0
Project: Ghana Emergency Medicine Collaborative
Document Title: Oral and Dental Emergencies: The Patient With A Sore
Throa...
Attribution Key
for more information see: http://open.umich.edu/wiki/AttributionPolicy
Use + Share + Adapt
Make Your Own A...
Oral and Dental Emergencies
The Patient with a Sore Throat
Joe Lex, MD, FACEP, FAAEM
Associate Professor, Department of
Em...
Objectives
1. Understand that teething does
not cause fever
2. Define, recognize, and treat
pericoronitis, periapical absc...
Objectives
5. Identify and differentiate among
these mouth lesions: aphthous,
HSV, herpangina, perlèche
6. Describe the de...
Teeth
David Shankbone, Wikimedia Commons
How Many Teeth?
32 permanent
• 8 incisors
• 4 canines
(cuspids)
• 8 premolars
(bicuspids)
• 12 molars
(tricuspids)
20 prim...
How to Name the Teeth
Gray’s Anatomy, Wikimedia Commons
Source Undetermined
Source Undetermined
Definitions
• Interproximal: the surfaces
between two adjacent teeth
• Mesial: interproximal surface
facing toward midline...
Definitions
• Labial: toward the lips, specific to
anterior teeth
• Buccal: toward the cheek, specific
to posterior teeth
...
Definitions
• Apical: toward the tip of the root of
the tooth
• Radicular: associated with the
root, especially the apical...
Basic Anatomy
• Dentin surrounds pulp, which is
neurovascular supply
• Crown: enamel on dentin, visible
portion of tooth
•...
Sam Fentress, Wikimedia
Commons
Basic Anatomy
• Periodontium = attachment
apparatus
• Periodontal ligament = collagen
fibers that extend from alveolar
bon...
Basic Anatomy
• Gingiva = keratinized stratified
squamous epithelium
–Free gingiva: 2- to 3- mm-deep
gingival sulcus in di...
Jonathon Colman, Flickr
Healthy teeth
Dozenist, Wikimedia Commons
Teething
Daniel Schwen, Wikimedia Commons
Vmg13, Wikimedia Commons
About ye seveth moneth, sometime more,
sometime lesse, after ye byrth, it is natural
for a child to breed teeth, in which ...
Death by Teething!!
• Common “Cause of Death” in
Middle Ages
• Usually weaned at same time
• Frequently lance erupting too...
Teething
• No data support association of
teething, fever, and diarrhea
• Possible mild dehydration from
excessive salivar...
Pain from Wisdom Teeth
• Erupting third molars
• Pericoronitis: inflammation of
gingival tissue overlying occlusal
surface...
Pericoronitis
Coronation Dental Specialty Group, Wikimedia Commons
Dental Caries
• Loss of tooth enamel integrity due
to exposure to acidic metabolic
byproducts of plaque bacteria
• Early: ...
Dental Caries
Dozenist, Wikimedia Commons
Dental Caries
Dozenist, Wikimedia Commons
Antibiotics for Toothache??
• Undifferentiated dental pain
without overt infection
• Penicillin vs. placebo
• Evaluation a...
Antibiotics for Toothache??
• 13 / 134 patients (9%) developed
infection
–6/64 (9%) in penicillin group
–7/70 (10%) in pla...
Antibiotics for Toothache??
• CONCLUSIONS: “These data
support the hypothesis that
penicillin is neither necessary nor
ben...
Periapical Abscess
• Most common source of severe
odontogenic pain: periapical
• Most common lesion: periapical
granuloma ...
Widened periodontal
ligament space
Source Undetermined
Periapical lucency
Source Undetermined
Periapical abscess
Source Undetermined
Periapical Abscess
• Exquisite pain with percussion
• Suppurative periodontitis = parulis
• X-rays rarely indicated
• Rx a...
Parulis = Fistula = Gum Boil
Source Undetermined
Parulis = Fistula
Damdent, Wikimedia Commons
Postextraction Pain
• Periosteitis: 24 to 48 hours,
common, easily treated
• Alveolar osteitis = dry socket:
second or thi...
Dry Socket
• Up to 35% after impacted 3rd
molar removal
• X-ray for retained root tip
• Irrigate socket with sterile salin...
Dry Socket
Source Undetermined
Infraorbital Nerve Block
Source Undetermined
Infraorbital Nerve Block
Source Undetermined
Infraorbital Nerve Block
Source Undeternined
Mental Nerve Block
Source Undetermined
Mental Nerve Block
Gray’s Anatomy, Wikimedia Commons
Mental Nerve Block
Source Undetermined
Mental Nerve Block
Source Undetermined
Palatal Nerve Block
Source Undetermined
Palatal Nerve Block
Source Undetermined
Palatal Nerve Block
Adapted from: Alan, Flickr
Inferior Alveolar Nerve Block
Gray’s Anatomy, Wikimedia Commons
Inferior Alveolar Nerve Block
Source Undetermined
Inferior Alveolar Nerve Block
Adapted from: Lusb, Wikimedia Commons
Inferior Alveolar Nerve Block
Source Undetermined
Inferior Alveolar Nerve Block
Mikael Häggström, Wikipedia
Frenum Diastema
i.e., gap-toothed
Bryon Viechnicki, Wikimedia
Commons
Tetracycline Staining
Source Undetermined
Gums
Mohamed Hamze, Wikimedia Commons
Periodontal Disease
• Gingivitis: accumulation of plaque
along gum margins
• Causes: bad hygiene, hormonal
variations (pub...
Periodontal Disease
Source Undetermined
Periodontal Disease
Source Undetermined
ANUG
• Acute Necrotizing Ulcerative
Gingivitis = Vincent ´s disease =
trench mouth
• Diagnostic triad: pain + ulcerated
or...
ANUG
• Invades otherwise healthy tissue
• Treatment:
–Identify, treat predisposing factors
–Chlorhexidine oral rinses twic...
ANUG
Source Undetermined
ANUG
Source Undetermined
Gingival Hyperplasia
• Associated with many commonly
used medications
• 50% of patients on chronic
phenytoin
• Also calciu...
