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GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
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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, …

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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  • 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. 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. 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. 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. 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. Teeth David Shankbone, Wikimedia Commons
  • 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. How to Name the Teeth Gray’s Anatomy, Wikimedia Commons
  • 9. Source Undetermined
  • 10. Source Undetermined
  • 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. 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. 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. 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. Sam Fentress, Wikimedia Commons
  • 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. 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. Jonathon Colman, Flickr
  • 19. Healthy teeth Dozenist, Wikimedia Commons
  • 20. Teething Daniel Schwen, Wikimedia Commons Vmg13, Wikimedia Commons
  • 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. 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. 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. 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. Pericoronitis Coronation Dental Specialty Group, Wikimedia Commons
  • 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. Dental Caries Dozenist, Wikimedia Commons
  • 28. Dental Caries Dozenist, Wikimedia Commons
  • 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. 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. 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. 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. Widened periodontal ligament space Source Undetermined
  • 34. Periapical lucency Source Undetermined
  • 35. Periapical abscess Source Undetermined
  • 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. Parulis = Fistula = Gum Boil Source Undetermined
  • 38. Parulis = Fistula Damdent, Wikimedia Commons
  • 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. 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. Dry Socket Source Undetermined
  • 42. Infraorbital Nerve Block Source Undetermined
  • 43. Infraorbital Nerve Block Source Undetermined
  • 44. Infraorbital Nerve Block Source Undeternined
  • 45. Mental Nerve Block Source Undetermined
  • 46. Mental Nerve Block Gray’s Anatomy, Wikimedia Commons
  • 47. Mental Nerve Block Source Undetermined
  • 48. Mental Nerve Block Source Undetermined
  • 49. Palatal Nerve Block Source Undetermined
  • 50. Palatal Nerve Block Source Undetermined
  • 51. Palatal Nerve Block Adapted from: Alan, Flickr
  • 52. Inferior Alveolar Nerve Block Gray’s Anatomy, Wikimedia Commons
  • 53. Inferior Alveolar Nerve Block Source Undetermined
  • 54. Inferior Alveolar Nerve Block Adapted from: Lusb, Wikimedia Commons
  • 55. Inferior Alveolar Nerve Block Source Undetermined
  • 56. Inferior Alveolar Nerve Block Mikael Häggström, Wikipedia
  • 57. Frenum Diastema i.e., gap-toothed Bryon Viechnicki, Wikimedia Commons
  • 58. Tetracycline Staining Source Undetermined
  • 59. Gums Mohamed Hamze, Wikimedia Commons
  • 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. Periodontal Disease Source Undetermined
  • 62. Periodontal Disease Source Undetermined
  • 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. 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. ANUG Source Undetermined
  • 66. ANUG Source Undetermined
  • 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. Gingival Hyperplasia Lesion, Wikimedia Commons
  • 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. Bleeding Gums Source Undetermined
  • 71. Bleeding Gums Source Undetermined
  • 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. 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. Pyogenic Granuloma Source Undetermined
  • 75. Pyogenic Granuloma Kuebi, Wikimedia Commons
  • 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. Cheeks & Lips & Palate 2T, Wikimedia Commons
  • 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. Oral Candidiasis James Heilman, MD, Wikimedia Commons
  • 80. Oral Candidiasis Centers for Disease Control and Prevention, Wikimedia Commons
  • 81. Angular Cheilitis = Perlèche • Breakdown at labial commissures • Candida albicans implicated • Radiation therapy • HIV • Dietary deficiencies • Antifungal with steroid may help
  • 82. Angular Cheilitis = Perlèche James Heilman, MD, Wikimedia Commons
  • 83. Angular Cheilitis = Perlèche Lesion, Wikimedia Commons
  • 84. Angular Cheilitis = Perlèche Source Undetermined
  • 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. Aphthous Stomatitis TheBlunderbuss, Wikimedia Commons
  • 87. Aphthous Stomatitis Noorus, Wikimedia Commons
  • 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. HSV = Cold Sores Centers for Disease Control and Prevention, Wikimedia Commons WarXboT, Wikimedia Commons
  • 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. Herpangina • Lasts 7 to 10 days • Distinguished from herpetic gingivostomatitis by lack of gingival involvement United Kingdom Royal Navy, Wikimedia Commons
  • 92. Herpangina Shawn C, Wikimedia Commons Aphilosophicalmind, Wikimedia Commons
  • 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. Hand, Foot, and Mouth MidgleyDJ, Wikimedia Commons James Heilman, MD, Wikimedia Commons Ngufra, Wikimedia Commons
  • 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. Lichen Planus Source Undetermined
  • 97. Cheek Chewing Source Undetermined
  • 98. Aspirin Burn (ASAcid!) Source Undetermined
  • 99. Aspirin Burn (ASAcid!) Source Undetermined
  • 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. Torus Palatinus Kozlovsk, Wikimedia Commons
