal: toward the biting edge of
incisors 14
 Basic Anatomy
• Dentin surrounds pulp, which is
neurovascular supply
• Crown: enamel on dentin, visible
portion of tooth
• Root: cementum on dentin,
extends into the alveolar bone

15
Sam Fentress (Wikipedia)

16
 Basic Anatomy
• Periodontium = attachment
apparatus
• Periodontal ligament = collagen
fibers that extend from alveolar
bone to root of tooth
• Gingivitis and periodontal disease
destroy peridontium  tooth
mobility and loss
17
 Basic Anatomy
• Gingiva = keratinized stratified
squamous epithelium
– Free gingiva: 2- to 3- mm-deep
gingival sulcus in disease-free state
– Attached gingiva: adheres to
alveolar bone and extends to oral
vestibule, floor of mouth
• Nonkeratinized alveolar mucosa
covers cheeks, lips, floor of mouth
18
Dozenist (Wikipedia)

Healthy teeth
19
 Healthy teeth
Source Undetermined

20
 Teething

ratterrell (Flickr)

Mathowie (Flickr)

21
 Thomas Phayre – 1530
The Boke of Children, London
About ye seveth moneth, sometime more,
sometime lesse, after ye byrth, it is natural
for a child to breed teeth, in which time
many one is sore vexed with sondry
diseases and pains, as swelling of ye
gummes and jaws, unquiet crying fevers,
cramps, palsies, fluxes, reumes and other
infirmities, specially when it is long or ye
teeth come forth, for the sooner they appear
the better and the more ease it is to the childe.
22
 Death by Teething!!
• Common “Cause of Death” in
Middle Ages
• Usually weaned at same time
• Frequently lance erupting tooth
• Malnutrition from watered-down
milk
• Typhus from infected milk
23
 Teething
• No data support association of
teething, fever, and diarrhea
• Possible mild dehydration from
excessive salivary production or
decreased intake
• Must seek other source
for fever, diarrhea
24
 Teething

Capital M (Flickr)
25
 Teething

Boston Public Library (Flickr)

26
Toothache

27
 Impacted Wisdom Teeth

Source Undetermined

28
 Wisdom Teeth
• Vestigial third molars
• Used to help grind down plants
• Diets changed  smaller jaw
• Agenesis ranges from practically
zero in Tasmanian Aborigines to
~100% in indigenous Mexicans
• Related to  PAX9 gene
29
Pain from Wisdom Teeth
• Pericoronitis: inflammation of
gingival tissue overlying occlusal
surface of erupting tooth
(operculum)
• Masseter irritation  trismus
• Rx irrigate debris, analgesia,
dental referral
30
Operculum = lid

Pericoronitis
Source Undetermined
31
 Pericoronitis

Source Undetermined

32
 Dental Caries
• Loss of tooth enamel integrity due
to exposure to acidic metabolic
byproducts of plaque bacteria
• Early: sensitive to cold or sweet
• Later: direct communication with
dental pulp  “pulpitis”
• Irreversible pulpitis: protracted
pain 33
 Dental Caries

Source Undetermined 34
 Dental Caries

35
Source Undetermined
Antibiotics for Toothache??
• Undifferentiated dental pain
without overt infection
• Penicillin vs. placebo
• Evaluation at enrollment, again at
5- to 7-day follow-up
• Outcome measure: overt dental
infection at follow-up

Acad Emerg Med. 2004 Dec;11(12):1268-71.

36
Antibiotics for Toothache??
• 13 / 134 patients (9%) developed
infection
– 6/64 (9%) in penicillin group
– 7/70 (10%) in placebo group
• No significant difference in
baseline characteristics,
compliance, VAS pain scores

Acad Emerg Med. 2004 Dec;11(12):1268-71.37

Antibiotics for Toothache??
• CONCLUSIONS: “These data
support the hypothesis that
penicillin is neither necessary nor
beneficial in the treatment of
undifferentiated dental pain in the
absence of overt infection.”

