Interactive Transcript
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I previously mentioned the entity of Ludwig's angina and
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mentioned that quite often this is associated
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with dental caries and dental infections.
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When you are reading head and neck imaging
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in the emergency department,
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you'd be surprised how often you are distracted,
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if you will, by dental caries, cavities of teeth,
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effectively.
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And I just want to go through briefly about dental
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caries because it is a very common incidental finding in
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head and neck CT scans in the emergency room and
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occasionally will be the source of the infection in
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the head and neck. So this is the anatomy of a tooth.
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You notice the E for enamel, the D for dentin,
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and this is the pulp chamber.
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And we have some of the cementum
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and then the periodontal ligament.
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You notice that I've drawn in here an area which shows
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the junction between the enamel and the dentin.
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This is where most dental caries occur.
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And then occasionally, you will get the infection that
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goes along the gingiva or along the edge of the tooth
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to cause some of the inflammatory
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process in the periodontal region.
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I don't expect you to remember this,
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but this is just a nice demonstration of the
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different locations where one can have dental caries
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or cavities. I usually refer to the cavities as occlusal,
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that is
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on the surface of the teeth where you occlude the mouth.
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So the occlusal surface of the teeth versus
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the proximal surface of the teeth,
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which is the junction between the teeth,
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side to side.
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You notice that as the classes go up in number,
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you get closer and closer to the involvement of different
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incisive teeth versus the posterior teeth,
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the molar teeth.
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And you can see that where these different
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dental caries are described.
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And you may hear your dentist talking about
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the caries in terms of this classification.
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But I usually use the term occlusal or occlusal
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surface or the proximal surfaces of the teeth.
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Here's one, number five,
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where it's actually the neck of the tooth as you
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get from the enamel into the pulp chamber.
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Dental caries obviously are seen very
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frequently on our CT scans. It's amazing.
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You probably would be surprised how in American
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teeth, how often there is such bad dental hygiene.
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This is a case of a proximal class two dental caries.
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And here you see dental caries, class two.
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And I think I have class five down here where you see
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it coming down a little bit lower into the
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neck of the tooth and eroding the
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occlusal surface of the enamel on this
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individual here. You can see the diagram of that cavity,
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as opposed to one on the sides.
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This one's taking out the top of the tooth,
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if you will,
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as well as the side of the tooth on the class two.
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So what do we say about dental caries?
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If it is indeed just an incidental finding on a
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patient who you're evaluating for the larynx
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or for a palatine tonsillitis, PTA case,
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then you might just use the term,
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"There are scattered dental caries in the teeth."
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If, on the other hand,
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you start to see erosions around the teeth,
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then you want to use the terms "endodontal" or
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"periodontal erosions." Endodontal erosions are,
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in general, at the tips of the roots of the teeth,
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whereas periodontal disease is on this side.
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So here you have a primary endodontal lesion coming out
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of the pulp chamber and out of the root of the tooth, and
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then secondary spread into the periodontal region.
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Here you have a patient who has primary periodontal
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disease, probably a dental caries right here.
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And then, the infection arises in the periodontal
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space and then goes to the endodontal region.
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Here you have one that is,
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as you can see by the arrows,
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is going both from the root of the tooth,
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maybe requiring root canal,
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as well as coming down from gingival infection at the
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edge of the tooth. And these different characteristics,
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we really actually don't see the arrows,
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so we might just call it endodontal disease
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as well as periodontal disease.
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But I think that a lot of times people,
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even at the tips of the roots when there's
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just a lucency around there,
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are calling it periodontal disease.
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No, that's really endodontal disease.
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It's the involvement on the lateral aspect of the
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tooth that we would call it periodontal disease.
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So, here we have some lucency around the tooth and it's
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coming between the teeth in the periodontal region,
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and that's what periodontal disease refers to.
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Bacterial accumulating at the tooth gingival gum
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interface and then going down along the side
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of the tooth in the periodontal space,
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which can lead to an erosion at the endodontal
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portion of the tooth. Periapical disease,
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again,
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sometimes we just see the lucency at the periapical
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region. Sometimes you will see a cyst.
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We call that either a radicular
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cyst or a periapical cyst.
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And that is something that is relatively painful and
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oftentimes requires removal of the tooth.
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In these periapical cyst or radicular cysts,
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if you have a persistent cyst after removal
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of the tooth, we call that a residual cyst.
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So it's probably more more than you want to know
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about dental caries and nomenclature for dental
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caries. More important for us, besides recommending
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oral cavity evaluation or dental evaluation, or oral
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surgeon evaluation, is whether or not they're
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spread to the deep spaces of the neck.
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And those include sublingual
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or submandibular spaces,
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the parapharyngeal space, sometimes even going
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into the vascular sheath. Again,
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if you have thrombophlebitis of the jugular vein,
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you may call that lemierre's disease with possibility
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of septic emboli to the lung.
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Rarely, you'll have spread of the
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dental infection to the orbit.
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More commonly we see just the sinusitis
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that may be odontogenic.
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And rarely, you will have spread into the
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pterygopalatine fossa and the nerves of the
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second division of the fifth cranial nerve.
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So here, again, spread of dental infection.
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In this case, you can see that there is a low
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density area in the floor of the mouth.
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This may be termed the Ludwig's angina,
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particularly when you have the spread
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to the venous structures.
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Here's the carier's tooth with the low density around
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the root of the tooth, the periapical spread.
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Here you have spread into the muscles of mastication.
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So this is the pterygoid musculature, lateral pterygoid
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medial pterygoid muscle with inflammation from dental
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infection extending into the masticator space.
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Here you have bad tooth over here and on the post
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gadolinium, floor of mouth view, you have an
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inflammatory collection that's located
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in the floor of the mouth.
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This one again could possibly perforate down into
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the submandibular space and be termed Ludwig's
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angina for an abscess in that location.
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And one more time.
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Here we have spread of infection
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to the lower orbit.
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This is very uncommon associated with
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a dental infection but can occur.
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You notice that there's some tenting backwards of this
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globe into a more of a oblong shaped, rather
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than the normal spherical shape.
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This is an inflammatory staphyloma associated with
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the infection that arose from maxillary molar
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dental infection.
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