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Vijay Mahendran (1) MOUTH For purposes of discussion in this chapter we will briefly deal with the common oral problems encountered in an emergency department. The mouth or oral cavity comprises of the lips, cheeks, floor of the mouth, tongue, alveolar ridges, gingiva and the palate. Lip Lesions Cheilitis Cracking, erythema and scaling at the corners of the mouth. There can be hyperkeratosis, erosions, crusting and skin thinning. Causes can be attributed to poor fitting dentures, vitamin deficiency, contact from lipsticks, sunscreens, dry lips and peppermint. Treatment: Mild topical corticosteroid ointments (hydrocortisone 0. !" #nti$candidal (clotrima%ole&nystatin", #nti$bacterial agents (mupirocin". Lip Erosions These can occur from impetigo, herpes simple' virus, erythema multiforme, fi'ed drug eruptions, %inc deficiency (acrodermatitis enteropathica", pemphigus. (ip ec%ema usually affects the lower lip and spreads beyond the vermillion border into the ad)acent skin. Treatment: of cause, lip balms, hydrocortisone ointment, dietary advice. White lesions Candida, s*uamous cell papiloma, verruca, lichen planus, drug eruptions, snuff&smoker lesions (epithelial hyperplasia". ed lesions +aemangioma, ,turge -eber syndrome, TT., Contact allergy. Pyogenic granuloma is granulation tissue causing a dome shaped papule that is red brown or purple. /estroyed with electro$cautery, cryotherapy or e'cisional surgery. !loor o" the Mo#th, Ton$#e and %alate Oral M#&o#s Cyst ' M#&o&oele ' an#la( This often occurs on the inner surface of the lower lip or floor of the mouth. 0t is a painless, translucent, dome shaped, tense, fluctuant, saliva$filled sac under the tongue mucous membrane. 1sually from a plugged duct or trauma causing salivary duct rupture. Treatment: 02/ or marsupialisation or may disappear spontaneously. 3efer to 4ral ,urgeon (non$urgent"

Oral "i)ro*a Traumatic fibroma, fibrous nodule or focus fibrous hyperplasia. # painless solitary firm, smooth, round mass in the sub mucosa slowly enlarging. May be sessile or pedunculated. 1sually occurring on the tongue, gingival, labial or buccal mucosa. Treatment: 1sually via e'cision 3efer to 4ral ,urgeon (non$urgent" U+#lar oede*a .atient complains of a foreign body sensation or fullness in the throat, possibly associated with a muffled voice or gagging. #sk about recent food, drugs 5#C6 inhibitors7, insect bites and hereditary angio oedema. 4n e'amination8 uvula swollen, pale and somewhat translucent (uvula hydrops". There may be associated rash or history of e'posure to physical stimuli or recurrent seasonal incidents. Treatment: 3isk of hypopharyngeal oedema and respiratory difficulty with or without stridor$ consider 09 antibiotics. May need intubation or cricothyroidotomy. Consider lateral soft tissue '$ray to rule out epiglottic swelling. 0f fever sore throat and pharyngeal in)ection : throat swab, streptococcal and + 0nfluen%ae antibiotic cover with either penicillins or erythromycin. ;ebuli%ed adrenaline and 09 hydrocortisone are also proven beneficial. Consider rapid access 6;T clinic. Glossitis 0nflammation of the tongue that may lead to loss of filiform papillae. Etiology: 9itamin deficiency (<=, <>, <?=, 0ron", infections (viral. candidal, T<" 0rritation ( alcohol, tobacco, citrus, toothpaste", trauma ( dentures", other (lichen planus, pemphigus, erythema multiforme, neoplasia, +,9". Presentation: 9ariable Most often red and smooth surface ,caling occurs with infection, trauma and lichen planus. 1lcerations with +,9, pemphigus and streptococcal infections. Migratory glossitis (@eographic tongue"A seen in /M and psoriasis. #nnular erythematous patch with grey white rim. Treatment: Treatment of cause, bland diet, Chlorhe'idine mouth washes, topical =! lignocaine or 0.?! triamcinalone. 4robase (pectin&gelatine" can be used. Erythe*ato#s Oral Lesions ErythroplasiaA non$specific red patch. .re malignant potential. 1sually occurs on the floor of the mouth and the soft palate. #ppears as a solitary red patch & macule, may be elevated and painless or the patient may complain of a burning sensation. <iopsy is re*uired. 4ther causes are erythema migrans, pemphigus vulgaris, pyogenic granuloma hypersensitivity, vitamin deficiencies and vascular causes (haemangiomas and #9M".

