Emergency Dental Procedures

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Chapter 64

Emergency Dental Procedures

Kip R. Benko

Complaints pertaining to the teeth and supporting maxillofacial structures are common, and patients frequently go to the emergency department (ED) for evaluation. Complaints may range in scope from a simple chipped tooth to an odontogenic deep space infection or a maxillofacial injury. Treating these patients can be challenging and frustrating for busy emergency clinicians. Many emergency clinicians and other acute care providers do not receive specific training in dental emergencies during their training, yet it is important for them to be able to recognize and treat a wide range of dental problems. Some dental emergencies can lead to significant morbidity such as loss of teeth, chronic pain, infection, and craniofacial abnormality, whereas others can lead to life-threatening airway compromise.

Management of specific dental emergencies requires a thorough understanding of adult and pediatric dentition. The relevant anatomy of both populations is outlined. The techniques described for management of the various traumatic and infectious problems are, in most cases, temporizing until definitive dental or oral and maxillofacial surgery referral can be obtained. Conditions that require emergency consultation are discussed. Topical, local, and regional modes of anesthesia are of particular importance and utility in the management of odontogenic emergencies, so the clinician should be very familiar with these techniques.

Although this chapter describes the diagnosis and treatment of dental injuries that may confront emergency clinicians, no standard of care mandates that complex dental problems (e.g., replacement of avulsed teeth, drainage of infection) be definitively handled in the ED setting. Advances in ED equipment and clinician training, as well as the introduction of dental skills laboratories into the resident curriculum, are gradually raising the existing standard of care. The initial stabilization of fractured, subluxed, luxated, and avulsed teeth is now within the treatment realm of the emergency clinician. It is appropriate to refer all significant dental pathology to a dentist or oral surgeon.

Teeth

The adult dentition normally consists of 32 teeth: 8 incisors, 4 canines, 8 premolars, and 12 molars. From the midline to the back of the mouth on each side, there is a central incisor, a lateral incisor, a canine, two premolars (bicuspids), and three molars, the last of which is the wisdom tooth (Fig. 64-1). The 20 primary or deciduous (baby) teeth include 8 incisors, 4 canines, and 8 molars. From the midline to the back of the mouth, there is a central incisor, a lateral incisor, a canine, and two molars (Fig. 64-2). Agenesis, or lack of proper formation of a tooth or teeth, is not uncommon, especially in the maxilla. Likewise, supernumerary, or extra, teeth may also occur. The adult teeth are numbered from 1 to 32, with the first tooth being the right upper third molar and the 16th tooth being the left upper third molar. The left lower third molar is the 17th, and the 32nd tooth is the right lower third molar. Numerous classification and numbering systems of the teeth exist; however, it is probably best for clinicians to simply describe the location and type of tooth in question (e.g., upper left second premolar, lower right canine). This removes any question wh en discussing a case with a consultant.

Figure 64-1 Anatomy of the teeth, primary and permanent. Note: An avulsed primary tooth need not be reimplanted if it is lost traumatically. (Netter illustrations used with permission of Elsevier, Inc. All rights reserved.)

Figure 64-2 Identification of teeth, adult and child. Each tooth has a number assigned to it. By 14 years of age, all primary teeth should normally be lost. Do not reimplant an avulsed primary tooth; rather, refer to a dentist to prevent future misalignment of the permanent teeth.

A tooth consists of the central pulp, the dentin, and the enamel (Fig. 64-3). The pulp contains the neurovascular supply of the tooth, which is responsible for carrying nutrients to the dentin, a microporous substance that consists of a system of microtubules. The dentin makes up the majority of the tooth, is a primary determinant of tooth color, and cushions the tooth during mastication. The enamel is the relatively translucent, outermost portion of the tooth and the hardest part of the body. The tooth may also be described in terms of the crown (coronal portion) and the root. The crown is the portion covered in enamel; the root is the part that serves to anchor the tooth in alveolar bone.

Figure 64-3 The dental anatomic unit.

The following descriptive terminology is used for the different anatomic surfaces of the tooth. These terms are useful when describing the specific tooth injury to a consultant or colleague:

l. Facial: The part of the tooth that faces the opening of the mouth. This is the part that you see when somebody smiles. It is a general term applicable to all teeth.

l. Labial: The facial surface of the incisors and canines.

l. Buccal: The facial surface of the premolars and molars.

l. Oral: The part of the tooth that faces the tongue or the palate. This is a general term applicable to all teeth.

l. Lingual: Toward the tongue; the oral surface of the mandibular (and maxillary) teeth.

l. Palatal: Toward the palate; the oral surface of the maxillary teeth.

l. Approximal/interproximal: The contacting surfaces between two adjacent teeth.

l. Mesial: The interproximal surface facing anteriorly or closest to the midline.

l. Distal: The interproximal surface facing posteriorly or away from the midline.

l. Occlusal: Biting or chewing surface of the premolars and molars.

l. Incisal: Biting or chewing surface of the incisors and canines.

l. Apical: Toward the tip of the root of the tooth.

l. Coronal: Toward the crown or the biting surface of the tooth.

The Periodontium

The periodontium, also known as the attachment apparatus, consists of two major subunits and is necessary for maintaining the integrity of the normal dentoalveolar unit.

The gingival subunit consists of the junctional epithelium and gingival tissue. Gingival tissue is composed of keratinized, stratified squamous epithelium; it can be divided into the free gingival margin and the attached gingiva. The free gingiva is the cuff of tissue formed around the neck of the tooth. The gingival sulcus is the space between the free gingiva and the tooth. It is rarely greater than 2 to 3 mm in depth in normal healthy dentition. The attached gingiva is the portion of gingiva attached to alveolar bone and extends apically (away from the tooth) to the mucogingival junction (or the mucobuccal fold). At this point the tissue, loose and nonkeratinized, is called the alveolar mucosa (or buccal mucosa).

The periodontal subunit includes the periodontal ligament, alveolar bone, and the cementum of the root of the tooth. The periodontal ligament consists of collagen that extends from the alveolar bone to the root of the tooth. One end of the periodontal ligament inserts into the alveolar bone and the other end into the cementum.

The gingival subunit is primarily responsible for maintaining the integrity of the periodontal subunit. Certain disease states such as gingivitis weaken the attachment apparatus and can result in loss of a tooth.

