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<\/a><\/p>\n Primary (baby) teeth<\/p>\n <\/p>\n Name of tooth <\/strong> Appearance in the mouth <\/strong> Central incisor 4-14 months Lateral incisor 8-18 months Canine tooth 14-24 months First molar 10-20 months Second molar 20-36 months<\/p>\n Permanent (adult) teeth<\/p>\n <\/p>\n Name of tooth <\/strong> Appearance in the mouth <\/strong>Central incisor 5-9 years Lateral incisors 6-10 years Canine tooth 8.5-14 years First premolar (bicuspid) 9-14 years Second premolar (bicuspid) 10-15 years First molar (6-year molar) 5-9 years Second molar (12-year molar) 10-15 years Third molar (wisdom tooth) 17-25 years<\/p>\n (EM Practice, May 2003)<\/p>\n Lingual is towards the tongue for the mandibular teeth<\/p>\n Palatal is towards the palate for the maxillary teeth<\/p>\n <\/p>\n Interproximal Surface is the surfaces of contact between two teeth<\/p>\n Mesial is the anteror or midline facing surface<\/p>\n Distal is the posterior or the surface facing away from midline<\/p>\n <\/p>\n Occlusal is the biting\/chewing surface of premolars and molars<\/p>\n Incisal is the biting surface of the incisors and canines<\/p>\n Apical is towards the root of the tooth<\/p>\n Coronal is towards the crown<\/p>\n Prehospital<\/p>\n Handle the tooth only by its crown<\/p>\n 1st Choice is Hank’s solution<\/p>\n 2nd is milk<\/p>\n 3rd is saline<\/p>\n X-Rays<\/p>\n Panorex view is the best (panoramic x-ray), though not available to most EDs<\/p>\n painful papillae, gray pseudomembrane, trench mouth<\/p>\n <\/p>\n <\/p>\n 3-4 days post-extraction, c pain free interval, pack c dental paste<\/p>\n Gingival hyperplasia-2nd to dilantin<\/p>\n pull jaw down then push back<\/p>\n Mandibular dislocation at the TMJ joint JEM 2004;27(2):167 Without further sedation, a third attempt using this new technique was performed successfully. The patient’s most recent sedation had been 20 min earlier. While facing the patient, the mandible was grasped with the physician’s thumbs at the apex of the mentum and fingers on the surface of the occlusal surface of the inferior molars ( Figure 2). By applying cephalad force with the thumbs and caudad pressure with the fingers, then pivoting at the wrists, the dislocated mandible was reduced with minimal difficulty. The patient immediately resumed normal movement of his jaw. The patient was subsequently discharged in good condition. Discussion Mandibular dislocation at the TMJ is an infrequent presentation to the ED. At our institution, consisting of two EDs with approximately 100,000 combined annual visits, 37 TMJ dislocations have presented over a 7-year period, 1995\u00962002. Although infrequent, reduction of TMJ dislocation is a technique EPs must have in their repertoire. The TMJ is a ginglymoarthrodial joint, combining gliding and hinge motions. Dislocation can occur anteriorly, posteriorly, laterally or superiorly. Discussion here will be limited to anterior dislocation as occurred to our patient, as it is by far the most common type and the only to occur without a fracture [ 4]. TMJ dislocation occurs when there is an interruption in the normal sequence of muscle action during closure from maximal opening. Interruption allows elevation of the mandible before retraction. This occurs when the protracting lateral pterygoid muscles fail to relax before the masseter and temporalis muscles elevate the mandible [ 5]. The condyle travels anteriorly along the eminence and becomes locked in the anterior superior aspect of the eminence ( Figure 3). The masseter, pterygoid, and temporalis muscles go into spasm attempting to close the mandible. Trismus results and the condyle cannot return to the temporal fossa [ 3]. Muscle spasm and edema result in significant pain to the patient. (34K) Figure 3. Anatomic description of TMJ dislocation. Fantastic review from B-Pod<\/a><\/p>\n common self-limited condition that affects approximately 20% of the population at one time or another.\u00a0 Evidence exists in the literature supporting the use of Amlexanox 5% paste<\/strong>.\u00a0 Applied two to four times a day to the ulcers, healing time was significantly improved in several randomized, controlled studies.<\/p>\n 5 cc of 1:1000 epi diluted in 5 cc of saline admin over 15 min by Neb controls this condition.\u00a0 No adverse CV effects even in the elderly pts (only three pts in study, though) (J Laryngol Otol 116:123 2002)<\/p>\n give dT<\/p>\n Most dentists do not use the Ellis Classification<\/p>\n may need only filing to take down sharp edge.\u00a0 Refer to dentist for bonding<\/p>\n The risk of untreated injury is pulp necrosis.\u00a0 Patient’s will complain of sensitivity to air and temperature<\/p>\n The yellow tint of the dentin can be seen through the white enamel<\/p>\n Cover with calcium hydroxide, zinc oxide or glass ionomer.\u00a0 CaOH is probably easiest for ED use.\u00a0 Dry the tooth.\u00a0 Some would recommend giving clindamycin or penicillin. Can also cover with dermabond.<\/strong><\/p>\n Often result in pulp necrosis if not treated.\u00a0 You will see the pink color of the pulp in the fracture site.\u00a0 Wipe off the tooth and observe for bleeding.\u00a0 Patient needs immediate referral or consult by a dentist or OMF surgeon.\u00a0 If referral is impossible, cover the tooth.\u00a0 Bleeding can be controlled by having the patient bite into gauze pads soaked in lido with epi<\/p>\n Subluxation-loose, Luxation-mobile is socket, Avulsed=Out.\u00a0 Luxations can be extrusive, lateral, intrusive, or complete<\/p>\n <\/p>\n Do not replace primary teeth, they will bond to the alveolar bone.\u00a0 However, if you are unsure whether a tooth is primary or secondary, replace it as it will not bond for days.<\/p>\n <\/p>\n <\/p>\n Repair the tooth then the gums<\/p>\n Buccal Mucosa<\/strong><\/p>\n most don’t require repair.\u00a0 If large however, us 4-0 or 5-0 chromic.\u00a0 Bury the knots.\u00a0 Through and through injurys need to be evaluated for injury to wharton’s and stenson’s ducts.\u00a0 Wharton’s exits the buccal mucosa under the tongue in the midline.\u00a0 Stenson’s exits at the buccal mucosa at the level of the upper 2nd molar.<\/p>\n Test all 5 branches of the facial nerve<\/p>\n Close Lacs larger than 1 cm.\u00a0 Close the mucosa first.<\/p>\n Gingiva injuries<\/strong><\/p>\n approximate with 4-0 or 5-0 chromic.\u00a0 If there is not enough tissue, wrap the suture around a tooth.<\/p>\n Frenulum Injuries<\/strong><\/p>\n Maxillary rarely needs repair<\/p>\n Lingual usually does just for hemostasis<\/p>\n Tongue Injuries<\/strong><\/p>\n if it is less than a cm and its edges are not gaping, does not need to be repaired<\/p>\n Use 4-0 chromic, or alternatively silk.\u00a0 If using absorbables, bury the knots.<\/p>\n Hemorrhage<\/strong><\/p>\n Dry socket.\u00a0 Localized osteomyelitis caused by loss of the formed clot after tooth extraction.\u00a0 Usually occurs several days after the extraction.\u00a0 Give a block, irrigate, then pack the socket with a gauze impregnated with eugenol (oil of cloves)\u00a0 Can also use a slurry of gelfoam and eugenol.<\/p>\n Localized Tooth Infection<\/strong><\/p>\n Carious destruction of the enamel allows bacteria access to the pulp.\u00a0 Often the inflammatory products created by this infection will drain through the rent in the enamel.\u00a0 If this becomes blocked, patients will then develop symptoms.<\/p>\n Periapical abscesses will\u00a0 follow the path of least resistance, which can be through the alveolar bone and gingiva into the mouth or more ominously into the deep spaces of the neck.\u00a0 In the ED, without x-rays, it is difficult to differentiate pulpitis from periapical abscess.\u00a0 It may be helpful to start antibiotics if there is pain with tongue blade tapping, fever, swelling, or trismus.<\/p>\n Deep Space Infections of the Head and Neck<\/strong><\/p>\n Deep Space Neck Infections (EM Practice, May 2003)<\/strong>Space <\/strong> Trismus <\/strong> Dysphagia <\/strong> Source <\/strong> Edema <\/strong> Unique Sign\/Symptom <\/strong>Peritonsillar Minimal Yes Tonsil Soft palate Uvular deviation, hot-potato voice, otalgia Submandibular (Ludwig\u0092s angina) Marked Yes 2nd and 3rd mandibular molars Diffuse, collar Brawny edema, firm floor of mouth Parapharyngeal (lateral pharyngeal) Severe Yes Teeth (odontogenic) Tonsil, lateral pharyngeal wall \u00b1 soft tissue of neck \u00a0 Carotid sheath Variable Variable Direct extension IV drug abuse, trauma Sternocleidomastoid muscle Pitting edema over sternocleidomastoid muscle, torticollis Retropharyngeal Yes Yes Upper respiratory infection, nasopharynx, sinuses Unilateral bulge, posterior pharyngeal wall \u00b1 Drooling, cervical rigidity, hot-potato voice Prevertebral Variable Variable Direct extension trauma, tuberculosis Midline bulge, posterior pharyngeal wall \u00b1 Drooling, cervical rigidity, hot-potato voice (tuberculosis may be chronic) Pterygopalatine Severe No Maxillary molars Gingiva, face, or eye \u00a0 Masticator Extreme No 3rd mandibular molar Posterior mandibular ramus External swelling minimal compared to trismus Visceral Variable Yes Direct extension trauma Variable \u00b1 Hoarseness, dyspnea, cutaneous emphysema<\/p>\n If the infection spreads up through maxillary areas, they can spread to the infraorbital to the cavernous sinus.<\/p>\n If the infection spreads in the mandibular spaces to bilateral infection of the submandibular and sublingual spaces, this is Ludwig’s angina.\u00a0 Use Unasyn, Zosyn, or Timentin.\u00a0 Cipro\/Clinda or Cephalosporin\/Clinda is acceptable for Pen allergic patients.<\/p>\n <\/p>\n <\/p>\n PCN VK 500 mg QID<\/p>\n Amox 500 mg TID<\/p>\n Clindamycin 150 mg TID<\/p>\n Doxycycline 100 mg BID<\/p>\n <\/p>\n lidocaine in gel form is more effective on oral mucosa than than liquids<\/p>\n <\/p>\n ideally suited for anesthesia of one or two teeth or a circumscribed portion of the maxilla. This technique will be utilized for most cases of individual tooth pathology and will probably be the procedure you use most in the ED for tooth anesthesia.\u00a0 Use more anesthetic for mandibular teeth due to thicker bone. Technique\u0097Retract the patient\u0092s lip to expose the tooth and vestibular mucosa. After applying topical, insert the needle at the greatest concavity of the mucobuccal fold and direct it at the apex of the tooth. Withdraw if you hit bone. Depth of insertion of any supraperiosteal infiltration is 3-4 mm. Remember to aspirate first. The amount of anesthetic is usually 1-2.5 cc for this infiltration. This block will be the one that is most commonly used for individual tooth pathology.<\/p>\n good for the central, lateral incisors and first premolar Technique\u0097retract the lip, apply topical, dry mucosa, and advance the needle until the tip is just above the periosteum adjacent to the apex of the canine. Aspirate and inject 1-2 cc slowly. Middle Superior Alveolar Nerve Injection<\/p>\n good for the maxillary premolars, adjacent bone, periodontal ligaments and adjacent soft tissues. Technique\u0097retract the corner of the mouth and the buccal mucosa adjacent to the premolars. Apply topical, dry mucosa, advance needle in the mucobuccal fold in the direction of the apex of the 2nd premolar. Advance 3-5 mm, aspirate, and inject 1-2 cc.<\/p>\n good for all three maxillary molars, adjacent bone, periodontal ligaments, and buccal gingiva. Is really a block, not an infiltration. This block can be difficult for the beginner and if anesthesia in incomplete, a supraperiosteal infiltration can be used to augment the effect. Technique\u0097retract the cheek and palpate the zygomatic process. A good rule of thumb is that the needle axis should be at an angle of 45 degrees to the occusal and midsagittal planes. The needle is inserted thru the mucosa and the underlying buccinator muscle to a depth of 1.5-2 cm. A total of 2-3 cc is slowly deposited after negative aspiration. Topical anesthetic can be used.<\/p>\n good for providing anesthesia to both the middle and anterior superior alveolar nerves as well as to the main trunk of the infraorbital nerve. Thus, an infraorbital block will numb the central incisor, lateral incisor, canine, premolars, the upper lip, lateral nose and lower eyelid. This block is a nice technique to use when lacerations are present on the lip or many front teeth are injured. Technique\u0097two techniques can be used, an intraoral approach and an extraoral approach. The extraoral approach has no advantages over the intraoral approach and has the disadvantages of requiring skin disinfectant, lack of effective topical anesthetic, and possibly increased patient fear. The intraoral technique is as follows: locate the infraorbital foramen. It is situated 5-10 mm below the infraorbital rim in a line which runs from the pupil to the corner of the mouth. Retract the patients upper lip with the thumb of your noninjecting hand. Keep the index finger of the same hand on the infraorbital foramen. After applying and drying the topical anesthetic, advance your needle into the mucobuccal fold in front of the second maxillary premolar. The needle should parallel the long axis of the tooth. Advance the needle approximately 1.5 cm and inject (after aspirating). Don\u0092t worry about puncturing the eyeball as it is protected by the infraorbital rim and and the orbital floor. You only need to be close to the nerve to achieve good results, not actually in the foramen. Figure 11.