Reviewed By Dr James Willis
Edited By Noah Berland
This Post is based on Teaching Shifts from the following residents: Drs. Noah Berland, Priscilla Chao, and Hope Taitt
Case 1:
A 38-year-old female with PMH of HTN, DM presents after assault with blunt maxillofacial trauma. No LOC. The primary survey is normal; secondary survery shows tooth 8- luxation, tooth 25- subluxation, and tooth 24- avulsion.
Ellis Dental Fracture Classifications:
Figure 1: Ellis Dental Fracture Classification
Table 1: Dental Fracture Managment
Luxations
Figure 2: Luxations from [3]
Table 2: Management of luxations
Case 2:
A 5-year-old girl presents with a toothache and facial swelling x 2 days. There are no systemic symptoms. Acetaminophen provides minimal relief. Exam: Well-appearing, TTP overlying gum of teeth B and C, mild left-sided facial swelling.
Dental Abscess
This child likely has an abscess. The differential includes (see FIgure 3 for structures mentioned):
- ● Pulpal abscess – localized collection of purulence within tooth
- ● Periapical abscess – around apex of tooth; necrotic pulp escapes tooth via apical foramen and involve periodontal ligament and surrounding alveolar bone
- ● Periodontal abscess – localize to supporting structures
- ● Pericoronitis – infection of adjacent soft tissues
Figure 3: Tooth Anatomy
All possible intraoral/dental abscesses will rarely progress to Ludwig’s Angina, cavernous sinus thrombosis, or Lemierre’s Disease. Treatment is drainage and antibiotics are often recommended to cover oral flora but not well supported by evidence:
Table 3
Dental Nerve Blocks:
For lip laceration repairs and most dental procedures, an emergency physician should at the minimum be proficient with two nerve blocks: infraorbital and inferior alveolar. To target all of the upper teeth, you would also need to be proficient with the posterior superior alveolar nerve block. Please see Figure 4 from WikEM for the areas covered by these nerve blocks. In most EDs, the most common options lidocaine and bupivacaine. In addition, you can use topical lidocaine gel, which can be applied to the gum or oral mucosa at the planned injection site.
Figure 4: Inferior Alveolar Block from [5]
Bupivacaine is generally available with or without epinephrine in concentrations of 0.25% and 0.75% with a maximum dose of 2.5 mg/kg and 3 mg/kg respectively. This works out to a dose of 1 ml/kg or 0.33 ml/kg of the 0.25% and the 0.75% concentrations without epinephrine, respectively.
Remember that two ‘i’s’ means the medication is an amide, and one ‘i’ means the medication is an ester, and patients generally are only allergic to one class. Key points are to always draw back prior to injecting to reduce the risk of endovascular injection, and be aware of Local Anesthetic Systemic Toxicity (LAST). LAST is generally considered more concerning with bupivacaine because you immediately develop arrhythmias and seizures and don’t have any prodromal symptoms. Check out Lipid Rescue for more information on using lipid emulsion therapy.
References:
1. Dailey M, Waseem M. Managing Dental Trauma in the Emergency Department. EM Docs. http://www.emdocs.net/managing-dental-trauma-emergency-department/. Published 2017.
2. Hurst K, Walton RE. An Urgent Care Provider’s Guide to Managing Dental Emergencies. Journal of Urgent Care Medicine. https://www.jucm.com/urgent-care-providers-guide-managing-dental-emergencies/.
3. Ashokkumar S. Back to Basics: Dental Trauma. EM DAILY. https://emdaily.cooperhealth.org/content/back-basics-dental-trauma. Published 2020.
4. Yee L, Holtz M, Donaldson R, Fan T, O’Brien M. Nerve Block: Infraorbital. WikEM, The Global Emergency Medicine Wiki. https://wikem.org/wiki/Nerve_Block:_Infraorbital. Published 2018.
5. Chung I, Arndt J, Lu K, et al. Nerve Block: Inferior Alveolar. WikEM, The Global Emergency Medicine Wiki. https://wikem.org/wiki/Nerve_Block:_Inferior_Alveolar. Published 2018.
6. Chung I, Lewis C. Nerve Block: Superior Alveolar. WikEM, The Global Emergency Medicine Wiki. https://wikem.org/wiki/Nerve_Block:_Superior_Alveolar. Published 2019.
Noah Berland
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