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Do you provide good care in dental emergencies?
While working in the ED one night, a nurse noticed a strange feeling around her left cheek.
"It was not painful and felt somewhat like a vibration or a twitch," recalls Victoria Leavitt, RN, CEN, regional nurse educator for emergency services at Franciscan Health System in Tacoma, WA. "I thought nothing of it, finished my shift, and went home."
She was awakened out of a sound sleep at 4 a.m. by an excruciating pain in the same area. "I drove myself to the ED, as I could not stand the pain. Thank goodness the staff knew me. They gave me immediate attention and medication for pain," she says.
There was no obvious cause for the severe pain Leavitt was experiencing. "There was even some joking about drug seeking," she says. "It turned out I had sustained a linear fracture of a tooth only visible on X-ray, and the tooth was not salvageable."
The incident underscores the tendency to view dental complaints as trivial in the ED, notes Leavitt. "EDs are rather primitive when it comes to dental pain, our approach to the dental patient, and the on-hand dental equipment that we have," she says.
According to new data from the National Hospital Ambulatory Medical Care Survey, conducted by the Hyattsville, MD-based National Center for Health Statistics, EDs treated nearly 3 million patients with complaints of tooth pain or tooth injury between 1997 and 2000, for an average of 738,000 visits annually.1
EDs may be the only place many patients, particularly individuals who lack private insurance, can go for dental-related complaints, says Charlotte Lewis, MD, MPH, the study’s principal investigator and assistant professor of pediatrics at the University of Washington in Seattle. As an ED nurse, you must be able to triage, diagnose, treat, and ensure appropriate follow-up care for all types of dental problems, she adds.
"There is great potential for nurses to make an important impact on oral health-related prevention and problems," adds Lewis. To improve care of dental emergencies, do the following:
• Assess patients for life-threatening injuries.
"Some dental emergencies may be life-threatening if left unchecked," warns Leavitt.
While assessing a nursing home resident who was sent to the ED for decreased level of consciousness and fever, Leavitt felt that something was being overlooked. "I knew that the way she was holding her mouth did not seem right, but I could not put my finger on it," she says.
Since there was no pronounced swelling, Leavitt and the ED physician proceeded with the usual septic work-up. "But that mouth position bothered me, so I put on some gloves and started examining her mouth," she says. "It took one feel of the floor of her mouth to find a massive woody’ swelling."
The woman later died of septic shock because of unrecognized Ludwig’s angina, says Leavitt. This is an inflammation and infection of the submandibular and sublingual space that usually develops as a result of a dental abscess, she explains.
"This represents a serious threat to the patient’s airway," says Leavitt. "The floor of the mouth may become hugely swollen, and in later stages, has a hard, almost woody feel."
Dental abscesses may extend to the deep facial planes of the neck and even into the mediastinum, notes Leavitt. "Though rare, this is most assuredly life-threatening," she says.
Odontogenic infections that spread into the fascial layers of the face and neck can obstruct the airway, says Lewis. "We have had a child die that became septic from an odontogenic infection," she says.
If you observe fractures of the posterior teeth related to an injury, this suggests an associated cervical spine injury, so you should consider implementing appropriate precautions, adds Lewis.
• Ensure appropriate pain management.
Dental pain is chronically undermedicated in the ED, according to Leavitt.
"Presentations to triage with a complaint of dental pain are often met with less than compassionate concern," she says. "Barring an obvious abscess or trauma, there may be a presumption of drug-seeking behavior."
Manage dental pain as you would any other painful condition, advises Leavitt. "If dental and oral pain were to be taken as seriously as a fractured arm, the initial assessment and ongoing care would be elevated to a level not seen in most EDs today," she says.
• Provide resources for follow-up care.
Do what you can to help patients identify other sources of dental care, urges Lewis.
"Access to dental care for low-income and/or uninsured adults is terrible," she says. "This is often why people come to the ED — because they do not have any other place to go."
Develop an ED task force to identify community dental resources and develop educational materials and referral sheets, suggests Lewis. If you do develop a referral sheet, make sure that it stays updated, or it will be useless, she adds.
"We need to be careful to avoid giving a list of dentists with no sense of whether they are accepting new patients, have a sliding payment scale, or what their waiting list is like," she adds. "Once you look into this, you get a sense of how dire the situation is."
1. Lewis C, Lynch H, Johnston B. Dental complaints in emergency departments: A national perspective. Ann Emerg Med. 2003; 42: 93-99.
For more information on treating dental emergencies, contact:
• Victoria Leavitt, RN, CEN, Regional Nurse Educator, Emergency Services, Franciscan Health System, St. Francis Hospital, 34515 Ninth Ave. S., Federal Way, WA 98003-6799. Telephone: (253) 942-4139. E-mail: VictoriaLeavitt@chiwest.com.
• Charlotte Lewis, MD, MPH, University of Washington, Box 354920, Seattle WA 98195. Telephone: (206) 616-1205. Fax: (206) 616-4623. E-mail: firstname.lastname@example.org.
The Dental Box kit for treating dental emergencies in the ED contains laminated reference cards and supplies to treat avulsed, fractured or subluxed teeth, loose fillings, crowns or bridges, odontalgia, alveolar osteitis, and lacerated, bleeding, or abraded mucosa. The cost is $410 plus $20 shipping. To order, contact: