CHAPTER 12 Dental, Ear, Nose, and Throat Emergencies

Daun A. Smith, RN, MSN

MAJOR TOPICS

General Strategy

Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Dental Emergencies

Odontalgia

Tooth Eruption

Pericoronitis

Dental Abscess

Ludwig’s Angina

Postextraction Pain and Bleeding

Acute Necrotizing Ulcerative Gingivitis (Trench Mouth)

Specific Ear Emergencies

Acute Otitis Externa

Acute Otitis Media

Ruptured Tympanic Membrane

Otic Foreign Body

Meniere’s Disease

Labyrinthitis

Specific Nose Emergencies

Rhinitis

Epistaxis

Nasal Foreign Body

Specific Throat Emergencies

Pharyngitis

Exudative Pharyngitis

Laryngitis

Peritonsillar Abscess

Retropharyngeal Abscess

Epiglottitis

Laryngeal Foreign Body

I. GENERAL STRATEGY

A. Assessment

1. Primary and secondary assessment/resuscitation (see Chapter 1)

2. Focused assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Pain: PQRST (see Chapter 9)

b) Bleeding or hemorrhage: estimated blood loss, syncope, or dizziness

c) Shortness of breath or obstructed airway

d) Swelling or edema

e) Lymphadenopathy

f) Foreign body aspiration or insertion

g) Facial asymmetry or bony dislocation

h) Fever, chills

i) Nausea, vomiting

j) Paresthesia, facial numbness

k) Dysphasia, dysphagia, muffled voice

l) Foul odor or bad taste in mouth

m) Loss of hearing

n) Tinnitus or vertigo

o) Trismus: spasm of masticatory muscles resulting in difficulty in opening mouth

p) Injury: mechanism and time (see Chapter 30)

q) Discharge or drainage: ears, nose, or mouth

r) Pruritus

s) Neck pain

t) Drooling

u) Bleeding gums

v) Excessive or decreased salivation

w) Headache

x) Dyspnea

y) Difficulty with sleeping in supine position

z) Efforts to relieve symptoms

(1) Home remedies

(2) Alternative therapies

(3) Medications

(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history

a) Current or preexisting diseases/illness

(1) Hypertension

(2) Cardiopulmonary disease

(3) Atherosclerosis

(4) Neurologic disease

(5) Cancer of head and neck

(6) Hematologic disease

(7) Diabetes

(8) Immunosuppressive conditions with or without chemotherapy or radiation

b) Dental or ear, nose, and throat (ENT) surgery

c) Previous injury or fractures

d) Previous dental or ENT infections

e) Exposure to noxious agents

f) Denture use

g) Substance and/or alcohol use/abuse

h) Smoking history

i) Last normal menstrual period: female patients of childbearing age

j) Current medications

(1) Prescription

(2) Over-the-counter

k) Allergies

l) Immunization status

3) Psychological, social, and environmental factors

a) Infrequent dental care or lack of maintenance (e.g., flossing and brushing)

b) Poor nutrition

c) Contact sports without correct mouth protectors

d) Swimming in contaminated water

e) Trauma resulting from attempts to clean or scratch an itching ear

f) Blast injuries

g) Air travel with upper respiratory tract infection without premedication

h) Possible/actual abuse, assault, or intimate partner violence situations (see Chapter 3)

i) Unsanitary living conditions

j) Contact with sick individuals

k) Cigarette, cigar, or pipe smoking

l) Occupational exposures

b. Objective data collection

1) General appearance

a) Level of consciousness, behavior, affect: including cranial nerve survey

b) Vital signs: include orthostasis if suspicion of significant blood

c) Odors

d) Gait

e) Hygiene

f) Level of distress/discomfort

2) Inspection

a) External ear and canal

(1) Position, size, and symmetry

(2) Skin color

(3) Drainage

(4) Edema, erythema

b) Tympanic membrane (TM): necessitates use of otoscope

(1) Color: pearly gray

(2) Landmark identification: cone of light at 5-o′clock position

(3) Mobility: use pneumatic otoscope and insufflator

c) External nose

(1) Position, shape, and symmetry

(2) Drainage

(3) Ecchymosis

d) Internal nose

(1) Nasal septum: color, integrity, and hematoma

(2) Inferior and middle turbinates and middle meatus: color and size

(3) Nasal mucosa: color and integrity

e) Mouth and pharynx

(1) Teeth: number, color, form, and occlusion

(2) Lips: color, symmetry, moisture, and surface characteristics

(3) Oral buccal mucosa/oropharynx: color, landmarks, surface characteristics, and structures

