Oral Lesions You Can’t Afford to Miss

HOW TO SPOT SIGNS OF COMMON DENTAL DISEASES

In 2010 in the United States, close to 1.4 million emergency department visits and about $1 billion in hospital charges were due to dental problems.⁴ Approximately 40% of these visits were made by individuals without insurance.⁴ Due to a lack of dental insurance, patients may present to a medical professional rather than a dental professional. Additionally, uninsured individuals may neglect their dental problem until it becomes a medical emergency. Family practice clinicians need to recognize dental disease and be able to provide basic management of emergencies.⁵

Dental abscess. A dental abscess can arise from pulpal infection (due to progression of caries) or periodontal infection (due to progression of periodontal disease). Pain symptoms are variable; however, intense, spontaneous cyclical pain is generally characteristic of a dental abscess of pulpal etiology, whereas a periodontal abscess can have less obvious symptoms. Swelling intraorally or extraorally indicates the spread of a localized infection (see Figure 5).

Severe infection and swelling can limit mouth opening and function and in extreme cases may obstruct swallowing and even breathing (eg, Ludwig’s angina). Affected teeth may or may not demonstrate obvious findings of advanced dental disease, such as gross caries, fracture, heavy calculus deposits, or marked periodontal attachment loss. Oral examination may reveal a parulis (focal erythematous swelling of the adjacent gingiva with a central draining sinus tract) (see Figure 6) and percussion of the affected tooth is generally painful.

Pericoronitis is infection and swelling of the gingival tissues that surround a tooth, typically in association with a partially erupted third molar. Signs and symptoms include pain, discomfort with eating and swallowing, and limited mouth opening. Examination demonstrates gingival inflammation around a tooth, with or without purulence (see Figure 7).

Acute necrotizing ulcerative gingivitis (ANUG) and periodontitis (ANUP) are severe conditions that are typically associated with psychological stress, severe malnutrition, and immunosuppression in patients with preexisting gingivitis or periodontitis.⁶ ANUG is associated with intense gingival pain, halitosis, generalized erythema, and destruction of the gingival papilla, often with bleeding.⁷ ANUP is a more advanced condition associated with damage and loss of the periodontium (including bone), often with loose teeth (see Figure 8).⁸

COMMON DENTAL DISEASES

Trauma. Dental trauma can be limited to the teeth and soft tissues, while more severe injuries can also affect the jaw bone.⁹ Accidental falls, assault, and motor vehicle traffic accidents are the most common causes of facial fractures in the United States and are often associated with dentoalveolar trauma (see Figure 9). The most commonly fractured facial bone is the mandible, characterized by painful opening and closing and an incomplete or altered bite.¹⁰

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