dental trauma in the ed: fractures and luxations resident grand rounds elizabeth haney 10 may 2007
TRANSCRIPT
Outline
Review of anatomy, and pertinent basics
Injury Overview
Management New products coming and how to use them
Thanks to Dr. Greenfield, Dr. Kalaydjian and Dr. Lobay
Goal
For you to leave today feeling more confident with your management and disposition of dental injuries.
Emerg Issues in Dental Injuries
Pain Management Oral Meds Nerve Blocks Covering the Exposed Root
Keep tooth alive Transient Storage Media
Stabilization until definitive management (ie: referral to our Dental colleagues)
Periodontal Paste
Numbers in the CHR
Interrogation of CHR initial complaints April 1 2006 – March 31 2007 FMC, RGH, PLC 1868 Dental/Oral related visits as primary complaint
2006 Health Records Info 196 discharge codes for Dental specific Dx
Which tooth is it?
Numbering System Differences
32 adult teeth 4 incisors (most
commonly injured) 2 canines 4 premolars 6 molars
Upper Right = 1 Upper Left = 2
Lower Right = 4
Lower Left = 3
Tooth Surface Terminology
Lingual surface faces tongue Buccal surface faces cheek Mesial surface faces midline Distal surface faces ramus of mandible
Fractures
Ellis classification used in Emerg
General description used/preferred by Dentists
ie: instead of Ellis III, saying # exposing the pulp
Enamel Fractures
Non – painful Chalky white
appearance Reassurance Consider filing sharp
edges Non-urgent Dentistry
referral
Dentin Fractures
May have sensitivity (temp, air, percussion)
Yellow dentin visible Management:
Block the tooth Dry tooth Cover the tooth (CaOH)
Dental f/u within 24h
Pulp Fractures Yellow dentin and pink
blush or frank blood Usually Painful
Block the tooth Dry the tooth Cover the tooth (Calcium
Hydroxide) Dental Consult if unable to
manage pain
Most require eventual root canal
Fractures Summary
All require Dentistry follow-up Enamel #’s: non-urgent (1-2 weeks) Dentin #’s: within 24 hours Pulp #’s: Immediate if possible, next day at latest
Subluxation, Luxation, Avulsion
Subluxation – Loose Tooth Luxation – Displaced Tooth
Intrusive: displaced into socket (apically) Extrusive: displaced out of socket Lateral: displaced any other way
Avulsion – Completely Out
Pain Control!
Subluxation
Increased mobility due to torn PDL fibers Tender to touch Not displaced If minimally mobile
Soft diet Non-urgent dental f/u
If grossly unstable Stabilize: Dentist Consult, or stabilize in ED and
Dentist in AM
Intrusive Luxation
Apical displacement into alveolar bone
Crushes PDL +/- neurovascular supply rupture
Immobile R/O avulsion if
completely intruded Consult Dentistry –
semi-urgent basis
Extrusive Luxation
Tooth appears long Mobile Gently reposition into
socket Stabilize Consult Dentistry
Lateral Luxation
Tooth displaced, apex moved close to bone
Usually immobile Reposition Stabilize Consult Dentistry
Avulsion Completely out of socket Torn PDL w/ fragments on
root and in socket Locate tooth!
Place the avulsed tooth in cold, isotonic solution
Consult Dentistry
1% chance of successful reimplantation lost q1min out of socket (dry)
General Avulsion Guidelines
Handle tooth by the crown (Minimize PDL damage)
Transport in appropriate media (next slide)
Gently rinse (wiping can remove PDL)
Flush socket with saline In ED, replant tooth,
stabilize
Tooth Storage Media
Order of Preference: Hank’s (ph) balanced salt
solution (HBSS) Cold milk Saliva Saline Water
NEVER Dry
Ozan et al. J Endod May 2007
Periodontal Paste & Calcium Hydroxide Do we have them in the ED?
NO. Not yet
I’m working on getting us samples and will keep you posted via e-mail
Stabilization and Capping Products
New Products and How to Use Them
Coe-Pak Surgical dressing &
Periodontal pack Supplied in 2 tubes: base &
catalyst Mix together into paste Roll into appropriate width &
length Press against mucosa and
teeth, flanking the injured tooth
Do not cover occlusal surface
Ca Hydroxide
Rigid self-setting material used for pulp capping & as a protective base/liner under dental filling materials
Supplied in 2 tubes: base & catalyst
Dispense equal volumes onto paper
Stir using applicator until uniform color (~10sec)
Apply to dried area Remove excess Set time: 2-3 min on paper,
less in mouth
It’s 2am….Do I Call the Dentist?
