EMCrit.org

Oral Medicine

Start tooth numbering at Upper R 3^rd molar and end at Lower R 3^rd Molar (1-32)  

(EM Practice, May 2003)

Terminology

Lingual is towards the tongue for the mandibular teeth

Palatal is towards the palate for the maxillary teeth

Interproximal Surface is the surfaces of contact between two teeth

Mesial is the anteror or midline facing surface

Distal is the posterior or the surface facing away from midline

Occlusal is the biting/chewing surface of premolars and molars

Incisal is the biting surface of the incisors and canines

Apical is towards the root of the tooth

Coronal is towards the crown

Prehospital

Handle the tooth only by its crown

1st Choice is Hank's solution

2nd is milk

3rd is saline

X-Rays

Panorex view is the best (panoramic x-ray), though not available to most EDs

Nontraumatic Problems

Acute Necrotizing Ulcerative Gingivitis (ANUG)

painful papillae, gray pseudomembrane, trench mouth

Dry Socket

3-4 days post-extraction, c pain free interval, pack c dental paste

Gingival hyperplasia-2^nd to dilantin

TMJ Dislocation

pull jaw down then push back

Mandibular dislocation at the TMJ joint
JEM 2004;27(2):167

Without further sedation, a third attempt using this new technique was performed successfully. The patient's most recent sedation had been 20 min earlier. While facing the patient, the mandible was grasped with the physician's thumbs at the apex of the mentum and fingers on the surface of the occlusal surface of the inferior molars ( Figure 2). By applying cephalad force with the thumbs and caudad pressure with the fingers, then pivoting at the wrists, the dislocated mandible was reduced with minimal difficulty. The patient immediately resumed normal movement of his jaw. The patient was subsequently discharged in good condition.

Discussion
Mandibular dislocation at the TMJ is an infrequent presentation to the ED. At our institution, consisting of two EDs with approximately 100,000 combined annual visits, 37 TMJ dislocations have presented over a 7-year period, 1995–2002. Although infrequent, reduction of TMJ dislocation is a technique EPs must have in their repertoire.

The TMJ is a ginglymoarthrodial joint, combining gliding and hinge motions. Dislocation can occur anteriorly, posteriorly, laterally or superiorly. Discussion here will be limited to anterior dislocation as occurred to our patient, as it is by far the most common type and the only to occur without a fracture [ 4]. TMJ dislocation occurs when there is an interruption in the normal sequence of muscle action during closure from maximal opening. Interruption allows elevation of the mandible before retraction. This occurs when the protracting lateral pterygoid muscles fail to relax before the masseter and temporalis muscles elevate the mandible [ 5]. The condyle travels anteriorly along the eminence and becomes locked in the anterior superior aspect of the eminence ( Figure 3). The masseter, pterygoid, and temporalis muscles go into spasm attempting to close the mandible. Trismus results and the condyle cannot return to the temporal fossa [ 3]. Muscle spasm and edema result in significant pain to the patient.


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Figure 3. Anatomic description of TMJ dislocation.






Potential causes of TMJ dislocation include any action that may involve the mouth being maximally open. Common causes include yawning and trying to chew a large food bolus. The literature has noted TMJ dislocation as a complication of anesthetic induction, intravenous sedation, Ehlers-Danlos Syndrome, trauma and even tetanus [ 4, 6, 7, 8, 9 and 10]. The complications of TMJ dislocation include recurrent subluxation/dislocation from injury to the articulating cartilage, as well as fracture [ 11]. The prognosis is usually excellent, although recurrent TMJ subluxation/dislocation may require surgical treatment [ 12 and 13].

Diagnosis may be made clinically if the following features are present. The patient will present with inability to close the mouth, severe pain anterior to the ears, absence of the condyle from the glenoid fossa resulting in a visible, palpable preauricular depression and a prominent-appearing lower jaw [ 14]. If dislocation is unilateral, the jaw deviates away from the involved side [ 15]. If trauma is involved, radiographic analysis is needed for the evaluation of possible fracture.