,#llo#s Oral Lesions Erythema multiforme: <listering oral lesions with associated target lesions on skin caused by bacterial viral and fungal infections, drugs (barbiturates, sulphonamides". Tretament: .rednisolone orally. Stevens- Johnson syndrome is a severe form of 6M with systemic symptoms and involvement of eyes, @0T and genitalia. Toxic Epidermal Necrolysis (TEN : B0! occur with mucous membrane (MM" lesions. #lso on associated con)unctival and anogenital areas. Treatment: stop offending agent. ,tart 090, transfer to burns unit for supportive care. Pemphigus !ulgaris: #utoimmune, middle age, affects skin and MM. 4ral cavity may be first presentation. 1sually superficial. Treatment: ;eeds biopsy, 4ral .rednisolone. 3efer /ermatology. 6mollient Mouth washes and antihistamine syrups are helpful. "ullous Pemphigoid: 3esembles .9. <ut usually more skin lesions, Fewer bullae, Tense vesicles. 1sually deep. Treatement: as above. Sto*atitis 0nflammation of the mucous membranes of the mouth. #ule outA trauma (cheek biting", thermal in)ury (hot foods", chemical in)ury (mouthwashes, toothpaste, tobacco". Treatment: topical analgesia (viscous =! lignocaine, <en%ydamine 5/ifflam7 sprays, <on)ela paste". ,imple analgesics, Chlorhe'idine mouth washes and aspirin gargles. ;ystatin pastilles ?00,000 01 at C mls D/, ' ?0 days. Mechanical ProtectionA @elclair (Carmellose gelatine paste" swish or spit T/, (mi'ed with water", do not swallowE 43 4rabase (Carmellose sodium" apply a thin layer after meals. <oth form a protective barrier around irritations $$x: +erpes stomatitis, denture related, angular stomatis, aphthous ulcers, s*uamous cell carcinoma and erythema multiforme ,mokers palate. White Oral Lesions %andidiasis (thrush & stomatitis: .seudomembranous lesion that mimics keratosis, has a predilection for palate and dorsum of tongue. 'our forms .seudomembranous : creamy, cheesy pla*ues. ,een in /M 6rthythematous : red or pink spot on the palate&tongue&buccal mucosa +yperplastic : hard pla*ues&nodules on the inner lip& palate &buccal mucosa #ngular cheilitis : cracks with white pla*ues on the angles of mouth TreatmentA ;ystatin pastilles ?00000 01 ie C mls *ds ' ?0 days or ketocona%ole =00mg&day for F days or 0tracona%ole ?00mg </ for ?0days. (ral )eu*opla*ia: a white patch or pla*ue that cannot be characterised clinically as any other diagnosis. 1sually caused by chronic irritation. Consider premalignant until proven otherwise. #ssociated with smoking and tobacco chewing. (eads to

hyperkeratotic changes. Fre*uently found on edentulous areas of the alveolar ridges and in patients who do not wear their prosthesis. (ater becomes leathery, whiter, asymmetrical and confluent. TreatmentA <iopsy and close follow up as risk of dyplasia, and carcinoma. Complete resection need not necessarily prevent carcinoma. 3efer oral surgeon Ul&ers-%#n&tate Oral Lesions Persistent +lcer: ma)or apthous ulcer, secondary to odontogenic infection, secondary to systemic disease, s*uamous cell carcinoma, traumatic ulcer, tumours, vitamin deficiency, ulcer in +09. Magic Mouth,ash: Chlorhe'idine mouthwashes : rinse with ?0mls for ? minute </ 43 mouthwashes with o'idising agentsA +ydrogen .ero'ide mouthwashes : rinse with ? mls T/,, Sore Mouth Medications: /entino' @el 43 gels&li*uids containing <en%ocaine, ,alicylic acid with or without menthol. "acterial -nfections: /o'ycycline =0mg bd for G months. .enicillins and Metronida%ole are also effective for short courses. .phthous +lcers: Most common ulcerative lesion on all ages. Can present as #phthous ,tomatitis. Presentation: burning prodrome. Can get secondarily infected. #nywhere in the mouth with a predilection for the lateral border of the tongue, buccal mucosa, lips and floor of the mouth. 1sually a shallow mm ulcer with erythematous border and necrotic base. May occur in clusters. ;o vescicles. 6'tremely painful. May not be confined to the oral cavity, they may be found elsewhere in the digestive tract. (esions outside the oral cavity are often associated with systemic disease. +ealing can take anywhere between C days to > weeks. ,carring necessitates the need for biopsy to rule out ,CC. Consider <?=, folate, Hinc and 0ron deficiency and coeliac disease. Treatment: #naesthetic gels and sprays, hygiene, nutrition, fluids, avoid spicy and acidic foods/ %orlan (+ydrocrtisone" pellets0 allow to dissolve in contact with the ulcer *ds. 1erpetic -nfections: Can occur as herpetic @ingivostomatitis Primary 1S!: Multiple vesicular eruptions at the vermilion border of lips, labial, buccal mucosa, tongue, palate, and gingival. Contagious, can sometimes present with fever. 0nitial vesicle formation followed by ulceration with a yellow$grey membrane on an erythematous base. (asts for C$B days. Treatment: #ciclovir topical cream ?! = hourly for C days (4intment is !" Secondary 1S!: =C$CI hr prodrome of burning sensation. The ulcers are fi'ed (keratinised" to the periosteum of the gingival, hard palate and alveolar ridge. Can occur in clusters with vesicles that rupture to form punctate ulcers. 1erpes la2ialisA 9ermilion border of lip (cold sore" : stimulated by fever, stress, sunlight, menstruation. Crust and heal. Treatment: as above. 4ral fluids, avoid sunlight, #ciclovir =00mg D/, for days 43 Famciclovir F 0mg 4/ for days.

