Most people will experience dental pain or a dental complication at some point in their lives. Dental pain is an incredibly common complaint by people of all ages, especially those who lack dental insurance and suitable hygiene habits. Sometimes, though, poor dentition or injury is simply a result of bad luck. Patients often present to the ED hoping to find a dentist and an answer to their problems.
Your first thought? “I am not a dentist. What am I going to do?” You’re right to an extent. We are not dentists, and often feel we have little to offer patients for acute issues that require equipment we don’t have and don’t know how to use. We certainly cannot assist with long-term tooth maintenance and treatment of chronic pain. As many of us know, pulling teeth in the ED is not something we do on demand and should not be expected to do.
Dental fracture, Ellis Type II, tooth #18, left, and common periodontal application kit and set up, right.
But we can do some procedures in the ED without a dentist being present or even consulted, and we can link the patient with some dental resources. There are many dental schools that accept patients for a marginal fee to improve their training skills. When it comes to educating your patients, suggest brushing twice a day, changing their toothbrush every six months, and having a dental cleaning at that time, too. In fact, we suggest you give out this information to all of your patients in the general discharge paperwork, even if they are not in your ED for dental pain. Give it to those especially on whom you complete smoking cessation instruction. Why not make it easy for them and their teeth? And while you are at it, ask them to tell their friends, too.
The best part about this particular procedure for dental fracture is that anyone can do it, and it only takes a few minutes. It is so simple that the actual procedure fit into a one-minute video.
n Stabilization of fractured tooth (teeth)
n Dental block (if indicated) or topical pain medication for pain control
n Imaging (if indicated)
n Repair of lacerations (if indicated)
n Prepping the area of damage appropriately
n Mixing and application of bonding agent/periodontal dressing (calcium hydroxide or CaOH)
n Follow up with an oral surgeon and or dentist in 24 hours
n Pain control, antibiotics (if indicated)
Regular strength Coe-Pak periodontal bonding agent, left, includes the base and the catalyst, which are needed for activation of the base agent. A set of two cotton swabs with long plastic or wooden stems are needed for mixing and applying the agent, center. A general swirling motion is used to mix the agents together before application, right.
n Have the patient lie on a stretcher at a 45-degree angle with excellent lighting.
n Have the patient bite down on gauze if areas in the mouth are bleeding.
n Depending on the type of fracture, complete appropriate dental block for pain relief. This is rarely needed, but it may be useful depending on patient’s comfort level and extent of dental injury.
n Consider imaging if you are concerned about aspirated foreign body, facial fractures, or head injury.
n Carefully examine the lips, especially those with lacerations. (The last fractured tooth I encountered ended up embedded in the patient’s upper lip, and it needed to be removed before suture repair.)
n Examine and count all teeth, note them by number and approximation. Look for obvious fractures and then also consider micro-fractures from partially damaged fillings or teeth.
n Note: Does your patient have a tongue ring? These can also cause dental trauma. Suggest to the patient that it be removed.
n Prep the area of injury by having a partner set up dry wall suction and applying cotton gauze to the sides of the injured area. Note: The area must be dry or the periodontal bonding agent will not adhere correctly or safely.
n Obtain bonding agents. There are many popular brands and agents (Coe-Pak, Reso-Pac, etc). We are specifically going to talk about Coe-Pak, which consists of a standard base and a catalyst.
n Most bonding agents require mixing the agents in a 1:1 ratio, but products may have different mixing requirements. Find a product you like working with and try to stick with it.
n Did you know that the majority of bonding agents come with a lined mixing packet card or pad? Place this card on a surface and use it to measure your bonding agents/materials before application. An injection gun is also a hot commodity, so hot that these items may be missing from your dental box. Just know they exist!
n Place 1 cm of catalyst and 1 cm of base on the mixing card or other sterile mixing surface. We suggest opening a laceration tray to assist with this procedure because the hemostats may assist in application and sculpting later around the periapical areas. You can also use the instrument tray to mix your chosen product.
n Use a swirling technique to mix the two agents if you have a small area to repair. A tongue blade may assist with this process. This is necessary to complete the chemical reaction and activation sequence of the agents. It takes about 30 seconds to mix most agents.
n Some agents require a “balling up” type of application where a powder is used. These can be applied with your fingers rather easily. Remember to mix the catalyst and base well regardless of the type of bonding. If you are working with a larger area, combine the base and catalyst in a “balling up” process and then roll it out on the table into a tube-like structure (as thin as a pencil) for application.
n Wait approximately five to 10 seconds before application. (Some products differ.)
n Again please note: You may use either method: balling or direct application. We prefer balling the material before application, but direct application is also effective.
n Retract the side of the mouth away from the injured area.
n The now putty-like composite resin can be applied to the dental fracture itself over the natural surface of the tooth, regardless of depth of injury.
n Shape and sculpt the periodontal bonding agent over the tooth/teeth. Create a flat surface (free of lumps and bumps) over the tooth and around the edges interproximally. Be sure the entire tooth is covered. This will allow for stronger hold and protection of the fractured tooth.
n Consider using a small-nosed hemostat to shape the bonding around the injury. DO NOT use scalpels or needles to shape the mixture.
n Most of the time, your fingers shape the area better than any tool. Use saliva from the patient’s mouth to keep it moist if it begins to dry out.
n Wait approximately 60 seconds after applying, and then have the patient bite down (if able) to form a small indentation over the bonding. Be sure the bonding agent has had at least one minute to rest, or the patient may pull off the covering when the teeth meet the bonding.
n Have the patient follow up with an oral surgeon or dentist within 24 hours.
n Dental pain can be excruciating. We suggest prescribing the adult patient ibuprofen 600-800 mg tablets po q. 6-8 hours prn pain relief. NSAIDs will help treat inflammation and irritation to the gums. If you are feeling generous, Percocet or Vicodin will help the patient get at least one night’s rest. Prescribe narcotic pain medication at your discretion and in relation to the extent of patient injury, history, and presentation.
n Suggest that the patient refrain from chewing food or gum on that side of the mouth. Encourage a soft diet.
n Smoking cessation as needed.
n Avoid brushing over the area with toothbrush, but the other teeth can be cleaned.