Gingival Hyperplasia
Lesion, Wikimedia Commons
Bleeding Gums
• Hemorrhage after scaling easily
controlled with peroxide mouth
rinses or direct gingival pressure
• Clotti...
Bleeding Gums
Source Undetermined
Bleeding Gums
Source Undetermined
Post-Extraction Bleeding
Usually a dislodged clot
1. Firm pressure usually adequate:
folded 2 × 2 gauze pad placed over
ex...
Pyogenic Granuloma
• “Pregnancy tumor”
• Benign proliferation of connective
tissue, primarily on gingiva
• Not pyogenic, n...
Pyogenic Granuloma
Source Undetermined
Pyogenic Granuloma
Kuebi, Wikimedia Commons
Before We Leave the Gums…
Intentional pain
And the taste of gums bleeding
Prevent toothlessness
Morsels sit between my tee...
Cheeks & Lips & Palate
2T, Wikimedia Commons
Oral Candidiasis
• Present in 60% of healthy adults
• Opportunistic pathogen: many risk
factors
• Adherent white plaque
• ...
Oral Candidiasis
James Heilman, MD, Wikimedia Commons
Oral Candidiasis
Centers for Disease Control and Prevention, Wikimedia Commons
Angular Cheilitis = Perlèche
• Breakdown at labial commissures
• Candida albicans implicated
• Radiation therapy
• HIV
• D...
Angular Cheilitis = Perlèche
James Heilman, MD, Wikimedia Commons
Angular Cheilitis = Perlèche
Lesion, Wikimedia Commons
Angular Cheilitis = Perlèche
Source Undetermined
Aphthous Stomatitis
• Canker sores: common
• Probable cell-mediated response
• Nonkeratinized epithelium
• Superficial pai...
Aphthous Stomatitis
TheBlunderbuss, Wikimedia Commons
Aphthous Stomatitis
Noorus, Wikimedia Commons
HSV = Cold Sores
• Type 1 most common
• Gingivostomatitis: painful
ulcerations on mucosal surfaces
• Fever, lymphadenitis ...
HSV = Cold Sores
Centers for Disease Control and Prevention, Wikimedia
Commons
WarXboT, Wikimedia Commons
Herpangina
• Coxsackieviruses
• Summer and autumn
• Sudden high fever, sore throat,
headache, malaise then vesicles
• Soft...
Herpangina
• Lasts 7 to 10 days
• Distinguished from herpetic
gingivostomatitis by lack of gingival
involvement
United Kin...
Herpangina
Shawn C, Wikimedia Commons
Aphilosophicalmind, Wikimedia Commons
Hand, Foot, and Mouth
• Coxsackievirus
• Vesicles on tongue, gums, soft
palate, buccal mucosa
• Rupture  painful, shallow...
Hand, Foot, and Mouth
MidgleyDJ, Wikimedia Commons
James Heilman, MD, Wikimedia Commons
Ngufra, Wikimedia Commons
Lichen Planus
• Chronic cutaneous
vesiculoerosive disease
• T- lymphocytes on basal cell layer
• Scattered white papules
i...
Lichen Planus
Source Undetermined
Cheek Chewing
Source Undetermined
Aspirin Burn (ASAcid!)
Source Undetermined
Aspirin Burn (ASAcid!)
Source Undetermined
Torus Palatinus
• Hard, firm isolated mass on hard
palate.
• May be several centimeters
• Appears in adulthood
• Don’t con...
Torus Palatinus
Kozlovsk, Wikimedia Commons
Torus Palatinus
Dozenist, Wikimedia Commons
Torus Mandibularis
Source Undetermined
Denture Stomatitis
Source Undetermined Source Undetermined
Nicotine Stomatitis
Source Undetermined
Uvulitis
• Quincke’s disease
• Patient complains “something
hanging down my throat”
• Bacteria, virus, angioedema
• Treatm...
Uvulitis
1luckygamble, Wikimedia Commons
Uvular Angioedema
Source Undetermined
Uvulitis
Alexnevzorov, Wikimedia Commons
Bifid Uvula
Adam6611, Wikimedia Commons
Tongue & Mouth Floor
Jim Flanagan, Flickr
Ludwig’s Angina
• Cellulitis of submandibular and
lingual spaces
• Potentially life threatening.
• Rapidly spreading cellu...
Ludwig’s Angina
• Epiglottis can be involved
• Airway compromise is immediate
concern
• Treatment: high- dose penicillin
a...
Ludwig’s Angina
Stevenfruitsmaak, Wikimedia Commons
Ludwig’s Angina
Source Undetermined
Geographic Tongue
• Erythema migrans = geographic
tongue = benign migratory
glossitis
• Multiple, well-demarcated zones
of...
Geographic Tongue
Bin im Garten, Wikimedia Commons
Geographic Tongue
Martanopue, Wikimedia Commons
Fissured Tongue
Kozlovsk, Wikimedia Commons
Scrotal Tongue
Source Undetermined
Median Rhomboid Glossitis
• Believed to be developmental
defect of the dorsal surface of the
tongue
• 1 x 2 cm ovoid eryth...
Median Rhomboid Glossitis
Klaus D. Peter, Wikimedia Commons
Black Hairy Tongue
• Discoloration of elongated filiform
papillae
• Can grow up to 18 mm
• Usually asymptomatic
• Treatmen...
White Hairy Tongue
Source Undetermined
Source Undetermined
Black Hairy Tongue
Source Undetermined
Source Undetermined
Pepto-Bismol® Tongue
• Bismuth + sulfur (in saliva) =
bismuth sulfide = black tongue
(and sometimes black stool)
• Harmles...
Strawberry Tongue
• Associated with erythrogenic
toxin-producing Streptococcus
pyogenes or Kawasaki disease
• Prominent re...
Strawberry Tongue
Source Undetermined
Strawberry Tongue
Source Undetermined
Leukoplakia (Precancerous)
Source Undetermined
Leukoplakia (Precancerous)
Source Undetermined
Frenulum
Jean-Rene Vauzelle, Wikimedia Commons Zabbed, Wikimedia Commons
Salivary Glands
BruceBlaus, Wikimedia Commons
Salivary Glands
• Parotid and submandibular
• Parotid (Stenson) duct opens
opposite upper second molar
• Submandibular duc...