Conventional techniques as described by standard Emergency Medicine textbooks describe the EP placing his protected thumbs on the occlusal surface of the patient's molars, wrapping his fingers laterally around the mandible and then applying a constant inferior and posterior force, gliding the mandibular condyles back into the glenoid fossa. The conventional reduction technique requires the physician to manually overcome the substantial force created by the pterygoid, masseter and temporalis muscles to achieve reduction ( Figure 1).

In the novel technique we describe, these forces are utilized to assist with reduction. The physician's thumbs are placed at the mentum of the mandible to apply an upward force and the fingers are wrapped laterally around the mandible. The angle of the mandible is then used as a fulcrum with the pterygoid, masseter and temporalis muscles exerting a force parallel to the EP's. Simultaneous pivoting action of the physician's wrists with the thumb (anterior portion of the fulcrum) pushing superiorly and the operator's fingers on the mandibular body pushing inferiorly allows the condyles to rotate back into the glenoid fossa ( Figure 2). It is important to note that these forces must be applied bilaterally to prevent mandibular fracture. The muscles of mastication provide assistance rather than impedance with this new technique as they promote rotation and reduction. Rather than attempting to lengthen the muscles that are in spasm to clear the condylar ridge, this technique pivots the mandibular condyle, easing the reduction into the fossa. The muscles of mastication provide a force-oriented superior and posterior. As the angle of the mandible rotates, these forces help bring reduction into the condyle.

To protect the operator's fingers during reduction, it is suggested that a bite block be used. This will prevent a human bite to the operator in the event of sudden closure of the mandible due to spasm, reduction, etc. Although not used in this particular patient, a bite block could prevent operator injury regardless of technique used.
 

Aphthous Ulcers (Canker Sore)

common self-limited condition that affects approximately 20% of the population at one time or another.  Evidence exists in the literature supporting the use of Amlexanox 5% paste.  Applied two to four times a day to the ulcers, healing time was significantly improved in several randomized, controlled studies.

Oropharyngeal Hemorrhage

5 cc of 1:1000 epi diluted in 5 cc of saline admin over 15 min by Neb controls this condition.  No adverse CV effects even in the elderly pts (only three pts in study, though) (J Laryngol Otol 116:123 2002)

Traumatic Injuries

Fractures

give dT

Most dentists do not use the Ellis Classification

Crown Fractures

Uncomplicated Crown Fracture through Enamel only (Ellis I)

may need only filing to take down sharp edge.  Refer to dentist for bonding

Uncomplicated Fractures through the Enamel and the Dentin (Ellis II)

The risk of untreated injury is pulp necrosis.  Patient's will complain of sensitivity to air and temperature

The yellow tint of the dentin can be seen through the white enamel

Cover with calcium hydroxide, zinc oxide or glass ionomer.  CaOH is probably easiest for ED use.  Dry the tooth.  Some would recommend giving clindamycin or penicillin. Can also cover with dermabond.

Complicated Fractures of the Crown involving the Pulp (Ellis Class III)

Often result in pulp necrosis if not treated.  You will see the pink color of the pulp in the fracture site.  Wipe off the tooth and observe for bleeding.  Patient needs immediate referral or consult by a dentist or OMF surgeon.  If referral is impossible, cover the tooth.  Bleeding can be controlled by having the patient bite into gauze pads soaked in lido with epi

Luxations, Subluxations, Intrusions, and Avulsions

Subluxation-loose, Luxation-mobile is socket, Avulsed=Out.  Luxations can be extrusive, lateral, intrusive, or complete

Do not replace primary teeth, they will bond to the alveolar bone.  However, if you are unsure whether a tooth is primary or secondary, replace it as it will not bond for days.