.cute Necrotising ulcerative 3ingivitis (.N+3 : #lso called !incent4s .ngina 43 Trench Mouth Mi'ed infection with fusospirochetal, spirochetes and anaerobes. 4ccur as ulcers =$G0mm on the gingiva covered with purulent grey e'udates. .atients usually have poor hygiene, smokers and sometimes immuno deficiencies. #;1@ is rapidly progressive, presents as fiery$red gingivitis and severe pain. .atient has a foul breath, malaise, lymphadenopathy and fever. (ater punched out lesions appear. ,ystemic diseases that mimic #;1@ include 0M;, (eukemia, aplastic anaemia and agranulocytosis. TreatmentA ,wabs, +=4= washes, Clindamycin&#ugmentin orally. )ichen Planus: Chronic disease of the skin and mucous membranes. Characterised by violaceous, pruritic papules on skin, -ith reticular, pla*ue or white& violet threadlike lesions in a ring like pattern (wickmanJs striae" on the buccal mucosa. The hypertrophied form can resemble leucoplakia. May be painful. Tx: ,ymptomatic, Topical steroids may be useful. /apsone for severe forms. (ther %auses of (ral +lcers: 3eiterJs ,yndrome(T'A ;,#0/, and .4 steroids", ,tevens$Kohnsons ,yndrome (re*uires systemic steroids", CM9, CrohnJs disease, <ehcetJs disease, 1lcerative Colitis, /M, ,CC, Contact allergies, Trauma, Mycotic and <acterial infections, #ctinomycosis, /rug reactions etc. .erosto*ia 3efers to dry mouth caused by decreased salivary gland flow in a patient with ade*uate hydration. .etiology: depression, an'iety, mouth breathing, ,)ogrenJs ,yndrome and /rugs (#nticholinergics, anticonvulsants, antihistamines" Treatment: oral hygiene, increase oral fluids, humidified air, small fre*uent meals, artificial saliva, pilocarpine orally. La&erations o" the Mo#th /ue to its rich vascularity, impact in)uries of the mouth can lead to dramatic haemorrhage. <lunt trauma to the face can cause secondary lacerations of the lip, frenulum, buccal mucosa, gingival and Tongue. Tetanus to'oid as indicated. Check for associated in)uries such as loose teeth, mandibular or facial fractures. Tears of the upper lip frenulum: suturing re*uired only if gum torn with the frenulum. ,imple laceration or avulsion of the frenulum heal nicely on their own. # torn frenulum in a child M#L be an indication of ;#0. (arge laceration can be sutured with absorbable vertical sutures (9icryl". 1sually a single stitch may be needed to control haemorrhage. Small puncture type laceration: +eal well if only the outer skin is closed and the intra oral laceration is left open.