Acad Emerg Med. 2004 Dec;11(12):1268-71.38

 Periapical Abscess
• Most common source of severe
odontogenic pain: periapical
• Most common lesion: periapical
granuloma = periradicular
periodontitis, results from pulpitis
• X-ray  widened periodontal
ligament space (radiolucent stripe)

39
 Widened periodontal
ligament space 40
Source Undetermined
 Periapical lucency
41
Source Undetermined
 Periapical abscess
Source Undetermined
42
 Periapical Abscess
• Exquisite pain with percussion
• Suppurative periodontitis = parulis
• X-rays rarely indicated
• Rx antibiotic (penicillin still best),
analgesia, referral
• Definitive treatment: extraction or
root canal

43
 Parulis = Fistula = Gum Boil

Source Undetermined 44
 Parulis = Fistula

45
Source Undetermined
 Postextraction Pain
• Periosteitis: 24 to 48 hours,
common, easily treated
• Alveolar osteitis = dry socket:
second or third post-op day 
exquisite oral pain due to bone
exposed to oral environment

46
 Dry Socket

47
Source Undetermined
 Dry Socket
• Up to 35% after impacted 3rd
molar removal
• X-ray for retained root tip
• Irrigate socket with sterile saline
• Pack socket with gauze soaked in
oil of cloves or eugenol
• Relief is immediate
• Antibiotic if severe
48
www.nysora.com/techniques/oral_maxilla/

49
Upper Incisors & Canines
• Innervated by superior alveolar
nn, branches of infraorbital n.
• Anastamose over midline
• Nasopalatine innervates palatal
gingiva, mucosa, periosteum
• Maxillary bone has porous lamina

50
Upper Incisors & Canines

Dozenist (Wikipedia)

51
Upper Incisors & Canines
• Anesthetized by buccal fold
infiltration
• Introduce near bone, inject
adjacent to tooth
• Slow injection 1 – 2 ml solution
• Central incisors: avoid nasal spine

52
 Upper Incisors & Canines

Source Undetermined

53
 Infraorbital Nerve Block

Infraorbital N.

Area of Anesthesia

Barry Langdon- Lassagne (Wikimedia Commons)

55
 Infraorbital Nerve Block

Source Undetermined

57
 Upper Premolars
• Convergent branches of superior,
posterior, and anterior alveolar
nerves  superior dental plexus
• Greater palatine nerve  palate
• Both irregular, may vary from
person to person

59
 Upper Premolars
• Infiltrate buccal
fold next to
tooth
• 1.0 – 1.5 ml at
apex

Source Undetermined 62
Supplemental Palate Injection
• Use small
volume (~0.5
ml) – hurts
like crazy

Source Undetermined 63
 Palatal Nerve Block

Source Undetermined
64
Upper Molars

Source Undetermined
69
 Upper Molars
• Buccal infiltration: puncture mesial
fold close to tooth
• Advance upward and backward
until bone felt
• Inject 1 – 2 ml solution

70
 Upper Molars

71
Source Undetermined
So for most upper teeth…

Local infiltration
is sufficient
73
 Lower Incisors & Canines

Source Undetermined

75
Lower Incisors & Canines
• Innervated by incisive nerve
• Lies within bone, but can be
anesthetized by diffusion through
thin, porous mandibular bone
lamina
• Tip of needle must contact bone in
lower front

77
Lower Incisors & Canines
• Buccal soft tissue:
mental nerve
• Lingual gingiva &
periosteum: sublingual
nerve

78
Lower Incisor Block
• Patient supine
• Inject through
buccal fold near
tooth

79
 Lower Premolars
• Local blocks don’t work
• Primarily inferior alveolar nerve
• Premolar buccal gingiva  buccal
nerve
• Lingual gingiva  sublingual
nerve
• Mental foramen: below and
between premolar apices
81
Mental Nerve Block

Nerve Block
Area of Anesthesia

Barry Langdon- Lassagne (Wikimedia Commons)

82
 Mental Nerve Block

84
Source Undetermined
Supplementary Lingual Nerve Block

Source Undetermined

• Use 0.5 – 1 mL
85
 Lower Molars
• Apices embedded in thick
compact bone
• Local blocks don't work
• Inferior alveolar nerve

87
Inferior Alveolar Nerve Block

91
Source: NYSORA.com
 Inferior Alveolar Nerve Block

Source: NYSORA.com 92
 Inferior Alveolar Nerve Block

Source Undetermined 93
 Facial Landmarks

Gray's Anatomy (Wikipedia) 95

www.nysora.com/techniques/oral_maxilla/

96
 Frenum Diastema

i.e., gap-toothed
Source Undetermined 97
 Tetracycline Staining

98
Source Undetermined
 Gums
99
Source Undetermined
 Periodontal Disease
• Gingivitis: accumulation of plaque
along gum margins
• Causes: bad hygiene, hormonal
variations (puberty, pregnancy),
medications (phenytoin), etc.
• Sulcus deepens  pockets 
periodontitis mineralization 
bone loss  tooth loss
100
 Periodontal Disease

