Bast Dental Emergencies

8/2/2019 Bast Dental Emergencies

1/28

11/5/2008

1

Dental EmergenciesDental Emergencies

Brian Bast D.M.D., M.D.Brian Bast D.M.D., M.D.

Assistant Clinical ProfessorAssistant Clinical Professor

UCSF/SFGHUCSF/SFGH

Department of Oral and MaxillofacialDepartment of Oral and MaxillofacialSurgerySurgery


PainPain

TraumaTrauma

InfectionInfection

PathologyPathology


PainPain

TraumaTrauma

InfectionInfection

PathologyPathology


2/28

11/5/2008

2






3/28

11/5/2008

3



Normal AnatomyNormal Anatomy

Normal AnatomyNormal Anatomy


4/28

11/5/2008

4

Normal AnatomyNormal Anatomy Normal AnatomyNormal Anatomy

Normal AnatomyNormal Anatomy Normal AnatomyNormal Anatomy


5/28

11/5/2008

5

AbAb--Normal AnatomyNormal Anatomy Normal AnatomyNormal Anatomy

Fordyces SpotsFordyces Spots

Palatal ToriPalatal Tori Mandibular ToriMandibular Tori

Dental PainDental Pain


Trigeminal NerveTrigeminal Nerve

AA (small myelinated)(small myelinated)

C (unmyelinated)C (unmyelinated)

Transmits only PainTransmits only Pain


6/28

11/5/2008

6

Dental PainDental Pain Dental PainDental Pain

AnalgesicsAnalgesics NSAID, Tyelenol/NarcoticNSAID, Tyelenol/Narcotic

AntibioticAntibiotic Penicillen, ClindamycinPenicillen, Clindamycin

Dental CareDental Care Filling, Root Canal etc.Filling, Root Canal etc.










7/28

11/5/2008

7





Mucosal PainMucosal Pain

UlcerationUlceration

DifferentialDifferential Neoplasm, Immune, InfectionNeoplasm, Immune, Infection

TraumaTrauma

Biopsy Directed TreatmentBiopsy Directed Treatment


Aphthous Ulcer /canker soreAphthous Ulcer /canker sore

EtiologyEtiology Immune MediatedImmune Mediated

IncidenceIncidence 40% Population40% Population

MinorMinor Small (3Small (3--10mm)10mm)

SuperficialSuperficial

Short Duration (7Short Duration (7--14d)14d)

MajorMajor Larger (greater than 10mm)Larger (greater than 10mm)

Deep (submucossal and mucsle)Deep (submucossal and mucsle)