Small lacerationsA if only minimal gaping, reassure and advice on aftercare. ,pontaneous healing occurs. 0f gaping or continuous bleeding or large flap, then anaesthetise with (ignocaine and ?A=00000 adrenaline, cleanse with copious saline, suture with G$0, C$0 or $0 absorbable suture like 9icryl or /e'on. Through and Through )acerationsA @et ,enior advice 43 refer to .lastic ,urgeons if department very busy. These are lacerations involving all layers (mucosa, muscle, subcutaneous tissue and skin". 1sually seen as a visible defect. The inside$out 43 bottom$up techni*ue is used to eliminate dead spaces. The oral mucosa, muscular layer and the subcutaneous layers can be closed with simple interrupted suturing techni*ue with absorbable 9icryl or de'on with a cutting needle. 6ach layer to close separately. #ny trapped food or F<Js should be removed and the wound irrigated with saline, anaesthetise with lignocaine and adrenaline. #t least C s*uare knots to be tied for each suture (motion of tongue easily dislodges them". ,kin closed with C$0 to >$0 prolene or nylon. La&erations o" the Ton$#e Most tongue lacerations that occur from falls or sei%ures /4 ;4T re*uire sutures. ,imple large or linear lacerations in the central portion of the tongue also heal surprisingly well, with minimal risk of infection. ,uturing is needed only for gaping wounds. Flap, bisecting, through and through wounds, wounds involving the muscular layers or labial margins need suturing and repair. # localised area of the tongue can be anaesthetised with a lignocaine = to C! soaked gau%e for to ?0 minutes. 4therwise local infiltration might be re*uired. #bsorbable suture material should be used and the stitch should include at least one half of the thickness of the tongue. For both mouth and tongue lacerations advice on aftercare should be given like lukewarm water rinses or half strength +=4= washes after meals. .rophylactic antibiotics are considered only for the large through and through lacerations.

/01 GUMS
Gin$i+al Hyperplasia %auses include anticonvulsants (phenytoin, valproate, phenobarbitone", calcium channel blockers, cyclosporine. 0t can lead to problems with speech and mastication. 6pulis or gingival hypertrophy occurs in pregnancy and can bleed easily. Treatment: /iscontinue medication (only after e'pert advice" and change to another class. Gin$i+itis 0s inflammation of the gums. 1sually occurs due to build up pla*ue and can lead to gum recession.

Presentation: patients complain of severe or generalised pain of the gums, often with a foul taste or odour. The gingiva appears oedematous and red with a greyish nectrotic membrane between the teeth. The gums bleed on touch and there is loss of gingival tissue, especially the interdental papillae. The patient is usually afebrile and shows no signs of systemic disease. !incent4s angina or Trench mouth has already been discussed above. ,evere .eriodontal disease with radiological bone loss will be dealt with in the chapter on Teeth. @ingivitis and periodontitis are /d' for the causes of orofacial pain. Treatment: 3efer to the /entist. 0nstruct the patient to use warm saline rinses along with flossing and gentle brushing using ;a+C4G toothpaste. 0n severe pain use viscous lignocaine 0n severe cases #ntibiotics like /o'ycycline 43 .enicillin 9 43 6rythromycin M Metronida%ole can be used.

Applied Anato*y There are two complete sets of teeth. .rimary (/eciduous" /entition (the Milk Teeth" : erupt between >months $ = years. .ermanent /entition replaces the milk teeth between > : ?= years. .rimary teeth : =0 (#,<,C / etcN" .ermanent : G= (C *uadrants of I each", upper 2 lower, left and right. 6ach *uadrant has central incisor, lateral incisor, canine, ?2= premolar, ?, = 2G molar. The ma)or component of the tooth is a bone like substance called /entine. 0nside the tooth lies the pulp (blood vessels and nerves". The crown is covered by enamel and the roots are covered by cementum. +rgent (,ithin 56 hrs $ental referral: 0f severe pain cannot be relieved by analgesics. Trauma, especially if avulsion. 4rofacial swelling that is new or enlarging. <leeding that cannot be controlled. Fever due to a dental infection. %eriodontitis 0nflammation of the supporting tissues and membranes around the base of the teeth. 1sually secondary to bacteria and pla*ue. Pla7ue is biofilm that contains micro organisms that form on the teeth and between them and the gingival margins. 0f not removed forms tartar. Can lead to gingival recession and erosion to the bone with tooth loss. TreatmentA 3efer to a /entist. /o'ycycline or #mo'ycillin with a Compound analgesic helps control periodontitis.

