SDCEP Guidelines Flashcards
Signs and symptoms of an acute apical abscess
Acute inflammation of the soft tissues surrounding the root apex of a tooth
Often caused by tooth decay = pulp necrosis
Can follow trauma
Pain (usually localised to a single tooth, quick onset, tooth TTP)
Swelling of gingiva, face or neck
Possible tooth mobility
Fever
Lethargy
Loss of appetite for children under 16 yrs old
Management of acute apical abscesses?
Initial Management:
- Determine if airway is compromised (can they swallow saliva and push tongue out of mouth)
- If compromised = A&E
- If not compromised: Recommend optimal analgesia, do not prescribe antibiotics unless signs of spreading infection (facial/neck swelling), systemic infection or immunocompromised and advice the patient to seek urgent dental care
Subsequent care to consider:
- Draining of abscess through affected tooth by irrigating the canal with 1-5.25% sodium hypochlorite or 0.2% chlorhexidine gluconate solution before drying and sealing in non-setting calcium hydroxide using a temp dressing material
- Drainage not usually carried out on a primary tooth
- Fluctuant soft tissue swelling = incisional draining asap
- Prescribe appropriate analgesia (NSAID) if drainage is inadequate
- Relieve occlusion of affected tooth if appropriate
Define pericoronitis
Swelling of the soft tissues surrounding a P/E crown
Signs and symptoms of pericoronitis?
Pain Swelling Discomfort with swallowing Limited mouth opening Unpleasant taste or odour from the affected area Fever Nausea Fatigue
Management of pericoronitis?
Airway compromised - A&E
Not compromised:
- Recommend optimal analgesics
- Antibiotics if signs of spreading infection (limited mouth opening, facial swelling), systemic infection or immunocompromised patient
- Rinse with 0.2% chlorhexidine MW or salty water
- Children: Analgesia, soft tissue brushing and rinsing after food
Subsequent care:
- Irrigate using 0.2% chlorhexidine
- Patient advice to keep area clean
- Extract tooth if repeated episodes
- Extract opposing tooth if trauma to the inflamed operculum if tooth is unlikely to achieve function
What are the main acute periodontal conditions?
Acute necrotising gingivitis
Acute necrotising periodontitis
Periodontal abscess
Perio-endo abscesses
Similarities and differences between ANUG and ANUP?
Both are severe inflammatory conditions of the gingiva caused by fusiform bacteria and spirochetes and are common in immunocompromised patients
Necrotising gingivitis related to lesions limited to the gingival tissue
Necrotising periodontitis involved loss of attachment
What is a periodontal abscess?
Represents an active period of periodontal breakdown which occurs whilst there is marginal closure of the deep periodontal pocket occluding drainage.
Develop in deep periodontal pockets.
Commonly seen in patients with untreated periodontitis or as a recurrent infection during treatment
Signs and symptoms of necrotising periodontal disease?
Pain Swelling Bleeding Halitosis Ulcerated gingival tissue Loss of attachment Malaise Fever
Signs and symptoms of periodontal abscess?
Pain and tenderness of gingival tissue Increased tooth mobility Fever and swollen or enlarged regional lymph nodes Presence of swelling on gingiva Suppuration from the gingiva
Perio-endo abscesses signs and symptoms?
Generalised periodontal disease may be present with localised pain
Swelling with or without suppuration on palpation
Deep pocketing to root apex with BOP
Management of acute periodontal conditions?
Initial:
Airway compromised - A&E
Airway not compromised - optimal analgesia recommendation, antibiotics if indicated
Advise patient to seek urgent dental care
Subsequent care:
- For all consider: Therapy with hygienist, dentist or periodontist
- Scaling teeth sub and supragingival (may require LA)
- Prescribing chemical plaque control (hydrogen peroxide and 0.2% chlorhexidine MW)
Necrotising periodontal disease:
- Plus gingival OHI and smoking cessation advice
- Prescribe metronidazole or amoxicillin if systemic involvement or swelling does not subside following local measures (metronidazole 200mg tds 3 days) OR (amoxicillin 500mg tds 3 days)
Periodontal abscess
- Plus scaling and irrigating periodontal pocket
- Extraction
Perio-endo lesions
- Also consider RCT or re-treatment
Management of dentine hypersensitivity?