Acute Toothache in the ED

Patients with an acute toothache (odontalgia) often come to the ED for dental evaluation and relief of symptoms. Although multiple problems can initially cause pain in the area of the teeth, the cause is usually pulpitis or dental trauma. Referral to a dentist is the logical definitive course of action, but pain relief can be initiated in the ED. Dental pain is, however, also a common complaint in drug seekers. Nonsteroidal antiinflammatory drugs (NSAIDs), acetaminophen, narcotics, and local nerve blocks can provide relief of pain, depending on the scenario. Hile and Linklater ¹ recently reported significant pain relief in a fractured tooth by applying 2-octylcyanoacrylate tissue adhesive (Dermabond, Ethicon Products) directly to the tooth. This intervention is currently anecdotal but may also provide temporary pain relief for patients with open decay when air and temperature exacerbate the pain. Dry the tooth thoroughly with gauze, and generously apply a few layers of the product to the affected area. This intervention lasts for a few days only but should not interfere with subsequent dental intervention. Note that the use of skin adhesives has not been approved for intraoral use; they tend to break down quickly in the oral cavity.

Pain in a tooth when exposed to hot liquids usually indicates pulpal inflammation. Sensitivity to cold can signify simple sensitivity or gum recession but can also indicate decay. Pain while biting down can indicate a fractured tooth or decay.

Many fillings can leak and cause pain, and microcracks can occur and not be readily apparent to someone who is not a dentist. One cause of microcracks—or even a totally fractured tooth—is constant trauma from the metal balls implanted with tongue piercing.

For years, clove oil (containing eugenol) has been a popular and reasonably effective short-term home remedy for an acute toothache or inflamed gingiva. For a cavity or gum pain, saturate a piece of cotton in clove oil and place the cotton directly in the cavity or along the gum. This will provide relief for a few hours. Clove oil should not be used more than a few times because of irritation and possible nerve damage. A paste made of water and activated charcoal has also been used. Another simple method of pain management is to apply viscous lidocaine directly onto the tooth or saturate a small cotton ball with the gel and place it in a cavity. This treatment is temporary, and caution should be exercised if reapplication is considered. Do not exceed the total recommended dosage of lidocaine.

Acute dental pain may also be referred pain, so a complete evaluation should be conducted if the area appears to be normal (Fig. 64-4). For example, acute sinusitis can cause tooth pain and vice versa. Obvious dental infection should be treated with antibiotics (e.g., penicillin, clindamycin, erythromycin, metronidazole, amoxicillin-clavulanate [Augmentin]) while awaiting dental evaluation. Chronic acetaminophen overdose is a known complication of overaggressive use of analgesics by patients unable to obtain dental care for an acute toothache.² Unfortunately, many patients have irreversible pulpitis by the time that they seek emergency care.³

Figure 64-4 This physician had severe pain in his jaw thought to be related to a dental problem. Two days after onset of the pain, the rash of herpes zoster appeared, which was the cause of the pain.

Antibiotics provide no benefit for pain from a simple toothache, dental cavity, or pulpitis, although some clinicians prescribe them because follow-up dental care may be delayed or difficult to obtain.⁴

Individual teeth (except the posterior molars) can be temporarily anesthetized with total pain relief by simply giving a periapical injection of a local anesthetic (see Chapter 30). Bupivacaine has a long duration of action (4 to 12 hours) and has been shown to decrease the narcotic requirement of postoperative oral surgery patients even after the anesthetic properties of the medication have worn off. Molars, which are more difficult to anesthetize with periapical injections, can be blocked via nerve block techniques. Recently, articaine (Septocaine) has been used for this purpose. It is fast acting and penetrates well. Many dentists have replaced lidocaine with articaine for local tooth anesthesia. Note, however, that this anesthetic is not used for nerve blocks, only local injection, because persistent paresthesias have been associated with nerve blocks.

Dentoalveolar Trauma

Dental Fractures

Dentoalveolar trauma is a common reason for ED visits. Injury to the maxillary central incisors accounts for between 70% and 80% of all fractured teeth.5–7 Trauma to the teeth is not usually life-threatening; however, the morbidity associated with dental fractures can be significant and includes failure to complete eruption, change in color of the tooth, abscess, loss of space in the dental arch, ankylosis, abnormal exfoliation, and root resorption. Dental injuries are often associated with intraoral lacerations. When a tooth is chipped or missing and there is a concomitant intraoral laceration, it should be noted that the missing portion of the tooth might be embedded in the depths of the laceration (Fig. 64-5).

Figure 64-5 A chipped front tooth after a punch to the mouth can result in a piece of tooth being aspirated or embedded in the laceration. When this lip laceration was explored, a piece of tooth was found embedded within the laceration. If this foreign body is not removed, an infection is certain to occur within a few days. Note the obvious chipped upper tooth, the source of the piece found in the upper lip laceration.

Some general principles apply to the evaluation and management of dental trauma. First, identify all fracture fragments and mobile teeth. Percuss each tooth surface for mobility and sensitivity. If a tooth is missing, it cannot always be assumed that it has been avulsed. Teeth can be aspirated into the respiratory tract, swallowed into the gastrointestinal tract, or fully intruded into the maxillary sinus, alveolar bone, or nasal cavity. Take radiographs if there is any suspicion of aspiration of tooth fragments or intrusion of fragments into the gingiva or alveolar bone. Second, the dentition is much more easily manipulated if the patient is not in significant discomfort. Tooth infiltration and common dental blocks should be part of the emergency clinician’s armamentarium. Third, topical tooth remedies and analgesics, both over the counter and prescribed, should be discouraged because their use can lead to the development of sterile abscesses and soft tissue irritation. Fourth, administer tetanus vaccine if needed.

Management of fractured teeth depends on the extent of fracture with regard to the pulp, the degree of development of the apex of the tooth, and the age of the patient. Dentoalveolar injuries and, in particular, tooth fractures can be classified in many ways.⁸ The Ellis classification is one system often cited in the emergency medicine literature; however, many dentists and maxillofacial surgeons do not use this nomenclature, thus making it less than ideal when discussing these types of injuries (Fig. 64-6).⁶ The most easily understood method of classification is one based on a description of the injury.

Figure 64-6 A, The Ellis classification for fractured alveolar teeth. The easiest method to classify fractured teeth is by description (e.g., fracture through the dentin of the first upper right molar). B, Ellis class I: only the enamel is fractured. These fractures pose no threat to the dental pulp and are not sensitive to temperature or forced air. C, Ellis class II: the crown fracture demonstrates involvement of the enamel and dentin, without exposure of the pulp. Immediate dental referral is necessary to prevent contamination of the pulp through the dentinal tubules. D, This crown fracture involves enamel, dentin, and the soft tissue of the pulp as well. Immediate dental referral is mandatory to save the tooth. (C and D, from Zitelli BJ McIntire SC, Nowalk AJ, eds. Zitelli and Davis’ Atlas of Pediatric Physical Diagnosis. 6th ed. St. Louis: Saunders; 2012.)