Viral Parotiditis
• Mumps: paramyxovirus
• Incubation period: 12 to 21 days.
• Infective from 3 days prior to 7
days after...
Viral Parotiditis
• Swelling bilateral ~70%
• May be surrounding edema
• No discharge from Stenson duct
• Benign in kids
•...
Viral Parotiditis
Source Undetermined
Viral Parotiditis
Source Undetermined
Suppurative Parotiditis
• Debilitated, dehydrated patients
• Tender, red, swollen parotid
• Bilateral in ~25%
• Fever and ...
Suppurative Parotiditis
Source Undetermined
Sialolithiasis
• Any age, peak from 30 to 60
• >80% are submandibular
• Mostly calcium phosphate
• Pain, swelling, tendern...
Sialolithiasis
• Diagnosis clinical; extraoral x-rays
~50% sensitive
• Therapy initiated on clinical
findings: analgesics,...
Sialolithiasis
Source Undetermined
Source Undetermined
Ranula – “little frog”
• Sublingual mucocele
• Benign, usually asymptomatic
• No special treatment
Ranula
Ph0t0happy, Wikimedia Commons
Klaus D. Peter, Wikimedia Commons
Piercings
Tommy T, Wikimedia Commons Sara Marx, Wikimedia Commons
Doct Blake, Wikimedia Commons
The Patient with a Sore Throat
U.S. Navy, Wikimedia Commons
ParentingPatch, Wikimedia Commons
Sore Throat
• Dysphagia = difficulty
swallowing
• Odynophagia = painful
swallowing
• Pharyngitis = infection or
irritation...
Pharyngitis
• Rare under 1 year
• Uncommon under 2 years
• Peak incidence: 4 to 7 years
• Higher incidence in winter
• Vir...
Principles of appropriate antibiotic
use for acute pharyngitis in adults
•Large majority of adults with acute
pharyngitis ...
• Offer all appropriate analgesics,
antipyretics, other supportive care
• Clinically screen adults with
pharyngitis for Ce...
Centor Score
1. history of fever
2. tonsillar exudates
3. no cough
4. anterior cervical lymphadenitis
Score 0-1 = <5% GABH...
Centor
Points
Pretest probability of GABHS (%)
5 10 15 20 25 40 50
0 1 2 2 3 5 10 14
1 2 3 5 7 9 17 23
2 4 8 12 16 20 33 4...
Principles of appropriate antibiotic
use for acute pharyngitis in adults
1. Rapid antigen if 2, 3, or 4
criteria; antibiot...
• Throat culture not recommended
for routine primary evaluation of
adult with sore throat or to confirm
negative rapid ant...
“We Prevent Rheumatic Disease”
• 1/3000 untreated GABHS leads to
acute rheumatic fever
• 1000 kids / 20% prevalence = 200
...
“We Prevent Rheumatic Disease”
• Prevalence now 40/840 ~5%
• Culture 95% sensitive, 95%
specific
• NNT = 798/38 = 21 cultu...
Pharyngitis – GABHS
James Heilman, MD, Wikimedia Commons
Pharyngitis – GABHS
Source Undetermined
Pharyngitis – GABHS
Real exudates
Source Undetermined
Epiglottitis
• Potentially life-threatening - rapid,
unpredictable airway obstruction
• Epiglottis plus aryepiglottic fold...
Epiglottitis
• Most common: Haemophilus
influenzae type b (Hib)
• 1- to 2-day prodrome resembles
benign URI
• Exam: appreh...
Epiglottitis
• Movement of upper trachea or
thyroid cartilage painful
• Diagnosis by history, examination,
radiographs, an...
Epiglottitis
• Lateral soft tissue neck x-ray:
vallecula obliterated, aryepiglottic,
prevertebral and retropharyngeal
soft...
Epiglottitis
• >1/3 moderate cases initially
misdiagnosed
• Immediate otolaryngologic consult
• Never leave patient unatte...
Epiglottitis
藤澤孝志, Wikimedia Commons
Epiglottitis
Insert tube here
Source Undetermined
Epiglottitis
Epiglottitis
Normal epiglottis
Source Undetermined
Epiglottitis
Source Undetermined
Epiglottitis
Source Undetermined
Mononucleosis
• Classic: fever, lymphadenopathy,
exudative pharyngitis, atypical
lymphocytosis, splenomegaly
• Severe sore...
Mononucleosis
• Treatment: supportive
• Ampicillin  rash (transient EBV-
induced antibodies against drug)
• Acyclovir has...
Mononucleosis
Source Undetermined
Mononucleosis
Note petechiae!
Wet white leather
Source Undetermined
Mononucleosis
Cervical adenopathy
James Heilman, MD, Wikimedia Commons
Mononucleosis
Atypical lymphocytes
Ed Uthman, MD, Wikimedia Commons
PTA
• Peritonsillar abscess = quinsy:
most common deep-space
infection of head and neck
• Young adults
• Predominant bugs:...
PTA
• Symptoms: fever, malaise, “hot-
potato voice,” odynophagia,
dysphagia, otalgia
• Signs: tonsil hypertrophy, swollen
...
PTA
• Diagnostic gold standard:
aspiration of pus through needle
• Majority treated with outpatient
needle aspiration, ant...
PTA
• Anesthetize mucosa using
lidocaine with epinephrine
• Insert 18-gauge needle medially
and superiorly within abscess
...
PTA
Large but
normal tonsils
Scurik 19, Wikimedia Commons
PTA
“Kissing” tonsils
Source Undetermined
PTA
Source Undetermined
PTA
Deviated uvula
Source Undetermined
PTA
Source Undetermined
Post-Tonsillectomy Bleed
• Classically 5 – 10 days postop
• Management: ensure airway,
control bleeding, consult ENT
• Dir...
Tonsillitis – GABHS
Pbeck, Wikimedia Commons
Tonsillectomy
~3 Days
Post-op
James Heilman, MD, Wikimedia Commons
Diphtheria
Adherent exudate
Frederick Magee Rossiter,
Wikimedia Commons
Source Undetermined
Steroids for Sore Throat?
