Post on 22-Jan-2018
• Oral emergencies generally can be divided into three categories:
• (1) orofacial pain
• (2) orofacial trauma, specifically dentoalveolartrauma
• (3) hemorrhage.
• The normal adult dentition consists of 32 permanent teeth.
• The adult dentition has four types of teeth: 8 incisors, 4 canines, 8 premolars, and 12 molars.
• The primary or deciduous dentition consists of 20 teeth of three types: 8 incisors, 4 canines, and 8 molars.
• Incisors are used for biting and cutting, canines and premolars for ripping, and molars for grinding.
• A tooth consists largely of dentin, which surrounds the pulp, or neurovascular supply of the tooth in the core of the tooth
• Dentin is a homogeneous material produced by pulpalodontoblasts throughout life.
• Dentin is deposited as a system of microtubules filled with odontoblastic processes and extracellular fluid.
• The crown, or the visible portion of tooth, consists of a thick enamel layer overlying the dentin. Enamel, the hardest substance in the human body, consists largely of hydroxyapatite and is produced by ameloblasts before eruption of the tooth into the mouth.
• The root portion of the tooth extends into the alveolar bone and is covered with a thin layer of cementum
• Essential for maintaining the integrity of the dentoalveolar unit. • The gingival component includes the junctional epithelium, gingival
tissue, and gingival fibers.• The periodontal component includes the periodontal ligament,
alveolar bone, and cementum of the root of the tooth. • The periodontal ligament consists of collagen fibers that extend
from the alveolar bone to the root of the tooth, adhering to the cementum by hemidesmosomal attachment.
• Disease states such as gingivitis and periodontal disease weaken and destroy the attachment apparatus, resulting in tooth mobility and tooth loss.
NORMAL PERIODONTIUM
Gingival tissue is keratinized stratified squamous epithelium. It can bedivided into the free gingival margin and the attached gingiva. The freegingiva is the portion that forms the 2- to 3-mm-deep gingival sulcus inthe disease-free state.
OROFACIAL PAINDifferential Diagnosis of Orofacial Pain
Pain of dental originmay be diffuse in nature, presenting as a headache, sinus pain, eye pain,or jaw or neck pain, or may be localized to a single tooth
PAIN OF ODONTOGENIC ORIGIN
• Tooth Eruption and Pericoronitis• Discomfort is commonly associated with the
eruption of primary or deciduous teeth in infants. • Irritability, drooling, and decreased intake are
commonly associated findings.• Eruption of permanent teeth, especially third
molars, or wisdom teeth, may cause pain.• Gingival irritation and inflammation associated
with tooth eruption are common and must be distinguished from pericoronitis.
• Pericoronitis is inflammation of the operculum, or the gingival tissue, overlying the occlusal surface of an erupting tooth.
• Because of the close proximity of the masticator space to third molars, infection can cause trismus and can extend into the parapharyngeal spaces.
• Treatment : penicillin VK, 500 mg QID or clindamycin, 300 mg QID
• Local irrigation of food and debris from underneath the operculum, saline mouth rinses, and analgesia with NSAIDs and opiates as appropriate.
• Refer to a general dentist or an oral and maxillofacial surgeon within 24 to 48 hours
Dental Caries and Pulpitis
• Causes loss of integrity of the tooth enamel from hydroxyapatitedissolution by prolonged exposure to the acidic metabolic by-products of plaque bacteria.
• occurs in areas where plaque accumulates such as pits and fissures of the occlusal surface, interproximally, and along the gingival margins.
• In reversible pulpitis : the duration of pain is short, lasting seconds, irreversible pulpitis : pain may last for minutes to hours.
• Spontaneous tooth pain usually represents pulpal death or necrosis • Treatment : Analgesia and penicillin VK 500 mg QID or clindamycin in
penicillin allergic patients, and referral to a general dentist.• The definitive treatment for irreversible pulpitis and pulpal necrosis is
root canal therapy or dental extraction.