Crown fractures may be divided into uncomplicated and complicated categories. Uncomplicated crown fractures result from injuries to the enamel alone or to a combination of the enamel and dentin. Complicated crown fractures extend into the pulp.

Ellis Class I Fractures

Uncomplicated crown fractures through only the enamel are known as Ellis class I fractures (see Fig. 64-6B). They are not usually sensitive to either temperature or forced air. These fractures generally pose minimal threat to the health of the dental pulp. They may feel sharp to the patient’s tongue, lips, or buccal mucosa. Immediate treatment is not necessary but may consist of smoothing the sharp edge of the tooth with an emery board or rotary disk sander. The patient should be reassured that a dentist can restore the tooth to its normal appearance with composite resins and bonding material. Follow-up is important with these injuries because pulp necrosis and color change can occur in rare cases (<1%).^6,9,10

Ellis Class II Fractures

Uncomplicated fractures through the enamel and dentin are called Ellis class II fractures. Fractures that extend into the dentin are at higher risk for pulp necrosis and therefore need more aggressive treatment by the emergency clinician (see Fig. 64-6C). The risk for pulp necrosis in these patients is less than 10%, but it increases as treatment time extends beyond 24 hours.⁶ These patients often complain of sensitivity to heat, cold, or forced air. Physical examination reveals the yellow tint of the dentin in contrast to the white hue of the enamel. With fractures closer to the pulp cavity, the dentin will have a pink tinge. The tooth is usually sensitive to percussion with a tongue blade. The porous nature of dentin allows passage of bacteria from the oral cavity to the pulp, which may result in inflammation and infection of the pulp chamber. This is more likely to occur after 24 hours of dentin exposure but occurs sooner if the fracture site is closer to the pulp. Likewise, patients younger than 12 years have a pulp-to-dentin ratio larger than that in mature adults and are at increased risk for pulp contamination. For this reason, younger patients should be treated aggressively and be seen by a dentist within 24 hours.^10,11

The goal of treating dentin fractures is twofold: to cover the exposed dentin and thus prevent secondary contamination or infection and to provide relief of the pain. After the tooth is covered, the dentist, using modern composites, can often rebuild the tooth directly over the calcium hydroxide (CaOH) cap that was placed in the ED. Perform supraperiosteal infiltration or a regional tooth block before any manipulation of the tooth. This will make application of the dressing easier because manipulation of the tooth will not cause discomfort. Dressings that may be applied to the surface of the tooth include CaOH, zinc oxide, skin adhesives, and glass ionomer composites. Some literature suggests that glass ionomer may be superior to other coverings; however, the difference is probably slight, and the increased cost of glass ionomer is not justified for routine use in the ED at this time.5,12 Certain composites may be cured with a bonding light. This is routinely done in the dentist’s office and is beyond the scope of most emergency practice. Bone wax and skin glue such as the cyanoacrylates are not recommended as dressings. Most dressings come as a base and a catalyst, which require mixing. This is easily accomplished with a dental spatula and a mixing pad, which can be obtained from any dental supply house. A commonly used ED dressing is calcium hydroxide (Dycal or other similar products). Mix the catalyst and the base in equal portions, and place a small amount on the exposed area with an applicator such as a dental spatula or another appropriate instrument (Fig. 64-7).

Figure 64-7 Calcium hydroxide application for the treatment of dentin fractures.

Dry the surface of the tooth before application to ensure adherence of the CaOH. Have the patient bite into gauze pads to accomplish this. Dycal will dry within minutes after being exposed to the moist environment of the mouth. Although placing dental foil over the CaOH dressing is recommended, it is not usually necessary if the patient plans to follow up with a dentist within 24 to 36 hours. To prevent dislodgment of the dressing, instruct the patient to eat only soft foods until seen by a dentist. Begin antibiotic treatment with penicillin or clindamycin until definitive dental treatment can be obtained.¹³

Many patients who sustain a fracture through the dentin will require a root canal or other definitive endodontic treatment. Timely application of an appropriate dressing in the ED, however, may prevent contamination of the pulp and make root canal therapy unnecessary. As with any trauma to the anterior teeth, explain to the patient that disruption of the neurovascular supply is possible and that long-term complications such as pulp necrosis, color change, and resorption of the root might occur.

Ellis Class III Fractures

Complicated fractures involving the pulp are also known as Ellis class III fractures (see Fig. 64-6D). Complicated fractures of the crown that extend into the pulp of the tooth are true dental emergencies. These fractures result in pulp necrosis in 10% to 30% of cases even with appropriate treatment.⁶ They may be distinguished from fractures of the dentin by the pink color of the pulp. Wipe the fractured surface of the tooth with gauze and observe for frank bleeding or a pink blush, which indicates exposure of the pulp. Fractures through the pulp are often excruciatingly painful, but occasionally, there is lack of sensitivity secondary to disruption of the neurovascular supply of the tooth.

Immediate management includes referral to a dentist, oral surgeon, or endodontist. The patient often requires pulpectomy (complete removal of the pulp) or, in the case of primary teeth, pulpotomy (partial removal of the pulp) as definitive treatment.5,9 The longer the pulp is exposed, the greater the likelihood of contamination and abscess formation. If a dentist cannot see the patient immediately, attempt to relieve the pain and cover the exposed pulp (Fig. 64-8). If significant pain is present, perform a dental block. Subsequently, cover the tooth with one of the dressings described earlier. Sometimes the bleeding is brisk. Control such bleeding by applying a dressing. Ask the patient to bite onto a gauze pad that has been soaked with a topical anesthetic containing a vasoconstrictor such as epinephrine. Alternatively, inject a small amount of anesthetic/vasoconstrictor into the pulp to control bleeding. After the covering is applied, instruct the patient to follow up as soon as possible with a dentist. Antibiotics with coverage directed at oral flora (e.g., penicillin, clindamycin) should be considered and only soft foods should be eaten. Removal of the pulp with specialized instruments by the emergency clinician is not recommended, although some authors have advocated this in the past. This procedure is the realm of the dental professional and is likely to result in complications if not done properly.

Figure 64-8 Application of periodontal calcium hydroxide paste to the fractured surface of the tooth. The paste hardens quickly in the moist environment of the mouth.

Luxation, Subluxation, Intrusion, and Avulsion

Luxation and Subluxation

Subluxation refers to teeth that are mobile but not displaced. Luxation refers to teeth that are displaced, either partially or completely, from their sockets. Luxation injuries are divided into four types (Fig. 64-9):

Figure 64-9 Classification of tooth trauma. A, Extrusive luxation occurs when the tooth is forced partially out of the socket in an axial direction. B, Intrusive luxation of a tooth compresses the periodontal ligament and vascular supply of the pulp. It may even crush the apical bone. C, Lateral luxation occurs when the tooth is displaced in a lingual, mesial, distal, or facial direction. Fractures of the alveolus frequently accompany lateral luxation injuries. (A-C, Adapted from King R. Orofacial infections. In: Montomery MT, Redding SW, eds Oral-Facial Emergencies—Diagnosis and Management. Portland, OR: JBK Publishing; 1994.)