Pain improve in 24 hours (VAS)
• 1.8 ± 0.8 w/ dexamethasone
• 1.2 ± 0.9 w/ placebo (P<.05)
Time ...
Steroids for Sore Throat?
CONCLUSION: In patients with
severe, acute exudative pharyngitis,
single-injection dexamethasone...
Steroids for Sore Throat?
12 and 24 hour pain relief (VAS)
• IM dexamethasone 4.2 ± 2.3
• Oral dexamethasone 3.8 ± 2.3
• P...
Steroids for Sore Throat?
CONCLUSIONS: Patients treated
with IM or oral dexamethasone had
significant relief of pain (rela...
Steroids for Sore Throat?
35 IM steroid plus oral placebo
35 IM placebo plus oral steroid
No difference in pain scores at ...
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GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training

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This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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Transcript of "GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training"

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Oral and Dental Emergencies: The Patient With A Sore Throat Author(s): Joe Lex, MD, FAAEM, FACEP (Temple University) 2013 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2
  3. 3. Oral and Dental Emergencies The Patient with a Sore Throat Joe Lex, MD, FACEP, FAAEM Associate Professor, Department of Emergency Medicine Temple University School of Medicine Philadelphia, PA
  4. 4. Objectives 1. Understand that teething does not cause fever 2. Define, recognize, and treat pericoronitis, periapical abscess, and alveolar osteitis 3. Describe treatment for ANUG 4. State three ways to treat bleeding gums
  5. 5. Objectives 5. Identify and differentiate among these mouth lesions: aphthous, HSV, herpangina, perlèche 6. Describe the demographics of GABHS 7. Memorize the Centor criteria 8. Know the rationale behind using antibiotics to treat a sore throat
  6. 6. Teeth David Shankbone, Wikimedia Commons
  7. 7. How Many Teeth? 32 permanent • 8 incisors • 4 canines (cuspids) • 8 premolars (bicuspids) • 12 molars (tricuspids) 20 primary or deciduous • 8 incisors • 4 canines • 8 molars
  8. 8. How to Name the Teeth Gray’s Anatomy, Wikimedia Commons
  9. 9. Source Undetermined
  10. 10. Source Undetermined
  11. 11. Definitions • Interproximal: the surfaces between two adjacent teeth • Mesial: interproximal surface facing toward midline • Distal: interproximal surface facing away from midline • Occlusal: chewing surface
  12. 12. Definitions • Labial: toward the lips, specific to anterior teeth • Buccal: toward the cheek, specific to posterior teeth • Palatal: toward the palate, specific to maxillary teeth • Lingual: toward the tongue, specific to mandibular teeth
  13. 13. Definitions • Apical: toward the tip of the root of the tooth • Radicular: associated with the root, especially the apical region • Coronal: toward the crown of the tooth • Incisal: toward the biting edge of incisors
  14. 14. Basic Anatomy • Dentin surrounds pulp, which is neurovascular supply • Crown: enamel on dentin, visible portion of tooth • Root: cementum on dentin, extends into the alveolar bone
  15. 15. Sam Fentress, Wikimedia Commons
  16. 16. Basic Anatomy • Periodontium = attachment apparatus • Periodontal ligament = collagen fibers that extend from alveolar bone to root of tooth • Gingivitis and periodontal disease destroy peridontium  tooth mobility and loss
  17. 17. Basic Anatomy • Gingiva = keratinized stratified squamous epithelium –Free gingiva: 2- to 3- mm-deep gingival sulcus in disease-free state –Attached gingiva: adheres to alveolar bone and extends to oral vestibule, floor of mouth • Nonkeratinized alveolar mucosa covers cheeks, lips, floor of mouth
  18. 18. Jonathon Colman, Flickr
  19. 19. Healthy teeth Dozenist, Wikimedia Commons
  20. 20. Teething Daniel Schwen, Wikimedia Commons Vmg13, Wikimedia Commons
  21. 21. About ye seveth moneth, sometime more, sometime lesse, after ye byrth, it is natural for a child to breed teeth, in which time many one is sore vexed with sondry diseases and pains, as swelling of ye gummes and jaws, unquiet crying fevers, cramps, palsies, fluxes, reumes and other infirmities, specially when it is long or ye teeth come forth, for the sooner they appear the better and the more ease it is to the childe. Thomas Phayre – 1530 The Boke of Children, London
  22. 22. Death by Teething!! • Common “Cause of Death” in Middle Ages • Usually weaned at same time • Frequently lance erupting tooth • Malnutrition from watered-down milk • Typhus from infected milk
  23. 23. Teething • No data support association of teething, fever, and diarrhea • Possible mild dehydration from excessive salivary production or decreased intake • Must seek other source for fever, diarrhea
  24. 24. Pain from Wisdom Teeth • Erupting third molars • Pericoronitis: inflammation of gingival tissue overlying occlusal surface of erupting tooth (operculum) • Masseter irritation  trismus • Rx irrigate debris, antibiotic, analgesia, dental referral
  25. 25. Pericoronitis Coronation Dental Specialty Group, Wikimedia Commons
  26. 26. Dental Caries • Loss of tooth enamel integrity due to exposure to acidic metabolic byproducts of plaque bacteria • Early: sensitive to cold or sweet • Later: direct communication with dental pulp  “pulpitis” • Irreversible pulpitis: protracted pain
  27. 27. Dental Caries Dozenist, Wikimedia Commons
  28. 28. Dental Caries Dozenist, Wikimedia Commons
  29. 29. Antibiotics for Toothache?? • Undifferentiated dental pain without overt infection • Penicillin vs. placebo • Evaluation at enrollment, again at 5- to 7-day follow-up • Outcome measure: overt dental infection at follow-up Acad Emerg Med. 2004 Dec;11(12):1268-71.
  30. 30. Antibiotics for Toothache?? • 13 / 134 patients (9%) developed infection –6/64 (9%) in penicillin group –7/70 (10%) in placebo group • No significant difference in baseline characteristics, compliance, VAS pain scores Acad Emerg Med. 2004 Dec;11(12):1268-71.