Tra#*ati& inj#ries to the Teeth 0n traumatic in)uries the tooth is laterally sublu'ed, intruded, e'truded or completely avulsed from its socket. #n (P3 is an 'ray of the )aw which is useful in such cases. %hipped teeth and cro,ns do not re*uire immediate attention. The patient can visit his&her dentist. Tooth fracture ,ith involvement of the pulp need to be referred to the ma'illofacial on call team. Tooth .vulsions: 6'tra articulation, traumatic loss. Complete displacement from its alveolar socket. Check for lacerations. CO3 if aspiration suspected. The tooth should not 2e allo,ed to dry/ .fter 89 minutes of dry storage0 irreversi2le damage to the periodontal cells occurs/ Treatment: .rimary tooth : bleeding control, /4 ;4T replace tooth. .ermanent tooth : 6mergency, tooth to be .(#C6/ <#CP #,#. (within = hours". 0f cannot be replaced, keep moist by storing in saline, saliva or milk until review by a dentist. .rognosis better if kept in the mouth under tongue. <est prognosis if replaced. Techni7ue of tooth #eimplantationA .rimary goal is to replace tooth if alveolar socket fracture is not present. Consider tetanus booster and parental #b' is bacteraemia. 4.@ for fractures. Consider parental analgesia 4r topical lignocaine. Flush the tooth socket to remove clots. /o not vigorously clean the tooth as it may remove vital tissue. 3inse the ape' and root of the tooth with saline, avoiding handling the root surface. +old the tooth with gau%e or a tooth forceps and plant the tooth as close as possible to it normal position using finger pressure. .ress tooth firmly into its socket simultaneously checking position. .atient should feel a click for ideal positioning and seating. The tooth must be splinted to ad)acent stable tooth until patient is seen by ma'illofacial on call or dentist. ,plinting may be improvised with mouth guards, QsilverJ packet from suture material or even chewing gum. 0nstruct the patient to bite down on gau%e or the mouth guard to assist repositioning. ,end patient to the on$call dentist. 1nrestricted tooth movement may interfere with vascular supply and )eopardi%e the survival of the tooth. $isplacement & Su2luxation & %oncussion: The tooth may be in abnormal position in comparison to ad)acent teeth. The patient complains of looseness, improper position, deformity, problem with bite or chewing, there may be sensitivity to pressure and percussion, gingival bleeding. -ntrusive $isplacement typically involves disruption of the alveolar socket, periodontal ligaments and in)ury to underlying marrow. .ulpal necrosis occurs in B>! of intruded teeth. %oncussion refers to in)ury to the periodontal structures supporting the tooth, but without displacement.

TreatmentA as above, leave intruded teeth alone8 reposition only luxated0 extruded or avulsed teeth only. 1rgent referral to Ma'Fa' team. 0f marginal problem only, then patient to see own dentist the ne't day. %ro,n 'ractures: ?&G of the dental in)uries. 1sually incomplete fracture or cracks in the enamel. 3efer to patients own dentist. .lveolar 'racture: pain likely, detected with palpation of sockets and gum line. /o place broken tooth. 1rgent dental referral. %ost Operati+e Hae*orrha$e - ,leedin$ a"ter Tooth E3tra&tion <leeding occurring longer C hours or delayed recurrent bleeding Treatment: .ressure. +ave the patient bite a tightly folded moistened ='= gau%e. 3echeck in =0 minutes. 0f unsuccessful, infiltrate =! lignocaine and adrenaline ?A=00000 locally (palatal & 2uccal & inferior : superior alveolar nerve 2loc*s and wash the socket. .acks with @elfoam, ,urgicel as haemostatic agents are helpful. 0f still unsuccessful, suture any gum tears with a hori%ontal mattress suture with an absorbable material. The idea is not to close the open wound but to tense the surrounding mucoperitoneum to produce localised ischaemia to arrest bleeding. 0f unsuccessful refer to dentist. 0nvolve ,eniors in department. %eriodontal A)s&ess #ssociated with periodontal or endodontal disease or both. #bcess formation in the supporting tissues and membranes around the base of the teeth. 1sually caused by dental caries. $iverse flora: anaerobes, streptococci, bacteriodes common. 0f fever, lymphadenopathy, tooth mobility, or odema of soft tissues then a Periapical a2scess has formed. The patient has gingival swelling and inflammation, localised pain worse with biting. .ulpal pain is throbbing, radiating (ear, temple, cheek" pain. -orse with cold&heat. There may be purulent e'udates or blood when the tissue is palpated. The tooth may be tender to percuss. Communication between the gingival sulcus and the abscess indicates periodontal involvement. Treatment: 3efer to /entist. .nti2iotics: .enicillin 9 43 #ugmentin 43 6rythromycin M Metronida%ole. Clindamycin is an alternative. #nalgesics.