1. Extrusive luxation is an injury in which the tooth is forced partially out of the socket in an axial direction (see Fig. 64-9A).

2. Intrusive luxation, or intrusion, occurs when the tooth is forced apically. It may be accompanied by crushing or fracture of the tooth apex (see Fig. 64-9B).

3. Lateral luxation occurs when the tooth is displaced either facially, lingually, mesially, or distally (see Fig. 64-9C). This injury is often associated with injuries to the alveolar wall.

4. Complete luxation, also known as complete avulsion, results in loss of the entire tooth from the socket.

Even minor trauma to the oral cavity requires meticulous examination for loose or missing teeth. Examine each tooth for mobility by applying a back-and-forth motion on each side of the tooth surface with either the fingertips or two tongue blades. Any blood in the gingival crevice (area where the gingiva touches the tooth) suggests a traumatized tooth.

Teeth that are minimally mobile and are not displaced do very well with just conservative treatment. The tooth will tighten up in the socket if not retraumatized. Instruct patients to eat only a soft diet for 1 to 2 weeks and see their dentist as soon as possible. Note that a seemingly lost (avulsed) tooth may actually be deeply intruded into the soft tissue (Fig. 64-10).

Figure 64-10 Intruded tooth secondary to trauma. A, On superficial examination it appears that the tooth was simply knocked out. This missing tooth could be simply lost, fully intruded, or aspirated or swallowed. B, In some cases a dental radiograph or computed tomography scan is necessary to determine intrusion or avulsion. Intruded teeth create the potential for infection or cosmetic deformities. Intrusion of an upper tooth into the maxillary sinus can cause recurrent sinusitis. Teeth can also intrude into the nasal cavity and cause infection or bleeding, or they can be aspirated into the airway. The incisors are the teeth most commonly intruded.

Grossly mobile teeth require some form of stabilization as soon as possible. It is important to note that in certain patients with poor gingival health, luxated teeth may not be salvageable because of disease of the attachment apparatus. Stabilization is best performed by a dental specialist with enamel bonding material or wire ligation. Although many different “home remedies” exist for splinting loosened teeth in the ED, the clinician must be aware of the possibility of aspiration of teeth if the splint fails. Avoid the use of unapproved medications in the mouth. Splinting techniques are suitable for the emergency clinician to perform as temporizing measures until definitive care can be arranged. One simple technique for emergency use is to apply periodontal paste, commercially available as Coe-Pak or other similar commercial products (Fig. 64-11). These products usually consist of a base and a catalyst that when mixed, form a moderately sticky claylike dressing that becomes firm after application. It is applied over the enamel and gingiva, as well as the adjacent teeth, to splint the subluxed tooth into place. Although the splint performs best if placed on the facial and buccal surfaces of the teeth, it is usually sufficient to apply the paste only to the front (facial) surface of the teeth. Make sure that the gingiva and enamel are completely dry. Lubricate your gloves with water or lubricating jelly before applying the dressing. Apply the dressing into the grooves between the teeth, as well as on the adjacent teeth. Remind the patient to eat a soft diet until seen in follow-up within 24 hours. Coe-Pak and other similar products are usually fairly simple for the dentist to remove during formal restoration.

Figure 64-11 Dental splint (Coe-Pak) application.

Teeth that are luxated in either the horizontal or the axial plane or are slightly extruded can also be splinted with the techniques described earlier. It is important that the loosened tooth be in perfect alignment when the final adjustments are made at the dentist’s office. However, the alignment does not need to be precise when the tooth is splinted in the ED. The important point is that the tooth be splinted adequately and follow-up ensured.

Intrusion and Avulsion

Intruded teeth are those that have been forced apically into the alveolar bone. This often results in disruption of the attachment apparatus or fracture of the supporting alveolar bone, especially in permanent teeth with mature roots.11,14 These teeth are usually immobile and do not require stabilization in the ED. Intruded teeth frequently require endodontic treatment because of pulp necrosis. It is important to consider the possibility of an intruded tooth anytime there is a space in the dentition (see Fig. 64-10). Undiagnosed intrusion of the teeth can lead to infection and craniofacial abnormalities. Obtain radiographs when it is uncertain whether a tooth is intruded or simply avulsed. Intruded teeth are best managed by a dentist or dental specialist; referral should take place within 24 hours. Permanent teeth often require repositioning and immobilization, but primary teeth are usually given a trial period to erupt on their own before any intervention is taken.

Primary teeth are not replaced after avulsion because they can fuse to the alveolar bone and potentially cause craniofacial abnormalities or infection. Reimplanted primary teeth may also interfere with eruption of the secondary teeth. The parents of these patients need to be reassured that a prosthetic replacement for the avulsed teeth can easily be made and worn until the permanent teeth erupt. See Figures 64-1 and 64-2 as a guide to identifying permanent versus primary teeth.

Avulsed permanent teeth are those that have been completely removed from their ligamentous attachments. These are true dental emergencies. The majority of patients seen in the ED with an avulsed tooth will lose that tooth, so patient and physician expectations should not be overly optimistic. Under ideal circumstances, such as arrival at a dentist’s office with a properly stored tooth avulsed less than 60 minutes previously, this situation may result in successful reimplantation 80% to 90% of the time but often requires specialized procedures and endodontics (root canal). Emergency clinicians are not expected to save an avulsed tooth, but prompt action may give that replanted tooth some chance for survival.

