Anatomy

The stomatognathic system comprises the musculoskeletal unit of the mandible, maxilla, and muscles of mastication; the dental unit (teeth); the attachment apparatus that anchors teeth; and other soft tissues of the oral cavity.

Pathophysiology

Examination of the Oral Cavity

The examiner should wear eye protection, a mask, and gloves in compliance with universal precautions when examining the oral cavity. Ideally the patient should be placed in a dental or ear, nose, and throat chair or on a cart at a 45-degree angle. Because pediatric patients are unlikely to cooperate with the examination, the following technique is used by some experienced practitioners. The child sits in the parent’s lap, or the child is first placed in the parent’s lap facing the parent. The examiner then sits in front of the parent. While the parent gently restrains the child’s arms and legs, the emergency physician can lean the child backward and lock the child’s head between the physician’s legs.²

An overhead examination light, headlight, or flashlight can be used for illumination. Other ancillary aids include a tongue depressor, 2 × 2-inch gauze, and possibly a dental mirror. Fogging of the mirror may be prevented by warming it under hot water or moistening it with the patient’s saliva.

Examination of the oral cavity should be systematic, beginning with the soft tissues and including the tongue. The base of the tongue is examined for lesions, and Wharton’s duct is milked. Stensen’s duct, opposite the maxillary molars, should be examined on each side. The teeth should be examined next. Percussing a tooth with a tongue blade or the handle of a mirror is a good way to elicit tenderness.

Radiographic evaluation of teeth is best accomplished with dental (periapical) films. These films are generally not available in the ED, however. A panoramic radiograph is a useful alternative (see Fig. 70-5).

Diagnostic Imaging

Radiographic evaluation of teeth is ideally accomplished using dental (periapical) films, but these films are generally not available in the ED. More commonly, the panoramic radiograph is a useful alternative if imaging is felt to be required (see Fig. 70-5). The diagnosis and treatment of a dental abscess, for example, can be determined on the basis of clinical examination alone. A recent study compared the use of ED bedside ultrasound with the use of a panoramic radiograph. The sensitivity and specificity of the ultrasound were 92% and 100%, respectively. The advantage of the ultrasound is the lack of ionizing radiation; in addition, it assists in the determination of the presence of pus for incision and drainage.³ Computed tomography (CT) is used primarily when there is concern for deep space abscesses.

Dental Caries

Dental caries is the most common cause of pain of odontogenic origin. The patient may give a variable history of a sudden or gradual onset of a sharp to dull, throbbing pain. In most cases the patient can indicate the specific tooth involved, but at times the pain may be generalized. Early pulpitis is sensitive to changes in temperature and aggravated by lying down; more advanced pulpitis is worsened by any stimulus, including air. Pain may be referred to the ear, temple, eye, neck, and rarely the opposite jaw.

Physical examination may reveal a grossly decayed tooth; however, if the carious process is between teeth (interproximal) or did not result in destruction of the outer table of enamel, the offending tooth may not be obvious. Localization of the involved tooth may be accomplished by percussing the teeth with a tongue blade or by having the patient bite on a tongue blade. Exquisite pain to percussion suggests an underlying periapical abscess, especially if the tooth is not sensitive to hot or cold (pulpal demise).

Simple Dental Abscess

Patients with dental pain should be examined carefully for swelling caused by abscessed teeth. A periapical abscess or a localized swelling of the gingiva adjacent to the apex of the tooth (called a parulis) may cause pain from distention of the tissues. More commonly, fluctuant abscesses are a result of either periodontal abscesses or subperiosteal abscesses from a periapical abscess that has eroded through the bony cortex.