(4) Gingiva: color and surface characteristics

(5) Tongue: symmetry, movement, color, surface characteristics, and ventral surface

(6) Hard and soft palates: color, surface characteristics, and landmarks

f) Paranasal sinuses: soft tissue over sinus area for erythema or swelling

g) Neck: symmetry of structures and abnormalities

3) Palpation

a) Skin temperature, moisture, and turgor

b) Paranasal sinuses tenderness

c) Temporomandibular joint (TMJ): mobility and crepitus

d) Cervical lymphadenopathy

3. Diagnostic procedures

a. Laboratory studies

1) Complete blood count (CBC) with differential

2) Erythrocyte sedimentation rate (ESR)

3) Coagulation profile

4) Aerobic and anaerobic cultures if suspected infection

5) Streptococcus screen/culture

6) Arterial blood gases (ABGs)

b. Imaging studies

1) Dental

a) Mandibular panoramic radiograph (Panorex)

b) Chest radiograph: rule out aspiration of foreign body in lungs if teeth are missing

c) Facial series radiograph: to detect fractures

2) ENT

a) Nasal bones radiograph: usually not indicated, diagnosis usually based on clinical presentation

b) Facial bones radiograph with Waters’ view

c) Cervical spine (C-spine) radiograph and odontoid view with neck trauma

d) Chest radiograph

e) Computed tomography (CT) scan

f) Magnetic resonance imaging (MRI)

c. Other

1) 12- to15-lead electrocardiogram (ECG)

B. Analysis: Differential Nursing Diagnoses/Collaborative Problems

1. Acute/chronic pain

2. Anxiety/fear

3. Risk for infection

4. Risk for deficient fluid volume

5. Ineffective tissue perfusion

6. Deficient knowledge

7. Risk for ineffective airway clearance

8. Risk for ineffective breathing pattern

C. Planning and Implementation/Interventions

1. Determine priorities of care

a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid/blood products/medications as needed

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension

3. Allow significant others to remain with patient if supportive

4. Educate patient and significant others

D. Evaluation and Ongoing Monitoring (see Appendix B)

1. Continuously monitor and treat as indicated

2. Monitor patient response/outcomes, and modify nursing care plan as appropriate

3. If positive outcomes are not demonstrated, reevaluate assessment and/or plan of care

E. Documentation of Interventions and Patient Response

F. Age-Related Considerations

1. Pediatric

a. Growth or development related

1) Eighty-five percent of foreign body aspirations occur in children younger than 3 years. Boys are twice as likely to aspirate a foreign body as girls; the peak incidence occurs between the ages of 1 and 2 years; foreign body ingestions occur equally in boys and girls between ages 6 months to 6 years; children with neurologic disorders, developmental delays, or who have had esophageal surgery are at higher risk of injury as a result of problems that impair their protective reflexes. In 20% to 38% of children with esophageal foreign body ingestions, there are no symptoms

2) Irritability and lack of feeding in infants should not be overlooked as potential signs of dental and ENT emergencies

b. “Pearls”

1) Persistent cough or chronic wheezing may be indicative of an aspirated foreign body

2) Difficulty with feeding may be indicative of a significant ENT emergency

3) Abrupt onset of upper respiratory and pulmonary symptoms suggests foreign body ingestion

2. Geriatric

a. Aging related

1) Difficulty in mastication and loss of sensation in mouth should be considered

2) Progressive hearing loss occurs as part of aging process and may be difficult to assess in the emergency department

b. “Pearls”

1) Malignant external otitis media and cholesteatoma should be considered in elderly patients and in diabetic patients with earache or recurrent ear infections

2) Most dental and ENT trauma in the elderly is related to falls, visual changes occurring with age, motor vehicle crashes, and assaults

