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Dental Emergencies
Brian Bast D.M.D., M.D. Assistant Clinical Professor UCSF/SFGH Department of Oral and Maxillofacial Surgery

Dental Emergencies
Pain Trauma Infection Pathology Pain Trauma Infection Pathology

Dental Emergencies

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Dental Emergencies

Dental Emergencies

Dental Emergencies

Dental Emergencies

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Dental Emergencies

Dental Emergencies

Normal Anatomy

Normal Anatomy

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Normal Anatomy

Normal Anatomy

Normal Anatomy

Normal Anatomy

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Ab-Normal Anatomy Ab-

Normal Anatomy

Palatal Tori

Mandibular Tori

Fordyces Spots

Dental Pain

Trigeminal Nerve A (small myelinated) C (unmyelinated)

Dental Pain

Transmits only Pain

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Dental Pain

Dental Pain

Analgesics NSAID, Tyelenol/Narcotic Antibiotic Penicillen, Clindamycin Dental Care Filling, Root Canal etc.

Dental Pain

Dental Pain

Analgesics NSAID, Tyelenol/Narcotic Antibiotic Penicillen, Clindamycin Dental Care Filling, Root Canal etc.

Analgesics NSAID, Tyelenol/Narcotic Antibiotic Penicillen, Clindamycin Dental Care Filling, Root Canal etc.

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Dental Pain

Mucosal Pain

Ulceration Analgesics NSAID, Tyelenol/Narcotic Antibiotic Penicillen, Clindamycin Dental Care Filling, Root Canal etc. Differential Neoplasm, Immune, Infection Trauma Biopsy Directed Treatment

Mucosal Pain
Aphthous Ulcer /canker sore Etiology Immune Mediated Aphthous Ulcer / Stages

Mucosal Pain

ProPro-dromal tingling, burning Pre Ulcer red papules

Incidence 40% Population

Ulcer superficial, white base Healing granulation, no scar/scar

Minor Small (3-10mm) (3Superficial Short Duration (7-14d) (7Major Larger (greater than 10mm) Deep (submucossal and mucsle) Longer Lasting

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Mucosal Pain
Aphthous Ulcer / Treatment No Treatmemt Topical Anesthetics Topical Antibiotics Tetracycline Corticosteroids topical, intra-lesional, intrasystemic

Mucosal Pain

Dental Trauma

Dental Trauma

Concussion Subluxation Intrusion Extrusion Lateral Luxation Avulsion

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Dental Trauma

Dental Trauma

Concussion Subluxation Intrusion Extrusion Lateral Luxation Avulsion

Concussion Subluxation Intrusion Dental Evaluation Good Prognosis Root Canal Analgesics/Antibiotics

Dental Trauma

Dental Trauma

Concussion Subluxation Intrusion Dental Evaluation Good Prognosis Root Canal Analgesics/Antibiotics

Concussion Subluxation Intrusion Extrusion Lateral Luxation Avulsion

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Dental Trauma

Dental Trauma

Concussion Subluxation Intrusion Extrusion Lateral Luxation Avulsion

Concussion Subluxation Intrusion Extrusion Lateral Luxation Avulsion

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Dental Trauma

Dental Trauma

Extrusion Lateral Luxation Repositioning and Splinting Dental Evaluation Analgesics/Antibiotics Guarded Prognosis

Concussion Subluxation Intrusion Extrusion Lateral Luxation Avulsion

Dental Trauma

Dental Trauma

Concussion Subluxation Intrusion Extrusion Lateral Luxation Avulsion

Avulsion Time Limitations 1h

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Dental Trauma

Dental Trauma

Avulsion Time Limitations 1h Storage Medium tissue culture, socket, saliva, milk, saline

Avulsion Time Limitations 1h Storage Medium tissue culture, socket, saliva, milk, saline Health of the Tooth

Dental Trauma
Avulsion/Replantation 1. Irrigate Tooth 2. Local Anesthetic 3. Irrigate Socket 4. Replant Tooth 5. Splint 6. X-Ray

Dental Trauma

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Dental Trauma

Dental Trauma

Dental Trauma

Avulsion Dental Evaluation Poor Prognosis Analgesics/Antibiotics

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Dental Trauma
Crown Fracture Root Fractures Dental Alveolar Crown Fracture Root Fractures Dental Alveolar

Dental Trauma

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Dental Trauma
Crown Fracture Root Fractures Dental Alveolar

Dental Trauma

Crown Fracture
Ellis Classification Class I Enamel Only Class II Enamel and Dentin Class III Enamel, Dentin and Pulp Class IV Root Fractures