Advice: Avoid acidic foods or drinks. Apply desensitising toothpaste and apply small amount to affected area
Eliminate other causes of dental pain (e.g. pulpititis)
Consider topical therapies such as fluoride varnish, dentine bonding agents, prime and bond
Reversible pulpitis features?
Inflamed pulp resulting in an exaggerated response to sensibility testing. Tooth is not TTP.
Sensitivity to sweet and cold.
Reversible pulpitis treatment?
Consider temp dressing
Restoring affected tooth
Irreversible pulpitis features?
Inflamed dental pulp resulting in pain that may be difficult to localise to a single tooth but may last several hours
May be dull and throbbing, may worsen with heat and be alleviated by cold
Spontaneous pain
Keeps patient awake
Irreversible pulpitis treatment?
Pulpotomy for children
Pulpectomy for adults using ledermix (corticosteroid-antibiotic paste)
Extract tooth
Signs and symptoms of alveolar osteitis (dry socket)?
Pain (24hrs-48hrs) after extraction
Unpleasant taste or odour from the area
Swelling occasionally
Management of alveolar osteitis?
Initial management:
Recommend optimal analgesia
Stop smoking and improve OH
Advise to seek urgent dental care
Subsequent care:
- Irrigate with saline
- Apply suitable material to dress the socket e.g. alvogyl
- Antibiotics if indicated
Post extraction haemorrhage management?
Initial management
- Rinse mouth with warm water to remove excess blood
- Advise patient to place a rolled up piece of gauze moistened with saline/water over the socket and to bite on it for 20 mins
- If pt is on anticoagulant medication = send pt for emergency care
- When bleeding stopped: Advise patient to avoid alcohol, smoking, exercise or effort for 24 hrs and to not disturb the blood clot
- If bleeding fails to stop and is persistent = A&E
- If not persistent = dental care
Subsequent care
- If pressure does not work, apply haemostatic dressing to the socket (e.g. oxidised cellulose such as surgicel or haemocollagene sponge)
- Suture wound to achieve good soft tissue closure
- If child consider referring to specialist to investigate underlying pathology
- Antibiotics only if indicated
Oral ulceration management?
Local measures:
- Rinse mouth with a salt solution 1/2 tsp in a glass of warm water
- Sodium chloride MW, Chlorhexidine MW 0.2% rinse for 1 minute with 10ml BD
OR Hydrogen peroxide MW 6%
- Benzydamine MW 0.15% rinse or gargle using 15ml every 1 and a half hrs or oromucosal spray form OR Lidocaine ointment 5%, lidocaine spray 10%
How long has it been present:
3 weeks plus = urgent referral to max fax
If less than 3 weeks:
- For all: Recommend optimal analgesia and prescription of topical analgesics (e.g. benzydamine oromucosal spray)
If recurrent and self limiting advise:
- 0.2% chlorhexidine MW (if over 7 years old) and to seek non urgent dental care.
- Doxycyline dispersible tablets 100mg qds for 3 days (for recurrent aphthous stomatitis)
- For children = optimal analgesia, soft diet and advise ulcers usually resolve within 1-2 weeks.
