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D.
Ask about allergies.
E.
Inquire about recent dental problems, especially dental
7: NASAL GUIDELINES
abscesses.
F.
Find out what home therapies and over-the-counter (OTC)
medications the client tried before the ofce visit.
G.
Ask if the client took a trip recently, especially by airplane.
H.
In pediatric clients, look for a foreign object up thenose.
I.
Inquire whether the client was swimming or diving recently.
J.
Review the client’s medical history for cystic brosis, nasal
anatomic abnormalities, asthma, and other respiratory problems.
DIFFERENTIAL
A.
Headache (cluster, migraine).
B.
Rhinitis (allergic or nonallergic).
C.
Nasal polyps.
D.
Temporomandibular joint disease.
E.
Trigeminal neuralgia.
F.
Cerebral spinal uid rhinorrhea.
G.
Tumor/neoplasm.
H.
Autoimmune disease.
I.
Odontogenic disease.
DIAGNOSES
PHYSICAL
A.
Check vitals: temperature, blood pressure, pulse, and
EXAMINATION
respirations.
B.
Inspect:
1.
Examine general appearance:
a.
Look for erythema, swelling, or tenderness. Facial
cellulitis may be an indication that acute sinusitis has
spread outside of the sinuses.
2.
Examine eyes
a.
Look for periorbital swelling, erythema, epiphora,
“allergic shiners,” and signs of orbital cellulitis (conjunctival edema, drooping lid, decreased extraocular
motion, and vision loss).
b.
Thorough ophthalmologic examination with extra-
ocular movements and visual acuity should be performed to rule out subperiosteal or intraorbital abscess.
3.
Examine ears, nose, and throat.
a.
Inspect nose with nasal speculum for erythema,
edema, discharge, patency, anatomic abnormalities,
polyps, or foreign body.
b.
Inspect oral cavity for evidence of oroantral stula
or dental causes for sinusitis or facial pain.
C.
Palpate:
1.
All sinuses for pain and tenderness:
a.
Frontal sinusitis: pain on palpation of the forehead.
b.
Maxillary sinusitis: the cheeks are tender, or the cli-
ent may present with jaw and tooth pain.
c.
Ethmoid sinusitis: swelling and tenderness in the
eyelids and surrounding tissue.
2.
Neck for lymphadenopathy.
D.
Auscultate:
1.
Heart.
2.
Lungs.
E.
Perform neurologic examination:
1.
Evaluate for signs of meningeal irrigation, assessing
Brudzinski sign, Kernig sign, and nuchal rigidity.
DIAGNOSTIC
A.
Diagnosis is usually made through history and physical.
B.
If the disease is refractory to initial treatment or becomes
TESTS
recurrent or chronic, further investigation may be necessary.
1.
Rule out immunodeciencies (cystic brosis, Wegener
granulomatosis, sarcoidosis, Churg–Strauss syndrome).
2.
Skin testing for allergies.
3.
Nasal endoscopy to detect abnormalities of the
nasal passage (polyps, pus). Culture can be obtained for
culture-directed antimicrobial treatment.
4.
Sinus CT is the best imaging method for viewing para-
nasal sinuses and reveals extent of inammation and disease. CT is not recommended for routine investigation of
acute rhinosinusitis. It is recommended for chronic and
recurrent sinusitis, for clients in immunocompromised
state, or if there is concern for complications (fungal sinusitis, disease that extends outside of the sinus cavities, etc.).
PLAN
A.
General interventions:
1.
Preventive techniques are suggested to avoid getting
acute viral sinusitis (hand hygiene, saline irrigations, etc.).
2.
Clients with recurrent sinusitis should be encouraged
to keep a log of potential triggers. Avoiding these triggers helps prevent the onset of acute sinusitis (e.g., avoid
smoke and use nasal saline irrigations).
3.
Clients with frequent recurrent sinusitis should have fur-
ther workup for other causes, such as autoimmune diseases.
B.
Client teaching: See Client Teaching Guide for this chapter,
"Sinusitis."
1.
Teach client to avoid allergens and irritants, including
smoking and secondhand smoke.
2.
Encourage regular use of nasal saline irrigations, espe-
cially after exposure to allergens or irritants or with onset
of sinusitis symptoms.
3.
Encourage the client to use medications as prescribed.
OTC medications, such as pain relievers and decongestants, can be helpful but should be used with caution.
4.
Application of warm, moist compress to the face sev-
eral times a day will help with discomfort.
5.
Humidiers can be helpful, especially in the winter
months.
C.