Dental fracture now dressed with periodontal dressing/bonding agent. It was later sculpted along the gum line for patient comfort and proper adherence.
n Do not remix additional bonding agent with dirty hands/contaminated gloves after working inside the patient’s oral cavity. The bonding set usually can be used repeatedly, and it is completely acceptable to store and use the agents again. Do not throw it away after opening, but be sure to adhere to all expiration dates and product directions.
n What happens if the patient swallows any of the periodontal dressing? Most likely, nothing. Tell your patient that the mixture is nontoxic and safe. In fact, people can swallow parts of their braces or actual teeth without any complications. The parts simply pass through the GI system. Inhaling the dressing, however, can be life-threatening.
Watch application of Coe-Pak to a patient’s dental fracture.
n The area of injury needs to be dry before application of bonding agent.
n After mixing the bonding agent, wait 10-20 seconds before application. If you apply the mixture immediately, it will not be very easy to use. If you apply it too late, it will harden and not adhere to the tooth for very long. Do not use the cotton portion of the swab to apply the periodontal dressing. Use the stick portion of the swab for mixing and application.
n Homeopathic treatments using clove oil were popular for many years. Clove oil contains eugenol and can help with toothache or inflamed gingiva. Eugenol can cause nerve damage, and should only be used a few times or for one or two days. Most periodontal bonding agents today do not contain eugenol.
n Use bupivacaine 0.5% for dental blocks because it lasts longer for pain control.
Tip of the Month: Ellis Fractures
Ellis I: These crown fractures extend through the enamel only. These teeth are usually not tender and have no visible color change but have rough edges.
Ellis II: This is any fracture that involves enamel and the dentin layer. Teeth will be tender to the touch or air exposure. You may notice exposed dentin (yellow in color).
Ellis III: These fractures involving the enamel, dentin, and pulp layers, and will be exquisitely tender. You will see an area of pink pulp, redness, or blood toward the center of the tooth.
Reminder: Dental pulp may become infected easily. Pulpitis can occur after a dental fracture while patients are waiting to see a dentist or oral surgeon. Place the patient on antibiotics (typically penicillin VK 500 mg PO 4x/day for 10 days). If the patient is allergic, substitute clindamycin 450 mg PO 3x/day for 10 days. Other accepted antibiotics for potential or known infection include erythromycin, metronidazole, and amoxicillin-clavulanate.
Evidence-Based Practice Pearl
Did you do a good job? What did the dentists have to say? A small retrospective study of 25 ED providers found three ways that providers could approach dental fractures or avulsions. (Ann Emerg Med 2009;54:585.) The periodontal pack took about four minutes to complete and was financially more appropriate. The study participants had no measurable or agreeable preference for a particular splinting or bandaging technique, but dentists preferred the use of reinforcement ribbon (96%) and light-cured composite (100%) when given the option. The only problem is that reinforcement ribbon and light-cured composite are difficult to obtain, stock, and use in the ED. It is also very costly and specialized, and those factors and the longer treatment time simply cannot be justified for use in the ED when CaOH bonding agents are just as effective. Although the specialist may prefer it, they may have to apply it.
The Language (NEW!)
Every specialty has some sort of new language with which you need to be familiar and use in documentation or description to your colleagues. If you are feeling adventurous and want to learn the dentistry lingo, here is a list of descriptive terminology used for differentiating tooth surfaces. Read our previous blog for more on tooth numbering and dental blocks. (http://bit.ly/1qrrPfA.) If you do consult the oral surgeon or dental consultant, he will want to know the number of the tooth and the location.
Facial Part of tooth that faces opening of mouth
Labial Facial surface of the incisors and canines
Buccal Facial surface of the premolars and molars
Oral Area that faces the tongue or palate
Lingual Toward the tongue; the oral surface of the mandibular
and maxillary teeth
Palatal Toward the palate; the oral surface of the maxillary teeth
Approximal/interproximal Contacting surfaces between two teeth
Mesial Interproximal surface facing anteriorly or closest
to the midline
Distal Interproximal surface facing posteriorly or away
from the midline
Occlusal Biting or chewing surface of the molars and premolars
Incisal Biting or chewing surface of the incisors and canines
Apical Toward the root of the tooth
Coronal Toward the crown or biting surface of the tooth
Source: Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th ed., Philadelphia: Saunders/Elsevier, 2014, pg. 1342.
If you want to hear some of the lingo, check out this very old video from the University of Michigan, free for public use and distribution for educational purposes. This classic video, although dated, uses principles we still use today. Watch here: http://bit.ly/1d9fxZ0.
The American Heart Association published guidelines in Circulation about using antibiotics prior to dental procedures. They suggested that only those at greatest risk for bad outcomes from infective endocarditis should receive short-term preventive antibiotics before routine dental procedures. (2012;125:2520.) This, of course, only applied to those who were waiting for a routine visit or procedure.
The literature found no compelling evidence that taking antibiotics prior to routine dental procedures prevents infective endocarditis in patients who are at risk of developing a heart infection because their hearts are already exposed to bacteria from the mouth, which can enter their bloodstream during basic daily activities such as brushing or flossing. Trauma, however, should always be considered as a possible increased risk of infection, and antibiotic use is best decided at time of presentation.