.&. Figure 77-3. Epistat nasal catheter for posterior

epistaxis. The 30-ml bal loon tamponades the anterior

na ris, and the 1 0-ml bal loon is used to provide

posterior tamponade of bleeding.

anteriorly to tamponade the bleeding. Inflate the anterior

balloon with 10-25 mL of sterile saline. Assess the posterior

oropharynx to assure cessation of bleeding. To tamponade

using the Foley catheter method, obtain a 14F Foley with

30-mL balloon. Cut the tip of the catheter just distal to the

balloon. Suction, anesthetize, and vasoconstrict the naris.

Insert the catheter into the nose until the t ip is seen in the

oropharynx. Inflate the balloon with 10-15 mL of sterile

saline. Pull back on the catheter until bleeding has stopped.

Place an anterior pack. Use gauze to secure the catheter and

prevent pressure necrosis on the nasal tip. If not done

already, consult ENT. As with anterior bleeds, place patients

with nasal packing on prophylactic antibiotics.

DISPOSITION

� Admission

Admission to a monitored setting is indicated for patients

with posterior epistaxis, even if hemorrhage is controlled.

Severe bleeding and fatal airway obstruction secondary to

dislodgment of the packing can occur. Although rare,

patients may develop a nasopulmonary reflex, manifested

by hypoxia, hypercarbia, dysrhythmias, or coronary ischemia secondary to posterior packing placement.

� Discharge

Discharge is appropriate for patients with anterior epistaxis

once bleeding is controlled. Remember to prescribe antibiotics to patients who have nasal packing in place. Follow-up

should be arranged in 2-3 days to have the packing removed.

SUGGESTED READING

Kucik CJ, Klenney T. Management of epistaxis. Am Pam

Physician. 2005;7 1:305-311.

Schlosser RJ. Epistaxis. N Engl J Med. 2009;360:784-789.

Summers SM, Bey T. Epistaxis, nasal fractures, and rhinosinisitis.

In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK,

Meckler GD. Tintinalli's Emergency Medicine: A Comprehensive

Study Guide. 7th ed. New York, NY: McGraw-Hill, 20 11,

pp. 1 564-1 572.

Dental Emergencies

Nicholas E. Kman, MD

Key Points

• Dental caries are the most common dental emergency

and can lead to pul pitis.

• Tooth fractures are categorized and treated according to

the Ellis classification.

• Clean avulsed teeth with care to avoid dislodging the

periodontal ligament.

INTRODUCTION

Dental complaints are common in the emergency department (ED). As much as 4% of ED workload is dental-related.

Uninsured patients and even patients with basic medical

coverage but no dental insurance are forced to seek care in

the ED. The first step to diagnosing the dental emergency is

to understand the anatomy. There are 32 teeth in most adults

(2 incisors, 1 canine, 2 premolars, and 3 molars per side).

The teeth are numbered from 1 to 16 on the top starting with

the right-hand side. Bottom teeth are numbered 17 to 32

starting on the left and ending with the bottom right.

Dental trauma is a common complaint encountered by

emergency providers. Approximately 80% of traumatized

teeth are maxillary teeth. Tooth fractures are based on the Ellis

classification. Ellis I fractures involve only the enamel. Ellis II

fractures include the dentin, and Ellis III fractures are present

when both the dentin and pulp are exposed (Figure 78-1).

• Permanent teeth that are avulsed should be reimplanted immed iately; avulsed primary teeth are never

reimplanted.

• Ludwig angina is a surgical emergency that requires

prompt drainage.

socket relates directly to subsequent tooth viability. A subluxed tooth refers to a tooth that is "loose" due to trauma.

Mandible fractures occur at the symphysis ( 16%),

body (28%), angle (25%), ramus (4%), condyle (26%),

and coronoid process ( 1%). They are most common after

blunt trauma to the jaw from either an altercation or a

Ellis class I

Alveolar

fracture

Tooth avulsion is a result of disruption of the tooth's

attachment apparatus. The periodontal ligament is the primary source of attachment of the tooth to the alveolar bone

and is of primary concern to the emergency physician.