Pharmaceutical therapy:
1.
Acute viral sinusitis:
a.
Supportive care, OTC medications (analgesics and
decongestants), and saline irrigations.
2.
Acute bacterial sinusitis:
a.
Pediatric drugs of choice for acute sinusitis:
i.
First-line treatment: Augmentin 45 mg/kg/d
PO in BID dosing for 10 to 14 days.
ii.
Second-line treatment: Augmentin 90mg/kg/d
PO in BID dosing for 10 to 14 days.
iii.
Beta-lactam allergy:
1)
Type I hypersensitivity: levooxacin 10 to
20mg/kg/d PO every 12 or 24 hours for 10 days.
2)
Non-type I hypersensitivity: cefpodoxime
10mg/kg/d PO in divided doses Q12H or cefdinir 14mg/kg/d PO every 12 to 24 hours or
levooxacin 10 to 20mg/kg in divided doses
every 12 to 24 hours.
iv.
Risk of antibiotic resistance or failed initial
therapy:
1)
Augmentin 90mg/kg/d PO BID for 10 to
14 days.
2)
Cefpodoxime 10 mg/kg/d PO in divided
doses Q12H.
3)
Cefdinir 14mg/kg/d PO in divided doses
every 12 or 24 hours.
4)
Levooxacin 10 to 20 mg/kg/d PO in
divided doses every 12 or 24 hours.
5)
Ceftriaxone 50mg/kg intramuscularly for 1
to 3 days followed by appropriate oral regimen.
b.
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Adult drugs of choice for acute sinusitis: Initial
treatment should be 5 to 7 days; if not improving on
initial therapy can extend to 10 to 14 days.
i.
First-line treatment: Augmentin 875mg BID or
500mg TID.
ii.
At risk of pneumococcal resistance or failed ini-
tial therapy: Augmentin 2,000 mg BID.
iii.
Beta-lactam allergy: doxycycline 100mg BID or
200mg daily.
iv.
Respiratory uoroquinolone can be considered
as alternative to penicillin-allergic clients but should
be reserved for those who have no alternative treatment options: levooxacin 750mg or 500mg daily
or moxioxacin 400mg daily.
3.
The same antibiotics can be used for chronic sinusitis,
but treatment should last 3 to 6 weeks.
4.
Oral and topical decongestants to correct the underly-
ing edematous mucosa (use cautiously with hypertension):
a.
Oxymetazoline (Afrin) 0.05% spray:
i.
Decongestant NOT recommended as monother-
apy in chronic treatment but can help with severe
nasal congestion.
ii.
6 years to adult, one to two sprays each nare,
one to two times daily.
iii.
Must not use longer than 3 days due to
rebound congestion.
b.
Phenylephrine (Neo-Synephrine) 1% spray or
drops:
i.
Decongestant NOT recommended as monother-
apy in chronic treatment, but can help with severe
nasal congestion.
ii.
12 years to adult, one to two spray/drop each
nare Q4H.
iii.
Must not use longer than 3 days due to
rebound congestion.
c.
Pseudoephedrine 60mg PO up to TID for adults.
5.
Nasal saline:
a.
Nasal saline irrigations or spray to nares one to three
times daily as needed for hydrating the nasal mucosa.
6.
Nasal corticosteroid sprays may be used to reduce
nasal inammation. These are only recommended for children if they have underlying allergic rhinitis.
a.
Fluticasone propionate (Flonase), 50 mcg/spray:
i.
Not recommended for children under 4 years.
ii.
Children 4 to 11 years, one spray each nare daily.
iii.
12 years to adult, two sprays each nare daily.
b.
Mometasone (Nasonex), 50 mcg/spray:
i.
Not recommended for children under 2 years.
ii.
Children 2 to 11 years, one spray each nare daily.
iii.
12 years to adult, two sprays each nare daily.
c.
Beclomethasone (Beconase) 42 mcg/spray or Qnasl
80 mcg/spray:
i.
Not recommended for children under 6 years.
ii.
Children 6 to 11 years, one to two sprays BID
with 42-mcg product.
iii.
12 years to adult, two sprays each nare daily
with 80-mcg product.
d.
Budesonide (Rhinocort), 32 mcg/spray:
i.
Not recommended for children under 6 years.
ii.
Children 6 to 11 years, one spray each nare BID.
iii.
12 years to adult, two sprays each nare daily.
e.
Triamcinolone (Nasacort), 55 mcg/spray:
i.
Not recommended for children under 2 years.
ii.
Children 2 to 5 years, one spray each nare daily.
iii.