Dental Emergencies: Avulsion Fracture to Pulp, if unable to control pain Any luxation Dental Hemorrhage Abscess needing drainage which is beyond our scope
Jaw # - OMF surgeon
If they’re coming in Order a PanorexThanks Dr. Kalaydjian
CHR Dentist’s On-Call Policy
Full coverage Each dentist 1 call q 2-3 weeks Call back within 5-10 minutes, able to be at
hospital within 30 minutes No formal compensation (only if pt pays)
Great policy on helping ED pts! Be Kind
CHR Resources
CHR Dental Clinic: Only medically compromised patients as regulars
CHR funded Community Dental Clinics: Patients pay 20% of actual fee
Call 228-3384 = “22-teeth” Sites: City Hall Dental Clinic, Northeast Dental Clinic
(Sunridge Mall), Airdrie www.calgaryhealthregion.ca/hecomm/oral/
reducedfeedental.htm
Take Home Points
Know the terminology, or where to find it Proper communication = Happier consultants Manage the pain We temporarily manage these injuries Definitive management left to the pros Know your tools and resources
Future Initiatives
Stocking of Stabilization and Capping products
Dental Trauma Patient Instructions Dedicated space in the Emerg for a dentistry
locked box of supplies
References
Marx. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6 th ed. 2006. ch. 69 Oral Medicine
Andersson et al. Guidelines for the management of traumaticdental injuries. I. Fractures and luxations of permanent teeth. Dental Traumatology 2007; 23: 66-71
Becker et al. Drug Therapy in Dental Practice: Nonopioid and Opioid Analgesics. Anesth Prog 2005; 52:140-149
Dale RA. Dentoalveolar trauma. Emerg Med Clin North Am 2000;18: 521-38 Po AL, Zhang WY: Analgesic efficacy of ibuprofen alone and in combination with codeine
or caffeine in post-surgical pain: A meta-analysis. Eur J Clin Pharmacol 1998; 53:303 Benko et al., Management of Dental Emergencies. EM Reports. Vol 27, N. 3. January
2006 Lynch MT, Syverud SA, Schwab RA, et al: Comparison of intraoral and percutaneous
approaches for infraorbital nerve block. Acad Emerg Med 1994; 1:514 Harkacz O, Carnes D, Walker W. Determination of periodontal ligament cell viability in the
oral rehydration fluid Gatorade and milks of varying fat content. J Endod 1997;23:687–90 Ozan et al. Effect of Propolis on Survival of Periodontal Ligament Cells: New Storage
Media for Avulsed Teeth. J Endod 2007;33:570-573 EMRap November 2006 Dental Trauma www.calgaryhealthregion.ca/hecomm/oral/reducedfeedental.htm
Useful Nerve Block Review
Supraperiosteal - Individual Teeth
Infraorbital – Maxillary Teeth and Upper Lip
Inferior Alveolar – Mandibular Teeth
Mental – Lower Lip
Supraperiosteal Block Individual tooth anesthesia How to:
Pt closes mouth slightly, relaxed
Pull lip taut with gauze Bevel facing bone, insert
@ mucobuccal fold Advance to apex Aspirate Inject 1-2 cc marcaine
slowly
Infraorbital Nerve Block Anesthetizes the midface How to (intraoral approach):
Keep a finger over the inferior border on the infraorbital rim
Retract cheek Puncture opposite the upper
second bicuspid (premolar) ~0.5 cm from buccal surface
Needle parallel w/ tooth Advance until palpated near
the foramen (~2.5cm depth) Aspirate Inject 2-3cc marcaine
adjacent to, not within, the foramen
Inferior Alveolar Nerve Block
Anesthetizes the hemimandible, lower lip & chin
How to: Palpate the anterior
ramus border Retract buccal tissue
laterally, stabilize mandible with finger behind ramus
Inferior Alveolar Nerve Block
Syringe barrel oriented over the contralateral mandibular bicuspids
Insertion site = 1cm above occlusal surface of 3rd molar
Insert until needle point touches medial surface of ramus
Back up ~1mm Aspirate Inject
Mental Nerve Block Anesthetizes lower lip Infiltration about the mental
foramen How to (intraoral approach):
Palpate the mental foramen ~1 cm inferior and anterior to the second premolar
Retract lip Insert needle (45° angle)
at mucosal junction of lower lip and gum beneath 2nd premolar
Aspirate Inject 1-2cc marcaine
Billing For the Block
Specific code for dental anaesthesia (33.99B) no longer exists in Emergency
But….. You can bill a local anaesthetic code
17.17A ($21.13), which is modifiable
Thanks to Dr. Rick Morris
ED Visit Month
Fracture Of Tooth Dislocation Of Tooth
Total Dent
al Trauma
Visits
FM RG PLC
Total All
Sites
FMC RGH PLC
Total All Sites
Jan-06 5 3 2 10 1 1 2 12
Feb-06 4 3 6 13 3 2 1 6 19
Mar-06 6 3 1 10 1 1 11
Apr-06 3 3 4 10 1 1 1 3 13
May-06 9 2 4 15 2 1 2 5 20
Jun-06 7 5 6 18 1 3 4 22
Jul-06 11 6 17 1 2 2 5 22
Aug-06 4 3 7 2 2 9
Sep-06 3 6 7 16 5 2 1 8 24
Oct-06 7 3 4 14 1 1 2 16
Nov-06 2 2 6 10 2 2 12
Dec-06 4 3 7 14 1 1 2 16
Cal Year 2006 Total 65 33 56 154 17 9 16 42 196
5th Cranial Nerve: Trigeminal
V1 = Ophthalmic V2 = Maxillary
(dentition) V3 = Mandibular
(dentition)
Coe-Pak MSDS Hazardous Ingredients
Denatured Alcohol 1-5% Ethanol Methanol
Petrolatum 5-10%
HEALTH HAZARD (Acute and Chronic): Denatured alcohol: Prolonged exposure to ethanol may result in
irritation of mucous membrane, headache, drowsiness, and fatigue. Methanol is also narcotic and affects are cumulative.
Sx & SYMPTOMS OF OVEREXPOSURE: Overexposure to methanol can result in acidosis and visual disturbances that may lead to permanent loss of vision.