Periradicular Periodontitis
• Extension of pulp disease, inflammation, or necrosis into the tissues surrounding the root and apex of the tooth
• A small swelling of the gingivawith a draining fistula adjacent to the affected tooth is known as a parulis, and can help identify the involved tooth.
• Erosion of a periradicular abscess through the cortical bone and subperiosteal extension results in intraoral or facial swelling and fluctuance that should be incised and drained intraorally.
• Treat dental abscesses or other periapical lesions with penicillin VK, 500 mg QID or clindamycin, 300 mg QID and analgesia with an NSAID .
• Prompt referral to a dentist for definitive treatment such as root canal therapy or extraction is indicated.
Facial Cellulitis
• Buccal extension of a periapical infection of the mandibular teeth will involve the buccinator space.
• Maxillary labial extension of infection involve the infraorbital space. • Perforation through the lingual cortical bone of mandibular molars,
particularly the second and third molars, involves the submandibular space.
• Lingual spread associated with mandibular anterior teeth will affect the lingual space.
• Cellulitis of bilateral submandibular spaces and the lingual space is called Ludwig angina and is potentially life threatening.
• Cavernous sinus thrombosis presents as an infraorbital or periorbitalcellulitis with rapidly developing meningeal signs, sepsis, and coma. Early recognition and treatment with a high-dose IV antibiotic as above are essential in decreasing morbidity and mortality.
Postextraction Pain
• Pain in the initial 24 to 48 hours after dental extraction, termed periosteitis, is related to the trauma of surgery
• Postoperative edema, such as with extraction of third molars, peaks within the first 24 to 48 hours and is best managed with ice packs, elevation of the head of the bed to 30 degrees, NSAIDs, and oral narcotics.
• Trismus can result from infection, direct injury to the temporomandibular joint, injury to the muscles of mastication during administration of the inferior alveolar nerve block or during the surgery, and normal perioperative inflammation
Postextraction Alveolar Osteitis
• Postextraction alveolar osteitis, or dry socket, usually occurs on the second or third postoperative day and is associated with exquisite oral pain.
• Displacement of the clot from the socket or fibrinolytic dissolution of the clot results in exposure of the alveolar bone and initiates a localized osteomyelitis of the exposed bone.
• Risk factors : smoking, preexisting pericoronitis or periodontal disease, a traumatic extraction, a prior history of alveolar osteitis, and hormone replacement Therapy
• The incidence is higher (20% to 35%) among impacted third molar extractions.
• Dental radiographs should be taken to ensure the absence of a retained root tip or other foreign body.
• Local or topical anesthesia may be needed to adequately treat a dry socket.
• First, thoroughly irrigate the dental socket with sterile normal saline.
• Next, prepare the packing material by saturating ribbon gauze with oil of cloves or eugenol and removing the excess moisture by compressing it with dry sterile gauze.
• Finally, carefully layer the medicated ribbon gauze into the socket. This results in an almost immediate relief of pain .
• Antibiotic therapy with penicillin VK, 500 mg QID or clindamycin, 300 mg QID.
• Thus, referral to a dentist within 24 hours is indicated.
Postextraction Bleeding
• Displacement of the clot may result in recurrent or continued bleeding.
• Generally, firm pressure applied to the extraction site is adequate to control bleeding.
• If direct pressure is not successful, then apply an absorbable gelatin sponge or microfibrillar collagen or regenerated cellulose into the socket to provide a matrix for clot formation.
• Sutures can be used for holding such agents in place or to loosely close the gingiva over the socket.
• careful injection of lidocaine with epinephrine may control the bleeding.
• Careful cautery with silver nitrate can also be useful• OMFS consultation
PERIODONTAL PATHOLOGY
• Periodontal Abscess : When plaque and debris are entrapped in the periodontal pocket, a periodontal abscess may form.
• Small periodontal abscesses respond to local therapy with warm saline rinses and antibiotics such as penicillin VK, 500 mg QID or clindamycin, 300 mg QID.