  31. 31. Antibiotics for Toothache?? • CONCLUSIONS: “These data support the hypothesis that penicillin is neither necessary nor beneficial in the treatment of undifferentiated dental pain in the absence of overt infection.” Acad Emerg Med. 2004 Dec;11(12):1268-71.
  32. 32. Periapical Abscess • Most common source of severe odontogenic pain: periapical • Most common lesion: periapical granuloma = periradicular periodontitis, results from pulpitis • X-ray  widened periodontal ligament space (radiolucent stripe)
  33. 33. Widened periodontal ligament space Source Undetermined
  34. 34. Periapical lucency Source Undetermined
  35. 35. Periapical abscess Source Undetermined
  36. 36. Periapical Abscess • Exquisite pain with percussion • Suppurative periodontitis = parulis • X-rays rarely indicated • Rx antibiotic (penicillin still best), analgesia, referral • Definitive treatment: extraction or root canal
  37. 37. Parulis = Fistula = Gum Boil Source Undetermined
  38. 38. Parulis = Fistula Damdent, Wikimedia Commons
  39. 39. Postextraction Pain • Periosteitis: 24 to 48 hours, common, easily treated • Alveolar osteitis = dry socket: second or third post-op day  exquisite oral pain due to bone exposed to oral environment
  40. 40. Dry Socket • Up to 35% after impacted 3rd molar removal • X-ray for retained root tip • Irrigate socket with sterile saline • Pack socket with gauze soaked in oil of cloves or eugenol • Relief is immediate • Antibiotic if severe
  41. 41. Dry Socket Source Undetermined
  42. 42. Infraorbital Nerve Block Source Undetermined
  43. 43. Infraorbital Nerve Block Source Undetermined
  44. 44. Infraorbital Nerve Block Source Undeternined
  45. 45. Mental Nerve Block Source Undetermined
  46. 46. Mental Nerve Block Gray’s Anatomy, Wikimedia Commons
  47. 47. Mental Nerve Block Source Undetermined
  48. 48. Mental Nerve Block Source Undetermined
  49. 49. Palatal Nerve Block Source Undetermined
  50. 50. Palatal Nerve Block Source Undetermined
  51. 51. Palatal Nerve Block Adapted from: Alan, Flickr
  52. 52. Inferior Alveolar Nerve Block Gray’s Anatomy, Wikimedia Commons
  53. 53. Inferior Alveolar Nerve Block Source Undetermined
  54. 54. Inferior Alveolar Nerve Block Adapted from: Lusb, Wikimedia Commons
  55. 55. Inferior Alveolar Nerve Block Source Undetermined
  56. 56. Inferior Alveolar Nerve Block Mikael Häggström, Wikipedia
  57. 57. Frenum Diastema i.e., gap-toothed Bryon Viechnicki, Wikimedia Commons
  58. 58. Tetracycline Staining Source Undetermined
  59. 59. Gums Mohamed Hamze, Wikimedia Commons
  60. 60. Periodontal Disease • Gingivitis: accumulation of plaque along gum margins • Causes: bad hygiene, hormonal variations (puberty, pregnancy), medications (phenytoin), etc. • Sulcus deepens  pockets  periodontitis mineralization  bone loss  tooth loss
  61. 61. Periodontal Disease Source Undetermined
  62. 62. Periodontal Disease Source Undetermined
  63. 63. ANUG • Acute Necrotizing Ulcerative Gingivitis = Vincent ´s disease = trench mouth • Diagnostic triad: pain + ulcerated or “punched out” interdental papillae + gingival bleeding • Etiology unclear, but opportunistic • Anaerobes always present
  64. 64. ANUG • Invades otherwise healthy tissue • Treatment: –Identify, treat predisposing factors –Chlorhexidine oral rinses twice daily –Debridement and scaling by dentist –Metronidazole 250 mg tid –Supportive therapy: soft diet rich in protein and vitamins
  65. 65. ANUG Source Undetermined
  66. 66. ANUG Source Undetermined
  67. 67. Gingival Hyperplasia • Associated with many commonly used medications • 50% of patients on chronic phenytoin • Also calcium channel blockers (especially nifedipine) and cyclosporine. • Treatment: fastidious oral hygiene
  68. 68. Gingival Hyperplasia Lesion, Wikimedia Commons
  69. 69. Bleeding Gums • Hemorrhage after scaling easily controlled with peroxide mouth rinses or direct gingival pressure • Clotting factor deficiencies, leukemia, and end- stage liver disease may first present as spontaneous gingival hemorrhage • Treatment: based on cause
  70. 70. Bleeding Gums Source Undetermined
  71. 71. Bleeding Gums Source Undetermined
  72. 72. Post-Extraction Bleeding Usually a dislodged clot 1. Firm pressure usually adequate: folded 2 × 2 gauze pad placed over extraction site, then firm pressure by clenching teeth for 20 minutes 2. Tea bag: tannic acid is hemostatic 3. Gel-Foam, Avitene, or Instat sutured snugly into socket 4. Infiltrate lidocaine with epinephrine
  73. 73. Pyogenic Granuloma • “Pregnancy tumor” • Benign proliferation of connective tissue, primarily on gingiva • Not pyogenic, not a granuloma • Usually recurs if removed during pregnancy • If not regressed 2 to 3 months postpartum, definitive removal
  74. 74. Pyogenic Granuloma Source Undetermined
  75. 75. Pyogenic Granuloma Kuebi, Wikimedia Commons
  76. 76. Before We Leave the Gums… Intentional pain And the taste of gums bleeding Prevent toothlessness Morsels sit between my teeth Minty, waxy nylon thread Saves my smile Two Flossing Haiku
  77. 77. Cheeks & Lips & Palate 2T, Wikimedia Commons
  78. 78. Oral Candidiasis • Present in 60% of healthy adults • Opportunistic pathogen: many risk factors • Adherent white plaque • Perioral = angular cheilitis • Rx topical oral (nystatin) or systemic (fluconazole) antifungal agent
  79. 79. Oral Candidiasis James Heilman, MD, Wikimedia Commons
  80. 80. Oral Candidiasis Centers for Disease Control and Prevention, Wikimedia Commons
  81. 81. Angular Cheilitis = Perlèche • Breakdown at labial commissures • Candida albicans implicated • Radiation therapy • HIV • Dietary deficiencies • Antifungal with steroid may help
  82. 82. Angular Cheilitis = Perlèche James Heilman, MD, Wikimedia Commons
  83. 83. Angular Cheilitis = Perlèche Lesion, Wikimedia Commons
  84. 84. Angular Cheilitis = Perlèche Source Undetermined