Dental Trauma
Crown Fracture Crown Fracture
Ellis Classification Class I Enamel Only Class II Enamel and Dentin Class III Enamel, Dentin and Pulp Class IV Root Fractures

Dental Trauma

Ellis Classification Class I Enamel Only Class II Enamel and Dentin Treatment Dental Referral Filling, Root Canal/Crown Analgesics

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Dental Trauma
Crown Fracture
Ellis Classification Class I Enamel Only Class II Enamel and Dentin Treatment Dental Referral Filling, Root Canal/Crown Analgesics

Dental Trauma
Crown Fracture
Ellis Classification Class III Enamel, Dentin and Pulp Treatment Dental Referral Root Canal/ Crown Possible Extraction Analgesics Antibiotics Penicillen, Clindamycin

Dental Trauma
Crown Fracture
Ellis Classification Class III Enamel, Dentin and Pulp Treatment Dental Referral Root Canal/ Crown Possible Extraction Analgesics Antibiotics Penicillen, Clindamycin

Dental Trauma
Root Fracture
Ellis Classification Class IV Root Fractures Treatment Dental Referral Extraction Analgesics Antibiotics Penicillen, Clindamycin

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Oral Infections
Periodontal Disease and Tooth Decay are the most common infectious diseases in the United states. Over 95% of the Population.

Oral Infections

Oral Infections
Periodontal Disease and Tooth Decay are the most common infectious diseases in the United states. Over 95% of the Population.

Oral Infections
Periodontal Disease and Tooth Decay are the most common infectious diseases in the United states. Over 95% of the Population.

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Oral Infections

Oral Infections

Odontogenic Infections Most common cause of an abscess in the deep spaces of the Head and Neck Spread of Infection depends on - Thickness of bone adjacent to tooth - Position of muscle attachment in relation to root apex - Host Defense - Virulence of bacteria

Odontogenic Infections Most common cause of an abscess in the deep spaces of the Head and Neck Spread of Infection depends on - Thickness of bone adjacent to tooth - Position of muscle attachment in relation to root apex - Host Defense - Virulence of bacteria

Oral Infections

Oral Infections

Primary Spaces
Palate Sublingual Submandibular Vestibular Buccal Canine Submental

Primary Spaces
Palate Sublingual Submandibular Vestibular Buccal Canine Submental

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Oral Infections

Oral Infections

Primary Spaces
Palate Sublingual Submandibular Vestibular Buccal Canine Submental

Primary Spaces
Sublingual Submandibular Submental

Oral Infections

Oral Infections

Primary Spaces
Sublingual Submandibular Submental

Primary Spaces
Sublingual Submandibular Submental

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Oral Infections

Oral Infections

Primary Spaces
Palate Sublingual Submandibular Vestibular Buccal Canine Submental

Primary Spaces
Sublingual Submandibular Submental

Oral Infections

Oral Infections

Primary Spaces
Palate Sublingual Submandibular Vestibular Buccal Canine Submental

Primary Spaces
Palate Sublingual Submandibular Vestibular Buccal Canine Submental

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Oral Infections Secondary Spaces

PterygomandibularPterygomandibular- spread from submandibular Masseteric Temporal All above+ Masticator space SignSign- Trismus Orbital Infratemporal Lateral Pharyngeal Retropharyngeal Prevertebral

Oral Infections Secondary Spaces

PterygomandibularPterygomandibular- spread from submandibular Masseteric Temporal All above+ Masticator space SignSign- Trismus Orbital Infratemporal Lateral Pharyngeal Retropharyngeal Prevertebral

Oral Infections Secondary Spaces

Orbital PeriPeri-Orbital

Oral Infections Secondary Spaces

Orbital PeriPeri-Orbital

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Oral Infections Secondary Spaces

Orbital PeriPeri-Orbital

Oral Infections Secondary Spaces

Orbital PeriPeri-Orbital Ophtho acuity, eom, pupils CT with contrast Treatment Drainage, Antibiotics

Oral Infections Most odontogenic infections are caused by multiple bacterial species. Primarily
Aerobic gram (+) cocci Anaerobic gram (+) cocci Anaerobic gram (-) rods (-

Oral Infections

Aerobic Species
Gram + rods Corynebacterium, Diptheroids Gram rods E. corrodens Haemophilus Enterobacteriaceae Gram + cocci (strep, staph) Gram cocci (Neisseria) (Neisseria) Spirochetes Fungi

