Dental and Opthalmologic Emergencies
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Transcript Dental and Opthalmologic Emergencies
Morehouse Pediatrics EM Lecture Series
November 23,2009
Taryn R Taylor, MD
Epidemiology
Tooth Eruption & Shedding Schedule
Clinical Evaluation
Dental Concussion & Subluxation
Avulsion Injuries
Tooth Displacement
Tooth Fractures
Dental Abscesses
Epidemiology
◦ 30% of children experience dental injuries
◦ Peak period of trauma to primary teeth is 18 to 40
months of age
◦ Trauma to permanent teeth
School aged boys suffer trauma twice as frequently as
girls
Upper (maxillary) central incisors are most frequently
injured
Tooth Eruption & Shedding Schedule
Clinical Evaluation
◦ Medical History
Assess need for SBE prophylaxis
Determine if child has a bleeding disorder or is
immunocompromised
Record current medications and medication allergies
Obtain history of previous surgeries
Determine if tetanus immunization is up to date
Determine if child lost consciousness due to injury
◦ Dental History
How the injury occurred: provides info regarding severity
When injury occurred: prognosis for injured tooth worsens
with every minute of delay in treatment
Where injury occurred: helps determine whether tetanus
prophylaxis is warranted
Clinical Evaluation
◦ Physical Examination
General assessment includes review of vital signs,
evaluation of potential head and cervical spine injury
as well as ocular damage
Extra oral evaluation
Palpate mandibular condyles, maxilla, zygoma & TMJ
Anterior open bite, malocclusion or limited mandibular
opening suggests condylar fractures or dislocation
Note extra oral lacerations, bruises or swelling
Lacerations must be inspected for foreign bodies i.e. gravel
or tooth fragments & be debrided if foreign body present
Physical Exam cont.
◦ Intra oral evaluation
Remove all clots and debris
Palpate alveolus to detect fractures
Have patient clench teeth to detect dental occlusion
Examine each tooth for damage or mobility
Examine labial mucosa, maxillary frenulum, gingival
tissues and tongue for bruising or lacerations
Lacerations must be cleaned & explored for presence of
foreign body
Frenulum will heal without long term consequences
Most tongue lacerations will heal on their own, unless
tissue edges are not self-approximating
Dental Concussion & Subluxation
◦ Concussion: Mild injury to periodontal ligament without
tooth mobility or displacement
◦ Subluxation: Significant injury to periodontal ligament
resulting in some tooth mobility
◦ These injuries may result in tooth discoloration
◦ Initial management
Tylenol as needed for pain
Ice as needed for swelling
Soft diet
Follow up with dentist
◦ Dental office management
Radiographs of primary tooth to evaluate for root fracture
Splinting of permanent tooth if extremely mobile
Avulsion Injuries
◦ Occurs when a tooth is completely displaced from the
dental socket
◦ Radiographs may be necessary if tooth cannot be found
◦ Primary Teeth
Not reimplanted, as the risk of injury to developing
permanent tooth bud is high
◦ Permanent Teeth
Best way to preserve an avulsed tooth is to replace it in its
socket as quickly as possible
Periodontal ligament is protective layer surrounding the root,
which suffers irreversible damage if allowed to dry
Do not touch root of tooth, handle by crown only
Rinse only if there is dirt covering it, don’t scrub or scrape tooth
Gently dislodge any clots, & reintroduce tooth into the dental
socket slowly
Avulsion Injuries cont.
◦ Post Reimplantation care
Dental consult immediately for splinting & tooth
stabilization
10 day course of prophylactic penicillin
Tetanus vaccination if wound is dirty or vaccination
requires updating
Chlorhexidine gluconate rinses, oral hygiene & soft
diet instructions
Analgesics for pain control
Dental follow up within one week
Tooth Displacement
◦ Luxation: Displacement of tooth in any direction,
while remaining in the socket
Lateral luxation is usually associated with fracture of
alveolar bone
Primary teeth: analgesia, proper dental hygiene,
prompt dentist follow
Permanent teeth: gently reposition tooth, additional
care similar to primary teeth
Tooth Displacement
◦ Extrusion: tooth is only partially removed from
socket
Care similar to other luxation injuries
◦ Intrusion: tooth is impacted into alveolar bone with
associated fracture
Intrusions of up to 3 mm have excellent prognosis
Care similar to other luxation injuries
Tooth Fractures
◦ Crown fractures are described by Ellis Classification
Ellis class I: involves enamel only, rarely painful, cosmetic
implications only
Ellis class II: involves enamel as well as dentin
Sensitivity to cold air & fluids
Emergency treatment aimed at protecting the pulp by applying
calcium hydroxide product
Dentist follow up in 48 hours
Ellis class III: dental pulp involved, often appears red
Exposure of nerve endings causes extreme pain
Exposure of pulp will lead to pulpal necrosis from bacterial
infection if left untreated
Emergency treatment aimed at protecting the pulp by applying
calcium hydroxide product
Dentist follow up within 24 hours
Dental Abscess
◦ Results when inflammation of the pulp is left
untreated
◦ Pain, tenderness, red, swollen gingiva with areas of
fluctuance
◦ Complications include localized cellulitis, fistula
formation
◦ Emergency management includes pain control and
oral penicillin