<\/p>\n Again, this procedure is good for one or two affected teeth and is relatively simple to perform. It is important that the needle is close to the mandibular periosteum overlying the root tip of the tooth. Technique\u0097Retract the lower lip, apply topical anesthetic and wipe off after 1 minute, and advance the needle slowly to the target. The needle should be inserted at the depth of the mucobuccal fold toward the mandibular periosteum. The depth of insertion is only a few millimeters. 1-2 cc of anesthetic is usually sufficient.<\/p>\n Good for anesthesia of the labial mucosa, gingiva, and the lower lip adjacent to the incisors and canine. To block the associated tooth pulps, a supraperiosteral infiltration or inferior alveolar nerve block is better. Figure 14. Technique\u0097Retract lip, apply topical, and wipe dry. Advance the needle into the mucobuccal fold adjacent to the second premolar. Advance the needle approximately 1 cm and aspirate. Deposition of 1-2 cm of anesthetic in this area is sufficient. Remember that crossinnervation occurs in the central incisor area.<\/p>\n <\/p>\n <\/p>\n good for anesthesia of the cheek and posterior buccal mucous membranes. Won\u0092t be used much in the ED. Usually used when excessive manipulation of the buccal mucosa is anticipated. Technique\u0097The nerve can be blocked at the level of the coronoid notch or the mandibular vestibule. For coronoid notch infiltration, retract the mucosa and apply topical anesthetic to the area. Needle puncture is made lateral and distal to the last mandibular molar at the level of the occusal plane. Insertion of the needle is limited to approx. 3 mm by the anterior edge of the ramus. Aspirate and inject 0.5-1.0 cc of anesthetic. Figure 15. For mandibular vestibule infiltration, the tissue is prepared as above and the infiltration is made submucosally at the depth of the vestibule just distal to the last molar.<\/p>\n This block is very useful for EM physicians in that it provides anesthesia to the mandible from retromolar region to the midline, to the anterior labial region and to the lingual areas. The nerve is very close to the lingual nerve which is often anesthetized simultaneously. Technique\u0097The needle end point is the mandibular sulcus. The landmarks that need to be identified are the coronoid notch on the anterior edge of the ramus of the mandible and the pterygomandibular raphe. The raphe is just a roll of soft tissue running from behind the mandibular third molar superiorly to the soft palate. In preparation for the block, grasp the posterior edge of the ramus (outside of the face) with the noninjecting hand. The thumb of that hand is placed inside the mouth, retracts the cheek and lies in the coronoid notch of the ramus. After placing the topical anesthetic, approach the injection point from the opposite premolars. The needle is placed in the raphe approx 2 cm posterior to the midline of your fingernail. Advance the needle approx 2 cm into the mucosa until you hit the bone. Withdraw slightly, aspirate, and inject. It may take up to 4 cc or so of anesthetic until you get comfortable with the procedure. Usually the lingual nerve is anesthetized as well as the inf. Alv. Nerve, but, if necessary, usual practice is to withdraw slightly (0.5 cc) and reinject.<\/p>\n Supraorbital and supratrochlear Nerves. These nerves are responsible for the sensory innervation of the forehead from the eyebrows posteriorly to the lambdoid sutures. Technique: Rather than attempting to localize each of the above nerves, it is easier and more effective to perform a regional block. This can best be accomplished by infiltration of 4-5 cc of anesthetic above the length of the eyebrow, slightly above the orbital rim.<\/p>\n <\/p>\n Ear Blocks<\/p>\n <\/p>\n<\/a><\/p>\n<\/span>Terminology<\/span><\/h2>\n
<\/span>Nontraumatic Problems<\/span><\/h2>\n
<\/span>Acute Necrotizing Ulcerative Gingivitis<\/strong> (ANUG)<\/strong><\/span><\/h3>\n
<\/a><\/p>\n<\/span>Dry Socket<\/strong><\/span><\/h3>\n
<\/span>TMJ Dislocation \/ Jaw Dislocation<\/span><\/h3>\n
