Mouth Teeth and Gums

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MOUTH, TEETH AND GUMSVijay Mahendran

(1) MOUTH

For purposes of discussion in this chapter we will briefly deal with the common oralproblems encountered in an emergency department. The mouth or oral cavitycomprises of the lips, cheeks, floor of the mouth, tongue, alveolar ridges, gingivaand the palate.

Lip Lesions

CheilitisCracking, erythema and scaling at the corners of the mouth. There can behyperkeratosis, erosions, crusting and skin thinning. Causes can be attributed to

poor fitting dentures, vitamin deficiency, contact from lipsticks, sunscreens, dry lipsand peppermint.Treatment: Mild topical corticosteroid ointments (hydrocortisone 0.!"#nti$candidal (clotrima%ole&nystatin", #nti$bacterial agents (mupirocin".

Lip ErosionsThese can occur from impetigo, herpes simple' virus, erythema multiforme, fi'eddrug eruptions, %inc deficiency (acrodermatitis enteropathica", pemphigus.

ip ec%ema usually affects the lower lip and spreads beyond the vermillion borderinto the ad)acent skin.

Treatment: of cause, lip balms, hydrocortisone ointment, dietary advice.

White lesionsCandida, 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 isred brown or purple. /estroyed with electro$cautery, cryotherapy or e'cisionalsurgery.

!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. t is apainless, translucent, dome shaped, tense, fluctuant, saliva$filled sac under thetongue mucous membrane. 1sually from a plugged duct or trauma causingsalivary duct rupture.Treatment: 2/ or marsupialisation or may disappear spontaneously. 3efer to 4ralurgeon (non$urgent"


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Oral "i)ro*aTraumatic 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 orbuccal mucosa.

Treatment: 1sually via e'cision 3efer to 4ral urgeon (non$urgent"

U+#lar oede*aatient complains of a foreign body sensation or fullness in the throat, possiblyassociated with a muffled voice or gagging.#sk about recent food, drugs 5#C6 inhibitors7, insect bites and hereditary angiooedema.4n e'amination8 uvula swollen, pale and somewhat translucent (uvula hydrops".There may be associated rash or history of e'posure to physical stimuli orrecurrent seasonal incidents.Treatment:

3isk of hypopharyngeal oedema and respiratory difficulty with or withoutstridor$ consider 9 antibiotics. May need intubation or cricothyroidotomy.

Consider lateral soft tissue '$ray to rule out epiglottic swelling.

f fever sore throat and pharyngeal in)ection : throat swab, streptococcaland + nfluen%ae antibiotic cover with either penicillins or erythromycin.

;ebuli%ed adrenaline and 9 hydrocortisone are also proven beneficial.

Consider rapid access 6;T clinic.

Glossitisnflammation of the tongue that may lead to loss of filiform papillae.

Etiology:9itamin deficiency (


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#llo#s Oral LesionsErythema multiforme:


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hyperkeratotic changes. Fre*uently found on edentulous areas of the alveolarridges and in patients who do not wear their prosthesis. ater becomes leathery,whiter, asymmetrical and confluent.TreatmentA


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.cute Necrotising ulcerative 3ingivitis (.N+3:#lso called !incent4s .ngina43 Trench MouthMi'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 outlesions appear.ystemic diseases that mimic #;1@ include M;, eukemia, aplastic anaemia andagranulocytosis.TreatmentA wabs, +=4= washes, Clindamycinugmentin 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 formcan 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 ;#/ and 4 steroids", tevens$Kohnsons yndrome(re*uires systemic steroids", CM9, CrohnJs disease,


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Small lacerationsA if only minimal gaping, reassure and advice on aftercare.pontaneous healing occurs. f gaping or continuous bleeding or large flap, thenanaesthetise with ignocaine and ?A=00000 adrenaline, cleanse with copioussaline, suture with G$0, $0 or $0 absorbable suture like 9icryl or /e'on.

Through and Through )acerationsA @et enior advice 43 refer to lastic urgeonsif department very busy.These are lacerations involving all layers (mucosa, muscle, subcutaneous tissueand 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 withsimple interrupted suturing techni*ue with absorbable 9icryl or de'on with a cuttingneedle. 6ach layer to close separately.#ny trapped food or F


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Presentation:patients complain of severe or generalised pain of the gums, oftenwith a foul taste or odour. The gingiva appears oedematous and red with a greyishnectrotic membrane between the teeth. The gums bleed on touch and there is lossof gingival tissue, especially the interdental papillae. The patient is usually afebrileand shows no signs of systemic disease.

!incent4s angina or Trench mouthhas already been discussed above.

evere eriodontal disease with radiological bone loss will be dealt with in thechapter on Teeth.

@ingivitis and periodontitis are /d' for the causes of orofacial pain.

Treatment:3efer to the /entist.nstruct the patient to use warm saline rinses along with flossing and gentle

brushing using ;a+C4G toothpaste.n severe pain use viscous lignocainen severe cases #ntibiotics like /o'ycycline 43 enicillin 9 43 6rythromycin Metronida%ole can be used.

/21 TEETH

Applied Anato*yThere 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 (#,


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Tra#*ati& inj#ries to the Teethn traumatic in)uries the tooth is laterally sublu'ed, intruded, e'truded or completelyavulsed from its socket.#n P3 is an 'ray of the )aw which is useful in such cases.

%hipped teethand cro,ns do not re*uire immediate attention. The patient can visithis&her dentist.Tooth fracture ,ith involvement of the pulpneed to be referred to the ma'illofacialon call team.

Tooth .vulsions: 6'tra articulation, traumatic loss. Complete displacement from itsalveolar socket. Check for lacerations. CO3 if aspiration suspected. The toothshould not 2e allo,ed to dry/ .fter 89 minutes of dry storage0 irreversi2le damageto the periodontal cells occurs/Treatment:

rimary tooth : bleeding control, /4 ;4T replace tooth.ermanent tooth : 6mergency, tooth to be #C6/


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TreatmentA as above, leave intruded teeth alone8 reposition only luxated0 extrudedoravulsedteeth only. 1rgent referral to Ma'Fa' team. f 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. /oplace broken tooth. 1rgent dental referral.

%ost Operati+e Hae*orrha$e - leedin$ a"ter Tooth E3tra&tion

Mouth Teeth and Gums

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