  85. 85. Aphthous Stomatitis • Canker sores: common • Probable cell-mediated response • Nonkeratinized epithelium • Superficial painful ulcers • Resolve in 10 – 14 days • Rx topical steroid: betamethasone syrup or 0.01% dexamethasone elixir mouth rinse
  86. 86. Aphthous Stomatitis TheBlunderbuss, Wikimedia Commons
  87. 87. Aphthous Stomatitis Noorus, Wikimedia Commons
  88. 88. HSV = Cold Sores • Type 1 most common • Gingivostomatitis: painful ulcerations on mucosal surfaces • Fever, lymphadenitis common • Prodrome: tingling 1 – 2 days before outbreak • Rx palliative: antivirals started during prodrome  severity
  89. 89. HSV = Cold Sores Centers for Disease Control and Prevention, Wikimedia Commons WarXboT, Wikimedia Commons
  90. 90. Herpangina • Coxsackieviruses • Summer and autumn • Sudden high fever, sore throat, headache, malaise then vesicles • Soft palate, uvula, posterior pharynx, tonsillar pillars • Buccal mucosa, tongue, gums spared
  91. 91. Herpangina • Lasts 7 to 10 days • Distinguished from herpetic gingivostomatitis by lack of gingival involvement United Kingdom Royal Navy, Wikimedia Commons
  92. 92. Herpangina Shawn C, Wikimedia Commons Aphilosophicalmind, Wikimedia Commons
  93. 93. Hand, Foot, and Mouth • Coxsackievirus • Vesicles on tongue, gums, soft palate, buccal mucosa • Rupture  painful, shallow ulcers with red halo • Lateral & dorsal fingers & toes • Fever day or two, rash 5 to 8 days • Treatment: palliative
  94. 94. Hand, Foot, and Mouth MidgleyDJ, Wikimedia Commons James Heilman, MD, Wikimedia Commons Ngufra, Wikimedia Commons
  95. 95. Lichen Planus • Chronic cutaneous vesiculoerosive disease • T- lymphocytes on basal cell layer • Scattered white papules interconnected with white lines (Wickham’s striae) • Symptomatic: topical steroids
  96. 96. Lichen Planus Source Undetermined
  97. 97. Cheek Chewing Source Undetermined
  98. 98. Aspirin Burn (ASAcid!) Source Undetermined
  99. 99. Aspirin Burn (ASAcid!) Source Undetermined
  100. 100. Torus Palatinus • Hard, firm isolated mass on hard palate. • May be several centimeters • Appears in adulthood • Don’t confuse with neoplasm • May interfere with dentures
  101. 101. Torus Palatinus Kozlovsk, Wikimedia Commons
  102. 102. Torus Palatinus Dozenist, Wikimedia Commons
  103. 103. Torus Mandibularis Source Undetermined
  104. 104. Denture Stomatitis Source Undetermined Source Undetermined
  105. 105. Nicotine Stomatitis Source Undetermined
  106. 106. Uvulitis • Quincke’s disease • Patient complains “something hanging down my throat” • Bacteria, virus, angioedema • Treatment symptomatic: antibiotic, antihistamine, nebulized steroid or epinephrine
  107. 107. Uvulitis 1luckygamble, Wikimedia Commons
  108. 108. Uvular Angioedema Source Undetermined
  109. 109. Uvulitis Alexnevzorov, Wikimedia Commons
  110. 110. Bifid Uvula Adam6611, Wikimedia Commons
  111. 111. Tongue & Mouth Floor Jim Flanagan, Flickr
  112. 112. Ludwig’s Angina • Cellulitis of submandibular and lingual spaces • Potentially life threatening. • Rapidly spreading cellulitis • Brawny induration of suprahyoid region and elevation of tongue
  113. 113. Ludwig’s Angina • Epiglottis can be involved • Airway compromise is immediate concern • Treatment: high- dose penicillin and metronidazole or cefoxitin, immediate oral and maxillofacial consultation
  114. 114. Ludwig’s Angina Stevenfruitsmaak, Wikimedia Commons
  115. 115. Ludwig’s Angina Source Undetermined
  116. 116. Geographic Tongue • Erythema migrans = geographic tongue = benign migratory glossitis • Multiple, well-demarcated zones of erythema due to atrophy of filiform papillae • Usually asymptomatic • Reassurance sufficient
  117. 117. Geographic Tongue Bin im Garten, Wikimedia Commons
  118. 118. Geographic Tongue Martanopue, Wikimedia Commons
  119. 119. Fissured Tongue Kozlovsk, Wikimedia Commons
  120. 120. Scrotal Tongue Source Undetermined
  121. 121. Median Rhomboid Glossitis • Believed to be developmental defect of the dorsal surface of the tongue • 1 x 2 cm ovoid erythematous area just anterior to circumvallate papillae • Devoid of papillae, asymptomatic • No treatment necessary
  122. 122. Median Rhomboid Glossitis Klaus D. Peter, Wikimedia Commons
  123. 123. Black Hairy Tongue • Discoloration of elongated filiform papillae • Can grow up to 18 mm • Usually asymptomatic • Treatment: frequent tongue brushing, avoid tobacco, strong mouthwashes, antibiotics • Resolution usually spontaneous
  124. 124. White Hairy Tongue Source Undetermined Source Undetermined
  125. 125. Black Hairy Tongue Source Undetermined Source Undetermined
  126. 126. Pepto-Bismol® Tongue • Bismuth + sulfur (in saliva) = bismuth sulfide = black tongue (and sometimes black stool) • Harmless, self limited Source Undetermined
  127. 127. Strawberry Tongue • Associated with erythrogenic toxin-producing Streptococcus pyogenes or Kawasaki disease • Prominent red spots on white- coated background. • Treatment: antibiotics directed at group A streptococci
  128. 128. Strawberry Tongue Source Undetermined
  129. 129. Strawberry Tongue Source Undetermined
  130. 130. Leukoplakia (Precancerous) Source Undetermined
  131. 131. Leukoplakia (Precancerous) Source Undetermined
  132. 132. Frenulum Jean-Rene Vauzelle, Wikimedia Commons Zabbed, Wikimedia Commons
  133. 133. Salivary Glands BruceBlaus, Wikimedia Commons
  134. 134. Salivary Glands • Parotid and submandibular • Parotid (Stenson) duct opens opposite upper second molar • Submandibular ducts open into mouth at either side of frenulum • Multiple sublingual ducts open into sublingual fold or submandibular duct
  135. 135. Viral Parotiditis • Mumps: paramyxovirus • Incubation period: 12 to 21 days. • Infective from 3 days prior to 7 days after salivary gland swelling • Repeat episodes possible • Others: influenza, enteroviruses, cytomegalovirus, human immunodeficiency virus (HIV).
