Patients are typically male and were often involved in an MVC, sports activity, or assault. Ellis I fractures are painless, and the patient may only note a jagged edge to the tooth. Ellis II fractures present with the primary complaint of hot and cold sensitivity as the exposed dentin is quite sensitive. Patients with Ellis III fractures present with severe pain, although pain may be absent if there is neurovascular compromise.
When a tooth avulses, the time the tooth spends out of the socket is one of the most important pieces of information to obtain. If the tooth is out for <20 minutes, prognosis is good. If >60 minutes has elapsed, a successful re-implant is much more difficult.
Patients with a mandible fracture report jaw pain, inability to open the mouth, and possible malocclusion of the teeth. Numbness of the lower lip suggests an injury to the inferior alveolar nerve.
Patients with dental caries present with dull, continuous pain made worse with any stimulus. They typically have poor dental hygiene with grossly carious teeth. Pain does not occur until decay impinges on the pulp and an inflammatory process develops. If a dental abscess is present, there is excruciating pain that is made worse with tapping on the tooth. These patients may have facial swelling, especially if periapical in location.
When evaluating for an abscess, elicit a history of fever, trismus, drooling, inability to handle secretions, and recent dental infection or trauma. Predisposing factors include dental caries, alcoholism, elderly, or diabetes mellitus. Ludwig angina presents with pain, dysphagia, odynophagia, dysphonia, trismus, and drooling. The patient may also complain of severe neck and sublingual pain. By some estimates, up to 33% can result in airway obstruction.
Patients with acute necrotizing ulcerative gingivitis present with pain, metallic taste, and foul breath. They may also complain of fever and malaise.
Inspect the teeth for Ellis fractures. The dentin is visualized on examination as a creamy yellow color present in the center of the broken tooth. The pulp is seen as a pink tinge or drop of blood within the exposed dentin. If tooth avulsion has occurred, evaluate the socket and surrounding soft tissue for lacerations, ecchymosis, or foreign bodies. When examining an avulsed tooth, do not touch the root. Malocclusion, deformity, or bleeding in the mouth suggests a mandible fracture. An intra-oral laceration may represent an open fracture. Pain, mental nerve paresthesia, and segment mobility may also be present. Ecchymosis under the tongue is highly suggestive of a mandible fracture. The tongue blade test is used to clinically exclude a mandible fracture. The patient is asked to bite on a tongue blade. If the examiner is able to break the blade by turning it while the patient bites down, then a mandible fracture is unlikely. The sensitivity of this test is 95%.
Dental caries are noted on inspection. If percussion tenderness or changes in temperature cause pain, consider pulpitis.
Dental abscesses are diagnosed based on the physical examination. A submental space infection is characterized by a firm midline swelling beneath the chin. This abscess is due to infection from the mandibular incisors. A sublingual space infection is indicated by swelling and pain of the floor of the mouth and dysphagia. It is due to an anterior mandibular tooth infection.
Submandibular space infection is identified by swelling around the angle of the jaw. Mild trismus is frequently present. These abscesses are caused by an infection of the mandibular molar. Buccal space infections present with cheek swelling (Figure 78-2A). Canine space infection is characterized by anterior facial swelling and loss of the nasolabial fold. This infection can extend into the infraorbital region and be confused with ocular pathology (Figure 78-2B). Masticator space infections present with trismus. Trismus is the inability to fully open the jaw due to tonic spasm of the muscles of mastication (lockjaw). In the absence of trauma, a patient with facial swelling and trismus has a masticator space infection until proven otherwise.
A. Buccal space infection. B. Canine space infection.
Ludwig angina presents with massive swelling in the floor of the mouth that is painful to palpation. The swelling may produce an elevation of the tongue, which can occlude the oropharynx (Figure 78-3). The patient's anterior neck may be brawny in character secondary to edema.
A patient with Ludwig angina. A. Tongue. B. Neck.
Alveolar osteitis is identified by a fresh extraction site with absence of clot. ANUG presents with a gray pseudomembrane, ulcerations, gingival bleeding, and fetid breath. Patients often have associated regional lymphadenopathy.