If receiving drug tx or has an underlying medical condition that may be the cause advise them to seek urgent medical care
If ulceration due to ill fitting denture = 0.2% chlorhexidine MW, keep dentures out where possible and seek non-urgent dental care
If trauma from tooth/ortho appliance = non-urgent dental care
If trauma when anaesthetised = avoid smoking, hot liquids and biting cheek and lip
Single ulcer with no trauma - 0.2% chlorhexidine MW until symptoms resolve or if fails to heal in a week see dentist
Subsequent care:
- Fix ill fitting denture
- Prescribe topical steroids:
Betamethasone soluble tablets 500 micrograms - qds dissolved in 10ml water as a MW
Hydrocortisone oromucosal tablets 2.5mg 1 dissolved next to lesion qds
- Referral to dermatology or oral medicine if vesicuobullous disorder suspected
- Primary herpetic gingivostomatitis or herpes zoster infection - if severe symptoms and patient is immunocompromised consider aciclovir, peniciclovir Rx)
- Refer to GMP if drug is causing ulceration
Medical conditions that can cause oral ulceration?
Viral infections:
- Herpetic stomatitis
- Hand, foot and mouth disease
- HIV
- Chicken pox
- Herpangina (CVA4)
Bacterial infections:
- Syphilis
- Tuberculosis
Mucocutaneous disease
- Lichen planus
- Behcet’s syndrome
- Pemphigus vulgaris
- Erythema mutliforme
- Pemphigoid
- Chronic ulcerative stomatitis
Haematological diseases
- Anaemia
- Leukaemia
- Haematinic deficiencies
- Neutropenia
Gastrointestinal disease
- Coeliac disease
- Ulcerative colitis
- Crohn’s disease
Management of ill-fitting or loose dentures?
May cause pain, difficulty speaking and eating
Post stroke paralysis or malignancy can cause ill fitting dentures
Are there signs of stroke? - Emergency care needed
No signs of stroke:
- Optimal analgesia
- Remove dentures
- Non-urgent dental care
- Temporary relining of dentures
- Make new dentures
- Refer to maxfax if malignancy potential
Orthodontic appliance problems?
If inhaled or ingested - emergency care required
For fixed appliances:
- Remove loose components
- Malleable warm onto sharp, removable parts of the appliance causing trauma
- Advise non-urgent orthodontic care
What is sinusitis?
Inflammation of the sinuses with inflammation of the adjacent mucosa.
Most common trigger = viral upper respiratory tract infection
Rarely bacterial in aetiology
Generally self limiting that has an average of 2 1/2 weeks
Pain (headache, facial, upper tooth ache) Nasal congestion/obstruction Decreased sense of smell Fatigue Fever Purulent discharge
Treatment of sinusitis?
Recommend optimal analgesia
Signs of bac infection?
- No signs = Advise steam inhlation and to see GMP
- Bacterial infection (persistent symptoms or purulent discharge for 7 plus days):
Drug treatment - Ephedrine nasal drops 0.5%
Antibiotics - amoxicillin 500mg tds 7 days, OR doxycyline capsules 100mg 2 capsules 1st day, 1 capsule daily
Signs and symptoms of acute tempormandibular joint disorders?
Pain Swelling Joint noises Limited mouth opening Headaches Ear aches Tinnitus
For dislocated jaw - unable to move jaw or jaw is displaced in an open position
TMD management?
Advise NSAIDs/analgesics
Consider short term course of diazepam to relax muscles (addictive)
Advise local heat packs or ice packs
Soft diet, avoid chewing gum and rest
Consider making occlusal splint
Monitor symptoms in follow up
Consider referral to specialist if symptoms do not improve
What is Bell’s palsy?
Acute onset paralysis or weakness of muscles only in the face, usually on 1 side
Bell’s palsy management?
Determine if signs of stroke e.g. facial weakness or distortion, arm weakness, speech problems - emergency care if so
No signs of stroke:
- Protect eyes with a patch, eye lubricants and possibly tape eyelids closed at night
- Advise urgent medical care
- GMP referral
Management of salivary gland obstruction or infection?