Spread of Infection to the Head and Neck

The presence of cellulitis or swelling in the contiguous spaces of the head and neck indicates the spread of a localized infection. In the early stages of such an infection, the upper half of the face is generally involved, with extension of infection from maxillary teeth; cellulitis from mandibular teeth generally involves extension to the lower half of the face and the neck (Fig. 70-6). More advanced infections may extend into any of the fascial planes of the head and neck down to the mediastinum. In the nondebilitated host, untreated dental infections tend to localize and drain spontaneously and extraorally. In the presence of a compromised host or aggressive microorganisms, spread into the fascial planes is more common, with a potential for greater morbidity and mortality. General indications for admission include suggested spread of infection to fascial planes, high fever, toxic appearance, trismus, and an immunocompromised host.

The potential sequelae of sepsis and airway obstruction must be appreciated. CT of the head and neck can be useful if the diagnosis is in doubt. Airway management should be undertaken when indicated, particularly if signs or symptoms of impending airway obstruction are present or developing (altered voice, drooling, stridor). The intubation should be approached as a difficult airway, as outlined in Chapter 1. An ear, nose, and throat specialist or oral maxillofacial surgeon should be consulted for ongoing management, including determination of the site of the initial focus so that pus can be evacuated.

Fever is common as with any infection. Any irritation of the internal pterygoid or masseter muscles results in trismus. Trismus is the inability to open the mouth because of involuntary muscle spasm. Trismus limits visualization of the pharynx and may make diagnosis of lateral or retropharyngeal space involvement difficult. Trismus is muscular in origin, not a result of impaired or augmented neuromuscular transmission, and so is often minimally improved or not improved at all after administration of a neuromuscular blocking agent (e.g., succinylcholine) for intubation, especially if the trismus is caused by localized swelling (vs. pain and spasm). Intubation in all patients with trismus is presumed to be difficult. Preparations should be made to perform a fiberoptic intubation or to establish a surgical airway.⁸ Difficulty swallowing or handling secretions suggests the possibility of retropharyngeal or parapharyngeal infection. Respiratory distress may be apparent, or the airway may occlude rapidly after a period of minimal signs of impending obstruction.

Spread of mandibular dental infection frequently results in a cellulitis called Ludwig’s angina, a bilateral, boardlike swelling involving the submandibular, submental, and sublingual spaces with elevation of the tongue. The most serious immediate sequela is airway obstruction. A characteristic brawny induration is present; there is no fluctuance for incision and drainage. Hemolytic Streptococcus is most commonly responsible for the infection, although a mixed staphylococcal-streptococcal flora is common, and both may lead to an overgrowth of anaerobic gas-producing organisms, including Bacteroides fragilis. Treatment consists of antibiotics and airway management. Although oral intubation can be attempted, an “awake” technique is recommended (see Chapter 1) because inability to displace the tongue into the submandibular space with a laryngoscope may make oral intubation impossible; fiberoptic nasopharyngoscopy is an option progressing to cricothyrotomy. In a study of 10 cases of Ludwig’s angina requiring surgical decompression, after inhalational anesthesia, the vocal cords were visualized in 9 of the 10 patients. One patient required tracheostomy.

High-dose antibiotic therapy, such as 24 million U of intravenous penicillin daily divided every 4 hours plus metronidazole 1 g intravenously (IV), followed by 500 mg IV q6h, is necessary to achieve good tissue penetration and to cover anaerobes (most commonly B. fragilis infections). Clindamycin 900 mg q6h also is effective for a penicillin-allergic patient. If antibiotic therapy is not helpful, surgery is performed to eliminate causative factors, to explore for pockets of pus, and/or to place drains. A CT scan can help to compartmentalize infection and guide the surgical approach.

Periodontal Disease

Periodontal disease represents a continuum of pathology. Early periodontal disease is manifested by inflammation of the gingiva, termed gingivitis. Gingivitis is generally the result of an inflammatory response to an irritant, such as dental bacterial plaque and calculus. With extension of inflammation, alveolar bone is ultimately lost, a condition termed periodontitis. A physiologic space from the crest of the alveolar bone to the base of the junctional epithelium is maintained for the insertion of gingival fibers into cementum. In response to a loss of alveolar bone, the gingiva migrates down the root of the tooth, a condition termed gingival resorption. This is often accompanied by formation of gingival pockets. Advanced periodontitis results from a continuation of this process and causes marked mobility of the teeth and eventual loss as the attachment apparatus is destroyed.