6 years to adult, two sprays each nare daily.
SINUSITIS
f.
Flonase furoate (Flonase Sensimist), 27.5 mcg/
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spray:
i.
Not recommended for children under 2 years.
ii.
Children 2 to 11 years, one spray each nare daily.
iii.
12 years to adult, two sprays each nare daily.
7.
Antihistamines are recommended to block histamine
production in response to allergy triggers and prevent
allergy symptoms.
a.
Cetirizine (Zyrtec):
i.
6 months to 2 years, 2.5 mg daily.
ii.
Children 2 to 5 years, 5 mg daily.
iii.
6 years to adult, 10mg daily.
b.
Levocetirizine (Xyzal):
i.
Children 6 to 11 years, 2.5 mg daily.
ii.
12 years to adult, 5 mg daily.
c.
Loratadine (Claritin):
i.
Children 2 to 5 years, 5 mg daily.
ii.
6 years to adult, 10mg daily.
d.
Fexofenadine (Allegra):
i.
6 months to 2 years, 15mg BID.
ii.
Children 2 to 11 years, 30mg BID.
iii.
12 years to adult, 180mg daily.
FOLLOW-UP
A.
Recheck the client in 5 to 7 days after initial therapy; if
no improvement, consider extending therapy or alternative
therapy.
B.
If client is not improving and may be resistant to antibiot-
ics, they may be switched to a different antibiotic for 14 days.
CONSULTATION/REFERRAL
A.
Admit client to the hospital if they show signs and symp-
toms that the disease has spread intracranially or intraorbitally.
B.
Refer client to an otolaryngologist if they do not improve
in 4 weeks or after failed medical therapy.
C.
Refer client to an otolaryngologist for suspected neoplasm,
abscess, osteomyelitis, meningitis, or sinus thrombosis.
INDIVIDUAL
A.
Pediatrics:
1.
CONSIDERATIONS
Children with clinical course consistent with acute
bacterial rhinosinusitis (purulent drainage, fever, etc. for
greater than 7–10 days) should be treated with antimicrobial therapy at time of presentation.
B.
Pregnancy:
1.
Pregnant individuals typically have worse rhinitis or
sinusitis symptoms due to increase in blood volume and
shifts to extravascular space.
2.
Watchful waiting is suggested for clients who have
good follow-up.
3.
Antibiotic therapy: Weigh risk and benet of treating
sinusitis during pregnancy. Antimicrobials with category
B rating include penicillins, cephalosporins, clindamycin,
erythromycin, and azithromycin. Avoid doxycycline and
uoroquinolones.
4.
Antihistamines: Loratadine and cetirizine are
category B.
5.
Intranasal steroid: Budesonide is category B.
C.
Geriatrics:
1.
Chronic sinusitis can affect cognitive functioning in the
older adults population.
2.
It is important to treat sinusitis in the geriatric popula-
tion, but considerations need to be made when prescribing
antibiotics in the setting of other comorbidities (e.g., renal
and hepatic insufciency).
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BIBLIOGRAPHY
Borish, L., Baroody, F. M., Kim, M. S., Lieberman, J. A., Peters, A., Stevens,
W. W., & Bernstein, J. A. (2022). Yardstick for the medical management
of chronic rhinosinusitis. Annals of Allergy, Asthma & Immunology,
128(2), 118–128.
Larson, L. E., & File, T. M. (2021). Treatment of respiratory infections in preg-
nant patients. In V. Berghella (Ed.), UpToDate. Wolters Kluwer. https://
www.uptodate.com/contents/treatment-of-respiratory-infectionsin-pregnant-patients?sectionName=Sinusitis&search=sinusitis&topic
Ref=83012&anchor=H7&source=see_link#H7
Patel, Z. M., & Hwang, P. H. (2021). Uncomplicated acute sinusitis and
rhinosinusitis in adults: Treatment. In . T. M. File, & D. G. Deschler
(Eds.), UpToDate. Wolters Kluwer. https://www.uptodate.com/
contents/uncomplicated-acute-sinusitis-and-rhinosinusitis-inadults-treatment?search=sinusitis&source=search_result&selectedTit
le=1~150&usage_type=default&display_rank=1#H17857080
Patel, Z. M., & Hwang, P. H. (2021). Uncomplicated acute sinusitis and
rhinosinusitis in adults: Clinical manifestations and diagnosis. In T. M.
