EMERGENCY MEDICINE PRACTICE EMPRACTICE.NET an EVIDENCE-BASED APPROACH to EMERGENCY MEDICINE May 2003 Acute Dental Emergencies Volume 5, Number 5
Total Page：16
File Type：pdf, Size：1020Kb
EMERGENCY MEDICINE PRACTICE EMPRACTICE.NET AN EVIDENCE-BASED APPROACH TO EMERGENCY MEDICINE May 2003 Acute Dental Emergencies Volume 5, Number 5 In Emergency Medicine Author “What do you mean, you don’t have a dentist in the emergency department?” Kip Benko, MD, FACEP Clinical Instructor in Emergency Medicine, “Go ahead, Doc—just pull it.” University of Pittsburgh School of Medicine; Attending Physician, Mercy Hospital of Pittsburgh, “I called my dentist’s office but got no answer. He pulled my tooth this morning Pittsburgh, PA. and now it’s bleeding like crazy. Oh, yeah—I’m on Coumadin!” Peer Reviewers OUND familiar? Complaints pertaining to teeth are common, and Marianne C. Burke, MD Spatients frequently present to the ED for initial care. Many patients Emergency Medicine Consultants, Los Angeles, CA. realize that definitive care must be provided by a dentist or oral surgeon, but either pain, trauma, inability to contact their dentist, or the lack of Charles Stewart, MD, FACEP Colorado Springs, CO. financial resources leads patients to our EDs.1 While treating dental emergencies in the ED can be challenging and frustrating, it can also be CME Objectives immensely satisfying. There is no more appreciative patient than one relieved of severe dental pain. Many emergency physicians are unable to Upon completing this article, you should be able to: recognize and treat acute dental problems because of a lack of specific 1. describe the structure, classification, training, yet proper initial care will limit morbidity such as tooth loss, pain, and identification of primary and infection, and, potentially, craniofacial abnormality. Moreoever, while permanent teeth; “dental patients” are often triaged as non-emergent, some of these patients 2. discuss appropriate historical questions deserve ICU-level care from the moment that they come into the ED. and physical examination techniques for both traumatic and non-traumatic dental emergencies; Critical Appraisal Of The Literature 3. describe appropriate anesthesia for patients with dental emergencies, including dental The literature regarding the treatment of dental emergencies in the ED is block techniques most frequently required in mostly extrapolated from other specialties. There are no ED-based outcome the ED; studies or randomized, controlled studies addressing specific treatment 4. describe the ED treatment of traumatic and modalities for fractured teeth, avulsed teeth, infected teeth, odontalgia and non-traumatic dental emergencies; and 5. describe appropriate disposition of patients nerve block anesthesia, or alveolar osteitis (dry sockets). Interestingly, with different types of dental emergencies, prospective outcome data with regard to traumatized teeth are also scarce including indications for referral. in the dental literature. There are no universally accepted guidelines regarding the ED treatment of acutely injured or infected teeth. Several Date of original release: May 1, 2003. studies are currently under way that address the treatment of dental pain Date of most recent review: April 9, 2003. with dental blocks in the ED, but none have yet been published. See “Physician CME Information” on back page. Editor-in-Chief New Mexico Health Sciences Vice-Chairman, Department of Francis P. Kohrs, MD, MSPH, Associate Medical Service, Orlando, FL. Center School of Medicine, Emergency Medicine, Morristown Professor and Chief of the Division Alfred Sacchetti, MD, FACEP, Stephen A. Colucciello, MD, FACEP, Albuquerque, NM. Memorial Hospital. of Family Medicine, Mount Sinai Research Director, Our Lady of Assistant Chair, Department of W. Richard Bukata, MD, Clinical School of Medicine, New York, NY. Lourdes Medical Center, Camden, Emergency Medicine, Carolinas Michael A. Gibbs, MD, FACEP, Chief, Professor, Emergency Medicine, NJ; Assistant Clinical Professor Medical Center, Charlotte, NC; Department of Emergency John A. Marx, MD, Chair and Chief, Los Angeles County/USC Medical of Emergency Medicine, Associate Clinical Professor, Medicine, Maine Medical Center, Department of Emergency Center, Los Angeles, CA; Medical Thomas Jefferson University, Department of Emergency Portland, ME. Medicine, Carolinas Medical Director, Emergency Department, Philadelphia, PA. Medicine, University of North Center, Charlotte, NC; Clinical San Gabriel Valley Medical Gregory L. Henry, MD, FACEP, Carolina at Chapel Hill, Chapel Professor, Department of Corey M. Slovis, MD, FACP, FACEP, Center, San Gabriel, CA. CEO, Medical Practice Risk Emergency Medicine, University Hill, NC. Assessment, Inc., Ann Arbor, Professor of Emergency Medicine Francis M. Fesmire, MD, FACEP, of North Carolina at Chapel Hill, and