Space infections of the head and neck occasionally result from periodontal disease. The combination of periodontal lesions and resultant pulpal pathology can create periapical abscesses with the same sequelae as those caused by dental caries alone.

Gingivitis and periodontitis in themselves rarely cause a patient to come to the ED, unless there is sudden alarm at seeing blood on a toothbrush or the realization that certain teeth are loose. Occasionally, a patient reports sensitive teeth. The patient can be advised to improve home care and see a dentist as soon as possible.

Acute Necrotizing Ulcerative Gingivitis

In contrast to gingivitis, in which the gingiva becomes inflamed in response to an irritant such as bacterial plaque but is not invaded by bacteria, acute necrotizing ulcerative gingivitis (ANUG) is a periodontal lesion in which bacteria actually invade non-necrotic tissue. ANUG lesions commonly are accompanied by systemic manifestations of fever, malaise, and regional lymphadenopathy. ANUG is characterized by painful edematous interdental papillae. The normally pointed interdental papillae are blunted and ulcerated. A gray pseudomembrane covers the tissue and leaves a bleeding surface when removed. The lesions can involve any part of the gingiva but are more common in the anterior incisor and posterior molar regions. The patient develops pain, a metallic taste, and foul breath (Fig. 70-7).

Gingival crevices in ANUG show a predominance of fusobacteria and spirochetes. Electron microscopy reveals a layering pattern showing fusobacteria in superficial layers with spirochetes invading in deeper layers. Other necrotizing ulcerative oral diseases, such as Vincent’s angina (extension of ANUG to the fauces and tonsils), cancrum oris (extension of ANUG to the lips and buccal mucosa, eroding through the teeth), and some pulmonary abscesses, also are caused by fusospirochetes. Because ANUG results from an overgrowth of bacteria normally present in the gingival crevice, immunologic factors probably contribute to the disease. ANUG has been associated with immunocompromised hosts, fatigue, local trauma, emotional stress, and smoking.

Oral Pain

Although dental caries is the most common source of oral pain, the following disease entities also may cause oral or facial pain.

Aphthous Stomatitis

Patients may report recurrent small oral mucosal ulcers. The ulcers are approximately 2 to 3 mm in size with a white center. The lesions tend to be tender but rarely become infected. Multiple ulcers that have coalesced can create an impressively large lesion. One third of the population may be affected by this condition, which is believed to be related to stress, nutrition, oral trauma, and hormonal causes. The condition is self-limiting, and treatment is symptomatic. There are numerous over-the-counter preparations that help with symptoms (hydrogen peroxide rinse; topical dental preparations such as benzocaine and an emollient gel; 50 : 50 mixture of diphenhydramine [Benadryl]; and Kaopectate or Maalox).²¹ Prescription regimens, such as steroid-antibiotic ointment (Kenalog in Orabase) or sucralfate are also useful. A topical sulfuric acid phenolic, Debacterol, available only by prescription, is applied to the ulcer and appears to seal the ulcer and promote rapid healing. Ulcers that may appear similar to aphthous ulcers are those on the soft palate associated with hand-foot-and-mouth disease or lesions on the gingivae and tongue from herpetic stomatitis.²²

Oral Manifestations of Systemic Disease

Although the oral manifestations of many systemic diseases are nonspecific, several diseases have distinct oral presentations. In certain instances, recognition of the oral signs aids in the specific diagnosis. In other disease states, the oral condition is a contributing factor to the overall pathophysiology.