3) Poor eyesight contributes to foreign bodies in the pharynx

II. SPECIFIC DENTAL EMERGENCIES

A. Odontalgia

Odontalgia, or toothache, is frequently the result of a cavity involving a portion of pulp tissue within the tooth. Pulpal inflammation (pulpitis) invades the soft tissue and produces pain that is provoked by eating sweets or changes in temperature, especially cold. Pain may begin suddenly or gradually, creating sharp to throbbing sensations. Pain may be localized or radiate to the ear, jaw, temple, or neck. If left untreated, the pulpal inflammation extends into the dentin and root apex, producing necrosis. This necrosis increases the risk for periapical and alveolar abscess, facial cellulitis, and tooth extraction. Treatment measures are aimed at relieving pain and ultimately preventing tooth decay from dental caries. Good oral hygiene is essential to prevent oral microbes, generated by diet, from invading tooth enamel and causing decay. When disease is present, it is important to rule out secondary complications that may be associated with abscessed teeth; if required, tooth extraction, root canal treatment, or incision and drainage may be performed. Antibiotics and analgesics can be administered until definitive treatment by a dentist is provided.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Pain (see Chapter 9)

(1) In diseased tooth: dental caries

(2) Referred to gum line, jaw, temple, ear, and neck

(3) Sharp, shooting pain in early phase progressing to intense, persistent, throbbing pain with tooth exquisitely sensitive to touch during later phase (pulp damage)

(4) More intense nocturnal pain from affected tooth

(5) Begins with heat or cold stimulus and occurs spontaneously with continued worsening

(6) No relief with analgesics; irreversible pain indicates necessity for root canal treatment or extraction

2) Past medical history

a) Current or preexisting diseases/illness

b) Previous dental caries, injuries, or gum disease

c) Medications

d) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Fetid breath

(2) Moderate distress/discomfort

b) Inspection

(1) Presence of tooth discoloration or obvious decay

(2) Facial swelling/redness

c) Palpation/percussion

(1) Tenderness of tooth

2) Diagnostic procedures: frequently none

2. Analysis: differential nursing diagnoses/collaborative problems

a. Acute pain

b. Anxiety/fear

c. Risk for infection

3. Planning and implementation/interventions

a. Establish IV access for administration of crystalloid fluid/medications as needed

b. Prepare for/assist with medical interventions

1) Dental nerve block

c. Administer pharmacologic therapy as ordered

1) Antibiotics

2) Non-narcotic analgesics

3) Narcotics

d. Educate patient and significant others

1) Explain disease process

2) Stress importance of follow-up dental care

4. Evaluation and ongoing monitoring (see Appendix B)

a. Pain relief

B. Tooth Eruption

Tooth pain is commonly experienced when the primary teeth in infants and children are erupting from the gums. This can also be experienced when the third molars (wisdom teeth) evolve during the second decade of life. Low-grade fever, diarrhea, and refusal to eat or drink may occur in infants and children during tooth eruption. Management is supportive and directed toward pain control, adequate hydration, and control of diarrhea if present. Analgesia (both oral and topical) and nonsteroidal anti-inflammatory drugs (NSAIDs) are used to alleviate discomfort.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Pressure or tenderness of erupting tooth

b) Irritability

c) Disrupted sleep

d) Decreased fluid intake

e) Associated symptoms: upper respiratory infection, diarrhea

f) Agitation

g) Nasal discharge

h) Crying

i) Fever (low grade)

2) Past medical history

a) Current or preexisting diseases/illness

b) Similar occurrences

c) Medications

d) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: fussy/consolable crying

(2) Elevated temperature: low-grade fever

(3) Mild to moderate distress/discomfort

b) Inspection

(1) Drooling

(2) Circumoral rash around mouth

(3) Reddened, edematous tissues over erupting tooth

(4) Reddened nasal mucosa and rhinorrhea

c) Palpation

(1) Tenderness on palpation of affected gum area

2. Analysis: differential nursing diagnoses/collaborative problems

a. Acute pain

b. Anxiety/fear

3. Planning and implementation/interventions

a. Prepare for/assist with medical interventions

1) Apply gentle massage to overlying gingival tissue with finger or teething ring

2) Place ice chips wrapped in a cloth over gingival tissue

b. Administer pharmacologic therapy as ordered

1) Topical anesthetic: benzocaine (e.g., Orajel or Numzit)