Tooth avulsion occurs with a prevalence of up to 15% of

cases. Management depends on whether the avulsed tooth is

a permanent or a deciduous tooth. Preservation of the periodontal ligament and limiting the length of time out of the • Figure 78-1. Ellis classification of fractured teeth.

327

CHAPTER 78

motor vehicle collision (MVC). Fractures are multiple in

half of cases because of the ring shape of the mandible.

Mandible fractures are the second most common fracture

of the facial bones behind nasal bone fractures.

Dental caries are the most common dental emergency. A

typical odontogenic infection originates from dental caries,

which decay the protective enamel. Traumatic injury, periodontal disease, or postsurgical infections can also contribute to disruption in the enamel. Once the enamel is

dissolved, bacteria travel through the microporous dentin

to the pulp, causing pulpitis. The bacteria then can t rack to

the root apex, soft tissues, and finally into the deeper fascial

planes. Dental abscesses form secondary to caries (periapical) or trapped food between gums and teeth (periodontal).

Several types of dental abscesses exist. Superficial

abscesses in the orofacial area include the buccal,

submental, masticator, and canine spaces. If unrecognized

or untreated, these infections spread to deeper spaces

within the head and neck. Ludwig angina is a rapidly

spreading cellulitis of the floor of the mouth involving the

sublingual, submental, and submandibular spaces bilater ­

ally. Its name originates from the sensation of choking and

suffocation that a patient with this infection experiences.

Ludwig angina is an emergency because the massive

swelling can result in airway obstruction. Ludwig angina

occurs secondary to an infection of the posterior

mandibular molars in 75% of cases. It can also be secondary to trauma. If the infection continues to spread, the

potential exists for adjacent retropharyngeal and mediastinal infection. Ludwig angina is most commonly due to

anaerobic (Bacteroides) and aerobic (Streptococcus,

Staphylococcus) oral flora in an immunocompromised

patient who is often elderly, diabetic, or an alcoholic.

Two other dental infections that may be encountered

are alveolar osteitis and acute necrotizing gingivitis

(ANUG). Alveolar osteitis (dry socket) occurs after a dental

extraction (usually mandibular third molars). Patients

typically present on day 2 or 3. Pain is due to premature

loss of healing clot with localized inflammation. ANUG

(trench mouth) is the only periodontal disease in which

bacteria invade nonnecrotic tissue. Etiology is usually secondary to fusobacteria and spirochete overgrowth of bacteria which is normally present. Human immunodeficiency

virus infection, previous necrotizing gingivitis, poor oral

hygiene, and stress are predisposing factors.

CLINICAL PRESENTATION

� History

Dental Trauma

Patients are typically male and were often involved in an

MVC, sports activity, or assault. Ellis I fractures are painless, and the patient may only note a j agged edge to the

tooth. Ellis II fractures present with the primary complaint

of hot and cold sensitivity as the exposed dentin is quite

sensitive. Patients with Ellis III fractures present with

severe pain, although pain may be absent if there is neuro ­

vascular compromise.

When a tooth avulses, the time the tooth spends out of

the socket is one of the most important pieces of information to obtain. If the tooth is out for <20 minutes,

prognosis is good. If >60 minutes has elapsed, a successful

re-implant is much more difficult.

Patients with a mandible fracture report jaw pain,

inability to open the mouth, and possible malocclusion of

the teeth. Numbness of the lower lip suggests an injury to

the inferior alveolar nerve.

Odontogenic Infection

Patients with dental caries present with dull, continuous

pain made worse with any stimulus. They typically have

poor dental hygiene with grossly carious teeth. Pain does

not occur until decay impinges on the pulp and an

inflammatory process develops. If a dental abscess is

present, there is excruciating pain that is made worse with

tapping on the tooth. These patients may have facial

swelling, especially if periapical in location.

When evaluating for an abscess, elicit a history of fever,

trismus, drooling, inability to handle secretions, and recent

dental infection or trauma. Predisposing factors include

dental caries, alcoholism, elderly, or diabetes mellitus.

Ludwig angina presents with pain, dysphagia, odynophagia, dysphonia, trismus, and drooling. The patient may also

complain of severe neck and sublingual pain. By some

estimates, up to 33% can result in airway obstruction.

