GINGIVITIS
Most emergency nurses have little education on dental conditions yet some new attendances to emergency departments are for dental problems, this article describes the signs and symptoms of three common gingival conditions, and briefly outlines treatment,
Anthony Summers says that emergency department staff should familiarize themselves with basic mouth and dental problems so that patients receive appropriate initial treatment before being advised to see dentists
Keywords Gingivitis; abscess; antibiotics
NURSE PRACTITIONERS are taught little about the diagnosis and management of conditions of the mouth. Researchers estimate, however, those between 0.3 and 0.5 per cent of new attendances to emergency departments (EDs) are for dental problems (Patel and Driscoll 2002, Pennycook et al 1993).
Junior doctors also receive little dental training during their education (Patel and Driscoll 2002) and so may be unable to offer nurse practitioners relevant information. Practitioners may therefore want to enhance their knowledge base to include basic dental conditions.
The author, a nurse practitioner, was prompted to investigate the diagnosis and management of mouth conditions after caring for a patient who presented with painful and bleeding gums (see Case study).
This investigation led to the discovery that there are several conditions referred to as gingivitis:gingivitis, necrotizing ulcerative gingivitis (NUG) and gingival abscess.
Gingivitis is a response to an accumulation of oral bacteria in the gingival sulcus of the mouth (Scott and Singer 2004) (Figure 1).
Diagnosis is made almost entirely on clinical presentation and visual examination. Signs ofgingivitis include inflammation, redness, swelling and bleeding on gentle provocation of the gingival sulcus (Armitage 1995).
A scale used to classify gingivitis, the gingival index, was first published in 1963 by Loe and Silness and is still used today (Table 1, page 20).
The extent of gingivitis is defined by the amount of bleeding that occurs on palpation or probing. This method also determines the success of treatment.
This condition often presents suddenly after episodes of debilitating disease, stress, poor nutrition, smoking or changes of lifestyle (Rodriguez and Sarlani 2005). There may also be a bacterial element to NUG, which can be treated with antibiotics (Corbet 2004).
For a diagnosis of NUG to be made, the following must be present in the mouth:
* Painful lesions that may be rapid in onset.
* Ulceration of the interdental papillae.
* Spontaneously or readily bleeding gingival ulcers
(Gmur et al 2004, Stevens et al 1984). The ulcers of the interdental papillae have a 'punched out', crater-like appearance and are often covered with sloughs of necrotic debris known as pseudo membranes (Rodriguez and Sarlani 2005).
Further clinical indications include:
* Fetid breath.
* Increased salivation.
* Fever.
* Lymphadenopathy, particularly of the submandibular and cervical lymph nodes, especially in children.
* Decreased appetite due to pain.
* Bleeding from minimal stimulation of the gingival tissues.
* A metallic taste in the mouth (Corbet 2004, Horning and Cohen 1995, Rodriguez and Sarlani 2005).
Patients with gingival abscesses usually present with acute and painful lesions with red, smooth and shiny surfaces (Figure 2). These will typically have expanded over 24 to 48 hours (Rodriguez and Sarlani 2005).
Gingival abscesses are caused by foreign substances that have been forced into the gingival tissues, triggering an inflammatory response. They are usually confined to the marginal gingival tissues, often at previously unaffected areas (Corbet 2004).
Common substances that can cause gingival abscesses are tooth brush bristles, popcorn kernels, dental floss and pieces of food, especially meat (Rodriguez and Sarlani 2005).
As the lesion expands, it becomes fluctuant and pointed, and can express purulent exudates as a result of bacteria carried into the area by the foreign substances. If allowed to fully develop, these lesions will rupture spontaneously (Rodriguez and Sarlani 2005).
The teeth next to the lesion often become sensitive to percussion, and this sensitivity can help differentiate gingival abscess from other causes of dental pain.
The three conditions require similar management, and all of these may require treatment with antibiotics, although this should depend on the severity of the patient's condition.