Fractures of Teeth

The anterior teeth are commonly injured from falls or direct blows to the teeth. Forceful blows to the mandible directed superiorly may result in fractures of the premolars and molars caused by a wedgelike effect of the cusps of the mandibular teeth in the central fossae of the maxillary teeth. Many children have an anterior overbite, which makes this part of the dentition more prone to injury. Blunt trauma to the dentition may result in damage to the neurovascular supply to the tooth, bleeding within the tooth, fractures of the root or crown, loosening of the tooth, or actual expulsion of the tooth from its socket. A long-term sequela of blunt trauma or reimplantation of teeth is resorption of the root.²⁴ Fractures of the anterior teeth are managed based on the type of fracture, its relation to the pulp of the tooth, and the patient’s age. Table 70-1 describes the classification of trauma to the teeth.

The simplest and most common dental fracture involves only the enamel portion of the tooth, leaving a chalky-white appearance. These injuries are usually minor unless a sharp portion of the tooth causes soft tissue trauma, in which case the sharp edge may be smoothed with an emery board. The patient or parents usually are concerned about the cosmetic deformity, but they can be reassured that the tooth can be restored to its natural appearance with the use of enamel-bonding plastic materials. Referral to the dentist is necessary but not urgent.

Fractures involving the dentin have an ivory-yellow appearance. The pulp continually lays down dentin throughout the life of the tooth in response to normal and noxious stimuli. In a child, the pulp is relatively large in size, and there is less dentin; the inverse is true in the adult. Because dentin is a microtubular tissue capable of allowing bacteria to percolate into the pulp chamber, fractures involving dentin are more serious in children and adolescents, as there is little dentin to protect the pulp after it is exposed to the oral cavity.

In younger patients the management of dentin fractures involves the immediate placement of a dressing of calcium hydroxide paste over the exposed dentin covered with dry foil, a metal band, or, more commonly, an enamel-bonded plastic. Early intervention may prevent contamination of the pulp and avoid the need for subsequent root canal treatment. A pediatric or general dentist should be notified as soon as possible. Exposed dentin may be exquisitely sensitive, so the patient should avoid extremes in temperature. In an adult, who has a greater thickness of dentin compared with pulpal tissue, there is less need for urgent referral to a dentist. A dressing can be placed on the tooth for comfort. Referral should be made to a dentist for the next working day.

Fractures of teeth resulting in pulp exposure are the most serious class of fractures of anterior teeth because the pulp chamber is immediately contaminated. Care should be taken to differentiate dentin exposure from the pulp. The tooth is wiped clean with a piece of gauze and examined for a pink blush or a drop of blood, indicating a pulpal exposure. There may be excruciating pain from exposure of the nerve, or the shock of the trauma may have disrupted the neurovascular supply at the apex of the tooth, eliminating most sensitivity. This injury is often accompanied by serious fractures of the tooth, possibly involving the entire crown or root.

Pulp exposures are true dental emergencies. In the primary dentition, exposure of the pulp can be treated by performing a pulpotomy, in which the pulp in the chamber is removed, the remaining tissue is mummified with formocresol and covered with a layer of calcium hydroxide, and the tooth is restored. In most cases, if there has been minimal contamination, the primary tooth lasts its natural lifetime. In an adult, the pulpotomy is not a successful procedure, and all pulpal tissue from the crown and root must be completely removed by means of a root canal, endodontic, treatment. Although management of pulp exposures is more urgent in a child, endodontic (root canal) therapy is less complicated and more successful in an adult if there is also a minimum of contamination; in the case of a pulpal exposure from a dental fracture, a general dentist, pedodontist, or endodontist should be notified immediately if possible, or the patient should be instructed to follow up the next working day. If no dentist is available, a piece of moist cotton can be placed over the exposed pulp and covered with a piece of dry foil or sealed with a temporary root canal sealant (e.g., Cavit). Although some authors have advocated removal of the exposed pulpal tissue by the emergency physician with a dental endodontic instrument called a barbed broach, this procedure is not recommended because this instrument breaks easily, even in the hands of a skilled endodontist. In cases of extreme pain, a dental anesthetic nerve block might be helpful.

Subluxed and Avulsed Teeth

Teeth that are loosened in their sockets as a result of a force are said to be subluxed. There may or may not be associated fractures. The diagnosis of subluxation can be made by gently tapping a tooth with two tongue blades. Any perceptible mobility is evidence of subluxation. A ring of blood may surround the gingival crevice. Minimally mobile teeth respond well to a soft diet for several days. Markedly mobile teeth require stabilization as soon as possible for 10 to 14 days. Teeth can be stabilized (generally by a dentist) by means of Erich arch bars, wire ligation, enamel bonding plastics, or a combination of modalities. Most of these techniques require an oral maxillofacial surgeon, hospital dentist, or pedodontist. They should be performed as soon as possible.

As a temporizing measure, the patient can bite gently on a piece of gauze, or the teeth can be stabilized for 24 to 48 hours with the application of a periodontal pack (e.g., Coe-Pak). A resin and catalyst paste are mixed together in equal quantities to a firm consistency and molded over the anterior and posterior aspects of the involved tooth and two or three adjacent teeth on each side. The patient is asked to close the mouth while the mixture hardens (Fig. 70-9). The patient is advised to avoid hot liquids, which would soften the pack; eat a liquid to soft diet; and see a dentist as soon as possible.

Avulsed teeth are completely torn from the socket and are a true dental emergency. If teeth are unaccounted for, the possibility of aspiration or entrapment in soft tissues should be considered. Management of recovered avulsed teeth depends on the age of the patient and the length of time for which the tooth has been absent from the oral cavity.²⁵ Avulsed primary teeth in a pediatric patient age 6 months to 6 years are not replaced in the socket. Reimplanted primary teeth ankylose or fuse to the bone, so although the dentofacial complex grows downward and forward, the reimplantation site does not. There also may be interference with the eruption of the permanent tooth. Cosmetic deformity results in either case.²⁶ Such patients should be referred to a pedodontist for consideration of a space maintainer or cosmetic appliance.

Avulsed permanent teeth require prompt intervention. When a tooth has been avulsed from its socket, the periodontal ligament fibers are torn; fragments remain attached both to the cementum on the root of the tooth and to the alveolar bone in the socket. Ideally, the best environment for an avulsed tooth is its socket, and it has been known since the mid-1960s that an avulsed tooth can be successfully replanted if it is returned to its socket within 30 minutes of the avulsion. A 1% chance of successful reimplantation is lost for every minute that the tooth is outside of its socket; however, there is often difficulty with immediate reimplantation. On-site personnel (parents, teachers, trainers, paramedics) may be unfamiliar or uncomfortable with tooth reimplantation. The tooth may be soiled, or the patient may be uncooperative. Occasionally, other, more serious life threats may preclude immediate reimplantation. Because of these factors, investigations were undertaken to find the ideal medium for transport and storage of an avulsed tooth.

The worst situation is to allow the tooth to be transported in a dry medium. Storage in plain water is not much better. Although saliva is a reasonable storage medium, milk is preferable because of its osmolarity and essential ion concentration of Ca²⁺ and Mg²⁺.²⁷ The best storage and transport medium is Hank’s solution, a balanced pH cell culture medium. This solution is commercially available as the Save-a-Tooth system (3M). Hank’s solution can maintain the viability of the cells for 12 to 24 hours or more.²⁷ If the tooth has been avulsed for more than 30 minutes or has been allowed to dry, placement of the tooth in Hank’s solution helps restore the periodontal ligament cells. With the Save-a-Tooth system, the tooth is simply dropped into the basket and the lid replaced. For removal, the lid is removed, the basket is lifted out of the solution, and the tooth is retrieved by tipping the basket over onto the padded lid.

If a call is received about an avulsed tooth, it first should be determined whether the tooth is permanent. If it is, the caller should be instructed to rinse the tooth off in saline or water and reimplant it immediately into the socket. If this cannot be performed for technical or emotional reasons, the patient should be instructed to place the tooth under his or her tongue or in the buccal pouch so that it is bathed in saliva. If the patient is too young, the tooth can be placed in the parent’s mouth. If this is unacceptable to the parent or if there is concern about aspiration or swallowing of the tooth, it should be transported in a cup of milk. If milk is unavailable, saline should be used. Ideally, the tooth should be transported in Hank’s solution.