File& D. G. Deschler (Eds.), UpToDate. Wolters Kluwer. https://www.
uptodate.com/contents/acute-sinusitis-and-rhinosinusitis-in-adults
-clinical-manifestations-and-diagnosis?search=sinusitis&source=sear
ch_result&selectedTitle=6~150&usage_type=default&display_rank=
3#H4
Wald, E. R. (2021). Acute bacterial rhinosinusitis in children: Microbiology
and management. S. L. Kaplan, G. C. Isaacson, & R. A. Wood
(Eds.), UpToDate. Wolters Kluwer. https://www.uptodate.com/
contents/acute-bacterial-rhinosinusitis-in-children-microbiologyand-management?search=sinusitis%20treatment%20children&source
=search_result&selectedTitle=1~150&usage_type=default&display_
rank=1#H3526500914
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CLIENT
TEACHING GUIDE
ALLERGIC RHINITIS
PROBLEM
discharge. It is not contagious; therefore, you cannot catch it from anyone and you cannot spread it to others.
CAUSE
voke an allergic reaction).
PREVENTION/CARE
A.
The best prevention is to avoid things you know you are allergic to, for example, pollens and molds, pet dander, dust mites,
and insects (cockroaches).
B.
Target to make bedroom as “allergy-free” by removing carpets, rugs, and window drapes; wash sheets weekly using hot water;
mop oors weekly; remove books and stuffed animals; and use pillow and mattress covers.
C.
Do not blow your nose too frequently or too hard. This will irritate the nasal tissue. It may also cause your eardrum to perforate
(tear). Blow through both nostrils at the same time to equalize the pressure.
D.
Use tissues when you blow your nose. Dispose of them and then wash your hands. If no tissue is available, do the “elbow
sneeze” into the bend of your arm (away from your open hands). Always wash your hands.
TREATMENT
A.
Use a high-efciency particulate air (HEPA) lter to reduce exposure to dust mites.
B.
Keep humidity level between 30% and 50% to reduce exposure to dust mites and molds.
C.
Dust your house often, using a cloth and cleaner or polish to keep dust from ying.
D.
Allergy testing may need to be done if you have had allergies for a long time. Ask your healthcare provider about a consultation
with an allergist.
Allergic
rhinitis is a chronic or recurrent condition. Common symptoms are nasal congestion, sneezing, and clear nasal
Yo u
are having an allergic response after being exposed to small airborne particles called allergens (substances that pro-
PLAN
Activity:
There are no activity restrictions. However, you may want to exercise indoors during the spring, summer, and fall when
pollen counts are high.
Diet:
Eat well-balanced meals. Drink at least six to eight glasses of water a day.
Medications:
A.
Antihistamines: Some antihistamines may cause drowsiness. Use with caution. You may consider using a different antihista-
Common medications used include antihistamines, decongestants, and nasal sprays.
mine during the day that does not cause drowsiness or take the antihistamine at night before bed.
B.
Decongestants: Decongestants may increase blood pressure and may also interact with other medications. Please consult
with your provider before using these medications.
C.
Nasal sprays: Nasal saline spray is safe to use in the nose several times a day. Nasal steroid spray is the treatment of choice
for chronic management of nasal allergies. Nasal decongestant sprays may be used for a short period of time. Do NOT use longer
than 3 days to prevent rebound side effects from this medication. Consult with your provider if using a nasal decongestant spray.
You
Have Been Prescribed:
You
Need to Take:
You
Need to Notify the Office If:
A.
You experience trouble breathing or catching your breath.
B.
You have asthma; call if your symptoms are worse.
C.
Your symptoms are worse after using the medications for three complete days or if they do not improve after 4 to 6 weeks of
using the allergy medications.
D.
Other:
Phone:
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
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CLIENT
TEACHING GUIDE
NOSEBLEEDS
PROBLEM
If
you have trouble breathing, chest pain, or feel woozy with a nosebleed,
CAUSES
A.
Trauma from nose-picking or forcefully blowing the nose.
B.
Frequent colds.
C.
Allergies or exposure to irritants.
D.
Drugs, including over-the-counter medications such as aspirin and Pepto-Bismol, or street drugs such as snorted cocaine.
E.
Breathing dry air all the time.
PREVENTION/CARE
A.
Avoid picking your nose. Keep ngernails trimmed short.
B.
Do not blow your nose too frequently or too hard (this may also cause eardrum tearing).
C.
Blow your nose through both nostrils at the same time to equalize pressure.
D.
Use a humidier in your home.
E.
Keep the inside of your nose moist and promote healing with a nasal saline spray or gel.
F.
Avoid smoking and secondhand smoke.