Patients with acute necrotizing ulcerative gingivitis

present with pain, metallic taste, and foul breath. They may

also complain of fever and malaise.

� Physical Examination

Dental Trauma

Inspect the teeth for Ellis fractures. The dentin is visualized

on examination as a creamy yellow color present in the

center of the broken tooth. The pulp is seen as a pink tinge

or drop of blood within the exposed dentin. If tooth avulsion has occurred, evaluate the socket and surrounding

soft tissue for lacerations, ecchymosis, or foreign bodies.

When examining an avulsed tooth, do not touch the root.

Malocclusion, deformity, or bleeding in the mouth suggests a mandible fracture. An intra-oral laceration may

represent an open fracture. Pain, mental nerve paresthesia,

and segment mobility may also be present. Ecchymosis

under the tongue is highly suggestive of a mandible frac ­

ture. The tongue blade test is used to clinically exclude a

mandible fracture. The patient is asked to bite on a tongue

blade. If the examiner is able to break the blade by turning

it while the patient bites down, then a mandible fracture is

unlikely. The sensitivity of this test is 95%.

Odontogenic Infection

Dental caries are noted on inspection. If percussion tenderness

or changes in temperature cause pain, consider pulpitis.

DENTAL EMERGENCIES

Dental abscesses are diagnosed based on the physical

examination. A submental space infection is characterized

by a firm midline swelling beneath the chin. This abscess is

due to infection from the mandibular incisors. A sublingual

space infection is indicated by swelling and pain of the

floor of the mouth and dysphagia. It is due to an anterior

mandibular tooth infection.

Submandibular space infection is identified by swelling

around the angle of the j aw. Mild trismus is frequently present. These abscesses are caused by an infection of the man -

dibular molar. Buccal space infections present with cheek

swelling (Figure 78-2A). Canine space infection is charac ­

terized by anterior facial swelling and loss of the nasolabial

fold. This infection can extend into the infraorbital region

and be confused with ocular pathology (Figure 78-2B).

Masticator space infections present with trismus. Trismus is

the inability to fully open the jaw due to tonic spasm of the

muscles of mastication (lockjaw). In the absence of trauma,

a patient with facial swelling and trismus has a masticator

space infection until proven otherwise.

Ludwig angina presents with massive swelling in the

floor of the mouth that is painful to palpation. The swelling

may produce an elevation of the tongue, which can occlude

the oropharynx (Figure 78-3). The patient's anterior neck

may be brawny in character secondary to edema. A

Alveolar osteitis is identified by a fresh extraction site

with absence of clot. ANUG presents with a gray

pseudomembrane, ulcerations, gingival bleeding, and

fetid breath. Patients often have associated regional

lymphadenopathy.

DIAGNOSTIC STUDIES

No laboratory test is essential for the diagnoses of dental

trauma or odontogenic infections. Panorex radiograph is useful to diagnose a mandible fracture and allows for the visualization of the entire mandible with 1 radiograph (Figure 78-4).

A soft-tissue lateral neck radiograph can be used to visualize

the retropharyngeal space and exclude other diagnoses.

Computed tomography is used to diagnose mandible frac ­

tures and to localize odontogenic infections. In patients with

potential airway compromise, evaluation and treatment

should not be delayed while waiting for imaging studies.

MEDICAL DECISION MAKING

See Figure 78-5 for a diagnostic algorithm for patients with

suspected odontogenic infections.

TREATMENT

...... Dental Trauma

Ellis I fractures require no immediate t reatment; patients

should be referred to a dentist. For Ellis II fractures, place

a calcium hydroxide paste, cement, or moist gauze over the

dentin, then cover the tooth with aluminum foil to

decrease contamination of the pulp. Patients will require

urgent follow-up with a dentist within 24 hours. Ellis III

B

Figure 78-2. A. Bucca l space infection. B. Ca nine

space infection.

fractures should be covered with calcium hydroxide,

cement, or moist gauze and then covered with foil. These

patients require immediate dental referral to avoid pulpal

necrosis and loss of the tooth. Definitive treatment includes

pulpotomy or pulpectomy.