  • 102. Torus Palatinus Dozenist, Wikimedia Commons
  • 103. Torus Mandibularis Source Undetermined
  • 104. Denture Stomatitis Source Undetermined Source Undetermined
  • 105. Nicotine Stomatitis Source Undetermined
  • 106. Uvulitis • Quincke’s disease • Patient complains “something hanging down my throat” • Bacteria, virus, angioedema • Treatment symptomatic: antibiotic, antihistamine, nebulized steroid or epinephrine
  • 107. Uvulitis 1luckygamble, Wikimedia Commons
  • 108. Uvular Angioedema Source Undetermined
  • 109. Uvulitis Alexnevzorov, Wikimedia Commons
  • 110. Bifid Uvula Adam6611, Wikimedia Commons
  • 111. Tongue & Mouth Floor Jim Flanagan, Flickr
  • 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. 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. Ludwig’s Angina Stevenfruitsmaak, Wikimedia Commons
  • 115. Ludwig’s Angina Source Undetermined
  • 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. Geographic Tongue Bin im Garten, Wikimedia Commons
  • 118. Geographic Tongue Martanopue, Wikimedia Commons
  • 119. Fissured Tongue Kozlovsk, Wikimedia Commons
  • 120. Scrotal Tongue Source Undetermined
  • 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. Median Rhomboid Glossitis Klaus D. Peter, Wikimedia Commons
  • 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. White Hairy Tongue Source Undetermined Source Undetermined
  • 125. Black Hairy Tongue Source Undetermined Source Undetermined
  • 126. Pepto-Bismol® Tongue • Bismuth + sulfur (in saliva) = bismuth sulfide = black tongue (and sometimes black stool) • Harmless, self limited Source Undetermined
  • 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. Strawberry Tongue Source Undetermined
  • 129. Strawberry Tongue Source Undetermined
  • 130. Leukoplakia (Precancerous) Source Undetermined
  • 131. Leukoplakia (Precancerous) Source Undetermined
  • 132. Frenulum Jean-Rene Vauzelle, Wikimedia Commons Zabbed, Wikimedia Commons
  • 133. Salivary Glands BruceBlaus, Wikimedia Commons
  • 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. 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. 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. Viral Parotiditis Source Undetermined
  • 138. Viral Parotiditis Source Undetermined
  • 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. Suppurative Parotiditis Source Undetermined
  • 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. Sialolithiasis • Diagnosis clinical; extraoral x-rays ~50% sensitive • Therapy initiated on clinical findings: analgesics, massage, and sialogogues, like lemon drops
  • 143. Sialolithiasis Source Undetermined Source Undetermined
  • 144. Ranula – “little frog” • Sublingual mucocele • Benign, usually asymptomatic • No special treatment
  • 145. Ranula Ph0t0happy, Wikimedia Commons Klaus D. Peter, Wikimedia Commons
  • 146. Piercings Tommy T, Wikimedia Commons Sara Marx, Wikimedia Commons Doct Blake, Wikimedia Commons
  • 147. The Patient with a Sore Throat U.S. Navy, Wikimedia Commons ParentingPatch, Wikimedia Commons
  • 148. Sore Throat • Dysphagia = difficulty swallowing • Odynophagia = painful swallowing • Pharyngitis = infection or irritation of pharynx
  • 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. 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. • 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. 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. 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. 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. • 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. “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. “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. Pharyngitis – GABHS James Heilman, MD, Wikimedia Commons
  • 159. Pharyngitis – GABHS Source Undetermined
  • 160. Pharyngitis – GABHS Real exudates Source Undetermined
  • 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. 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. Epiglottitis • Movement of upper trachea or thyroid cartilage painful • Diagnosis by history, examination, radiographs, and laryngoscopy • Use extreme care – unpredictable sudden airway obstruction
  • 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. 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. Epiglottitis 藤澤孝志, Wikimedia Commons
  • 167. Epiglottitis Insert tube here Source Undetermined
  • 168. Epiglottitis Epiglottitis Normal epiglottis Source Undetermined
  • 169. Epiglottitis Source Undetermined
  • 170. Epiglottitis Source Undetermined
  • 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. 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. Mononucleosis Source Undetermined
  • 174. Mononucleosis Note petechiae! Wet white leather Source Undetermined
  • 175. Mononucleosis Cervical adenopathy James Heilman, MD, Wikimedia Commons
  • 176. Mononucleosis Atypical lymphocytes Ed Uthman, MD, Wikimedia Commons
  • 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. 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. 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. 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. PTA Large but normal tonsils Scurik 19, Wikimedia Commons
  • 182. PTA “Kissing” tonsils Source Undetermined
  • 183. PTA Source Undetermined
  • 184. PTA Deviated uvula Source Undetermined
  • 185. PTA Source Undetermined
  • 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. Tonsillitis – GABHS Pbeck, Wikimedia Commons
  • 188. Tonsillectomy ~3 Days Post-op James Heilman, MD, Wikimedia Commons
  • 189. Diphtheria Adherent exudate Frederick Magee Rossiter, Wikimedia Commons Source Undetermined
  • 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. 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. 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. 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. 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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