The first consideration in treating dental avulsions is to ask, “Where is the tooth?” Missing teeth may have been intruded, fractured, aspirated, swallowed, or embedded into the soft tissues of the oral mucosa. Therefore, radiographs should be considered anytime that an avulsed tooth cannot be located. Management of an avulsed tooth in the ED depends on a number of factors, including the age of the patient, the amount of time that has elapsed since the tooth was avulsed, associated trauma to the oral cavity such as alveolar ridge fractures, and the overall health of the periodontium.¹⁴ Time is the other important consideration when deciding whether to replace an avulsed tooth. In general, the longer the tooth is out of the socket, the higher the incidence of necrosis of the periodontal ligament and subsequent failure of reimplantation. Periodontal ligament cells generally die within 60 minutes outside the oral cavity if they are not placed in an appropriate transport medium.¹⁵ A significant amount of research has been conducted on different media used to keep cells of the periodontal ligament alive. Various transport media have been studied, including milk, Hank’s Balanced Salt Solution, Save-A-Tooth, saliva, cell culture media, and water. Although certain cell culture media have been developed to stimulate cells of the periodontal ligament to proliferate and remain viable, milk and the commercially available Save-A-Tooth and EMT Toothsaver are the best and easiest for both prehospital care and ED storage (Fig. 64-12).^15,16 Milk will preserve the periodontal ligament for 4 to 8 hours; the commercial products will preserve the ligament for 12 to 24 hours. However, reimplantation should take place at the earliest possible opportunity after the socket has been adequately prepared. The key is to get the tooth into the transport medium immediately because even 10 minutes outside some type of storage medium can cause desiccation and death of the periodontal ligament cells. Use saliva at the scene if milk, EMT Toothsaver, or Save-A-Tooth is not available. The patient should reimplant the tooth in the prehospital setting if possible. The principles cited here should be followed when providing instructions to prehospital providers or to a patient who calls for advice. It is always preferable to refer such patients directly to a dentist rather than the ED if this is practical. Patients should be requested do the following:

Figure 64-12 With the “Save-A-Tooth” (A) or “EMT Toothsaver” (B) systems, an avulsed permanent tooth is placed into the container and closed. Avulsed primary teeth are not replanted. The preservative will increase the life span of traumatized periodontal ligament cells. Unpreserved teeth replanted after 60 minutes rarely survive; those that do require root canal procedures and close follow-up. This system prolongs the time to successful reimplantation but does not ensure success.

l. Determine whether this is a permanent tooth. By 14 years of age, all primary teeth should have been lost.

l. Handle the tooth by the crown only because handling the tooth by the root can damage the alveolar ligament.

l. Do not replace the tooth if it is fractured or if significant maxillofacial trauma has occurred such as an alveolar ridge fracture.

l. If the tooth can be replaced in the prehospital setting, gently rinse off the root first to remove any debris. Do not wipe off the root because this removes the periodontal ligament.

l. If the tooth cannot be reimplanted successfully in the field, place it in a transport medium as described earlier. Do not transport the tooth in the oral cavity such as inside the the cheek because it can be aspirated. This location is also not ideal for keeping the periodontal ligament alive because of the bacterial flora and low osmolality of saliva.

Once the patient arrives in the ED, confirm proper placement and alignment. It is not important that the tooth be in perfect position because the dentist can make final adjustments. Splinting the repositioned tooth with periodontal paste or composite as outlined earlier may be necessary if mobility is present.

Should reimplantation not be successful in the prehospital setting, it must be done in the ED according to the following guidelines:

l. Store the tooth in an appropriate medium if reimplantation is delayed for any reason.

l. Perform supraperiosteal dental infiltration with a local anesthetic before manipulating or replacing teeth to make the procedure more comfortable for the patient and easier to perform.

l. Check the oral cavity for trauma. If an alveolar ridge fracture is present or the socket is significantly damaged, do not reimplant the tooth.

l. Gently suction the socket first with a Frasier suction tip to remove any accumulated clot. Be careful to not damage the walls of the socket because this can further damage periodontal ligament fibers. Irrigate gently after suctioning. If the clot is not removed, reimplantation and realignment will be difficult. Rinse off any debris on the tooth with saline but do not scrub it. Implant the tooth into the socket with firm, but gentle pressure. Remember to handle the tooth only by the crown.

l. Ask the patient to bite down gently on gauze to help align the tooth. The tooth may require splinting after replacement. If significant mobility is present such that temporizing splints are not adequate, consult a dentist to see whether wiring or arch bars are necessary.

l. Update the patient’s tetanus status as necessary.

l. Prescribe a liquid diet until the patient is seen in follow-up.

Antibiotics are controversial in the treatment of fractured and avulsed teeth. Although the American Association of Endodontics does not recommend the routine use of antibiotics for fractures or avulsions, other authors recommend the use of antibiotics effective against mouth flora (e.g., penicillin, clindamycin) to decrease inflammatory resorption of the root.6,17 It is probably reasonable to use antibiotics if the root or socket is heavily soiled; otherwise, treatment should be tailored to the individual patient and discussed with a knowledgeable and experienced consultant.

Ideally, but rarely possible in real life, the patient is immediately referred to a dentist, and the reimplanted tooth is held in place by biting on gauze. The tooth may be temporarily held in place with Coe-Pak or another similar product (see Fig. 64-11) or the technique described in Figure 64-13.

Figure 64-13 Temporary suturing to hold a replanted tooth in place. A, Use a silk suture. Start by puncturing the gingiva at the border of the replaced tooth (A). Bring the suture behind the tooth and then cross over the front of the tooth to the other side. Penetrate the gingiva (B), go behind the tooth, cross over the front again, and tie the suture (A). B and C, Multiple teeth can be reimplanted.

The Tongue

Tongue lacerations are challenging. Although they may be tempting to suture, most large lacerations of the body of the tongue, such as those that occur from a seizure, will heal well without suturing (Fig. 64-19). Tongue lacerations that have the wound edges approximated do not need to be sutured. Repair larger lacerations that gape because the cleft left by the wound will epithelialize and leave a grooved or bifid or lateral flap appearance. Approximate wounds that are bleeding profusely, are flap shaped, involve muscle, or are on the edge of the tongue. Small avulsions (divots) or those in the center of the tongue usually heal without intervention.

Figure 64-19 Tongue lacerations. A, A large gaping tongue laceration in a toddler produced by the upper front teeth being forced through the tissue by a fall with the tongue protruded. This type of injury requires suturing. B, This small laceration, though gaping slightly, does not require surgical closure. (From Zitelli BJ, McIntire SC, Nowalk AJ, eds. Zitelli and Davis’ Atlas of Pediatric Physical Diagnosis. 6th ed. St. Louis: Saunders, 2012.)

Explain the procedure in detail to the patient before repairing these wounds. Ask an assistant to secure the tongue by holding it with gauze. If the tongue cannot be secured in this manner, apply a towel clip to the end of the anesthetized tongue. Children with tongue lacerations that need repair generally require sedation or repair by a specialist in the surgical suite, but many of these lacerations are small and heal uneventfully on their own.

Begin the repair with either local infiltration of an anesthetic or a lingual block (see Chapter 30). To promote hemostasis, infiltrate locally with lidocaine with epinephrine. Use absorbable sutures such as 4-0 chromic, Vicryl, or Dexon. Silk can be used, but it must be removed in 7 to 10 days. Do not use nylon because it is very irritating to the surrounding tissues. For lacerations extending through muscle, close with one deep stitch penetrating both the mucosa and the muscle. When possible, bury the knots of absorbable suture because they will often work their way loose. Full-thickness lacerations can be closed in a number of ways. Place a suture through all three layers or close the top mucosa and muscle together and do the same thing on the underside of the tongue. Bleeding from large lacerations is almost always controlled with primary repair. In some instances, hemostasis can be achieved without the use of sutures by using Gelfoam impregnated with topical thrombin (Fig. 64-20).