CHAPTER 78

B

Figure 78-3. A patient with Ludwig angina. A. Tongue.

B. Neck.

Never reimplant avulsed primary teeth, as they can

ankylose and block the eruption of permanent teeth. If the

avulsed tooth is permanent, care should be taken to hold

the tooth by the crown, carefully avoiding the periodontal

ligament. If the ligament is damaged, the success of

re-implantation may be compromised. In the ED, the tooth

should be rinsed gently with saline; do not "brush" the

.A Figure 78-4. Panorex demonstrating fractu res to

the right body and left angle of the mandible.

tooth clean, as this will disrupt the periodontal ligament.

The socket is rinsed with normal saline to remove blood

clot. Then re-implant the tooth in its socket with a firm

pressure into the socket. Have the patient bite on gauze to

maintain the tooth in the socket. If unable to replace the

tooth, place it in Hank solution, which preserves the liga ­

ment for 4-6 hours. Milk is an acceptable alternative if

Hank solution is not available. Patients require prophylactic antibiotics, soft diet, tetanus immunization, and an

immediate dental referral for tooth stabilization. A tooth

loosened in its socket or moved may require repositioning

if the bite is impacted. Other general instructions for loose

teeth include soft diet, pain control, and dental referral.

Patients with a mandibular fracture will require

narcotic pain control. Antibiotics (penicillin G 2-4 million

U intravenously [IV] or clindamycin 900 mg IV) are

administered for open fractures. Be sure to update tetanus

status. Oral surgery consultation for operative repair is

indicated, with the exception of isolated nondisplaced

condylar fractures, which can be managed nonoperatively.

� Odontogenic Infection

A nonsteroidal anti-inflammatory drug with or without

narcotics is indicated for patients with dental caries.

Consider dental blocks with local anesthetics as an adjunct

for pain control. Most patients do not require antibiotics

unless there is an obvious associated infection. Consider

outpatient dental referral.

Patients with dental abscesses are treated with analgesics,

antibiotics, and drainage. Most emergency physicians can

drain a perigingival abscess, whereas most periapical

abscesses need to be referred to an oral surgeon. Patients

with localized infection should be treated with antistreptococcal oral antibiotics, such as oral penicillin (500 mg three

times daily in adults or 50 mglkg/day divided into three

doses in children). In cases of penicillin allergy, erythromycin or clindamycin (Cleocin) may be substituted. Definitive

therapy is root canal or extraction. Ideally, patients should

be evaluated by a dentist within 1-2 days but warned to

return earlier if swelling or pain worsens.

The treatment of Ludwig angina involves maintenance

of the airway, IV antibiotics, and surgical drainage in the

operating room (OR). The primary concern to the emer ­

gency physician is maintenance of the patient's airway.

Maintain the patient in a seated position and place airway

equipment at the bedside. The patient should be given

IV penicillin plus metronidazole, cefoxitin, or clindamycin.

Ear, nose, and throat should be consulted immediately and

arrangements made for transfer to the OR for surgical

decompression and possible airway intervention.

Alveolar osteitis is treated with gentle irrigation followed by

packing of the socket with iodoform gauze dampened with

eugenol. Consider analgesia with a nerve block before irrigation.

Ensure close follow up. ANUG is treated with chlorhexidine

oral rinses, analgesics, and oral antibiotics (metronidazole).

Most patients require dental referral for definitive care.

DENTAL EMERGENCIES

Sublingual,

submental, or

submandibular

space infection

Suspected odontogenic

infection

Masticator

space

infection

• Consult oral

surgeon for

drainage

• Admin ister IV

antibiotics

• Consult oral

surgeon for

drainage

• Admin ister IV

antibiotics

.A. Figure 78-5. Dental emergencies diag nostic algorithm.

DISPOSITION

� Admission

Patients with an open mandible fracture require admission

for IV antibiotics and operative repair. Patients with

mandible fractures also require admission for airway

compromise (early intubation), excessive bleeding, displaced

fractures, infected fractures, comorbid diseases, or if they are

elderly. Patients with odontogenic deep space infections and

Ludwig angina require drainage of the abscesses in a controlled setting.