DENTAL EMERGENCIES

ZAMEERA FIDA, DMD, LINDA P. NELSON, DMD, MScD, AND STEPHEN SHUSTERMAN, DMD

GOALS OF THERAPY

Nontraumatic orofacial emergencies can appear suddenly and are frightening for children and their families. Patients may present with pain or facial swelling, complications after recent dental procedures, or with new lesions affecting the oral mucosa. Identifying the underlying etiologies, providing necessary interventions in the emergency department (ED), and recognizing indications for utilizing specialty consultation with dentistry are the aim of emergency care. Addressing symptoms and findings related to traumatic orofacial emergencies are addressed separately in Chapter 113 Dental Trauma.

KEY POINTS

The infant or young child who may have dental pain often cannot localize the discomfort.

An acute dental emergency may be the first opportunity for many children to receive dental care.

The challenge with dental emergencies is recognizing which conditions can be treated primarily by emergency physicians or outpatient referral and which require urgent consultation with a dentist

RELATED CHAPTERS

Signs and Symptoms

• Oral Lesions: Chapter 47

Medical, Surgical, and Trauma Emergencies

• Infectious Disease Emergencies: Chapter 102

• Dental Trauma: Chapter 113

ODONTOGENIC OROFACIAL PAIN

CLINICAL PEARLS AND PITFALLS

• Children often cannot distinguish between tooth pain and soft-tissue pain from a lesion such as an aphthous ulcer.

• A careful intraoral examination should be performed to identify the source of the discomfort.

• In the case of significant swelling secondary to infection, consider hospitalization for parenteral antibiotics to halt the potentially dangerous spread of facial infection.

• Establishing drainage through the tooth or soft tissue is important to relieve the symptoms from abscesses, but analgesics and antibiotics are often necessary.

• Heat can be applied extraorally for symptomatic relief, without concern for resultant development of an external fistula.

Odontalgia—Simple Toothache

Toothaches are common in the pediatric population. The latest National Health and Nutrition Examination Survey (NHANES) data found that 42% of 2 to 11 year olds had caries in primary teeth and 23% have unmet dental needs. In addition, 21% of 6 to 11 year olds had caries in their permanent teeth. As low-income populations have the greatest dental needs and are also least likely to seek dental care, presentation to the emergency department with odontalgia is common.

Tooth pain may be present without associated infection. The emergency physician may note a grossly carious tooth or large restoration (i.e., filling). Swelling or inflammation in the surrounding soft tissue may be present. The tooth may be sensitive to percussion and may exhibit excessive mobility.

Oral analgesia should be provided to address pain. If symptoms can be improved and the patient is able to tolerate oral intake, a referral for outpatient dental care is appropriate. If significant swelling is noted, or pain cannot be adequately addressed with oral medications, a dental consultation is necessary.

Dentoalveolar Infection and Abscess

Odontogenic infections often results from dental caries or periodontal disease. They may also result from recurrent tooth decay, trauma, or chronic irritation from a large restoration. Dental caries develop following bacterial colonization of the tooth surface, i.e., plaque. Certain bacteria, commonly Streptococcus mutans and Streptococcus sobrinus, invade the tooth surface and can eventually infect the pulp tissue. Infected pulp causes pressure buildup in the confined space, which results in a clinical symptom of pain. Pus may egress out of the root of the infected tooth, causing local swelling. Infection can also spread and become quite extensive. Infection travels along planes of least resistance, which is predetermined by anatomic barriers, i.e., muscle, bone, and fascia. Pus perforates bone where it is thinnest and weakest: in the mandible on the lingual aspect of molars and buccal aspect of anteriors; in the maxilla on the buccal surface throughout. The infection may spread into the subperiosteal area and then to the surrounding soft tissues. If it does not drain intraorally, the infection can progress rapidly along the fascial planes of the face or neck. Resultant facial cellulitis can have severe systemic consequences, including cavernous sinus thrombosis, preseptal or orbital cellulitis, intracranial spread and meningitis, or even sepsis.

The following are clinical manifestations of a dentoalveolar abscess in a child:

Pain: The child may present with pain or it may be elicited with percussion.

Mobility: The tooth may have greater than normal degree of movement in the socket when palpated.

Swelling: The soft tissues surrounding the tooth may be edematous and erythematous.

Temperature elevation: The child may be febrile.

Fistulous tracts: A pustule-like lesion may be noted on the gingiva (rarely on the face) when the infection has been longstanding.

Extrusion: The tooth may become extruded because of the presence of fluid in the periradicular space.

Lymphadenopathy: Lymph node enlargement can occur at any time during the infective process.

As with other abscesses, the treatment of choice for a localized dentoalveolar abscess is symptomatic control (oral analgesics, and moist heat) and drainage. In cases which have progressed to facial cellulitis with lymphadenopathy, antibiotics should be given. Amoxicillin or amoxicillin with clavulanate potassium are first line agents in children. Alternatively clindamycin can be used if there is a known penicillin allergy, though the palatability of the liquid preparation may make compliance challenging. Erythromycin and tetracycline are no longer recommended due to increasing resistance of some strains of bacteria.

If extensive or rapidly progressive swelling is noted, a hospital admission may be required for parenteral antibiotics. Other factors to consider in determining the need for hospital admission include the child’s ability to take fluids and the likelihood of the parent’s cooperation for follow-up dental care. In addition to antibiotics, warm oral saline rinses can be used (if the child is able to cooperate) or warm moist heat applied to the area of swelling. Analgesic therapy with acetaminophen or ibuprofen is usually sufficient though opiates may be required in more severe cases. Dental consultation should be obtained. As with abscesses elsewhere in the body, the basic surgical principles of treatment are to establish drainage and remove the underlying cause. For dentoalveolar abscesses specifically, definitive treatment may include venting or extraction of the offending tooth, and possibly incising any fluctuant mass when needed. Treatment of facial cellulitis is covered in Chapter 102 Infectious Disease Emergencies. In the rare case of systemic infection, blood cultures should be obtained and broad-spectrum parenteral antibiotic given.