◦ Prompt dental follow-up
◦ Emergent ENT consultation for patients requiring
incision and drainage due to severe pain or with
extension of infection into deeper tissues
Landmarks of the eye
Different types of eye injuries
Emergency care for eye injuries
Orbital Cellulitis
The globe of the eye, or eyeball is a sphere
approximately 1” in diameter
Five most important landmarks of the eye:
◦ Sclera- the “white” of the eye
◦ Cornea- clear, front portion of the eye that covers
the pupil
◦ Pupil- opening in which light enters
◦ Iris-colored portion of the eye
◦ Retina- back of the eye
Ocular trauma is the leading cause of
noncongenital unilateral blindness in children
younger than 20
Most eye trauma occurs during sports
activities
Clinical Assessment
◦ Mechanism: blunt or sharp object, foreign body
present
◦ Symptoms: pain, photophobia, eye movements,
visual acuity
◦ Exam: Pupil size, shape, reaction to light: orbital
rims, floor, extra ocular motion
Eye injuries are usually not life-threatening
Time is of the essence in your treatment
Six different types of eye injuries:
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Foreign object in the eye
Corneal Abrasions
Lid injury
Injury to the globe
Injury to the orbits
Chemical burn to the eye
Extra ocular Foreign Objects
◦ Dust, dirt, sand or fine pieces of metal can be
blown into the eye & lodged on conjunctiva or
cornea
Signs & Symptoms
Pain, foreign body sensation
Excessive tearing
Reddening of conjunctiva
Decreased visual acuity
Extra ocular Foreign Body
◦ Flush eye for at least 20
minutes
◦ If object cannot be flushed,
attempt to remove
◦ Evaluate for possible corneal
abrasion
To remove object:
Pull down lower lid while
patient looks up, or evert
upper lid while patient looks
down
Remove object with sterile
gauze
Corneal Abrasions
◦ Most common eye injury in all ages
◦ Scraping away of the corneal surface, caused by:
Injury
Blowing dust, sand, debris
Extended contact lens wear
Ocular foreign bodies, embedded under an eyelid
◦ Signs and symptoms
Red, irritated eye
Foreign body sensation
Increased tearing
Photophobia
Fluorescein uptake under Woods lamp
◦ Treatment
Polytrim antibiotic ointment or gtts
Eyelid Lacerations
◦ Control bleeding with LIGHT pressure
◦ Ocular injury should always be suspected
◦ Lids should be everted and conjunctival surface
examined
◦ Orbital CT if suspected ocular penetration
◦ Laceration repair with 6-0 nonabsorbable suture
◦ Optho referral for repair:
Lacerations involving nasolacrimal duct
Full thickness lacerations
Eyelid margin lacerations
◦ Lacerations from animal or human bites require
tetanus prophylaxis
Injuries to Globe
◦ Subconjunctival Hemorrhage
Blood between conjunctiva & sclera, stops at cornea
Not an emergency
Heals like any other bruise
◦ Hyphema
Accumulation of blood in the anterior chamber
Complications include inflammation and increased IOP
Patients with sickle cell disease or trait & thalassemia are
at risk for central retinal artery and optic nerve damage
Patients are at risk for rebleeding 3-5 days after initial
injury
Initial treatment: bed rest, elevation of head of bed 30
degrees, optho referral
Hyphemas > 50% should be admitted
Avoid aspirin & NSAIDS
Injuries to Globe
◦ Globe Rupture
Can occur after significant laceration of cornea or
sclera due to sharp objects, or blunt trauma
Visual loss, bloody chemosis, soft globe
Protective shield should be placed over the eye
AVOIDING direct pressure on globe
Broad-spectrum IV antibiotics against skin flora &
tetanus prophylaxis should be administered
Analgesics, sedatives and antiemetics to decrease IOP
from vomiting
Immediate ophthalmologic consultation required
Orbital Fractures
◦ “Blowout” Fracture
Following blunt trauma, eye is pushed through floor of
orbit, causing fracture of orbital wall
Trapping of intraocular muscle prevents movement of
eye away from fracture site
Facial asymmetry, sunken eye, paralysis of upwards
gaze, double vision
◦ Orbital roof fractures
Occur mostly in children under 5 years
Possibility of communication between orbit &
intracranial cavity
Pulsating proptosis
◦ CT scan with immediate ophthalmologic
consultation
Chemical Burns
◦ Represent a DIRE emergency
◦ Permanent damage can occur within seconds
◦ Burning and tissue damage will continue to occur as
long as substance is left in eye
◦ Signs and Symptoms
Irritated, swollen eyelids
Redness of the eye
Blurred/diminished vision
Irritated, burned skin around the eyes
Chemical Burns
◦ Emergency Care
Immediately begin irrigation with NS or LR
Continuously irrigate for a minimum of 20 minutes
Remove contact lenses-may trap chemicals
Wash your hands afterward to prevent contamination
to yourself
Contact Poison Control Center for further information
Referral to ophthalmologist
Orbital Cellulitis
◦ An infection of the orbit itself, which occurs
As a complication of sinusitis with extension of the
infection to the orbit
Secondary to penetrating trauma
As an extension of a nearby facial infection
◦ Signs & Symptoms
Erythema, edema, induration and tenderness to peri
orbital tissues
Decreased eye movement
Proptosis, chemosis, decreased visual acuity and
papilledema
Orbital cellulitis
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CT scan of orbit
Prompt treatment with IV antibiotics
Inpatient admission for frequent monitoring
Ophthalmologic consultation
Questions?