Anaerobic Species
Gram + rods Actinomyces, Lactobacillus, Propionbacterium acnes, Clostridia Gram rods Bacteroides, Fusobacterium, Wollinella Gram + cocci Streptococcus, Peptostreptococcus Gram - cocci Veillonella

Aerobic / Anaerobic characteristics

Aerobic Infection Anaerobic Infection Combination Infection 5-7% 30% 70%

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Oral Infections
Trends Microbiology of Maxillofacial Infections
Increase in Beta-Lactamase, E. Corrodens, S. Aureus , questionable decrease in Bacteroides *Storoe et al; The changing face of odontogenic infection, JOMS, 2001: 59, 739-48

Oral Infections
Management of Odontogenic Infections Determine severity History and Physical Imaging Studies -Panorex -CT with contrast:

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.

Oral Infections
Management of Odontogenic Infections Determine severity Identifying drainable fluid collection in face and neck regions Clinical exam: sensitivity 55%, specificity 73% CT : sensitivity 95%, specificity 53% CT and Clinical exam: sensitivity 95%, specificity 80% Miller et al., Laryngoscope, 109 (11) 1999:1873-1879.

Oral Infections
Hospital Admission Airway Trismus, Floor of Mouth Lateral Pharynx Fever WBC Immunocomp DM, HIV, EtOH

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Oral Infections
Oral Hospital Admission Airway Trismus, Floor of Mouth Lateral Pharynx Fever WBC Immunocomp DM, HIV, EtOH Treatment Airway Drainage Extraction Antibiotics
Penicillin V Amoxicillin Augmentin Cephalexin Clindamycin

Oral Infections
24h
$0.56 $0.93 $10.95 $4.28 $3.92 $16.88

1wk
$9.99 $13.89 $104.99 $24.89 $31.29 $118.27 $10.02 $80.59

Metronidazole Ciprofloxacin

$2.88 $8.30

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

Oral Infections
Intravenous
24h Penicillin G Ampicillin Unasyn Cefazolin
$21.28 $21.24 $73.80 $17.70

Oral Infections
Pericornitis Bacterial infection and inflammation of the soft tissue around a partiallly erupted third molar. Pain, Trismus, Fever FOM Soft

1wk
$148.96 $148.68 $516.60 $123.90 $375.68 $541.52 $476.00

Clindamycin $53.64 Metronidazole $77.36 Ciprofloxacin $68.00

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

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Oral Infections
Pericornitis Bacterial infection and inflammation of the soft tissue around a partiallly erupted third molar. Treatment Extraction Antibiotics PCN, Clindamycin Chlorhexidine(.12%)/H2O2

Oral Infections
Pericornitis Bacterial infection and inflammation of the soft tissue around a partiallly erupted third molar. Treatment Extraction Antibiotics PCN, Clindamycin Chlorhexidine(.12%)/H2O2

Oral Infections
Acute Necrotizing Ulcerative Gingivitis Trench Mouth Putrid Sore Mouth Gilmers Disease Vincents Infection Diphtheroid Angina

Oral Infections
Acute Necrotizing Ulcerative Gingivitis Fusiform and Spirochete Bacterial infection of the gingiva.

Signs and Symptoms Pain, bleeding, gingival necrosis, fever, Foul oral odor. Treatment Antibiotic PCN, Clindamycin Chlorhexidine/H2O2 Dental Cleaning

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Oral Pathology
Bone Pathology Cysts Tumors

Oral Pathology

Oral Pathology
Bone Pathology Cysts Tumors Bone Pathology Cysts Tumors

Oral Pathology

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Oral Pathology
Soft Tissue Pathology Mucocele Mucus Extravisation Mucus Retention Painless, recurrent swelling with periods of drainage Treatment: Treatment: excision of gland. Soft Tissue Pathology Carcinoma 90% SCCa Painful, nonhealing ulcer White leukoplakia Red erythroplakia

Oral Pathology

Oral Pathology
Soft Tissue Pathology Carcinoma 90% SCCa Painful, nonhealing ulcer White leukoplakia Red erythroplakia Adenopathy Soft Tissue Pathology Carcinoma 90% SCCa Painful, nonhealing ulcer White leukoplakia Red erythroplakia Risk Factors: Tobacco, Etoh No Risk Factors

Oral Pathology

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Oral Pathology
Soft Tissue Pathology Carcinoma 90% SCCa Painful, nonhealing ulcer White leukoplakia Red erythroplakia Biopsy Directed Treatment

See Ya Later Alligator !!!!

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