• Larger periodontal abscesses require incision and drainage. • Chlorhexidine, 0.1% mouth rinses twice daily are useful for
short term, but if used chronically can discolor teeth. • Provide analgesia with NSAIDs or narcotics as indicated.
Acute Necrotizing Ulcerative Gingivitis
• Also known as Vincent disease or trench mouth, it is part of a spectrum of disease ranging from localized ulceration of the gingiva to necrosis spread to the adjacent tissues of the cheeks, lips, and underlying facial bones.
• The diagnostic triad includes pain, ulcerated or “punched out” interdental papillae, and gingival bleeding.
• Secondary signs include fetid breath, pseudomembrane formation, “wooden teeth” feeling, foul metallic taste, tooth mobility, lymphadenopathy, fever, and malaise.
• Anaerobic bacteria such as Treponema, Selenomonas, Fusobacterium, and Prevotella
• Predisposing factors : HIV, previous episode of necrotizing gingivitis , poor oral hygiene, unusual emotional stress, poor diet and malnutrition, inadequate sleep
• Treatment : • Chlorhexidine 0.1% oral rinses twice a day• professional debridement and scaling• Antibiotic therapy with metronidazole, 500 mg PO TID• Soft diet rich in protein, vitamins, and fluids
Trigeminal neuralgia
• Most common of the cranial neuralgias.
• Trigeminal neuralgia is almost always unilateral.
• The maxillary branch of the fifth cranial nerve is most commonly affected.
• Recurrent episodes of excruciating, electric shocklike paroxysmal pain of short duration, separated by pain-free periods are characteristic.
• Associated contraction of the facial and masticatory muscles is typical, resulting in the term tic douloureux.
• Treatment : carbamazepine 100 mg BD
ORAL CANDIASIS
• Predisposing factors : extremes of age, intraoral prosthetic devices such as dentures, malnourished states, associated mucosal disorders, concurrent infections, antibiotics, and immunocompromisedconditions such as AIDS, transplant recipients, radiation therapy, and chronic immunosuppressive therapy.
• Three oral clinical types have been described. • Pseudomembranous type, or thrush with white, curd-like plaques.
These plaques are easily scraped off to reveal an underlying erythematous mucosal base.
• The second type is atrophic, or erythematous, and usually involves the dorsum of the tongue. Atrophy of the filiform papillae is seen.
• Finally, the lesions of hyperplastic candidiasis are raised white plaques that can only be partially removed with scraping due to deeper infiltration into the underlying tissue.
• Perioral candidiasis, presenting as angular cheilitis or scaling patches of the perioral facial tissues is common.
• Treatment is with topical oral antifungal agents such as nystatin oral suspension, 500,000 units (swish and swallow) four times a day, clotrimazole, 10 mg troches five times per day, or systemic agents such as fluconazole, 100 milligrams PO per day
APHTHOUS STOMATITIS
• cell-mediated immune response to a yet unidentified triggering agent.
• Predisposing factors : an immune imbalance, a breach in the mucosal barrier, and an allergic response.
• Aphthous ulceration begins as an erythematous macule that ulcerates and forms a central fibropurulent eschar.
• Lesions measure from 2 to 3 mm to several centimeters in diameter, are painful, and frequently are multiple. They usually resolve spontaneously in 10 to 14 days.
• Major form has larger, deeper ulcers that take up to 6 weeks to heal.
• A third form, called herpetiforme aphthae, has up to 100 ulcers, each 1 to 2 mm in diameter, and takes 7 to 10 days to heal.
• Treatment consists of topical corticosteroids such as betamethasone syrup or 0.01% dexamethasone elixir as a mouth rinse.
• Fluocinonide, 0.05% gel, applied topically to isolated lesions is acceptable.
• Intralesional steroid injection or systemic steroid therapy.
HERPES SIMPLEX
• The primary infection, herpes gingivostomatitis, causes acute painful ulcerations on the gingiva and mucosal surfaces.
• Fever and lymphadenopathy may occur.• Vesicular lesions appear and rupture after 1 to 2 days,
leaving painful ulcers that heal gradually over 1 to 2 weeks.