Longer LastingLonger Lasting


Aphthous Ulcer / StagesAphthous Ulcer / Stages

ProPro--dromaldromal tingling, burningtingling, burning

Pre UlcerPre Ulcer red papulesred papules

UlcerUlcer superficial, white basesuperficial, white base

HealingHealing granulation, no scar/scargranulation, no scar/scar


8/28

11/5/2008

8


Aphthous Ulcer / TreatmentAphthous Ulcer / Treatment

No TreatmemtNo Treatmemt

Topical AnestheticsTopical Anesthetics

Topical AntibioticsTopical Antibiotics TetracyclineTetracycline

CorticosteroidsCorticosteroids topical, intratopical, intra--lesional,lesional,

systemicsystemic


Dental TraumaDental Trauma


ConcussionConcussion

SubluxationSubluxation

IntrusionIntrusion

ExtrusionExtrusion

Lateral LuxationLateral LuxationAvulsionAvulsion


9/28

11/5/2008

9




IntrusionIntrusion

ExtrusionExtrusion

Lateral LuxationLateral Luxation

AvulsionAvulsion




IntrusionIntrusion

Dental EvaluationDental Evaluation

Good PrognosisGood Prognosis

Root CanalRoot CanalAnalgesics/AntibioticsAnalgesics/Antibiotics




IntrusionIntrusion

Dental EvaluationDental EvaluationGood PrognosisGood Prognosis

Root CanalRoot Canal

Analgesics/AntibioticsAnalgesics/Antibiotics




IntrusionIntrusion

ExtrusionExtrusion



10/28

11/5/2008

10




IntrusionIntrusion

ExtrusionExtrusion


AvulsionAvulsion




IntrusionIntrusion

ExtrusionExtrusion


AvulsionAvulsion


11/28

11/5/2008

11


ExtrusionExtrusion


Repositioning and SplintingRepositioning and Splinting



Guarded PrognosisGuarded Prognosis




IntrusionIntrusion

ExtrusionExtrusion


AvulsionAvulsion




IntrusionIntrusion

ExtrusionExtrusion



AvulsionAvulsion

Time LimitationsTime Limitations 1h1h


12/28

11/5/2008

12


AvulsionAvulsion


Storage MediumStorage Medium

tissue culture, socket,tissue culture, socket,saliva, milk, salinesaliva, milk, saline


AvulsionAvulsion


Storage MediumStorage Medium

tissue culture, socket,tissue culture, socket,saliva, milk, salinesaliva, milk, saline

Health of the ToothHealth of the Tooth


Avulsion/ReplantationAvulsion/Replantation

1.1. Irrigate ToothIrrigate Tooth

2.2. Local AnestheticLocal Anesthetic

3.3. Irrigate SocketIrrigate Socket

4.4. Replant ToothReplant Tooth

5.5. SplintSplint6.6. XX--RayRay



13/28

11/5/2008

13

Dental TraumaDental Trauma Dental TraumaDental Trauma


AvulsionAvulsion


Poor PrognosisPoor Prognosis



14/28

11/5/2008

14


Crown FractureCrown Fracture

Root FracturesRoot Fractures

Dental AlveolarDental Alveolar






15/28

11/5/2008

15







Ellis ClassificationEllis Classification

Class IClass I Enamel OnlyEnamel Only

Class IIClass II Enamel and DentinEnamel and Dentin

Class IIIClass III Enamel, Dentin and PulpEnamel, Dentin and Pulp

Class IVClass IV Root FracturesRoot Fractures













TreatmentTreatment

Dental ReferralDental ReferralFilling, Root Canal/CrownFilling, Root Canal/Crown

AnalgesicsAnalgesics


16/28

11/5/2008

16






TreatmentTreatment

Dental ReferralDental Referral

Filling, Root Canal/CrownFilling, Root Canal/Crown






TreatmentTreatment


Root Canal/ CrownRoot Canal/ Crown

Possible ExtractionPossible Extraction

AnalgesicsAnalgesicsAntibioticsAntibiotics Penicillen, ClindamycinPenicillen, Clindamycin





TreatmentTreatment


Root Canal/ CrownRoot Canal/ CrownPossible ExtractionPossible Extraction


AntibioticsAntibiotics Penicillen, ClindamycinPenicillen, Clindamycin


Root FractureRoot Fracture



TreatmentTreatment


ExtractionExtractionAnalgesicsAnalgesics

AntibioticsAntibiotics Penicillen, ClindamycinPenicillen, Clindamycin


17/28

11/5/2008

17

Oral InfectionsOral Infections


Periodontal Disease and Tooth DecayPeriodontal Disease and Tooth Decay

are the most common infectiousare the most common infectiousdiseases in the United states.diseases in the United states.

Over 95% of the Population.Over 95% of the Population.


Periodontal Disease and Tooth DecayPeriodontal Disease and Tooth Decayare the most common infectiousare the most common infectiousdiseases in the United states.diseases in the United states.



Periodontal Disease and Tooth DecayPeriodontal Disease and Tooth Decayare the most common infectiousare the most common infectiousdiseases in the United states.diseases in the United states.



