Dental caries are the most common dental emergency and can lead to pulpitis.
Tooth fractures are categorized and treated according to the Ellis classification.
Clean avulsed teeth with care to avoid dislodging the periodontal ligament.
Permanent teeth that are avulsed should be reimplanted immediately; avulsed primary teeth are never reimplanted.
Ludwig angina is a surgical emergency that requires prompt drainage.
Dental complaints are common in the emergency department (ED). As much as 4% of ED workload is dental-related. Uninsured patients and even patients with basic medical coverage but no dental insurance are forced to seek care in the ED. The first step to diagnosing the dental emergency is to understand the anatomy. There are 32 teeth in most adults (2 incisors, 1 canine, 2 premolars, and 3 molars per side). The teeth are numbered from 1 to 16 on the top starting with the right-hand side. Bottom teeth are numbered 17 to 32 starting on the left and ending with the bottom right.
Dental trauma is a common complaint encountered by emergency providers. Approximately 80% of traumatized teeth are maxillary teeth. Tooth fractures are based on the Ellis classification. Ellis I fractures involve only the enamel. Ellis II fractures include the dentin, and Ellis III fractures are present when both the dentin and pulp are exposed (Figure 78-1).
Tooth avulsion is a result of disruption of the tooth’s attachment apparatus. The periodontal ligament is the primary source of attachment of the tooth to the alveolar bone and is of primary concern to the emergency physician. Tooth avulsion occurs with a prevalence of up to 15% of cases. Management depends on whether the avulsed tooth is a permanent or a deciduous tooth. Preservation of the periodontal ligament and limiting the length of time out of the socket relates directly to subsequent tooth viability. A subluxed tooth refers to a tooth that is “loose” due to trauma.
Mandible fractures occur at the symphysis (16%), body (28%), angle (25%), ramus (4%), condyle (26%), and coronoid process (1%). They are most common after blunt trauma to the jaw from either an altercation or a motor vehicle collision (MVC). Fractures are multiple in half of cases because of the ring shape of the mandible. Mandible fractures are the second most common fracture of the facial bones behind nasal bone fractures.
Dental caries are the most common dental emergency. A typical odontogenic infection originates from dental caries, which decay the protective enamel. Traumatic injury, periodontal disease, or postsurgical infections can also contribute to disruption in the enamel. Once the enamel is dissolved, bacteria travel through the microporous dentin to the pulp, causing pulpitis. The bacteria then can track to the root apex, soft tissues, and finally into the deeper fascial planes. Dental abscesses form secondary to caries (periapical) or trapped food between gums and teeth (periodontal).
Several types of dental abscesses exist. Superficial abscesses in the orofacial area include the buccal, submental, masticator, and canine spaces. If unrecognized or untreated, these infections spread to deeper spaces within the head and neck. Ludwig angina is a rapidly spreading cellulitis of the floor of the mouth involving the sublingual, submental, and submandibular spaces bilaterally. Its name originates from the sensation of choking and suffocation that a patient with this infection experiences. Ludwig angina is an emergency because the massive swelling can result in airway obstruction. Ludwig angina occurs secondary to an infection of the posterior mandibular molars in 75% of cases. It can also be secondary to trauma. If the infection continues to spread, the potential exists for adjacent retropharyngeal and mediastinal infection. Ludwig angina is most commonly due to anaerobic (Bacteroides) and aerobic (Streptococcus, Staphylococcus) oral flora in an immunocompromised patient who is often elderly, diabetic, or an alcoholic.
Two other dental infections that may be encountered are alveolar osteitis and acute necrotizing gingivitis (ANUG). Alveolar osteitis (dry socket) occurs after a dental extraction (usually mandibular third molars). Patients typically present on day 2 or 3. Pain is due to premature loss of healing clot with localized inflammation. ANUG (trench mouth) is the only periodontal disease in which bacteria invade nonnecrotic tissue. Etiology is usually secondary to fusobacteria and spirochete overgrowth of bacteria which is normally present. Human immunodeficiency virus infection, previous necrotizing gingivitis, poor oral hygiene, and stress are predisposing factors.
Patients are typically male and were often involved in an MVC, sports activity, or assault. Ellis I fractures are painless, and the patient may only note a jagged edge to the tooth. Ellis II fractures present with the primary complaint of hot and cold sensitivity as the exposed dentin is quite sensitive. Patients with Ellis III fractures present with severe pain, although pain may be absent if there is neurovascular compromise.
When a tooth avulses, the time the tooth spends out of the socket is one of the most important pieces of information to obtain. If the tooth is out for <20 minutes, prognosis is good. If >60 minutes has elapsed, a successful re-implant is much more difficult.
Patients with a mandible fracture report jaw pain, inability to open the mouth, and possible malocclusion of the teeth. Numbness of the lower lip suggests an injury to the inferior alveolar nerve.
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