TREATMENT
A.
If you experience a nosebleed, take the following steps:
1.
2.
3.
4.
5.
6.
or hard nose-blowing.
B.
Gently blowing your nose also reduces or stops a nosebleed.
Most
nosebleeds stop on their own within 15 to 20 minutes.
call 911.
Nosebleeds
may be due to several problems:
PLAN
Sit up and lean forward.
Pinch the soft area toward the bottom of your nose below the bone, hold for 15 minutes (5 minutes in children).
If the bleeding continues, spray Afrin into your nostril.
If the bleeding still continues, lightly soak a cotton ball with Afrin, insert it into your nose, and pinch for 15 minutes.
If the bleeding continues, seek medical care.
If the bleeding stops, use nasal saline spray and gel to keep the area moist and promote healing. Avoid picking your nose
Activity:
A.
B.
C.
D.
Diet:
Medications:
You
You
You
A.
B.
C.
Phone:
Avoid or limit the following activities for 3 to 5 days after a nosebleed:
Heavy lifting.
Straining.
Bending over from the waist.
Very hot showers.
Avoid hot, spicy foods for 3 to 5 days after a nosebleed.
Avoid medications that increase bleeding, such as aspirin and Pepto-Bismol.
Have Been Prescribed:
Need to Take:
Need to Notify the Office If:
Bleeding does not stop with pressure or nasal spray applied to the bleeding site.
You keep having nosebleeds (more than two in a week or four in a month).
Other:
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
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193
CLIENT TEACHING GUIDE
SINUSITIS
PROBLEM Sinusitis (sinus infection) is classied as an acute, subacute, or chronic condition. In acute sinusitis, the sinus inam-
mation is resolved after treatment. In subacute sinusitis, there are persistent symptoms despite treatment. In chronic sinusitis,
episodes of prolonged inammation continue longer than 3 months despite treatment.
CAUSE Sinusitis occurs when the mucous lining in your sinus cavities becomes inamed due to a virus, bacteria, or allergen. This
can also occur after a cold or tooth abscess.
PREVENTION/CARE
A. If you have a tooth abscess, see your dentist and nish all your antibiotics.
B. Do not blow your nose too frequently or too hard. This will irritate the nasal tissue. It may also cause your eardrum to perforate
(tear). Blow through both nostrils at the same time to equalize pressure.
C. To prevent spreading germs to others, cover your mouth when you cough.
1. Use tissues when you blow your nose. Dispose of them and then wash your hands.
2. If no tissue is available, do the “elbow sneeze” into the bend of your arm (away from your open hands).
D. Always wash your hands after coughing or using tissues.
TREATMENT PLAN
A. Avoid smoking and secondhand smoke.
B. Use steam inhalation to liquefy secretions.
C. Use a room humidier. Keep your humidier clean—it can grow bacteria.
Activity: There are no activity restrictions; however, diving, swimming, and ying may increase the occurrence of symptoms or
make them worse. Make sure to get plenty of rest each day.
Diet: Eat a healthy diet. Drink at least 8 to 10 glasses of water every day.
Medications: Take all of your prescribed medications (antibiotics and/or steroids), even if you feel better.
Over-the-Counter Medications:
A. Pain relievers: ibuprofen (Advil) or acetaminophen (Tylenol) as needed for facial pain.
B. Antihistamines: Some antihistamines may cause drowsiness. Use with caution. You may consider using a different antihista-
mine during the day that does not cause drowsiness or take the medication before bed.
C. Decongestants: Decongestants may increase blood pressure and may also interact with other medications. Please consult
with your provider before using these medications.
D. Nasal sprays: Nasal saline spray is safe to use in the nose several times a day. Nasal decongestant sprays may be used for
a short period of time. Do NOT use longer than 3 days to prevent rebound side effects from this medication. Consult with your
provider if you are using a nasal decongestant spray.
You Have Been Prescribed:
You Need to Take:
You Need to Call the Office If:
A. Your eyelids begin to swell or droop, or you experience decreased or double vision.
B. You have stiffness in your neck or increased fever.
C. You have asthma and you are getting worse.
D. You begin vomiting and are unable to keep down your antibiotic.
E. You are a diabetic and your blood sugars are elevated, or you notice ketones in your urine.
F. You have confusion or difculty thinking clearly.
G. Other:
Phone:
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
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C H A P T E R
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THROAT AND MOUTH GUIDELINES
Jill C. Cash
AVULSED TOOTH
DEFINITION
A. An avulsed tooth is a tooth that has been completely dis-
placed from its alveolar socket.