18/28

11/5/2008

18


Odontogenic InfectionsOdontogenic Infections

Most common cause of an abscess in theMost common cause of an abscess in thedeep spaces of the Head and Neckdeep spaces of the Head and Neck

Spread of Infection depends onSpread of Infection depends on

-- Thickness of bone adjacent to toothThickness of bone adjacent to tooth

-- Position of muscle attachment inPosition of muscle attachment inrelation to root apexrelation to root apex

-- Host DefenseHost Defense-- Virulence of bacteriaVirulence of bacteria


Odontogenic InfectionsOdontogenic Infections

Most common cause of an abscess in theMost common cause of an abscess in thedeep spaces of the Head and Neckdeep spaces of the Head and Neck

Spread of Infection depends onSpread of Infection depends on

-- Thickness of bone adjacent to toothThickness of bone adjacent to tooth

-- Position of muscle attachment inPosition of muscle attachment inrelation to root apexrelation to root apex

-- Host DefenseHost Defense-- Virulence of bacteriaVirulence of bacteria


Primary SpacesPrimary Spaces

PalatePalateSublingualSublingual

SubmandibularSubmandibular

VestibularVestibular

BuccalBuccalCanineCanineSubmentalSubmental








19/28

11/5/2008

19



PalatePalate

SublingualSublingualSubmandibularSubmandibular


BuccalBuccalCanineCanine

SubmentalSubmental




SubmentalSubmental



SublingualSublingual


SubmentalSubmental



SublingualSublingual


SubmentalSubmental


20/28

11/5/2008

20



PalatePalate



BuccalBuccalCanineCanine

SubmentalSubmental




SubmentalSubmental














21/28

11/5/2008

21


Secondary SpacesSecondary Spaces

PterygomandibularPterygomandibular-- spread fromspread from

submandibularsubmandibularMassetericMasseteric

TemporalTemporal

All above+ Masticator spaceAll above+ Masticator spaceSignSign-- TrismusTrismus

OrbitalOrbitalInfratemporalInfratemporal

Lateral PharyngealLateral PharyngealRetropharyngealRetropharyngeal

PrevertebralPrevertebral



PterygomandibularPterygomandibular-- spread fromspread from

submandibularsubmandibularMassetericMasseteric

TemporalTemporal

All above+ Masticator spaceAll above+ Masticator spaceSignSign-- TrismusTrismus

OrbitalOrbitalInfratemporalInfratemporal

Lateral PharyngealLateral PharyngealRetropharyngealRetropharyngeal

PrevertebralPrevertebral



OrbitalOrbitalPeriPeri--OrbitalOrbital



OrbitalOrbitalPeriPeri--OrbitalOrbital


22/28

11/5/2008

22



OrbitalOrbital

PeriPeri--OrbitalOrbital



OrbitalOrbital

PeriPeri--OrbitalOrbital

OphthoOphthoacuity, eom, pupilsacuity, eom, pupils

CT with contrastCT with contrast

TreatmentTreatment

Drainage, AntibioticsDrainage, Antibiotics


Most odontogenic infections are caused by multipleMost odontogenic infections are caused by multiplebacterial species.bacterial species.

PrimarilyPrimarilyAerobic gram (+) cocciAerobic gram (+) cocci

Anaerobic gram (+) cocciAnaerobic gram (+) cocci

Anaerobic gram (Anaerobic gram (--) rods) rods

Aerobic / Anaerobic characteristicsAerobic / Anaerobic characteristicsAerobic InfectionAerobic Infection 55--7%7%

Anaerobic InfectionAnaerobic Infection 30%30%

Combination InfectionCombination Infection 70%70%


Aerobic SpeciesAerobic Species

Gram + rodsGram + rodsCorynebacterium, DiptheroidsCorynebacterium, Diptheroids

GramGram rodsrodsE. corrodensE. corrodens

HaemophilusHaemophilus

EnterobacteriaceaeEnterobacteriaceaeGram + cocci (strep, staph)Gram + cocci (strep, staph)GramGram cocci (cocci (NeisseriaNeisseria))