Infection:
- Acute gland pain that does not fluctuate with meal times
- Erythema, systemically unwell, parotid swelling, fever
= Seek urgent medical care
Mumps
- Young patient (under 21) experiencing swelling at side of the face under the ear, systemically unwell and raised temperature
- Recommend optimal analgesia, stay at home to avoid spread, urgent medical care
Obstruction without infection (major salivary gland)
- Intermittent pain and swelling, within an hour of meal times, no erythema or fever
- Analgesics, drink fluids, dental care
Obstruction without infection (minor salivary gland)
- (Mucocele) - dental care
Subsequent care:
- Refer to oral and maxillofacial surgery if symptoms persist
- Consider referral for further investigations to identify underlying cause of xerostomia
What patients are predisposed to candidal infections?
Drugs - inhaled corticosteroids, cytotoxics, broad spectrum antibacterials
Patients with diabetes
Nutritional deficiencies
Systemic disease - leukaemia, malignancies, HIV infection (immunocompromised patients)
Prostheses - no exfoliation
Low saliva - no flow = reduces soluble defence
Management of pseudomembranous candidosis and erythematous candidosis?
Own notes:
Idenfify and remove predisposing factors after confirming diagnosis by swab/oral rinse
Guidelines:
If using corticosteroid inhaler - rinse mouth with water or brush teeth after using it
Nystatin suspension poorly tolerated due to taste
Fluconazole/muconazole prescription: Do NOT use if taking warfarin or statins:
- Fluconazole capsules 50mg OD (max of 14 days)
- Miconazole oromucosal gel 80g tube - apply pea sized amount after food 4x daily (do not use for 7 days after lesions have healed)
- If above contraindicated: nystatin oral suspension 100,000 units/ml, 1ml after food qds for 7 days (rinse and then retain suspension near lesion for 5 mins before swallowing, continue to use for 48 hours after lesions have healed)
Monitor symptoms at follow ups
GMP referral if systemically unwell plus candidal infection
What are the 4 main types of angioedema?
Allergic
Idiopathic
Drug induced
Hereditary
Angioedema signs and symptoms?
Sudden onset swelling
Swelling usually around eyes and lips but can affect throat, hands, feet
If difficulties breathing (wheezing), itching (urticaria) and the patient is hypotensive (flushed or faint) = could be anaphylaxis
What is temporal arteritis/giant cell arteritis?
Inflammation and damage to blood vessels in the head, typically the superficial temporal arteries in patients over 50 years old
Signs and symptoms of temporal arteritis?
Pain (headache, unilateral) Burning sensation Swelling Fever Tender to touch Vessels visible and palpable Fatigue Vision difficulties = emergency care required
What medications can cause gingival overgrowth?
Phenytoin
Ciclosporin
Nifedipine
Procyclidine
What medications can cause oral ulceration?
NSAIDs Nicorandil Beta blockers Methotrexate Cytotoxic drugs Sulphonamides Anticonvulsants (phenytoin, carbamazepine) Allopurinol Penicillin Gold
What can cause dry mouth?
Analgesics (opiods) Antidepressants (tricylic) - Amitriptyline SSRI - fluoxetine, citalopram Anticonvulsants - Carbamazepine Beta blockers - Atenolol Diuretics
How to assess the bleeding risk?
Assess whether treatment is likely to cause bleeding and if it has a risk of bleeding complications:
- High risk = complex extractions or more than 3 at once, flap raised, gingival recontouring and biopsies
- Low risk = Simple extractions, drainage of intraoral swellings, 6 ppc, RSD, subgingival margins of restorations
Ask patient about use of anticoagulants or antiplatelet drugs
- If short therm medication (e.g. for acute deep vein thrombosis/pulmonary embolism) consider delaying procedures which may cause bleeding
Ask patient about medical conditions they have
Ask about the patient’s bleeding history
General advice for treating patients on anticoagulants/antiplatelets
Consider consulting their GMP/consultant
If on time limited course of medication delay non-urgent procedures where possible
Tx early in day and week
Atraumatic technique
Local measures
Discharge patient when haemostasis is achieved
Advise paracetamol
Written and verbal POI and emergency contact details
List antiplatelet drugs
Aspirin Clopidogrel Dipyridamole Prasugrel Ticagrelor