INCIDENCE
A. Avulsion accounts for 0.5% to 3% of all dental injuries to the
permanent teeth. It occurs predominantly in children between
the ages of 7 and 10 years. Multiple studies have shown that
this is one of the most serious dental injuries. The upper central incisor is the most frequent tooth that is avulsed.
PATHOGENESIS
A. Trauma causes a tooth to be completely displaced from its
alveolar socket.
PREDISPOSING FACTOR
A. Erupting teeth are most susceptible to avulsion due to
immature periodontal ligaments.
COMMON COMPLAINTS
A. Tooth displaced.
B. Pain.
C. Bleeding.
SUBJECTIVE DATA
A. Ascertain the client’s age and note if the avulsed tooth is
primary or permanent. Only permanent teeth are considered
for reimplantation.
B. Determine the time span for which the tooth has been
avulsed (minutes or hours).
C. Ask the client about the underlying cause or trauma. Are
there any other injuries that need assessment, such as lacerations or concussion?
D. Did the tooth fall out of the mouth or remain in the mouth?
PHYSICAL EXAMINATION
A. Check temperature, pulse, respirations, and blood pressure.
B. Inspect:
1. Observe general appearance:
a. Check for signs that are secondary to traumatic eti-
ology, such as lacerations, concussion, facial injury, and
eye injury.
b. Keep the client calm. Check to be sure that the client is
not in respiratory distress or has not aspirated the tooth.
2. Inspect gums and avulsed tooth, noting poor dental
hygiene. Do not touch the root surface.
3. If the tooth is not in the mouth, rinse off briey under
cold running water (<10 seconds).
DIAGNOSTIC TESTS
A. Dental x-ray should be considered to assess for fracture.
Immediate referral to a dental specialist for emergency dental
evaluationis recommended.
DIFFERENTIAL DIAGNOSES
A. Avulsed tooth.
B. Luxation injuries: concussion and subluxation.
PLAN
A. General interventions:
1. Refer immediately for emergency dental evaluation
and treatment as prognosis is highly dependent on actions
taken promptly after the avulsion occurs.
2. Clinician should attempt to reposition the tooth into the
socket if there is no concern of the child swallowing the tooth
or dropping it. If this is not possible, place the tooth in a glass
of milk or another suitable storage medium, such as saline or
Hanks balanced storage medium. Avoid storage in water.
B. Client teaching:
1. If the client or parent is not in a healthcare setting,
phone triage should include informing the client not to let
the tooth air-dry; it may cause permanent destruction of
the periodontal cells.
2. Instruct the client to avoid touching the root base, and
to attempt to insert the tooth in the tooth socket and bite
on a gauze or a small handkerchief to help hold the tooth
in position.
3. If unable to transport inside the tooth socket, as above,
advise client to use another medium to transport the tooth,
such as milk.
C. Pharmaceutical therapy:
1. Consider administering oral antibiotics prophylac-
tically. Consider tetracycline or doxycycline for adults.
Amoxicillin may be used for children.
2. If the tooth had contact with soil, determine tetanus
status and administer tetanus booster if necessary.
FOLLOW-UP
A. Follow-up is done with the dentist until stabilization is
complete.
CONSULTATION/REFERRAL
A. Immediately refer the client to a dentist or an ED. Teeth
replanted within 30 minutes have the best prognosis. Teeth
avulsed longer than 2 hours have a poor prognosis.
INDIVIDUAL CONSIDERATIONS
A. Pediatrics:
1. Primary teeth do not need to be replaced.
The contributions of Moya Cook and Jamie Wiggleton to this chapter in prior editions are acknowledged here.
196
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8: THROAT AND MOUTH GUIDELINES
BIBLIOGRAPHY
American Academy of Pediatric Dentistry. (n.d). Guidelines for the manage-
ment of traumatic dental injuries: 2. Avulsion of permanent teeth https://
www.aapd.org/globalassets/media/policies_guidelines/
e_avulsion.pdf
Doshi, D. (2009). Bet 3. Avulsed tooth brought in milk for replantation.
Emergency Medicine Journal, 26(10), 736–737.
Sedlaceck, P., Poi, W. R., Amaral, M. F., Castilho, L. R., Panzarini, S. R.,
Saito, C. T. M. H., & Brandini, D. A. (2022). Educational impact of notebook covers on the knowledge of sixth-grade primary pupils about
tooth avulsion and replantation: A randomized trial. Health Education
& Behavior, 49(3), 525–533. https://doi-org.proxy.library.vanderbilt.
edu/10.1177/1090198121991468
DENTAL ABSCESS
DEFINITION
A. A dental abscess is a space infection of the gingival or peri-
odontal tissues.