  136. 136. Viral Parotiditis • Swelling bilateral ~70% • May be surrounding edema • No discharge from Stenson duct • Benign in kids • 25% of men suffer orchitis • Diagnosis: clinical • Treatment: supportive
  137. 137. Viral Parotiditis Source Undetermined
  138. 138. Viral Parotiditis Source Undetermined
  139. 139. Suppurative Parotiditis • Debilitated, dehydrated patients • Tender, red, swollen parotid • Bilateral in ~25% • Fever and trismus common • Pus from Stenson duct • Staphylococcus aureus mixed with anaerobes. • Diagnosis is clinical
  140. 140. Suppurative Parotiditis Source Undetermined
  141. 141. Sialolithiasis • Any age, peak from 30 to 60 • >80% are submandibular • Mostly calcium phosphate • Pain, swelling, tenderness • Similar to parotitis, ductal obstructive symptoms (pain and swelling) exacerbated by meals
  142. 142. Sialolithiasis • Diagnosis clinical; extraoral x-rays ~50% sensitive • Therapy initiated on clinical findings: analgesics, massage, and sialogogues, like lemon drops
  143. 143. Sialolithiasis Source Undetermined Source Undetermined
  144. 144. Ranula – “little frog” • Sublingual mucocele • Benign, usually asymptomatic • No special treatment
  145. 145. Ranula Ph0t0happy, Wikimedia Commons Klaus D. Peter, Wikimedia Commons
  146. 146. Piercings Tommy T, Wikimedia Commons Sara Marx, Wikimedia Commons Doct Blake, Wikimedia Commons
  147. 147. The Patient with a Sore Throat U.S. Navy, Wikimedia Commons ParentingPatch, Wikimedia Commons
  148. 148. Sore Throat • Dysphagia = difficulty swallowing • Odynophagia = painful swallowing • Pharyngitis = infection or irritation of pharynx
  149. 149. Pharyngitis • Rare under 1 year • Uncommon under 2 years • Peak incidence: 4 to 7 years • Higher incidence in winter • Viruses, bacteria, fungi, parasites • Most common causes: rhinovirus and adenovirus
  150. 150. Principles of appropriate antibiotic use for acute pharyngitis in adults •Large majority of adults with acute pharyngitis have self-limited illness •Antibiotic treatment benefits only patients with GABHS infection •Adults with sore throat: “Strep throat” prevalence 5 –15% Cooper et al. Ann Emerg Med. June 2001;37:711-719
  151. 151. • Offer all appropriate analgesics, antipyretics, other supportive care • Clinically screen adults with pharyngitis for Centor criteria • Do not test or treat patients with zero or one; they are unlikely to have GABHS Cooper et al. Ann Emerg Med. June 2001;37:711-719 Principles of appropriate antibiotic use for acute pharyngitis in adults
  152. 152. Centor Score 1. history of fever 2. tonsillar exudates 3. no cough 4. anterior cervical lymphadenitis Score 0-1 = <5% GABHS Score 2-3 = 5 – 30% GABHS Score 4 = 30 – 60% GABHS Cooper et al. Ann Emerg Med. June 2001;37:711-719
  153. 153. Centor Points Pretest probability of GABHS (%) 5 10 15 20 25 40 50 0 1 2 2 3 5 10 14 1 2 3 5 7 9 17 23 2 4 8 12 16 20 33 43 3 10 19 27 34 41 58 68 4 25 41 53 61 68 81 86 Post-test probability of GABHS
  154. 154. Principles of appropriate antibiotic use for acute pharyngitis in adults 1. Rapid antigen if 2, 3, or 4 criteria; antibiotic only if test + 2. Rapid antigen if 2 or 3 criteria; antibiotic if test + or 4 criteria 3. Antibiotic if 3 or 4 criteria; no rapid antigen testing Cooper et al. Ann Emerg Med. June 2001;37:711-719
  155. 155. • Throat culture not recommended for routine primary evaluation of adult with sore throat or to confirm negative rapid antigen • Preferred antibiotic for GABHS pharyngitis: penicillin or erythromycin if penicillin-allergic Cooper et al. Ann Emerg Med. June 2001;37:711-719 Principles of appropriate antibiotic use for acute pharyngitis in adults
  156. 156. “We Prevent Rheumatic Disease” • 1/3000 untreated GABHS leads to acute rheumatic fever • 1000 kids / 20% prevalence = 200 • Strep screen 80% sensitive, 95% specific • Treat 160, send cultures on other 840 TP = 160 FP = 40 TN = 760 FN = 40
  157. 157. “We Prevent Rheumatic Disease” • Prevalence now 40/840 ~5% • Culture 95% sensitive, 95% specific • NNT = 798/38 = 21 cultures to find one positive • 3000 x 21 = 63,000 prevent one case ARF • NNH = 15 TP = 38 FP = 2 TN = 798 FN = 2
  158. 158. Pharyngitis – GABHS James Heilman, MD, Wikimedia Commons
  159. 159. Pharyngitis – GABHS Source Undetermined
  160. 160. Pharyngitis – GABHS Real exudates Source Undetermined
  161. 161. Epiglottitis • Potentially life-threatening - rapid, unpredictable airway obstruction • Epiglottis plus aryepiglottic folds and pre-epiglottic and paraglottic loose connective tissue • Traditional: children 2 – 8 years • Contemporary: adults increasing
  162. 162. Epiglottitis • Most common: Haemophilus influenzae type b (Hib) • 1- to 2-day prodrome resembles benign URI • Exam: apprehensive, drooling, difficulty lying flat, stridor, tongue protruding • Fever initially absent in 30 – 50%