When the patient arrives in the ED, the tooth should be reimplanted at the earliest opportunity. If this cannot be done, the tooth can be placed in Hank’s solution or a Save-a-Tooth system (especially if avulsion occurred more than 30 minutes previously or if the patient has other life threats that are being managed). A recent study demonstrated that simple oral rehydration solution is as effective as Hanks solution for this purpose and may be more readily available in an ED.²⁸ If Hank’s solution or oral rehydration solution is not available, the tooth is rinsed with saline, the socket is suctioned if necessary, and the tooth is immediately implanted. Local anesthesia may be necessary. The tooth should be manipulated only by the crown, if possible, so that the remaining periodontal ligament fibers are not damaged. Stabilization must be performed immediately, or the tooth will exfoliate. Stabilization is performed as described for markedly subluxated teeth (see Fig. 70-9). Other methods of stabilization with use of light-cured bonding resins are possible and, in a recent study, have been shown to be very satisfactory for the emergency physician if he or she has been trained to use them.²⁹ The status of tetanus immunization should be checked, and the patient should be treated according to the standard for a non–tetanus-prone wound (i.e., 10-year immunization update). Although there is inconclusive evidence to support the practice, dentists typically place patients on phenoxymethylpenicillin (penicillin VK) 250 mg four times a day or doxycycline 100 mg bid in an effort to increase the likelihood of periodontal ligament healing.³⁰

The patient is placed on a liquid diet for several days and advanced to a soft diet for 1 week. Stabilization is maintained for approximately 2 weeks, and the tooth is gradually brought into function to prevent ankylosis. Teeth that have been avulsed for longer than 30 minutes invariably require endodontic therapy owing to loss of pulp viability.26,31 Although there may be concern about the anatomic orientation of the tooth or more confusion about which socket to use when several teeth are avulsed, each tooth should be placed into a socket with the best fit so that the tooth remains in a good physiologic environment. The dentist can make any necessary readjustments before final stabilization.

Alveolar Bone Fractures

Dental fractures and subluxated or avulsed teeth may be associated with fractures of the alveolus. Alveolar fractures may be apparent clinically from exposed pieces of bone or diagnosed radiographically. In massive facial trauma, care should be taken to conserve as much of the alveolar bone as possible, unless there is a great danger of aspiration. Indiscriminate loss of alveolar bone results in tremendous cosmetic deformity that is difficult to restore with prosthetic devices or leaves no foundation for a dental implant, thus necessitating autologous bone grafting procedures.³²

An alveolar fracture requires 6 weeks of stabilization for adequate healing; if there is an associated subluxed or avulsed tooth, stabilization is maintained at the expense of possible ankylosis of the tooth. The loss of alveolar bone ultimately results in more cosmetic deformity for the patient. A permanently ankylosed tooth can remain functional for some time, and although it may be difficult for an oral and maxillofacial surgeon to remove, it can be reconstructed more easily than supporting alveolar bone. The dental materials, including local anesthesia supplies and the Save-a-Tooth system, are conveniently assembled in a commercial package called The Dental Box (Dental Box Co., Pittsburgh, Penn.).

Soft Tissue Injuries

Dentoalveolar trauma is commonly associated with soft tissue injuries of the lips, intraoral mucosa, and tongue. Wounds should be examined for debris and tooth fragments. As with any surgical wound, débridement and irrigation should be performed. Final closure of soft tissue injuries should await the initial management of fractured teeth or the procedures necessary for stabilizing teeth because manipulation of the soft tissues is required. Carefully placed sutures may be torn and have to be replaced in already compromised tissue if soft tissue closures are performed first.