INCIDENCE
A. Incidence is unknown.
PATHOGENESIS
A. An abscess occurs when bacteria gain access into the
gingiva or periodontal tissues. The most common bacteria
are Streptococcus viridans, Peptostreptococcus, Prevotella, and
staphylococci.
C. Note if pain is brought on by contact with hot, cold, or
sweet substances; this may indicate periapical abscess or dental caries.
D. Ask if the client has a fever. If so, how high and for how
long?
E. Inquire about history of mitral valve prolapse or rheu-
matic fever.
PHYSICAL EXAMINATION
A. Check temperature, pulse, respirations, and blood pressure.
B. Inspect:
1. Inspect teeth for caries, mobility, or protrusion from
sockets, and gum disease.
2. Examine the teeth for erosion, enamel decalcication,
diminished tooth size, discoloration, and sensitivity to
temperature changes.
C. Palpate:
1. Neck and submental area for enlarged, tender lymph
nodes.
D. Percuss:
1. Teeth tenderness is diagnostic of an abscess.
E. Auscultate:
1. Heart if indicated.
DIAGNOSTIC TESTS
A. None usually required; however, check white blood cell
count (WBC)if cellulitis is suspected.
PREDISPOSING FACTORS
A. Poor dental hygiene.
B. Dental caries.
C. Certain underlying diseases, such as diabetes melli-
tus, rheumatoid arthritis, and various genetic disorders that
impair neutrophil function.
COMMON COMPLAINTS
A. Constant, severe jaw pain.
B. Swelling.
C. Difculty in chewing with tooth due to pain.
OTHER SIGNS AND SYMPTOMS
A. Fever.
B. Warmth and redness.
C. Loss of appetite.
D. Heat and cold sensitivity.
E. Halitosis.
POTENTIAL COMPLICATIONS
A. Risk of complications increases with valvular disease.
The following are the complications:
1. Extension to potential orofacial space infections (buccal,
submental, masticator, and infratemporal fossa) or deep in
the head and neck (parapharyngeal space infections).
2. Facial cellulitis.
4. Orocutaneous stula.
5. Sepsis.
6. Hematogenous dissemination to native or prosthetic
heart valves, joints, or other devices.
SUBJECTIVE DATA
A. Elicit information from the client regarding the onset,
duration, location, and quality of pain.
B. Note the radiation of pain as well as alleviating or aggra-
vating factors.
DIFFERENTIAL DIAGNOSES
A. Periodontal disease.
B. Cellulitis.
C. Oral cancer.
PLAN
A. General interventions:
1. Initiate antimicrobial therapy.
2. Refer to the dentist for immediate evaluation and
treatment.
B. Client teaching:
1. Advise the client to apply a heating pad to the painful
facial area for comfort.
2. Advise a soft diet until pain resolves.
3. Review daily dental care and hygiene with the client.
C. Pharmaceutical therapy:
1. Given increasing resistance due to beta-lactamase
production, amoxicillin-clavulanate 875mg BID for 7 to
14 days (pediatric dosage 25–45 mg/kg Q24H divided
BID, maximum dosage 1,750 mg/d, using amoxicillin
400mg/clavulanate 57mg formulation) is the preferred
regimen.
2. For penicillin-allergic clients, use clindamycin 450mg
Q8H for 7 to 14 days (pediatric dosage 10–30mg/kg Q24H
divided every 6 to 8 hours).
3. For discomfort and fever, use ibuprofen (Advil) 400 to
600mg orally every 6 to 8 hours, not to exceed 1,200mg/d
(pediatric dosage: 10mg/kg/dose every 6 to 8 hours).
FOLLOW-UP
A. Follow up 2 to 3 days after dental examination to evaluate
results.
CONSULTATION/REFERRAL
A. Advise the client to see a dentist promptly, even if pain
resolves.
EPIGLOTTITIS
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197
INDIVIDUAL CONSIDERATIONS
A. Pregnancy:
1. It is safe for clients to have dental procedures during
pregnancy.
2. X-ray lms may be taken with a lead shield over the cli-
ent’s abdomen.
3. Epinephrine and nitrous oxide should not be used dur-
ing dental procedures.
4. Tetracycline should not be used; it causes staining of
fetal bones and teeth.