Alveolar Bone Fractures

Dentoalveolar Soft Tissue Trauma

Repair the tooth then the gums

Buccal Mucosa

most don't require repair.  If large however, us 4-0 or 5-0 chromic.  Bury the knots.  Through and through injurys need to be evaluated for injury to wharton's and stenson's ducts.  Wharton's exits the buccal mucosa under the tongue in the midline.  Stenson's exits at the buccal mucosa at the level of the upper 2nd molar.

Test all 5 branches of the facial nerve

1. Temporal:  elevate the brow

2. Zygomatic by shutting eyes

3. Buccal and Mandibular by having patient smile and then frown

4. Cervical by contracting the platysma

Close Lacs larger than 1 cm.  Close the mucosa first.

Gingiva injuries

approximate with 4-0 or 5-0 chromic.  If there is not enough tissue, wrap the suture around a tooth.

Frenulum Injuries

Maxillary rarely needs repair

Lingual usually does just for hemostasis

Tongue Injuries

if it is less than a cm and its edges are not gaping, does not need to be repaired

Use 4-0 chromic, or alternatively silk.  If using absorbables, bury the knots.

Hemorrhage

• Gently irrigate the area to remove clots.  Then insert dental tampon covered by 2 x 2s and have the pt bite down for 15 minutes.  The gauze can be moistened with epi.

• If still bleeding, infiltrate with anesthetic containing a vasoconstrictor.  Reapply the gauze and have pt bite for another 15 minutes.

• Electrocautery works very well

Alveolar Osteitis

Dry socket.  Localized osteomyelitis caused by loss of the formed clot after tooth extraction.  Usually occurs several days after the extraction.  Give a block, irrigate, then pack the socket with a gauze impregnated with eugenol (oil of cloves)  Can also use a slurry of gelfoam and eugenol. 

Dentoalveolar Infections

Localized Tooth Infection

Carious destruction of the enamel allows bacteria access to the pulp.  Often the inflammatory products created by this infection will drain through the rent in the enamel.  If this becomes blocked, patients will then develop symptoms. 

Periapical abscesses will  follow the path of least resistance, which can be through the alveolar bone and gingiva into the mouth or more ominously into the deep spaces of the neck.  In the ED, without x-rays, it is difficult to differentiate pulpitis from periapical abscess.  It may be helpful to start antibiotics if there is pain with tongue blade tapping, fever, swelling, or trismus.

Deep Space Infections of the Head and Neck

If the infection spreads up through maxillary areas, they can spread to the infraorbital to the cavernous sinus.

If the infection spreads in the mandibular spaces to bilateral infection of the submandibular and sublingual spaces, this is Ludwig's angina.  Use Unasyn, Zosyn, or Timentin.  Cipro/Clinda or Cephalosporin/Clinda is acceptable for Pen allergic patients. 

Dental Antibiotics

PCN VK 500 mg QID

Amox 500 mg TID

Clindamycin 150 mg TID

Doxycycline 100 mg BID

Facial Anesthesia

lidocaine in gel form is more effective on oral mucosa than than liquids

Maxillary Blocks

Supraperiosteal Injection

ideally suited for anesthesia of one or two teeth or a circumscribed portion of the maxilla. This technique will be utilized for most cases of individual tooth pathology and will probably be the procedure you use most in the ED for tooth anesthesia.  Use more anesthetic for mandibular teeth due to thicker bone.
Technique—Retract the patient’s lip to expose the tooth and vestibular mucosa. After
applying topical, insert the needle at the greatest concavity of the mucobuccal fold and direct it at
the apex of the tooth. Withdraw if you hit bone. Depth of insertion of any supraperiosteal
infiltration is 3-4 mm. Remember to aspirate first. The amount of anesthetic is usually 1-2.5 cc for this
infiltration. This block will be the one that is most commonly used for individual tooth pathology.