Chairman, Department of MI; Clinical Professor, Department Chapel Hill, NC. Associate Editor Director, Heart-Stroke Center, of Emergency Medicine, Emergency Medicine, Vanderbilt Erlanger Medical Center; University of Michigan Medical Michael S. Radeos, MD, MPH, University Medical Center; Andy Jagoda, MD, FACEP, Vice- Assistant Professor of Medicine, Medical Director, Metro Nashville Chair of Academic Affairs, School, Ann Arbor, MI; President, Attending Physician, Department UT College of Medicine, American Physicians Assurance of Emergency Medicine, Lincoln EMS, Nashville, TN. Department of Emergency Chattanooga, TN. Medicine; Residency Program Society, Ltd., Bridgetown, Medical and Mental Health Center, Mark Smith, MD, Chairman, Director; Director, International Valerio Gai, MD, Professor and Chair, Barbados, West Indies; Past Bronx, NY; Assistant Professor in Department of Emergency Studies Program, Mount Sinai Department of Emergency President, ACEP. Emergency Medicine, Weill College Medicine, Washington Hospital School of Medicine, New York, NY. Medicine, University of Turin, Italy. of Medicine, Cornell University, Center, Washington, DC. Jerome R. Hoffman, MA, MD, FACEP, New York, NY. Michael J. Gerardi, MD, FACEP, Professor of Medicine/Emergency Charles Stewart, MD, FACEP, Editorial Board Clinical Assistant Professor, Medicine, UCLA School of Steven G. Rothrock, MD, FACEP, FAAP, Colorado Springs, CO. Medicine, University of Medicine Medicine; Attending Physician, Associate Professor Thomas E. Terndrup, MD, Professor Judith C. Brillman, MD, Residency and Dentistry of New Jersey; UCLA Emergency Medicine Center; of Emergency Medicine, University and Chair, Department of Director, Associate Professor, Director, Pediatric Emergency Co-Director, The Doctoring of Florida; Orlando Regional Emergency Medicine, University Department of Emergency Medicine, Children’s Medical Program, UCLA School of Medicine, Medical Center; Medical Director of of Alabama at Birmingham, Medicine, The University of Center, Atlantic Health System; Los Angeles, CA. Orange County Emergency Birmingham, AL. Although adequate treatment guidelines can be consultants. Simply saying “There’s a broken middle derived from other specialty literature, it must be upper tooth that’s bleeding” is not very informative to remembered that because dentists and maxillofacial/oral your dental colleague. surgeons often provide definitive care, their recom- The adult dentition consists of 32 teeth, of which mended modalities are not necessarily appropriate for there are four types: eight incisors, four canines, eight the ED. Several textbooks make treatment recommenda- premolars, and 12 molars. From the midline to the back tions based on dental literature that are impractical or not of the mouth there is a central incisor, lateral incisor, appropriate for emergency physicians unskilled in those canine, two premolars (bicuspids), and the three molars, techniques. There are several reviews in the emergency the last of which is the troublesome wisdom tooth. (See medicine literature that present guidelines for emergency Figure 1.) The adult teeth are numbered from 1 to 32, with physicians, but these are not based on ED studies.2-4 The the #1 tooth being the right upper third molar and the application of principles based on the dental literature to #16 tooth being the left upper third molar. The left lower an ED population requires a working knowledge of basic third molar is #17, and the #32 tooth is the right lower dental anatomy and physiology as well as an under- third molar. (See Figure 2.) It is more important that the standing of the medications, medicaments, anesthetics, emergency physician be able to describe the tooth glues, pastes, and bonding/splinting materials used in involved rather than remembering which number the dental professional’s office. belongs to which tooth. Therefore, simply describe the location and type of the problem tooth (for example, “the Epidemiology, Etiology, And Pathophysiology upper left second premolar” or “the lower right canine”). The primary dentition (“baby teeth”), likewise, is The incidence of dental complaints presenting to the ED best described by determining which tooth is involved. appears to be rising, ranging from 0.4% to 10.5%, which The earliest teeth to erupt in a child are the central may reflect the increasing use of EDs as primary care incisors, usually at 4-8 months. The child usually has a 1,5 facilities. Injuries in the younger population are often full complement of primary teeth by the end of the third related to falls or accidents, whereas those in the older year of life. The primary dentition is designated as age group are often secondary to falls, assaults, or motor vehicle accidents.1,3 Dental trauma presenting to EDs usually involves the permanent dentition and most Figure 2. Identification