Figure 64-20 A, For persistent bleeding of a tongue, mucosa, or dental extraction site, topical thrombin can be used (Thrombin-JM, King Pharmaceuticals). Topical thrombin is available in a spray pump, in a syringe for application, or as a reconstituted powder to saturate absorbable Gelfoam. B, A tongue laceration such as this one will heal well without sutures once the bleeding is controlled. Topical thrombin may be an option if hemostasis is problematic, such as in a patient taking warfarin.

Oral Hemorrhage

Bleeding from the oral cavity is not unusual and is most commonly associated with dental procedures. It is important to ascertain whether any recent dental work has been performed and what was done. Spontaneous bleeding of the gingiva or oral cavity not associated with dental manipulation or trauma is suggestive of advanced periodontal disease or an underlying systemic process. Ask the patient about other medical conditions that predispose to bleeding (e.g., liver disease, platelet abnormalities), as well as historical factors that may suggest a bleeding abnormality or clotting factor deficiency. Find out whether the patient is taking aspirin or other anticoagulants. Consider laboratory testing if pathologic coagulopathy is a significant concern, but not routinely in a patient seen after dental manipulation.

Control gingival bleeding after scaling or minor dental procedures with direct pressure and saline or hydrogen peroxide rinses. Persistent bleeding from the gingival areas despite pressure and rinses raises suspicion of a bleeding abnormality. A much more common cause of oral hemorrhage seen in the ED is postextraction bleeding. Minor oozing after dental extractions, such as wisdom tooth extraction, is normal for 2 to 4 days after surgery, but many patients get concerned when the bleeding persists despite warnings from the oral surgeon. These patients usually go to the ED when their dentist cannot be contacted and after futile attempts to stop the bleeding at home. The emergency clinician has a number of options to achieve hemostasis of postextraction bleeding.

Direct Pressure

Although the patient may have been using this technique at home, a few simple procedures may make it more effective. If a clot is present inside a recently removed tooth socket, leave it intact. If excessive clot has built up around the oozing site, remove the excess clot with a suction catheter and then gently irrigate the area. Frequently, this clot is missing or partially missing. Once the clot is removed, place gauze as firmly as possible directly onto the bleeding site. This is best accomplished by using dental roll gauze (see “Dental Material,” later in this chapter). Insert it directly over the bleeding site and then cover it with 2- × 2-inch gauze. Dental roll gauze fits more precisely between the teeth and therefore affords more pressure; however, 2- × 2-inch gauze can be substituted. Moisten the roll gauze with a topical vasoconstrictor before placing it over the bleeding site. Instruct the patient to bite down and hold pressure for 15 minutes or so.

If active bleeding persists after 15 minutes, infiltrate the bleeding area and the gingiva surrounding the socket with lidocaine and epinephrine (1 : 100,000) until blanching occurs. Reapply the gauze over the site and instruct the patient to bite down for 15 more minutes. The injection serves two purposes: it causes vasoconstriction, and it anesthetizes the area so that adequate pressure can be generated during biting.

If the bleeding persists, insert a coagulation sponge, such as Gelfoam, into the socket and then loosely close the gingiva surrounding the socket with a 3-0 absorbable figure-of-eight suture. Instruct the patient to bite down on gauze placed over the sutures. Soaking Gelfoam with topical thrombin before placement is a good way to halt minor persistent bleeding (see Fig. 64-20). A new agent showing great promise for oral hemorrhage is the chitosan dental bandage (HemCon), which is designed specifically for postextraction and oral bleeding. This shrimp-based bandage forms a sticky matrix when it contacts blood, and it quickly forms a seal that stops the bleeding. If these measures fail to control the bleeding, consult a specialist. It is also reasonable to check blood counts and coagulation profiles at this time.

Patients whose bleeding is controlled can be discharged and instructed not to take anything by mouth for 4 hours and then only liquids and soft foods. If silk sutures are used, remove them in 7 days.

Alveolar Osteitis (Dry Socket)

The pain associated with an extracted tooth is significant but usually manageable with current pharmacologic modalities. The pain associated with a dry socket, however, can be very severe and often requires more definitive treatment. Alveolar osteitis, or dry socket, is a localized inflammation that occurs when the alveolar bone becomes inflamed. This condition usually occurs when the clot that is normally present in the socket after a tooth extraction becomes dislodged or dissolves. It is most common in the 2- to 4-day period after a tooth extraction. The examination is essentially unremarkable with the exception of a missing clot where the tooth was extracted. Signs and symptoms of dry socket include the following:

1. Moderate to severe pain localized to the area or frequently radiating to the ear

2. A foul odor or taste in the absence of purulence or suppuration

3. Symptoms that occur 3 to 5 days after tooth extraction

4. Absence of swelling, purulence, or lymphadenitis

5. Duration of 5 to 40 days

Anything that increases negative intraoral pressure in the mouth (e.g., smoking, excessive rinsing, spitting, drinking from a straw), as well as hormone replacement and periodontal disease, will predispose a patient to a dry socket. In only a small percentage of patients (2% to 5%) will a dry socket develop; however, this number increases with traumatic extractions or impacted third molars.13,19

The following contribute to the development of a dry socket:

1. Excessive trauma during extraction

2. Inadequate blood supply to the extraction site

3. Preexisting localized infection

4. Loss of clot from sucking, straw use, rinsing, or smoking

5. Foreign bodies remaining in the socket

6. Use of oral contraceptives

7. Use of corticosteroids

8. Pericoronitis

The pain associated with a dry socket is extremely severe, and if a patient is seen several days after an extraction with relatively normal findings on examination and severe pain, it is probably a dry socket. It must be distinguished from osteomyelitis, which is characterized by fever, leukocytosis, malaise, and nausea. The pain related to a dry socket will not be relieved with traditional pain medications, but a dental block usually provides instant relief. Once the block is performed, the alveolar osteitis can be treated. Irrigate the socket and gently suction out any accumulated debris. Next, fill the socket to prevent recurrence of pain and allow healing to begin. A variety of materials are suitable to fill the socket again.