BIBLIOGRAPHY
Biyani, P., Lundgren, R., Thompson, A., & Orr, R. (2021). Not all swellings
are dental abscesses: A cautionary tale. Dental Update, 48(4), 279–282.
https://doi-org.proxy.library.vanderbilt.edu/10.12968/denu.2021.
48.4.279
Menegas, S., Moayedi, S., & Torres, M. (2021). Abscess management: An
evidence-based review for emergency medicine clinicians. Journal of
Emergency Medicine (0736-4679), 60(3), 310–320. https://doi-org.proxy.
library.vanderbilt.edu/10.1016/j.jemermed.2020.10.043
Stephens, M. B., Wiedemer, J. P., & Kushner, G. M. (2018). Dental problems
in primary care. American Family Physician, 98(11), 654–660.
EPIGLOTTITIS
DEFINITION
A. Epiglottitis is acute, rapidly progressive inammation and
swelling of the epiglottis. Due to dangers of potentially fatal
airway obstruction, it is considered a medical emergency.
INCIDENCE
A. The incidence of epiglottis has decreased dramatically
since the Haemophilus inuenzae type B (Hib) vaccine was
introduced.
B. In immunized populations, epiglottis is estimated to range
from 0.6 to 0.8 cases per 100,000.
C. Epiglottis affects children and adults. It presents more
acutely in young children than in adolescents and adults.
D. The median age of children with epiglottitis has increased
from 3 years of age to 6 to 12 years since the introduction of
vaccines against Hib.
PATHOGENESIS
A. Epiglottitis is most commonly caused by H. inuenzae.
Other pathogens include Streptococcus (including group A
streptococcus), Staphylococcus, and H. parainuenzae.
B. Viruses have not been established as causes of acute
epiglottitis.
C. Other causes include trauma/injury or ingesting caustic
agents.
PREDISPOSING FACTORS
A. Upper respiratory infection.
B. Lack of immunization against Hib.
C. Immune deciency.
D. Associated with comorbid conditions, including hyperten-
sion, diabetes mellitus, and substance abuse in adults.
COMMON COMPLAINTS
A. Children:
1. Sudden onset of dysphagia, drooling, and distress
(“the three Ds”) are hallmarks of epiglottitis.
2. Children present in distress and anxious; they may have
the classic “tripod” or “snifng” posture, that is, sitting
position with trunk leaning forward, neck hyperextended,
and chin thrust forward.
3. Sudden onset of high fever.
4. Severe sore throat and/or odynophagia.
5. Stridor.
B. Adults:
1. Sore throat or odynophagia: the most common present-
ing symptom.
2. Fever.
3. Mufed voice or hoarseness.
4. Drooling.
5. Stridor.
C. Airway compromise is less common in adults than in
children.
SUBJECTIVE DATA
A. Determine the onset, duration, and course of illness.
B. Is the client’s breathing labored or does the client have
stridor?
C. Has the client had a fever?
D. Has the client had trouble swallowing or talking?
PHYSICAL EXAMINATION
A. Check temperature, pulse, respirations, and blood pressure.
B. Inspect:
1. Observe overall appearance.
2. Check nail beds and lips for cyanosis.
3. Note drooling or difculty in swallowing.
4. Note breathing pattern and rhythm.
5. Do not examine the throat—airway occlusion may
result.
C. Auscultate:
1. Heart.
2. Lungs.
DIAGNOSTIC TESTS
A. Lateral neck radiograph conrms diagnosis, typically reveal-
ing enlarged edematous epiglottis (the “thumbprint sign”).
However, this test may delay the establishment of an airway.
DIFFERENTIAL DIAGNOSES
A. Epiglottitis.
B. Bacterial tracheitis (a pediatric emergency).
C. Laryngotracheitis.
D. Angioedema (anaphylaxis).
E. Foreign-body aspiration.
F. Retropharyngeal or peritonsillar abscess.
PLAN
A. General interventions:
1. Prompt recognition and appropriate treatment usually
result in rapid resolution of swelling and inammation.
2. Obtain emergency medical transport to ED.
3. Management of the airway is the most critical aspect of
initial care when epiglottitis is suspected. While awaiting
transport, start oxygen, assemble airway equipment, and
move the client as little as possible.
4. If the client is unable to maintain an airway, bag-valve-
mask ventilation with 100% oxygen should be initiated.
B. Client teaching:
1. Educate the client and their family that epiglottitis is a
medical emergency.
2. If client has drooling and no cough, diagnosis is most
likely epiglottitis.
C. Pharmaceutical therapy:
1. Defer pharmaceutical therapy with steroids and antibi-
otics to hospital team.
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