• Treatment : adequate pain management to ensure oral hydration.
• In severe cases, treatment with acyclovir, 75 milligrams/kg/day divided into five doses per day (maximum daily dose, 2 grams) for 7 days.
• Secondary infection affects mostly the lips but may affect the hard palate and attached gingiva.
• The virus is harbored in sensory ganglion such as the gasserian ganglion of the trigeminal nerve.
• Vesicles rupture within 2 to 3 days, forming small, shallow ulcers that heal in 6 to 10 days.
• Treatment is usually palliative;• In adults, antiviral therapy with acyclovir, 400 mg
PO 3 to 5 times per day for 5 days, or valacyclovir, 2 grams PO twice a day for 1 day,
VARICELLA-ZOSTER
• Vesicular involvement of the oropharynx is common in chicken pox and may precede skin involvement.
• Maintainadequate hydration
• Herpes zoster occurs along the distribution of the trigeminal nerve 15% to 20% of the time.
• Vesicular eruptions characteristically occur unilaterally, don’t cross the midline, and last 7 to 10 days.
HERPANGINA
• Coxsackievirus group A, types 1 to 6, 8, 10, and 22.
• Sudden onset of high fever, sore throat, headache, and malaise followed by eruption of oral vesicles 1 to 2 mm in size within 24 to 48 hours.
• The soft palate, uvula, posterior pharynx, and tonsillarpillars are usually affected, sparing the buccal mucosa, tongue, and gingiva.
• The disease lasts 7 to 10 days and can be distinguished from herpetic gingivostomatitis by the lack of gingival involvement.
HAND-FOOT-AND-MOUTH DISEASE
• Coxsackievirus type A16 and, occasionally, types A4, A5, A9, and A10
• Development of a few small vesicles on the tongue, gingiva, soft palate, and buccal mucosa.
• These vesicles rupture, resulting in painful, shallow ulcers with a surrounding red halo.
• The buttocks, palms, and plantar surfaces of the feet may be affected.
• Fever is usually of short duration, and the disease lasts 5 to 8 days. Treatment is supportive
TRAUMATIC ULCERS
• Common sources of trauma include rough or jagged edges on teeth or restorations, ill-fitting dentures, oral hygiene mishaps, and.
• Removal of persistent sources of trauma is essential;
• Treatment is palliative.
PYOGENIC GRANULOMA
• Common, benign proliferation of connective tissue in response to local trauma or irritation .
• It occurs primarily on the gingiva.• Not a true granuloma but rather an accumulation of
granulation tissue.• A specific pyogenic granuloma occurring in pregnancy is
referred to as a pregnancy tumor. • This tumor is benign and usually recurs if removed
during pregnancy.• If the tumor does not regress 2 to 3 months postpartum,
definitive removal is indicated.
MEDICATION-RELATED SOFT TISSUE ABNORMALITIES
• Gingival hyperplasia related to phenytoin, cyclosporine, and calcium channel blockers
• Inflammation causes edematous changes and an erythematous coloration. Inflamed tissue bleeds readily
• Treatment includes fastidious oral hygiene to slow the hyperplasia and gingivectomy in advanced cases.
Xerostomia and associated mucosal alterations : anticholinergics, antidepressants, and antihistamines.Stomatitis or mucosal ulcerations from chemotherapeutic agents is also common
SEXUALLY TRANSMITTED DISEASES
• Oral mucosa is as susceptible to the transmission of sexually transmitted diseases as the urogenital mucosa.
• Gonorrhea most commonly causes a pharyngitis involving the uvula and tonsils and may present with or without pustules or exudates.
• Human papillomavirus (HPV), associated with HPV-6, -11, and -45, is most commonly associated with condyloma acuminatum, or venereal warts, and can result in similar oral lesions.
• The primary chancre of syphilis can occur orally.
• In secondary syphilis, oral lesions are common and frequently accompany cutaneous lesions.