2) Non-narcotic analgesics

3) Antipyretics

c. Educate patient and significant others/parents

1) Use warm saline mouth rinses

2) Soft solid diet

3) Dental referral if eruption site remains soft or swollen: probable eruption cyst, which may rupture and bleed

4. Evaluation and ongoing monitoring (see Appendix B)

a. Pain relief

C. Pericoronitis

Pericoronitis is inflammation of the gingival tissue surrounding the crown of a tooth. It is usually associated with erupting or impacted teeth. The space between the crown, overlying tooth, and gingival flap has a tendency to accumulate food and bacteria and thus cause increased inflammation. This is commonly seen in adults entering their third decade of life but can be found in teenagers as well. Pain is the primary symptom and may radiate to the ears, throat, and floor of the mouth. General treatment measures consist of saline irrigations, warm mouth rinses, and pain control with analgesic medications. Occasionally, systemic symptoms occur and may include lymphadenopathy, fever, and fatigue. Antibiotics, débridement, excision of the gingival flap, or extraction of the molar may be necessary. Cellulitis, peritonsillar abscess, and Ludwig’s angina are rare complications that should be considered when systemic symptoms are present.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Pain (see Chapter 9)

(1) Nonspecific, diffuse, extraoral pain or pain on opening mouth

(2) Earache on affected side

(3) Sore throat or neck or jaw pain

2) Past medical history

a) Current or preexisting diseases/illness

b) Unerupted third molar tooth in area of discomfort or pain

c) Medications

d) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Elevated temperature: greater than 100°F (37.7°C)

(2) Mild to moderate distress/discomfort

b) Inspection

(1) Submandibular lymphadenopathy

(2) Red, inflamed soft tissues around crown of partially erupted tooth

(3) Trismus if infection has spread

2) Diagnostic procedures: mandibular panoramic radiograph (Panorex)

2. Analysis: differential nursing diagnoses/collaborative problems

a. Acute pain

b. Risk for infection

3. Planning and implementation/interventions

a. Prepare for/assist with medical interventions

1) Apply gentle massage to overlying gingival tissue with finger or teething ring

2) Irrigate under pericoronal flap with warm normal saline to remove debris

3) Assist with draining of abscess, if present

b. Administer pharmacologic therapy as ordered

1) Antibiotic therapy if infection present

2) Antipyretics

3) Non-narcotic analgesics

4) Narcotics

c. Educate patient and significant others

1) Dental referral for débridement of pericoronal flap or tooth extraction and follow-up therapy

4. Evaluation and ongoing monitoring (see Appendix B)

a. Pain relief

D. Dental Abscess

A dental abscess occurs from the localized accumulation of pus in a cavity of a tooth. Gingival swelling results as plaque and debris collect in the space between the tooth and gingiva. Periodontal disease results when infections extend into the surrounding tissues, gingival epithelium, periodontal ligament, or alveolar bone. Periapical (alveolar) abscess (infection spread beyond the bone) and periodontal abscess (bony destruction at the periodontal membrane) result when bacterial, viral, or mycotic pathogens are able to colonize. Treatment measures are aimed at managing infection with antibiotics. In some cases, incision and drainage of the soft tissue are necessary to prevent involvement to the extending fascial areas of the head and neck.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Pain (see Chapter 9)

(1) Affected tooth and surrounding tissue radiating to jaw, ear, and neck

(2) Mild to severe depending on extent of abscess

(3) Not relieved by analgesics

b) Swelling of face or neck on affected side

c) Fever or chills

d) Malaise

e) Foul breath

f) Unpleasant taste in mouth

g) Sore gums

2) Past medical history

a) Current or preexisting diseases/illness

b) Previous dental abscess

c) Previous dental caries or gum disease

d) Infrequent dental care or lack of maintenance

e) Medications

f) Allergies

g) Immunization status

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: agitation or restlessness

(2) Elevated temperature: greater than 99°F (37.2°C)

(3) Moderate to severe distress/discomfort

b) Inspection

(1) Edematous face (if minor and localized abscess)

(2) Edematous face and neck (if major and extending abscess)