Anterior Superior Alveolar Nerve Injection

good for the central, lateral incisors and first premolar
Technique—retract the lip, apply topical, dry mucosa, and advance the needle until the tip
is just above the periosteum adjacent to the apex of the canine. Aspirate and inject 1-2 cc slowly.
Middle Superior Alveolar Nerve Injection

good for the maxillary premolars, adjacent bone, periodontal ligaments and adjacent soft tissues.
Technique—retract the corner of the mouth and the buccal mucosa adjacent to the
premolars. Apply topical, dry mucosa, advance needle in the mucobuccal fold in the direction of the
apex of the 2nd premolar. Advance 3-5 mm, aspirate, and inject 1-2 cc.

Posterior Superior Alveolar Nerve Block

good for all three maxillary molars, adjacent
bone, periodontal ligaments, and buccal gingiva. Is really a block, not an infiltration. This block can
be difficult for the beginner and if anesthesia in incomplete, a supraperiosteal infiltration can be
used to augment the effect.
Technique—retract the cheek and palpate the zygomatic process. A good rule of thumb is
that the needle axis should be at an angle of 45 degrees to the occusal and midsagittal planes. The
needle is inserted thru the mucosa and the underlying buccinator muscle to a depth of 1.5-2 cm. A
total of 2-3 cc is slowly deposited after negative aspiration. Topical anesthetic can be used.

Infraorbital Nerve Block

good for providing anesthesia to both the middle and anterior superior alveolar nerves as well as to the main trunk of the infraorbital nerve. Thus, an infraorbital block will numb the central incisor, lateral incisor, canine, premolars, the upper lip, lateral nose and lower eyelid. This block is a nice technique to use when lacerations are present on
the lip or many front teeth are injured.
Technique—two techniques can be used, an intraoral approach and an extraoral
approach. The extraoral approach has no advantages over the intraoral approach and has the
disadvantages of requiring skin disinfectant, lack of effective topical anesthetic, and possibly
increased patient fear.
The intraoral technique is as follows: locate the infraorbital foramen. It is situated 5-10 mm
below the infraorbital rim in a line which runs from the pupil to the corner of the mouth. Retract the
patients upper lip with the thumb of your noninjecting hand. Keep the index finger of the same
hand on the infraorbital foramen. After applying and drying the topical anesthetic, advance your
needle into the mucobuccal fold in front of the second maxillary premolar. The needle should
parallel the long axis of the tooth. Advance the needle approximately 1.5 cm and inject (after
aspirating). Don’t worry about puncturing the eyeball as it is protected by the infraorbital rim and
and the orbital floor. You only need to be close to the nerve to achieve good results, not actually in
the foramen. Figure 11.

MANDIBULAR ANESTHESIA

Supraperiosteal Infiltration

Again, this procedure is good for one or two affected teeth
and is relatively simple to perform. It is important that the needle is close to the mandibular
periosteum overlying the root tip of the tooth.
Technique—Retract the lower lip, apply topical anesthetic and wipe off after 1 minute, and
advance the needle slowly to the target. The needle should be inserted at the depth of the
mucobuccal fold toward the mandibular periosteum. The depth of insertion is only a few
millimeters. 1-2 cc of anesthetic is usually sufficient.

Mental Nerve Infiltration

Good for anesthesia of the labial mucosa, gingiva, and the
lower lip adjacent to the incisors and canine. To block the associated tooth pulps, a
supraperiosteral infiltration or inferior alveolar nerve block is better. Figure 14.
Technique—Retract lip, apply topical, and wipe dry. Advance the needle into the
mucobuccal fold adjacent to the second premolar. Advance the needle approximately 1 cm and
aspirate. Deposition of 1-2 cm of anesthetic in this area is sufficient. Remember that crossinnervation
occurs in the central incisor area.