Gaping intraoral lacerations tend to become ulcerated, secondarily infected, and painful. Fibrotic healing results in a cumbersome scar that is subject to repeated trauma during chewing. A well-prepared mucosal wound is closed with No. 4-0 absorbable suture. Chromic gut has the advantage of dissolving more rapidly in the oral cavity; some physicians prefer polyglactin 910 (Vicryl) owing to its softer nature for both handling and patient comfort.³³ Gingival and tongue lacerations are best closed with an absorbable polyglactin or nonabsorbable suture or black silk (4-0 or 5-0) because these materials are less irritating to the touch. Absorbable suture is preferred for children. Large tongue lacerations, especially if the border is involved, should be well approximated or a cleft will form during healing, necessitating a revision. Anesthesia can be achieved by either direct local injection or lingual block. Small (<1 cm) lacerations are best left alone, especially in children. Even larger tongue lacerations can be left alone in children if there is no chance of a resulting cleft deformity.³⁴ The management of through-and-through lacerations involving skin and oral mucosa is controversial. With proper preparation, mucosa can be closed as described previously. Subcutaneous sutures (absorbable) are placed to close the subcutaneous tissues from the outside, removing tension from the skin. Skin is closed with No. 6-0 or No. 7-0 synthetic nonabsorbable sutures that are removed in 3 to 4 days, depending on the amount of muscle tension on the wound. Intraoral silk closures are removed in approximately 7 days. There has been no well-designed prospective randomized trial to evaluate the benefit of prophylactic antibiotics after intraoral laceration repair. Some studies show, at best, a potential trend in benefit for through-and-through lacerations. Simple lacerations do not seem to benefit, and wounds that are over 24 hours old become universally infected. Therefore at this time the use of prophylactic antibiotic coverage is based on clinical judgment.³⁵ Typically, if antibiotics are prescribed for prophylaxis, choices would include penicillin 250 mg four times a day or doxycycline 100 mg bid for 10 days. The patient is advised to maintain oral hygiene, use saline rinses six times a day, place a triple-antibiotic ointment over the skin closure, and watch carefully for infection. These patients should be seen in 48 to 72 hours to check for infection. Normal postoperative soft tissue swelling should not be mistaken for an infected wound.

Temporomandibular Joint Dislocation

The mandibular condyles may dislocate from trauma, but more often, dislocation follows extreme opening of the mandible such as occurs after a yawn or laughter. TMJ dislocation occurs when the condyle travels anteriorly along the eminence and becomes locked in the anterosuperior aspect of the eminence. The masseter, internal pterygoid, and temporalis go into spasm attempting to close the mandible; trismus results, and the condyle cannot return to the temporal fossa. Mandibular dislocation is painful and frightening for the patient. Patients prone to mandibular dislocation include individuals with anatomic disharmonies between the fossa and articular eminence, weakness of the capsule and the temporomandibular ligaments, or torn ligaments. Dystonic reaction to drugs may result in mandibular dislocation. Patients who have had one episode of mandibular dislocation are predisposed to further dislocations. If a unilateral dislocation has occurred, the jaw deviates to the opposite side. More commonly, a symmetrical dislocation occurs. In cases of traumatic dislocation, a panorex or CT scan of the facial bones should be taken to exclude the possibility of a fracture (Figs. 70-10 and 70-11).