Gauze (¼ inch) impregnated with eugenol (oil of cloves) or a local anesthetic may be used. Replace the gauze in 24 to 36 hours because it tends to dry out and loosen. The patient should be seen by a dentist the next day if at all possible. The socket may also be packed with a slurry of Gelfoam and eugenol. The Gelfoam acts as a matrix to hold the eugenol in the socket. A commercial product, such as Dry Socket Paste or Dressol-X (Fig. 64-21), can also be applied by itself into the socket or mixed with Gelfoam and placed into the socket. Dry Socket Paste is a very sticky thick paste containing eugenol. It may stay in place longer than gauze and does not dry out. Whichever packing material is used for a dry socket, one or more packings might be necessary before healing is complete.

Figure 64-21 Dry Socket Paste.

Although antibiotics may be given to prevent alveolar osteitis, they are not usually necessary once the socket has been packed and should be prescribed at the discretion of the patient’s oral surgeon or dentist.11–13 NSAIDs should also be prescribed because they seem to work better than narcotics for dry socket.²⁰

Dentoalveolar Infections

Infections of the oral cavity run the spectrum from minor, easily managed abscesses to severe, life-threatening, deep space infections that require airway management and operative drainage. Although dental infections of all severity are encountered in the ED, the most common are those related to pulp disease. Others are associated with the attachment structures of the teeth such as the gingiva, periodontal ligament, and alveolar bone. These infections are often chronic conditions, but they can progress to the point where periodontal abscesses form and emergency treatment is required.

Emergency clinicians will be called on to drain abscesses of dental origin that do not extend into the deep spaces and that have well-defined boundaries easily accessible by intraoral or external drainage.

Disease of the Pulp

Disease of the pulp can occur as a result of trauma, operations, or other unknown causes, but the most frequent cause is invasion of microorganisms after carious destruction of the enamel. As the enamel is destroyed, caries progresses more rapidly through the dentin and into the pulp chamber and causes an inflammatory response referred to as pulpitis. If the path of carious destruction through the tooth is adequate for drainage of the developing inflammation, the patient may be only mildly symptomatic or even asymptomatic for a long time. If drainage is blocked, however, the process may progress to rapidly involve the entire pulp cavity and the periapical space. The tooth is usually exquisitely tender at this point. Abscesses in the periapical region are generally picked up on dental x-rays and less commonly on a Panorex film. However, unless extension through the cortex exists, it is not important for the emergency clinician to make the distinction between pulpitis and a periapical abscess. Examination often reveals gross decay of one or many teeth and tenderness of the abscessed tooth to percussion. A periapical abscess will follow the path of least tissue resistance if not treated. This may be through alveolar bone and the gingiva and into the mouth or the deep structures of the neck. If the infection has progressed apically through alveolar bone and localized swelling and tenderness are present, incision and drainage should be performed (discussed subsequently).

In the ED setting it is uncertain whether a periapical abscess or simple pulpitis exists. Dental x-rays are not usually available. In the absence of trauma or recent instrumentation, it is prudent to begin antibiotic coverage for the typical oral flora. Penicillin, amoxicillin, metronidazole, and clindamycin are good choices. Analgesia should be provided as well. In most cases, perform a supraperiosteal infiltration (tooth block) with a long-acting anesthetic such as bupivacaine because this not only provides immediate and long-lasting relief but also decreases the requirement for narcotic analgesics once the anesthetic effect has dissipated. Avoid performing a supraperiosteal injection if the abscess has extended through gingival tissue and is present near the injection site. In this case a regional block away from the infected tissue may be more appropriate.

Disease of the Periodontium

Periodontal disease is also very common and affects practically all adults to some degree. Periodontal disease refers to infection of the attachment apparatus of the teeth: the gingiva, periodontal ligament, and alveolar bone. Unlike pulpal disease, periodontal disease is not usually symptomatic and is therefore rarely a primary reason to seek treatment in the ED. Gingivitis is an inflammation of the gingiva caused by bacterial plaque. In advanced disease, the gingiva becomes red and inflamed and tends to bleed easily. With chronic periodontal disease, an abscess can form when organisms become trapped in the periodontal pocket. The purulent material usually escapes through the gingival sulcus; however, it occasionally invades the supporting tissues, the alveolar bone, and the periodontal ligament (periodontitis). Periodontal abscesses that are not draining spontaneously through the sulcus can be drained in the ED. Saline rinses are encouraged to promote drainage. Antibiotics should be reserved for severe cases or for abscesses that cannot be drained. If it is uncertain whether the abscess originates from the pulp or the periodontium, prescribe antibiotics even if the abscess has been drained.13,19

Pericoronitis is a localized inflammation that occurs when the gingiva overlying erupting teeth becomes traumatized and inflamed. Third molars are especially susceptible; however, any tooth can be affected. The gingiva overlying the crown may entrap bacteria and debris, and infection may subsequently develop. Typical signs of inflammation and infection may develop, including erythema, edema, pus, and foul breath. Examination of the overlying gingiva with a tongue blade or finger will elicit tenderness and may produce drainage from the infection underlying the tissue flap. The pain may be moderate to severe, and referral of the pain to an ear region is common. The localized infection occasionally spreads to deeper areas such as the pterygomandibular or submasseteric spaces. Clinically, patients with significant spread of a pericoronal infection will have trismus secondary to irritation of the masseter and pterygoid muscles.

ED treatment of pericoronitis is directed at detecting regional spread to the deeper spaces. Trismus or other systemic signs of advanced infection require intravenous antibiotics and urgent consultation for drainage procedures, which usually requires extraction of the offending tooth. If pericoronal infection is localized, local or nerve block anesthesia is followed by removal of submucosal debris. Saline rinses and oral antibiotics are prescribed along with dental follow-up in 24 to 48 hours.

Drainage of Dentoalveolar Infections

The important determination for the emergency clinician to make is whether the odontogenic infection is localized, confined, and easily accessible or whether it is complex and involves several potential spaces. Likewise, determine whether the patient appears to be in a toxic state, has trismus, or exhibits any signs of airway compromise. Patients not meeting these criteria require specialist referral. Dental infections are not always obvious and can be mistaken for sinusitis, or vice versa (Figs. 64-22 and 64-23).

Figure 64-22 A, This patient had facial swelling up to the right eye. She stated that her sinusitis had returned. She had minor tooth pain but mostly complained of an ache in her face. Radiographs revealed maxillary sinusitis with an air-fluid level. B, Intraoral examination revealed a pea-sized pointing abscess (arrow) at the base of an upper tooth, the cause of the sinusitis. After a local anesthetic was applied, a No. 11 blade was used to puncture the abscess, and copious pus was drained. C, A hemostat was inserted into the abscess cavity and spread open to yield more pus. Intravenous antibiotics (clindamycin) were administered followed by oral antibiotics, and the patient saw her dentist the next day. She recovered fully.