<\/a><\/a><\/a> Potential causes of TMJ dislocation include any action that may involve the mouth being maximally open. Common causes include yawning and trying to chew a large food bolus. The literature has noted TMJ dislocation as a complication of anesthetic induction, intravenous sedation, Ehlers-Danlos Syndrome, trauma and even tetanus [ 4, 6, 7, 8, 9 and 10]. The complications of TMJ dislocation include recurrent subluxation\/dislocation from injury to the articulating cartilage, as well as fracture [ 11]. The prognosis is usually excellent, although recurrent TMJ subluxation\/dislocation may require surgical treatment [ 12 and 13]. Diagnosis may be made clinically if the following features are present. The patient will present with inability to close the mouth, severe pain anterior to the ears, absence of the condyle from the glenoid fossa resulting in a visible, palpable preauricular depression and a prominent-appearing lower jaw [ 14]. If dislocation is unilateral, the jaw deviates away from the involved side [ 15]. If trauma is involved, radiographic analysis is needed for the evaluation of possible fracture. Conventional techniques as described by standard Emergency Medicine textbooks describe the EP placing his protected thumbs on the occlusal surface of the patient’s molars, wrapping his fingers laterally around the mandible and then applying a constant inferior and posterior force, gliding the mandibular condyles back into the glenoid fossa. The conventional reduction technique requires the physician to manually overcome the substantial force created by the pterygoid, masseter and temporalis muscles to achieve reduction ( Figure 1). In the novel technique we describe, these forces are utilized to assist with reduction. The physician’s thumbs are placed at the mentum of the mandible to apply an upward force and the fingers are wrapped laterally around the mandible. The angle of the mandible is then used as a fulcrum with the pterygoid, masseter and temporalis muscles exerting a force parallel to the EP’s. Simultaneous pivoting action of the physician’s wrists with the thumb (anterior portion of the fulcrum) pushing superiorly and the operator’s fingers on the mandibular body pushing inferiorly allows the condyles to rotate back into the glenoid fossa ( Figure 2). It is important to note that these forces must be applied bilaterally to prevent mandibular fracture. The muscles of mastication provide assistance rather than impedance with this new technique as they promote rotation and reduction. Rather than attempting to lengthen the muscles that are in spasm to clear the condylar ridge, this technique pivots the mandibular condyle, easing the reduction into the fossa. The muscles of mastication provide a force-oriented superior and posterior. As the angle of the mandible rotates, these forces help bring reduction into the condyle. To protect the operator’s fingers during reduction, it is suggested that a bite block be used. This will prevent a human bite to the operator in the event of sudden closure of the mandible due to spasm, reduction, etc. Although not used in this particular patient, a bite block could prevent operator injury regardless of technique used.<\/p>\n<\/span>Aphthous Ulcers (Canker Sore)<\/span><\/h3>\n
<\/span>Oropharyngeal Hemorrhage<\/span><\/h3>\n
<\/span>Traumatic Injuries<\/span><\/h2>\n
<\/span>Fractures<\/span><\/h3>\n
<\/span>Crown Fractures<\/span><\/h3>\n
Uncomplicated Crown Fracture through Enamel only (Ellis I)<\/h4>\n
Uncomplicated Fractures through the Enamel and the Dentin (Ellis II)<\/h4>\n
Complicated Fractures of the Crown involving the Pulp (Ellis Class III)<\/h4>\n
<\/span>Luxations, Subluxations, Intrusions, and Avulsions<\/span><\/h3>\n
<\/a><\/p>\n<\/span>Alveolar Bone Fractures<\/span><\/h3>\n
<\/span>Dentoalveolar Soft Tissue Trauma<\/span><\/h3>\n
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\n
<\/span>Alveolar Osteitis<\/span><\/h3>\n
<\/span>Dentoalveolar Infections<\/span><\/h2>\n
<\/a><\/p>\n<\/a><\/a><\/p>\n<\/span>Dental Antibiotics<\/span><\/h2>\n
<\/span>Facial Anesthesia<\/span><\/h2>\n
<\/a><\/p>\n<\/span>Maxillary Blocks<\/span><\/h3>\n
Supraperiosteal Injection<\/h4>\n
Anterior Superior Alveolar Nerve Injection<\/h4>\n
Posterior Superior Alveolar Nerve Block<\/h4>\n
Infraorbital Nerve Block<\/h4>\n
<\/span>
<\/a><\/a> MANDIBULAR ANESTHESIA<\/span><\/h3>\nSupraperiosteal Infiltration<\/h4>\n
Mental Nerve Infiltration<\/h4>\n
<\/a><\/p>\nBuccal Nerve Block<\/h4>\n
Inferior Alveolar (lingual) Nerve Block<\/h4>\n
<\/a><\/a><\/p>\n<\/span>Forehead Anesthesia<\/span><\/h3>\n
<\/a><\/a><\/a><\/p>\n