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GEMC- Oral and Dental Emergencies: The Patient with a Sore Throat- Resident Training
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
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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
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
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
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
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
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)
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
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
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
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
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
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
91. Herpangina
• Lasts 7 to 10 days
• Distinguished from herpetic
gingivostomatitis by lack of gingival
involvement
United Kingdom Royal Navy,
Wikimedia Commons
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
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
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
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
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
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
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
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
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
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
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
177. PTA
• Peritonsillar abscess = quinsy:
most common deep-space
infection of head and neck
• Young adults
• Predominant bugs: Streptococcus
pyogenes, peptostreptococcus,
bacteroides, Staphylococcus
aureus
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
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
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