  163. 163. Epiglottitis • Movement of upper trachea or thyroid cartilage painful • Diagnosis by history, examination, radiographs, and laryngoscopy • Use extreme care – unpredictable sudden airway obstruction
  164. 164. Epiglottitis • Lateral soft tissue neck x-ray: vallecula obliterated, aryepiglottic, prevertebral and retropharyngeal soft tissues swollen, hypopharynx ballooned • Find hyoid bone to find epiglottis • Epiglottis: large, thumb-shaped
  165. 165. Epiglottitis • >1/3 moderate cases initially misdiagnosed • Immediate otolaryngologic consult • Never leave patient unattended • Initial treatment: IV hydration, oxygen, monitor, IV antibiotics. • Be prepared for difficult intubation
  166. 166. Epiglottitis 藤澤孝志, Wikimedia Commons
  167. 167. Epiglottitis Insert tube here Source Undetermined
  168. 168. Epiglottitis Epiglottitis Normal epiglottis Source Undetermined
  169. 169. Epiglottitis Source Undetermined
  170. 170. Epiglottitis Source Undetermined
  171. 171. Mononucleosis • Classic: fever, lymphadenopathy, exudative pharyngitis, atypical lymphocytosis, splenomegaly • Severe sore throat is common complaint • Physical: severe bilateral exudative tonsillitis / pharyngitis – “wet white leather”
  172. 172. Mononucleosis • Treatment: supportive • Ampicillin  rash (transient EBV- induced antibodies against drug) • Acyclovir has in vitro effects on EBV replication, but in vivo clinical studies have failed to show any clinically significant effect
  173. 173. Mononucleosis Source Undetermined
  174. 174. Mononucleosis Note petechiae! Wet white leather Source Undetermined
  175. 175. Mononucleosis Cervical adenopathy James Heilman, MD, Wikimedia Commons
  176. 176. Mononucleosis Atypical lymphocytes Ed Uthman, MD, Wikimedia Commons
  177. 177. PTA • Peritonsillar abscess = quinsy: most common deep-space infection of head and neck • Young adults • Predominant bugs: Streptococcus pyogenes, peptostreptococcus, bacteroides, Staphylococcus aureus
  178. 178. PTA • Symptoms: fever, malaise, “hot- potato voice,” odynophagia, dysphagia, otalgia • Signs: tonsil hypertrophy, swollen deviated uvula, inferior and medial displacement of infected tonsil, tender cervical nodes, drooling, bad breath, trismus
  179. 179. PTA • Diagnostic gold standard: aspiration of pus through needle • Majority treated with outpatient needle aspiration, antibiotics, pain medication • High-dose penicillin is drug of choice
  180. 180. PTA • Anesthetize mucosa using lidocaine with epinephrine • Insert 18-gauge needle medially and superiorly within abscess cavity no more than 1 cm (use needle guard) • Carotid artery lies laterally and inferiorly
  181. 181. PTA Large but normal tonsils Scurik 19, Wikimedia Commons
  182. 182. PTA “Kissing” tonsils Source Undetermined
  183. 183. PTA Source Undetermined
  184. 184. PTA Deviated uvula Source Undetermined
  185. 185. PTA Source Undetermined
  186. 186. Post-Tonsillectomy Bleed • Classically 5 – 10 days postop • Management: ensure airway, control bleeding, consult ENT • Direct pressure to tonsillar bed • Silver nitrate, electric cautery, oxidized cellulose, thrombin packs, gauze moistened with lidocaine / epinephrine
  187. 187. Tonsillitis – GABHS Pbeck, Wikimedia Commons
  188. 188. Tonsillectomy ~3 Days Post-op James Heilman, MD, Wikimedia Commons
  189. 189. Diphtheria Adherent exudate Frederick Magee Rossiter, Wikimedia Commons Source Undetermined
  190. 190. Steroids for Sore Throat? Pain improve in 24 hours (VAS) • 1.8 ± 0.8 w/ dexamethasone • 1.2 ± 0.9 w/ placebo (P<.05) Time to onset of pain relief • 6.3 ± 5.3 hrs w/ dexamethasone • 12.4 ± 8 .5 hrs w/ placebo (P<.01) O'Brien et al. Ann Emerg Med 1993;22(2):212-5
  191. 191. Steroids for Sore Throat? CONCLUSION: In patients with severe, acute exudative pharyngitis, single-injection dexamethasone compared with placebo resulted in statistically and clinically significant more rapid onset and greater degree of pain relief O'Brien et al. Ann Emerg Med 1993;22(2):212-5
  192. 192. Steroids for Sore Throat? 12 and 24 hour pain relief (VAS) • IM dexamethasone 4.2 ± 2.3 • Oral dexamethasone 3.8 ± 2.3 • Placebo 2.1 ± 2.0 Onset of pain relief average 4 hours earlier in IM dexamethasone group Wei JL, et al. Laryngoscope 2002;112(1):87-93
  193. 193. Steroids for Sore Throat? CONCLUSIONS: Patients treated with IM or oral dexamethasone had significant relief of pain (relative to baseline) compared with patients given placebo. Wei JL, et al. Laryngoscope 2002;112(1):87-93
  194. 194. Steroids for Sore Throat? 35 IM steroid plus oral placebo 35 IM placebo plus oral steroid No difference in pain scores at 24 (p=0.13) or 48 hours (p=0.82) No difference in hours to relief of pain (p=0.06) Marvez-Valls EG, et al. Acad Emerg Med 2002;9:9-14
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