SpirochetesSpirochetes

FungiFungi

Anaerobic SpeciesAnaerobic Species

Gram + rodsGram + rodsActinomyces, Lactobacillus,Actinomyces, Lactobacillus,

Propionbacterium acnes, ClostridiaPropionbacterium acnes, Clostridia

GramGram rodsrodsBacteroides, Fusobacterium,Bacteroides, Fusobacterium,

WollinellaWollinellaGram + cocciGram + cocci

Streptococcus, PeptostreptococcusStreptococcus, Peptostreptococcus

GramGram -- coccicocciVeillonellaVeillonella


23/28

11/5/2008

23


Trends Microbiology of Maxillofacial InfectionsTrends Microbiology of Maxillofacial Infections

Increase inBeta-Lactamase, E. Corrodens, S. Aureus , questionabledecrease in Bacteroides

*Storoe et al; The changing face of odontogenic infection, JOMS, 2001: 59,

739-48

Unlikely shift in the types of bacteria seen in odontogenic infections in the

last decade*Haug RH, The changing microbiology of maxillofacial infections, Oral

Maxillofacial Surg N Am, 2003: 15, 1-15.


Management of OdontogenicManagement of OdontogenicInfectionsInfections

Determine severityDetermine severityHistory and PhysicalHistory and Physical

Imaging StudiesImaging Studies

--PanorexPanorex--CT with contrast:CT with contrast:


Management of Odontogenic InfectionsManagement of Odontogenic InfectionsDetermine severityDetermine severity

Identifying drainable fluid collection inIdentifying drainable fluid collection inface and neck regionsface and neck regions

Clinical exam: sensitivityClinical exam: sensitivity55%, specificity 73%55%, specificity 73%

CT : sensitivity 95%,CT : sensitivity 95%,specificity 53%specificity 53%

CT and Clinical exam:CT and Clinical exam:sensitivity 95%, specificitysensitivity 95%, specificity80%80%

Miller et al., Laryngoscope, 109 (11)1999:1873-1879.


Hospital AdmissionHospital Admission

AirwayAirway

Trismus, Floor of MouthTrismus, Floor of MouthLateral PharynxLateral Pharynx

FeverFeverWBCWBC

ImmunocompImmunocompDM, HIV, EtOHDM, HIV, EtOH


24/28

11/5/2008

24


Hospital AdmissionHospital AdmissionAirwayAirway

Trismus, Floor of MouthTrismus, Floor of Mouth

Lateral PharynxLateral PharynxFeverFever

WBCWBCImmunocompImmunocomp

DM, HIV, EtOHDM, HIV, EtOH

TreatmentTreatment

AirwayAirwayDrainageDrainage

ExtractionExtractionAntibioticsAntibiotics


OralOral 24h24h 1wk1wk

PenicillinPenicillin VV $0.56$0.56 $9.99$9.99

AmoxicillinAmoxicillin $0.93$0.93 $13.89$13.89

AugmentinAugmentin $10.95$10.95 $104.99$104.99

CephalexinCephalexin $4.28$4.28 $24.89$24.89

ClindamycinClindamycin $3.92$3.92 $31.29$31.29

$16.88$16.88 $118.27$118.27

MetronidazoleMetronidazole $2.88$2.88 $10.02$10.02

CiprofloxacinCiprofloxacin $8.30$8.30 $80.59$80.59

**Flynn et al., Oral Maxillofacial Surg Clin N Am 15 (2003), 34.Flynn et al., Oral Maxillofacial Surg Clin N Am 15 (2003), 34.