101
Source Undetermined
 Periodontal Disease

Source Undetermined
102
 ANUG
• Acute Necrotizing Ulcerative
Gingivitis = Vincent ´s disease =
trench mouth
• Diagnostic triad: pain + ulcerated
or “punched out” interdental
papillae + gingival bleeding
• Etiology unclear, but opportunistic
• Anaerobes always present
103
 ANUG
• Invades otherwise healthy tissue
• Treatment:
– Identify, treat predisposing factors
– Chlorhexidine oral rinses twice daily
– Debridement and scaling by dentist
– Metronidazole 250 mg tid
– Supportive therapy: soft diet rich in
protein and vitamins
104
 ANUG

Source Undetermined 105

 ANUG

Source Undetermined 106

 ANUG

107
Source Undetermined
 Gingival Hyperplasia
• Associated with many commonly
used medications
• 50% of patients on chronic
phenytoin
• Also calcium channel blockers
(especially nifedipine) and
cyclosporine.
• Treatment: fastidious oral hygiene
108
 Gingival Hyperplasia

Source Undetermined 109

 Bleeding Gums
• Hemorrhage after scaling easily
controlled with peroxide mouth
rinses or direct gingival pressure
• Clotting factor deficiencies,
leukemia, and end- stage liver
disease may first present as
spontaneous gingival hemorrhage
• Treatment: based on cause
110
 Bleeding Gums

Source Undetermined 111

 Bleeding Gums

Source Undetermined
112
Post-Extraction Bleeding
Usually a dislodged clot
1. Firm pressure usually adequate:
folded 2 × 2 gauze pad placed over
extraction site, then firm pressure by
clenching teeth for 20 minutes
2. Tea bag: tannic acid is hemostatic
3. Gel-Foam, Avitene, or Instat sutured
snugly into socket
4. Infiltrate lidocaine with epinephrine
113
 Pyogenic Granuloma
• “Pregnancy tumor”
• Benign proliferation of connective
tissue, primarily on gingiva
• Not pyogenic, not a granuloma
• Usually recurs if removed during
pregnancy
• If not regressed 2 to 3 months
postpartum, definitive removal
114
 Pyogenic Granuloma

Source Undetermined

Source Undetermined
115
 Pyogenic Granuloma

Source Undetermined 116

I got a tooth knocked out

msspider66 (Wikimedia Commons)

117
I got a tooth knocked out
• Rinse with water; do not scrub
• Hold gently by crown, not root
• In cooperative adult, gently put
back in socket
• Transport tooth to doctor or dentist
in saline, milk, or saliva
– Dry tooth will damage in minutes

118
I got a tooth knocked out
• Child, uncooperative adult: "tooth
saver" solution
• Loosened, pushed in, broken
teeth: avoid eating or drinking
• Tooth broken in pieces: retrieve
parts and transport in suggested
solutions as above

119
I got a tooth knocked out
• 90% of replantations performed
within 30 minutes are successful
• If wait 2 hours, falls to 5%
• Insert slowly into socket, hold
pressure for 10 to 15 minutes
– If forced abruptly, will be extruded
• Consult dentist
Lind GL. Anesth Analg
61(5):469, May 1982 120
I got a tooth knocked out
• Stabilization with arch bars and
wires for two weeks
• If primary (baby) tooth, no long-
term problems anticipated
– Primary tooth: blue-white
– Permanent tooth: yellow-white
– No reimplantation if primary

121
I got smacked in the mouth
• Remove debris, especially tooth or
denture fragments
• Irrigate copiously
• Avoid radical debridement
• Can close up to 24o after injury
• Penicillin (or erythromycin) for
through and through, but no
studies Potter BC. Amer Fam Phys
18(5):96,1978 122
I got smacked in the mouth
• Tongue cuts:
rarely need
repair

Source Undetermined

Potter BC. Amer Fam Phys

18(5):96,1978 123
I got smacked in the mouth

• Cheek / lip cuts:

close to prevent
food entrapped
Source Undetermined

• Frenulum cut: let

heal on own

Source Undetermined 124

 And finally…
Two Flossing Haiku

Intentional pain
And the taste of gums bleeding
Prevent toothlessness

Morsels sit between my teeth

Minty, waxy nylon thread
Saves my smile

125