Reduction of a dislocated mandible is straightforward, although often difficult because the strength of the masseter contraction must be overcome. The patient requires procedural analgesia and sedation as for any other dislocation. Either facing the patient or from behind, the emergency physician grasps the mandible with both hands; the thumbs rest on the ridge of the mandible intraorally, posterior to the molars, and the fingers wrap around the outside of the jaw. It is best to have the patient sitting up, with a firm surface behind the head, so that posterior and inferior pressure can be exerted without accompanying movement of the patient’s entire head. Some physicians prefer to place the thumbs on the occlusal surfaces of the teeth; in this case the thumbs are wrapped with gauze to protect them when reduction is accomplished because the masseter muscles can contract with tremendous force. Firm, progressive, downward pressure is applied on the mandible to free the condyles from the anterior aspect of the eminence; the mandible is guided caudally, then posteriorly and superiorly back into the temporal fossae (Fig. 70-12). If this maneuver is unsuccessful, both hands can be used on the affected side of the mandible, with reported success.³⁶ The patient is advised to avoid extreme opening of the mandible such as occurs during laughing and yawning, to begin a soft diet for 1 week, and to apply warm compresses in the TMJ area. NSAIDs and muscle relaxants may be helpful. Patients with chronic dislocation may be helped initially with the application of a Barton bandage (elastic fabricated bandage that wraps around the top of the head and mandible). Intermaxillary fixation with wire and elastics may be necessary. Patients who have difficulty reducing the dislocation by themselves or who experience frequent recurrences may require surgical revision of the eminence for relief.

Hemorrhage

Oral hemorrhage is a common complication of dental scalings, periodontal surgery, and dental extractions. Hemorrhage is controlled easily with local measures postoperatively. Patients may have sustained or recurrent hemorrhage after these procedures, however, and visit the ED. History should be obtained for recent dental procedures, drugs with antiplatelet activity such as aspirin or clopidogrel, underlying coagulopathy, or a history of spontaneous bleeding. Spontaneous gingival hemorrhage without an inciting factor warrants a screen for coagulopathy and a complete blood count and differential. Diseases that result in spontaneous gingival hemorrhage are discussed in the section on oral manifestations of systemic disease. Management of coagulopathies caused by factor deficiencies requires factor replacement, and other coagulopathies require appropriate management based on the cause (e.g., warfarin reversal or platelets for platelet-inhibiting agents).

Bleeding after extraction is the most common cause of oral hemorrhage. History of cigarette smoking, excessive spitting, or use of straws is helpful information because each behavior creates negative pressure in the oral cavity, which dislodges blood clots from the socket. Excessive clots should be removed from the oral cavity. The patient should be allowed to bite on gauze for 20 minutes. If bleeding has not stopped, the extraction site should be infiltrated with 2% lidocaine with 1 : 100,000 epinephrine so that the tissue blanches. Gauze pressure should be repeated for another 20 minutes. If bleeding continues, the socket should be packed with an absorbable gelatin sponge or oxidized regenerated cellulose and secured with a No. 4-0 silk suture. Gauze pressure is applied again. Failure to respond to these measures warrants an evaluation for an underlying coagulopathy. Patients who have had multiple extractions without adequate bone recontouring and soft tissue closure may require revision of the surgical site to achieve hemostasis.

Patients who have bleeding after periodontal surgery usually respond to local measures and continued application of gauze pressure. Patients who are bleeding excessively after a deep scaling may be helped by injection of local anesthetic with epinephrine or the placement of a periodontal pack. Patients who recently have undergone periodontal surgery involving gingival flaps may have dislodged the periodontal packs that were placed to ensure proper tissue alignment and wound healing. The periodontist should be informed if possible so that the pack can be replaced as soon as possible to ensure appropriate healing.

Crown and Bridge

On occasion, a patient may have a loose artificial crown or a bridge that may have come loose from the underlying tooth. The crown or the bridge can be recemented in the ED. First, the inside of the crown is inspected for any residual cement. The tooth surface needs to be relatively free of cement. An attempt is made to insert the crown or bridge, and the patient is asked to bite. If the patient says the occlusion feels like it always has (not high), the crown or bridge can be cemented with any commercial dental cement. The crown surfaces are covered with some Vaseline so the cement does not stick; care is taken not to get Vaseline inside the crowns. Usually, dental cements will come as a powder and a liquid, which need to be mixed together to a thick, pudding-like consistency. The crown(s) are filled with the cement and immediately placed over the teeth. The patient is asked to bite and hold until the cement hardens. Any residual cement around the gingival border is flicked off with a dental explorer. The patient should be referred to the dentist the next working day to have the crown checked, the subgingival space checked for any residual cement, or, often, the crown recemented.

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