Tag Archives: Dental

Conference Notes 08/30/23

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Emergency Management of Dentition and Midface

  • Dentoalveolar trauma can include fractures, avulsions, displacement of teeth
  • An avulsed tooth is only viable within one hour, however, even outside of this window it is still worth replacing the tooth. In some cases, they may then get a root canal with dentistry
  • Alveolar fractures need timely treatment or risk poor cosmetic outcome and infection
  • Most oral abscesses can be drained in the ED with close dental follow-up
  • The need to obtain CT is dependent on the full clinical picture. If pt has significant RFs for deep space infection or cancer, it may warrant a face CT
  • Trismus sometimes can be confused with guarding due to pain. Can be worthwhile to provide analgesia and reassess
  • Buccal and canine space infections can present with significant facial swelling. These should be assessed with CT, drainage should occur from within the oral cavity near the involved tooth, not through the skin of the face
  • Radiology reads will frequently indicate Ludwig’s, however, this is often overread. True Ludwig’s is a surgical emergency. Can cause significant airway compromise
  • As a general approach to anesthetic for oral abscesses, should first infiltrate around the abscess, then can attempt direct injection
  • Inferior alveolar N blocks can be challenging due to surrounding vessels as well as the parotid gland that can be inadvertently damaged

Anti-Arrhythmics

  • Among the sodium channel blockers, they are divided into IA, IB and IC. Procainamide is the common IA, Lidocaine is a IB and Flecanide is IC
  • Class II antiarrhythmics are the beta blockers
  • Class III antiarrhythmics are K channel blockers. Amiodarone is the most common example
  • Class IV antiarrhythmics are the Ca channel blockers
  • Beta-blockers and calcium channel blockers should be used with caution in the setting of CHF exacerbation given their negative inotropic effects
  • Amiodarone has both rate and rhythm-control properties
  • Ibutilide and procainamide are the safest medications to give in the setting of WPW
  • Dr Huecker: Can also consider adding magnesium to any of the aforementioned therapies

Infective Endocarditis

  • Defined by the Modified Duke Criteria
  • Most commonly caused by Staph species
  • Don’t forget about pseudomonal coverage in those with prosthetic valves
  • Valves are at high risk of infection given their lack of robust vasculature as well as the turbulent flow around them
  • IE cases are increasing due to both increased IVDU as well as increased prosthetics being placed
  • The average age of IE is now >65. Majority will require surgical intervention
  • Recall Osler nodes, Janeway lesions, splinter hemorrhages, Roth spots/ conjunctival petechiae
  • IVDU leads to right-sided IE
  • When IE is diagnosed don’t forget to get blood cx from 3 separate sites
  • Empirically give Vancomycin. Add on pseudomonal coverage if pt has a prosthetic valve
  • The biggest RF for IE is prior IE
  • Undomiciled patients are at increased risk of IE due to Bartonella species given flea exposure

Ultrasound in the Unstable Patient

  • CXR sensitivity for edema/ effusions is low
  • Ultrasound has good sensitivity in confirming ETT placement
  • Palpating pulses during ACLS has poor sensitivity/ specificity, another area where ultrasound can be helpful, in addition to checking for reversible causes of a patient’s arrest
  • Ultrasound can be used to find the CO plus the SVR, which together can be very valuable information when resuscitating an undifferentiated shock/ SOA/ hypotensive patient

Facial Edema

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This was an interesting presentation from a Peds shift.

15 y/o AAM with no significant medical history who presents with facial swelling. Patient noticed significant swelling to the left side of his face upon awakening in the morning. The swelling involved his entire left cheek, inferior lid of his left eye, upper lip and part of his right cheek. The patient denies any pain, tongue swelling, voice change, difficulty breathing or swallowing, fevers, recent ill symptoms (cough, congestion, vomiting, diarrhea), dysuria, hematuria, rectal bleeding, sore throat, ear complaints. He denies any new exposures including new medications, new soaps, detergents, animal exposures, environmental exposures, recent travel, insect bites.

PMH:none. PShx: had 4 wisdom teeth removal 1 month prior (finished antibiotics), no other recent surgeries or dental work. No EtOH, drugs. No current medications. No known allergies.

Vitals: 97.8, 90, 110/70, 18, 99 % on RA

Exam: HEENT- moderate swelling of the left buccal area, inferior lid of the left eye, upper lip. Mild swelling to the right buccal area. No erythema or palpable areas of fluctuance. No swelling surrounding the right eye. No conjunctival injection. No erythema within the ears, TMs normal. No mastoid tenderness. No lingual swelling, no erythema within the mouth or palpable areas of fluctuance. No signs of infection from previously removed wisdom teeth. No posterior oropharyngeal swelling or uvular deviation. No lymphadenopathy.

Heart- normal. Lungs- clear, no wheezing or stridor. Abdomen- normal. No CVA tenderness.

Treatment started with Benadryl for possible allergic reaction. Basic labs obtained and urine for possible nephrotic syndrome. WBC-17, otherwise normal. Urine with 200 protein, no RBC or WBC- nephrology consulted and recommended repeat POC labs as outpatient and follow-up in clinic, but no intervention at this time. Patient had mild improvement with Benadryl. Discharged home with Benadryl and steroids.

Patient re-presents 6 hours later (just came back for my shift the next day)

Facial swelling has worsened. Now involves bilateral buccal areas, bilateral lower eyelids and upper lip. No fevers, no difficulty breathing, no dysphagia. Patient had taken 1 repeat dose of Benadryl at home and had not started steroids yet. No other changes in HPI except patient mentions some bleeding from the inside of his upper lip. Upon exam, patient has some bleeding and purulent drainage from the gumline of his left central incisor. No palpable fluctuance, but able to express drainage with pressure to upper lip.

Labs obtained: WBC 17, CRP 1.6, ESR 41. UA- minimal protein. All other labs unremarkable. CT face with contrast obtained showing left central incisor periapical abscess with cortical erosion as well as extensive cellulitis of the midface. Also some concern for phlegmon within the paranasal sinus. ENT, OMFS, and finally pediatric dentistry consulted. Patient admitted for IV clindamycin, Unasyn for cellulitis and dentistry consult for possible root canal versus tooth extraction.

Bottom line: Odontogenic infections can cause orofacial infections and rarely but more importantly peripharyngeal space infections as well as jaw osteomyelitis. If concerned about deep facial infection, CT face is warranted. Treatment includes draining of pus from abscesses (either through I&D or needle aspiration) and culture as well as antibiotic therapy. Common regimens include a penicillin plus metronidazole, clindamycin, augmentin, or unasyn depending on disposition. Dentistry should be involved whether through consult or outpatient follow-up for root canal versus tooth extraction.