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Case #139 “Chomper Challenges″ by Charlene Babcock Irvin, MD, FACEP

July 13th, 2010 · No Comments · OB/GYN and Surgery

A 22 y/o male presents with jaw pain.  He notes he has had a toothache for the past week, but yesterday his jaw began to swell.  Today the pain is worse. 

PE:  Fever 101.8, RR=18, HR=110, BP=138/88, Sat=97% (RA)

He has facial swelling on his right mandible and cheek area.  He has difficulty opening his mouth more than 2 cm.  Oral examination reveals severe caries to #29-31.  Tooth number 30 is very tender, and is essentially dissolved down to the gum line second to destruction of the tooth from caries.  There is mucosal swelling throughout these teeth and on palpation the mucosa is indurated.   No fluctuance is palpated.

Neck is supple, and otherwise exam is unremarkable.

Questions:

1. What is the numbering system for teeth?  How are primary teeth identified in children?

See images below.  Permanent teeth are numbered starting on the patient’s upper right.  Children with primary (nonpermanent) teeth are identified with letters and not numbers.  Their numbering system also starts in the patient’s upper right with the letter A.  I like to remember to start in the middle and go back or forward because often adults may not have their wisdom teeth, which makes the number off by one.  So I remember ‘8, 9, 24, 25’ and go back or forward from the middle upper 2 front teeth and 2 front lower teeth.

Universal tooth numbering system.
Teeth numbering chart for adult teeth:

Teeth numbering chart for adult teeth

Orientation of the Universal tooth numbering chart is traditionally “patient’s view“, i.e. patient’s right corresponds to tooth chart’s right side. The designations “left” and “right” on the chart correspond to the patient’s left and right, respectively.

Universal tooth numbering system.
Teeth numbering chart for deciduous (primary) teeth:

Teeth numbering chart for deciduous (primary) teeth

2. Can you name at least 4 different locations of dental space infections?

Infections can be divided into where the swelling is:  Mandibular and Middle/lateral facial swelling. (1)

A. Mandibular:
a. Submental space:  Firm midline swelling beneath the chin. Usually from mandibular incisors.
b. Sublingual space:  Swelling of the floor of the mouth with possible tongue elevation.  Usually an anterior mandibular tooth infection.
c. Submandibular space:  Swelling around the angle of the jaw.  Mild trismus is typical.  Usually caused by mandibular molar infections.
d. Retropharyngeal space:  Molar infections that spread deeper into the retropharyngeal space.  This can quickly become very serious because once the infection reaches the retropharyngeal space; it can spread to the mediastinum.
e. Ludwig’s Angina.  This space infection is a continuation of an infection in the sublingual, submental, or submandibular spaces.  This can also quickly become life threatening by airway compromise or spread into the mediastinum. 

B. Middle and Lateral facial swelling :
a. Buccal space:  Patient will have cheek edema, and usually an infection of maxilla premolars or molars.
b. Masticator space: These patients will likely have trismus, and the infection is usually from the third mandibular molars. (2)
c. Canine space:  Swelling is noted anteriorly with loss of the nasolabial fold and extension up to the infraorbital region.  This is usually due to an infection of the maxillary canines.  This infection may spread to the cavernous sinus.

3. How are tooth fractures described?

The Ellis classification is helpful when describing dental fractures.  The tooth is made up of Enamel (white) on the outside, Dentin (yellow) below the enamel, and the Pulp (red, pink, or with some blood) is the middle of the tooth. The pulp is where the neurovascular bundle is.

Fractures only through the enamel are not painful, but may have sharp edges. Fractures to the dentin level are tender to palpation or when exposed to air.  Same is true for fractures down to the pulp, but in addition to yellow, you may see the pink pulp. 

So, recalling the anatomy helps in the Ellis classification: (3)

Ellis Class I:  Through the enamel only.  Edge may be rough, but no treatment is needed, except you may need to file down any sharp edges if the patient may be at risk to cut their tongue. 

Ellis Class II:  Through to the Dentin, but no pulp exposed.  As the dentin is very porous, these patients will experience pain.  Local anesthetic block may help, as will covering the tooth with something (dental wax, over the counter materials sold for this purpose or other commercial agents).  Note that Dermabond (2-octyl cyanoacrylate) has also been used for this purpose in one case report (4).  Consider covering the patient with antibiotics to decrease infection risk.  These patients need dental referral.

Ellis Class III:  Through to the pulp.  Again, these patients will have pain, and local tooth blocks, along with systemic pain medication will help.  Also covering the surface will also help control pain.  Finally, consider covering them with antibiotics until prompt dental evaluation.

4. How has the addition of fluoride to public drinking water affected the incidence of dental caries in the US? 

The US began to add fluoride to public drinking water in the late 1970’s.  And, in the US, there was a 36% decrease in dental caries from 1972 to 1980.  (1)

Outcome:
WBC was 12.8, and his fever did come down with Tylenol. He was never toxic. Panorex did not show any ostio, and oral surgery was consulted.  He was started on IV antibiotics, placed in observation where oral surgery later came and drained his submandibular space infection.

References:
1.  Peng, LF, Kazzi AA, Cheng R.   Dental Infections.  Emedicine.  Aug 11, 2009.  Accessed at: http://emedicine.medscape.com/article/763538-overview
2.  Murray AD, Marcincuk MC.  Deep Neck Infections.  Emedicine.  Nov 18, 2009.  Accessed at: http://emedicine.medscape.com/article/837048-overview
3. Thomas JJ, Edwards AR.  Fractured Teeth.  Emedicine.  Mar 29, 2009.  Accessed at: http://emedicine.medscape.com/article/82755-overview
4. Hile LM, Linklater DR. Use of 2-octyl cyanoacrylate for the repair of a fractured molar tooth. Ann Emerg Med. May 2006;47(5):424-6   Accessed at: http://www.ncbi.nlm.nih.gov/pubmed/16631981

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