The current recommended antibiotic regime is either penicillin V 500mg four times a day for seven days, or metronidazole 500mg twice a day for seven days (Rodriguez and Sarlani 2005).
Precipitating factors should be discussed with patients along with changes in their behaviour, diet or dental hygiene techniques that can reduce the likelihood of recurrence. Patients with stress-induced gingivitis, for example, may be helped by stress reduction techniques.
Smoking cessation is also an important part of treatment because smoking can mask the symptoms of gingivitis, causing it to be well advanced and therefore harder to treat before it is discovered (Salvi et al 2005).
Treatment for gingival abscesses involves the location and removal of the foreign substances that have led to their formation. Once this has been undertaken, lesions often resolve without further treatment.
One common aspect to all three conditions is that they can be painful so any treatment strategy should include pain relief. Non-steroidal anti-inflammatory drugs (NSAIDs) can provide effective pain relief, (Rodriguez and Sarlani 2005) and can be combined with paracetamol to relieve breakthrough pain.
Patients who cannot take NSAIDs can use paracetamol alone or in combination with codeine. However, strategies for pain management should follow local guidelines.
The final stage of treatment is ensuring that the mouth is kept clean with saline rinses or mouthwashes containing chlorhexidine to prevent a recurrence of each form of gingivitis(Corbet 2004, Rodriguez and Sarlani 2005).
Chlorhexidine mouthwashes often taste unpleasant, can alter taste sensation and discolour the teeth (Paraskevas and van der Weijden 2006), which discourages patients from using them.
Other mouthwashes containing phenolic compounds are available, and patients may find these more palatable than and just as effective as chlorhexidine in preventing gingivitis (Sekino and Ramberg 2005).
Whichever mouthwash is chosen though, it needs to be used until signs and symptoms are resolved.
Finally, anyone who presents at an ED with mouth or teeth problems should be advised to visit, or be referred to, his or her dentist for review and further management.
In the case study, a diagnosis of gingivitis was made. Although this was appropriate, an alternative diagnosis of NUG could have been made based on the patient's halitosis. However, at the time, the author was unaware of this condition and the significance of bad breath.
The patient was prescribed a chlorhexidine mouthwash. Had a diagnosis of NUG been made, he may also have been given antibiotics.
The general lack of knowledge among ED staff about dental conditions is such that patients who attend with them must be referred to their dentists.
This will ensure that more serious conditions are detected, that initial ED treatment can be reviewed, and that further management can be instigated as required.
The training that nurse practitioners receive in oral health problems is determined by the patients they see. If they wish to expand the parameters of practice into dealing with oral health problems, they should learn about them by spending time with dentists or other oral health specialists. Now test your knowledge on page 36.
0 No inflammation: Gingival tissue is normal
1 Mild inflammation: There are small changes to the color and texture of the gingival tissue, but there is no bleeding on palpation or probing
2 Moderate inflammation. There is some redness, glazing of the gingival tissue, which bleeds on palpation or probing
3 Severe inflammation: there is marked redness, edema and ulceration of the gingival tissue, which tends to bleed spontaneously
Summers, A. (2009). Gingivitis: diagnosis and treatment. Emergency Nurse, 17(1), 18-20.
Comment
This article is about the importance of go to the dentist twice per year for detecting the problems in people specially mouth problems. This article explains what the gingivitis is and what are the causes and symptoms. I chose this article because explain in a good away the gingivitis types with the objective that patients can understand the importance of a good dental health and avoid the dental plaque what is the main cause of gingivitis around the world for this reason people should brush the teeth three times a day also they should use dental floss and mouthwashes.
Video
I agree with this video because a good factor to prevent the gingivitis is the examination and the professional cleaning, because with that clinic test doctor can detect the signs and people can avoid this disease. For this reason I chose this video because it explains the causes and it gives us additional steps to prevent gingivitis and with video professionals in this field can help to patients.
By Stephanie López Contreras