IntravenousIntravenous

24h24h 1wk1wk

Penicillin GPenicillin G $21.28$21.28 $148.96$148.96

AmpicillinAmpicillin $21.24$21.24 $148.68$148.68

UnasynUnasyn $73.80$73.80 $516.60$516.60

CefazolinCefazolin $17.70$17.70 $123.90$123.90

ClindamycinClindamycin $53.64$53.64 $375.68$375.68

MetronidazoleMetronidazole$77.36$77.36 $541.52$541.52

CiprofloxacinCiprofloxacin $68.00$68.00 $476.00$476.00

**Flynn et al., Oral Maxillofacial Surg Clin N Am 15 (2003), 34.Flynn et al., Oral Maxillofacial Surg Clin N Am 15 (2003), 34.


PericornitisPericornitis

Bacterial infection andBacterial infection andinflammation of the soft tissueinflammation of the soft tissuearound a partiallly eruptedaround a partiallly erupted

third molar.third molar.

Pain, Trismus, FeverPain, Trismus, Fever

FOM SoftFOM Soft


25/28

11/5/2008

25



Bacterial infection andBacterial infection andinflammation of the soft tissueinflammation of the soft tissue

around a partiallly eruptedaround a partiallly eruptedthird molar.third molar.

TreatmentTreatment

ExtractionExtraction

AntibioticsAntibiotics PCN, ClindamycinPCN, Clindamycin

Chlorhexidine(.12%)/H2O2Chlorhexidine(.12%)/H2O2



Bacterial infection andBacterial infection andinflammation of the soft tissueinflammation of the soft tissue

around a partiallly eruptedaround a partiallly eruptedthird molar.third molar.

TreatmentTreatment

ExtractionExtraction

AntibioticsAntibiotics PCN, ClindamycinPCN, Clindamycin

Chlorhexidine(.12%)/H2O2Chlorhexidine(.12%)/H2O2


Acute Necrotizing Ulcerative GingivitisAcute Necrotizing Ulcerative Gingivitis

Trench MouthTrench Mouth

Putrid Sore MouthPutrid Sore Mouth

Gilmers DiseaseGilmers Disease

Vincents InfectionVincents Infection

Diphtheroid AnginaDiphtheroid Angina


Acute Necrotizing Ulcerative GingivitisAcute Necrotizing Ulcerative Gingivitis

Fusiform and Spirochete BacterialFusiform and Spirochete Bacterialinfection of the gingiva.infection of the gingiva.

Signs and SymptomsSigns and Symptoms

Pain, bleeding, gingival necrosis, fever,Pain, bleeding, gingival necrosis, fever,

Foul oral odor.Foul oral odor.

TreatmentTreatment

AntibioticAntibiotic PCN, ClindamycinPCN, Clindamycin

Chlorhexidine/H2O2Chlorhexidine/H2O2

Dental CleaningDental Cleaning


26/28

11/5/2008

26

Oral PathologyOral Pathology


Bone PathologyBone Pathology

CystsCysts

TumorsTumors



CystsCysts

TumorsTumors



CystsCysts

TumorsTumors


27/28

11/5/2008

27


Soft Tissue PathologySoft Tissue Pathology

MucoceleMucocele

Mucus ExtravisationMucus Extravisation

Mucus RetentionMucus Retention

Painless, recurrent swelling withPainless, recurrent swelling withperiods of drainageperiods of drainage

TreatmentTreatment: excision of gland.: excision of gland.



CarcinomaCarcinoma

90% SCCa90% SCCa

Painful, nonhealing ulcerPainful, nonhealing ulcer

WhiteWhite leukoplakialeukoplakia

RedRed erythroplakiaerythroplakia



CarcinomaCarcinoma

90% SCCa90% SCCa




AdenopathyAdenopathy



CarcinomaCarcinoma

90% SCCa90% SCCa




Risk Factors:Risk Factors:

Tobacco, EtohTobacco, Etoh

No Risk FactorsNo Risk Factors


28/28

11/5/2008

28



CarcinomaCarcinoma

90% SCCa90% SCCa




Biopsy Directed TreatmentBiopsy Directed Treatment

See Ya Later Alligator !!!!See Ya Later Alligator !!!!

Bast Dental Emergencies

Documents

Transcript of Bast Dental Emergencies