Buccal Nerve Block

good for anesthesia of the cheek and posterior buccal mucous
membranes. Won’t be used much in the ED. Usually used when excessive manipulation of the
buccal mucosa is anticipated.
Technique—The nerve can be blocked at the level of the coronoid notch or the mandibular
vestibule. For coronoid notch infiltration, retract the mucosa and apply topical anesthetic to the
area. Needle puncture is made lateral and distal to the last mandibular molar at the level of the
occusal plane. Insertion of the needle is limited to approx. 3 mm by the anterior edge of the ramus.
Aspirate and inject 0.5-1.0 cc of anesthetic. Figure 15.
For mandibular vestibule infiltration, the tissue is prepared as above and the infiltration is
made submucosally at the depth of the vestibule just distal to the last molar.

Inferior Alveolar (lingual) Nerve Block

This block is very useful for EM physicians in
that it provides anesthesia to the mandible from retromolar region to the midline, to the anterior
labial region and to the lingual areas. The nerve is very close to the lingual nerve which is often
anesthetized simultaneously.
Technique—The needle end point is the mandibular sulcus. The landmarks that need to be
identified are the coronoid notch on the anterior edge of the ramus of the mandible and the
pterygomandibular raphe. The raphe is just a roll of soft tissue running from behind the
mandibular third molar superiorly to the soft palate.
In preparation for the block, grasp the posterior edge of the ramus (outside of the face) with
the noninjecting hand. The thumb of that hand is placed inside the mouth, retracts the cheek and
lies in the coronoid notch of the ramus. After placing the topical anesthetic, approach the injection
point from the opposite premolars. The needle is placed in the raphe approx 2 cm posterior to the
midline of your fingernail. Advance the needle approx 2 cm into the mucosa until you hit the bone.
Withdraw slightly, aspirate, and inject. It may take up to 4 cc or so of anesthetic until you get
comfortable with the procedure. Usually the lingual nerve is anesthetized as well as the inf. Alv.
Nerve, but, if necessary, usual practice is to withdraw slightly (0.5 cc) and reinject.

Forehead Anesthesia

Supraorbital and supratrochlear Nerves.
These nerves are responsible for the sensory innervation of the forehead from the eyebrows
posteriorly to the lambdoid sutures.
Technique: Rather than attempting to localize each of the above nerves, it is easier and
more effective to perform a regional block. This can best be accomplished by infiltration of 4-5 cc of
anesthetic above the length of the eyebrow, slightly above the orbital rim.

Ear Blocks

Deep Space Infections

Sialolithiasis

Pearls (From EMEDhome.com)

Stone formation is not associated with systemic abnormalities of calcium metabolism.  The only systemic illness known to predispose to salivary stone formation is Gout, where the stones are made up predominately of uric acid.

In any gland with swelling and sialolithiasis, infection should be assumed. Antistaphyloccocol antibiotics are administered.

Calculi may form in any of the salivary glands of the head and neck. The submandibular gland is the most common site by far (80% to 92%). The parotid gland (6% to 20%), and sublingual glands and minor glands (1% to 2%) follow at a lower rate of occurrence.  Minor salivary glands, when involved, are usually in the buccal mucosa or upper lip, forming a firm nodule that may mimic tumor.

The submandibular gland forms the largest stones. A stone of 55 mm in length is reported as the largest. ^] Salivary stones are single in 70% to 80% and multiple in the remaining portion, with approximately 5% of patients having three or more stones.

In 1989, lithotripsy first was used to successfully treat a parotid stone. Since this time, multiple reports have entered the literature using this modality in mainstream treatment of sialolithiasis.

Patients presenting with sialolithiasis certainly may benefit from a trial of a conservative management, especially if the stone is small.  Patients may be relatively asymptomatic with infrequent bouts of sialadenitis relating to their stones. These patients may elect not to have any surgical intervention and leave their stones in place. If this is the treatment plan, the patient needs to be cognizant of the need for early use of antibiotics, should symptoms reoccur. They also should be aware that the stone may increase in size over time and become more symptomatic.
 

Black Hairy Tongue

Black hairy tongue may be associated with the use of doxycycline and bismuth (NEJM, 12/6/07, pg. 2388).