• Multiple, oval-shaped, slightly raised ulcers or erosions covered with a gray membrane. Condyloma lata rarely occur intraorally
LESIONS OF THE TONGUE
• Geographic tongue, or benign migratory glossitis is a common benign finding.
• Females are affected twice as often as males.• The typically multiple, well-demarcated zones of
erythema on the tongue are caused by atrophy of the filiform papillae.
• The lesions concentrate on the tip and lateral borders of the tongue and heal in several days
• Reassurance ; fluoconide gel if discomfort is present
Strawberry Tongue
• Strawberry tongue is associated with erythrogenic, toxin-producing Streptococcus pyogenes.
• Clinically, the tongue has prominent red spots on a white-coated background.
• Microscopically, the fungiform papillae are hyperemic with a smooth glossy surface.
• Treatment is with antibiotics directed at Group A streptococci.
Leukoplakia and Erythroplakia
• Leukoplakia is a white patch or plaque that cannot be scraped off and cannot be classified as any other disease.
• Leukoplakia is the most common oral precancer;. • The cause is unknown, but tobacco, alcohol, ultraviolet radiation,
candidiasis, HPV,• tertiary syphilis, and trauma have all been implicated.• Sites : buccal mucosa, hard and soft palates, maxillary gingiva, and lip
mucosa. • Biopsy is mandatory for all persistent leukoplakic lesions. Leukoplakic• Lesions demonstrating dysplastic changes warrant removal.
• Erythroplakia is defined as a red patch that similarly cannot be clinically• or pathologically characterized as any other disease ;greater potential• for dysplastic changes.
ORAL CANCER
• 90% of all oral malignancies are squamous cell carcinoma. • Lymphomas, Kaposi sarcoma, and melanoma comprise most of the
remainder.• Extrinsic factors include tobacco use, especially chewing tobacco or snuff;
excessive alcohol consumption; and sunlight exposure • Intrinsic factors include general malnutrition and chronic iron-deficiency
anemia. • Oral candidiasis, immunosuppressive states such as HIV infection, and
oncogenic viruses such as HPV, herpes simplex virus, and various adenoviruses and retroviruses may play some role in the etiology of oral cancer.
All ulcers, erythroplakic lesions, and leukoplakic lesions of the oral cavity that do not respond to palliative treatment in 10 to 14 days warrant biopsy.Treatment depends on site of involvement and staging of disease
Dentoalveolar trauma
• Management of dentoalveolar trauma depends on the extent of tooth and alveolar involvement, the degree of development of the apex of the tooth, and the age of the patient.
• In injuries in younger patients, especially those who are <12 years of age, the pulp of anterior teeth is quite large and dental fractures involving the pulp are common
Dental Fractures
• The goal of the emergency treatment of a fractured tooth is maintaining pulpalvitality.
• Treatment is aimed at sealing the dentinal tubules and creating a barrier between the dental pulp and the oral environment.
• Ellis class I fractures involve the enamel portion of the tooth only.
• Generally, no emergency treatment is indicated, except to smooth sharp corners that may irritate the tongue or mucosa.
• Referral to a general dentist for aesthetic repair depends on the degree of cosmetic concern of the patient
• Ellis class II fractures involve the dentin of the tooth and require intervention ; account for 70% of tooth fractures.
• Symptoms and visualization of exposed dentin, which is a creamy yellow color compared with the whiter enamel..
• Microorganism contamination of the pulp, oral irritants, or desiccation from mouth breathing initiates an inflammatory process in the pulpal tissue.
• A delay in treatment increases the likelihood of pulpal necrosis.• A glass ionomer dental cement that is easily mixed according to the
manufacturer’s instructions and carefully applied to the dried exposed dentin.
• In Ellis class III fractures, exposure of the pulp has occurred .
• After carefully controlling pulpal bleeding with sterile gauze or a cotton pellet
• Cover the exposed pulp with a calcium hydroxide base• Cover this and the remaining exposed dentin with glass
ionomer cement • Dental evaluation • Defenite treatment is endodontic or root canal therapy.• Oral analgesics should be prescribed and topical
analgesics avoided