(3) Possible edema of pharynx and surrounding structure on affected side

c) Palpation/percussion

(1) Tenderness of affected tooth

2) Diagnostic procedures

a) CBC with differential: elevated white blood cell (WBC) count

b) Mandibular panoramic radiograph (Panorex)

c) Culture and sensitivity testing of any drainage: aerobic and anaerobic

d) Soft tissue neck radiograph

2. Analysis: differential nursing diagnoses/collaborative problems

a. Acute pain

b. Infection

c. Anxiety/fear

3. Planning and implementation/interventions

a. Prepare for/assist with medical interventions

1) Incision and drainage of abscess if fluctuance is present, leaving drain in place

2) Obtain culture and sensitivity testing of exudate

b. Administer pharmacologic therapy as ordered

1) Non-narcotic analgesics

2) Narcotics

3) Antibiotics

4) Antipyretics

c. Educate patient and significant others

1) Use warm normal saline mouth rinses every 1 to 2 hours while patient is awake

2) Refer to dentist or endodontist for follow-up care

4. Evaluation and ongoing monitoring (see Appendix B)

a. Pain relief

E. Ludwig’s Angina

Ludwig’s angina usually results from a secondary dental infection involving the lower second and third molars and can lead to airway management problems. Bilateral diffuse swelling and extending cellulitis involving the submandibular, submental, and sublingual areas occur. The neck and face are swollen with protrusion and elevation of the tongue, which cause difficulty in talking and swallowing. Breathing becomes compromised as oropharyngeal swelling evolves and descends down the fascial planes of the neck toward the mediastinum. In addition, fever, chills, and trismus are commonly present. Aerobes and anaerobes are responsible for most infections, which are caused by the proliferation of hemolytic streptococci and Bacteroides melaninogenicus. Treatment of infection includes the use of penicillin, clindamycin (Cleocin), or third-generation cephalosporins. Incision and drainage are performed to provide relief from swelling and infection and further protect the airway.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Severe pain (see Chapter 9)

b) Swelling of jaw and neck

c) Fever or chills

d) Malaise

e) Difficulty in swallowing (dysphagia)

f) Difficulty in talking (dysphasia)

2) Past medical history

a) Current or preexisting diseases/illness

b) Dental infection and treatment

c) Medications

d) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: agitation

(2) Tachypnea

(3) Elevated temperature: greater than 101°F (38.3°C)

(4) Possible stridor

(5) Severe distress/discomfort, critically ill

b) Inspection

(1) Marked bilateral swelling of jaw and neck

(2) Marked elevation of tongue and floor of mouth toward palate

(3) Pallor or cyanosis

(4) Trismus

(5) Possible poor dental hygiene/multiple caries

c) Palpation

(1) Firm induration of swollen soft tissue of the anterior neck

(2) Diaphoresis

2) Diagnostic procedures

a) CBC with differential: elevated WBC count

b) ESR

c) ABGs if cyanosis or respiratory distress is present

d) Culture and sensitivity testing of exudate

e) Soft tissue neck radiograph or CT scan

2. Analysis: differential nursing diagnoses/collaborative problems

a. Impaired gas exchange

b. Acute pain

c. Infection

d. Anxiety/fear

e. Risk for ineffective airway clearance

f. Risk for deficient fluid volume

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen as indicated

1) Rapid-sequence intubation (RSI) and ventilatory support if airway compromise is present

2) High-flow oxygen

c. Establish IV access for administration of crystalloid fluids/medications as needed

d. Prepare for/assist with medical interventions

1) Advanced airway management

a) Nasal or oral intubation

b) Laryngeal mask airway

c) Combitube

d) Surgical airway (e.g., cricothyrotomy)

2) Assist patient to Fowler’s position

3) Institute cardiac and pulse oximetry monitoring

4) Assist with intraoral incision and drainage of infected area: procedural sedation may be required (see Chapter 9)

5) Assist with hospital admission

e. Administer pharmacologic therapy as ordered

1) RSI premedications: sedatives, analgesics, neuromuscular blocking agents

2) Non-narcotic analgesics

3) Narcotics

4) Antipyretics

5) Antibiotic: pharyngeal culture obtained prior to antibiotic administration

6) Procedural sedation medications (see Chapter 9)