Figure 64-23 Osteomyelitis manifested as a dental infection. A, This patient had a chronic toothache for months and got minimally better with antibiotics from numerous emergency departments. No history of trauma was forthcoming. There was diffuse soft tissue swelling with malocclusion. B, A Panorex radiograph revealed nonunion of a fractured mandible with osteomyelitis. C, In this case a fractured mandible with osteomyelitis produced an obvious abscess. She had been treated for a presumed dental abscess many times in the past and got temporary relief.

Several anesthetic techniques can make the drainage process more comfortable. Nerve blocks and local injections work best. Benzocaine 20% gel or a combination of lidocaine, prilocaine, and tetracaine generally provides good topical anesthesia before injection (Fig. 64-24). Application of these medications to the dry mucosa before injection of the local anesthetic decreases the pain associated with injection. After applying the topical anesthetic, slowly infiltrate local anesthetic with a vasoconstrictor until the tissue blanches. Either a short-acting anesthetic (2% lidocaine) or a longer-acting anesthetic (0.5% bupivacaine) may be used, depending on the clinical circumstances. Regional or dental blocks may be performed instead of local infiltration if needle placement would track already infected tissues into healthy areas. Otherwise, consider local infiltration over the site of the abscess. Instruments necessary for drainage of dentoalveolar abscesses are those usually found on a standard incision and drainage tray and include hemostats, scalpel (No. 15 or 11 blade), packing material (¼-inch gauze), and a fenestrated Penrose drain.

Figure 64-24 Apply a dollop of 20% benzocaine gel to dry mucosa before injection of local anesthetic to decrease the pain of infiltration.

Intraoral Technique

Intraoral abscesses do not routinely require any antiseptic mucosa preparation before drainage. After anesthetizing the region, make a small incision (0.5 to 1.0 cm) over the area of fluctuance while keeping the point of the blade directed toward the alveolar bone. Use a hemostat to bluntly dissect the abscess and break up any loculations. Cultures are not necessary unless the patient is immunocompromised. Irrigate the wound profusely with normal saline. If the wound is large enough to place a drain or gauze inside, tack one end to the mucosa with a silk suture to prevent aspiration. Advise the patient to perform salt water rinses hourly and arrange follow-up in 24 to 48 hours with a dentist or oral surgeon to remove the drain and provide continued management. Because the source of the abscess is not always known to the emergency clinician, prescribe antibiotics.

Extraoral Technique

Most simple dental infections can be drained intraorally, but occasionally, an abscess spreads to the face and requires drainage through the skin. It is important to realize that most dental infections should be drained through the mouth, if possible, because any extraoral drainage will cause some scarring. Abscesses on the face, which should be drained in the ED, are usually very localized and fluctuant and have not spread to any of the deep spaces in the head or neck. It is also important to never make any incisions on the face in direct proximity to important structures such as the facial nerve or the parotid gland and duct. Refer to Chapter 37 for more detail on the incision and drainage technique.

Prepare the patient for incision and drainage with a skin scrub and application of povidone-iodine (Betadine). Drape the face and infiltrate the skin with a local anesthetic containing a vasoconstrictor (1% or 2% lidocaine with epinephrine). Make any incision on healthy skin slightly below the area of fluctuance along dynamic skin tension lines. After making the incision, use blunt dissection in the fluctuant area until adequate drainage is achieved. Irrigate the abscess cavity profusely. Place a drain or packing material in the abscess cavity while being careful to not pack it too tightly. It should be just enough to keep the incision open and draining. Unlike intraoral drainage, suturing the drain in place is not necessary. Instruct the patient to take antibiotics and follow up with an oral surgeon in 24 to 48 hours for packing change and definitive management.

Remember that not all infections about the mouth are the result of a simple dental infection. Osteomyelitis of the mandible, various tumors, and other exotic diseases can simulate a dental infection.

Deep Space Infections of the Head and Neck

It is not unusual for odontogenic infections to spread into the various potential spaces of the face and neck (Fig. 64-25). The signs and symptoms consist of fever, chills, pain, difficulty with speech or swallowing, and trismus. Although infections of certain teeth usually spread to particular contiguous spaces, the rapid spread of these infections often makes localizing the exact space difficult. Any space, including the buccal, temporal, submasseteric, sublingual, submandibular, parapharyngeal, and others, may be involved (Figs. 64-26).

Figure 64-25 A, Location of temporal space abscesses. B, Route of infection into the buccal space, vestibular spaces, submandibular space, sublingual space, and palatal space. (From Eisele D, McQuone S, eds. Emergencies of the Head and Neck. St. Louis: Mosby; 2000.)

Figure 64-26 A, Advanced dental infection with characteristic facial swelling, probably involving the masseter space. B, Local anesthetic (lidocaine with epinephrine) is injected with a 27-gauge needle into an area of obvious fluctuance (shown by the probe). A mandibular nerve block is an alternative to local injection. C, After the site is punctured with a No. 11 blade, a hemostat is inserted into the cavity and spread. Copious pus is drained with a suction catheter. Initial intravenous antibiotics (clindamycin), oral antibiotics, and outpatient follow-up yielded good results. The offending tooth was extracted when the infection was controlled.

Maxillary extension of periapical abscesses can spread into the infraorbital space and, subsequently, to the cavernous sinus through the ophthalmic veins and result in cavernous sinus thrombosis. Cavernous sinus involvement is associated with periorbital cellulitis, as well as meningeal signs or a decreased level of consciousness. Periapical infections of the anterior mandibular teeth often spread to the buccinator space or the sublingual space, whereas those of the mandibular molars spread into the submandibular space.

The submandibular space connects with the sublingual space. Infection involving both these spaces is known as Ludwig’s angina, which can be life-threatening. The source is usually a decayed lower tooth, with the tooth itself being relatively asymptomatic (Fig. 64-27). Initially, this infection may be subtle, but it can progress rapidly. As the infection progresses, the submandibular, submental, and sublingual spaces all become edematous, and there may be elevation of the tongue and the soft tissues of the mouth (Fig. 64-28). This is not a simple abscess that can be readily drained. It is considered a true dental emergency. Intervention includes intravenous antibiotics and emergency ear, nose, and throat (ENT) or oral surgery consultation. Patients with established cases of Ludwig’s angina cases are admitted to the hospital and undergo operative intervention often involving multiple drains. Minor early cases can be treated and observed for 6 to 8 hours in the ED with close follow-up if the infection is deemed benign. The soft tissues of the posterior aspect of the pharynx can also become involved. Securing the airway becomes of paramount importance. The suprahyoid region of the neck appears tense and indurated, and landmarks may be obscured. A CT scan can further delineate Ludwig’s angina if the diagnosis is in doubt, but in most cases, if the diagnosis is suspected, emergency consultation should be instituted early with careful monitoring for airway compromise.