4. Evaluation and ongoing monitoring (see Appendix B)

a. Airway patency

b. Level of consciousness

c. Hemodynamic status

d. Breath sounds and pulse oximetry

e. Cardiac rate and rhythm

f. Pain relief

F. Postextraction Pain and Bleeding

Pain and swelling are generally present up to 24 hours after a tooth extraction. This condition is known as periostitis and usually responds well to analgesics, NSAIDs, or narcotic analgesics. However, pain lasting more than 2 to 3 days may be caused by alveolitis, commonly referred to as “dry socket” syndrome. Pain may radiate to the ear on the affected side and may last from days to weeks. It is most commonly found in patients who have had the mandibular posterior teeth removed and results from loss of the healing blood clot and localized infection. Alveolitis is best treated with irrigation of the socket and topical analgesic medication or gauze moistened with eugenol (oil of cloves) that is changed daily. Fever or swelling should be reported. Antibiotic therapy should be initiated, and the patient should be referred to a dentist within 24 hours for definitive management and monitored for complications such as osteomyelitis.

Postextraction bleeding may occur from small vessels that continue to bleed after a tooth extraction. After the clot is removed, a pressure dressing using cotton wrapped in gauze may be applied directly to the extraction site for approximately 30 minutes. This may be repeated until the bleeding resolves. If bleeding continues, the site may be anesthetized using lidocaine with epinephrine and sutured. In addition, oxidized cellulose, topical thrombin in a gelatin sponge, or microfibrillar collagen can be placed in the socket to act as a hemostatic agent and to tamponade bleeding. A patient with prolonged bleeding should be referred to the oral surgeon for definitive treatment.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Tooth extraction usually within previous 24 hours if bleeding present

b) Severe pain (see Chapter 9) several days after tooth extraction (dry socket)

2) Past medical history

a) Current or preexisting diseases/illness

b) Previous difficult extractions

c) Smoking history

d) Medications

e) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Mild to moderate distress/discomfort

b) Inspection

(1) Bleeding from socket

(2) Socket healing: may be delayed in dry socket syndrome

2) Diagnostic procedures

a) Clot removal from socket

2. Analysis: differential nursing diagnoses/collaborative problems

a. Risk for deficient fluid volume

b. Acute pain

c. Anxiety/fear

d. Risk for infection

3. Planning and implementation/interventions

a. Prepare for/assist with medical procedures

1) Control bleeding

a) Have patient bite on gauze over extraction site for 30 minutes

b. Administer pharmacologic therapy as ordered

1) Non-narcotic analgesics

2) Narcotics

3) Pack socket with oil of wintergreen or other local anesthetic

c. Educate patient and significant others

1) Bite on gauze over extraction site if bleeding reoccurs

2) Refer to dentist for follow-up

3) Avoid eating hard or hot foods

4. Evaluation and ongoing monitoring (see Appendix B)

a. Bleeding control

b. Pain relief

G. Acute Necrotizing Ulcerative Gingivitis (Trench Mouth)

Acute necrotizing ulcerative gingivitis (ANUG) is a noncontagious infection commonly referred to as trench mouth or Vincent’s angina. ANUG is associated with debilitating illnesses, immunosuppression, emotional stressors, nutritional deficiencies, and smoking. It is often found in patients following an upper respiratory tract infection. It is commonly seen in adolescents and young adults but can occur in all age groups. Both spirochete and fusiform bacilli that affect gingival tissue cause ANUG. Inflammation, painful bleeding gums, fever, cervical lymphadenopathy, and fetid breath may result. Ulcerations may develop within the gingival tissue and may form a gray membrane that bleeds with pressure or when removed. Treatment measures include local débridement, good oral hygiene with one-half strength hydrogen peroxide (H₂O₂) or oral chlorhexidine (e.g., Peridex) rinses, antibiotics, and adequate nutrition. Efforts to avoid irritation should be encouraged, and analgesics should be provided after initial débridement to minimize pain. Recovery usually occurs within 24 hours. Patients may require gingival curettage.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Pain (see Chapter 9)

b) Fever, chills, and malaise

c) Bleeding gums

d) Halitosis, foul metallic taste

2) Past medical history

a) Current or preexisting diseases/illness

(1) Immunosuppression

(2) Gum disease or pharyngeal infection

b) Previous dental injury

c) Poor nutrition and dental habits

d) Medications

e) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Odors: fetid breath

(2) Elevated temperature: greater than 101°F (38.3°C)

(3) Mild distress/discomfort

b) Inspection

(1) Spontaneous gingival bleeding

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