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Chapter 21 NONTRAUMATIC ENT EMERGENCIES138

11. When should I consult an ENT specialist?

ENT referral is needed if you cannot control the anterior bleed with adequate bilateral nasal

packing, raising suspicion of a posterior bleed. The patient may need endoscopic

cauterization, ligation of the sphenopalatine artery, embolization, or septal surgery.

An outpatient referral can be made for those patients with recurring anterior epistaxis.

12. What is the role of interventional radiology (IR)?

Severe epistaxis may be refractory to more traditional packing methods. Surgical ligation or

arterial embolization may be required. IR-based techniques were developed in response to the

near 15% failure rate for surgical ligation and are typically targeted at embolizing the

sphenopalatine artery. However, the decision-making process when choosing between these

two techniques remains controversial. Severe epistaxis from the ethmoidal system may be

better treated with surgical ligation because of the subsequent risk of blindness and stroke

associated with embolization of the internal carotid system. In contrast, critical patients may

not be stable enough for general anesthesia. In a recent study of nearly 10,000 inpatients with

an admitting diagnosis of epistaxis, no difference was found between transfusion rates or

length of stay in those patients treated with packing, ligation, or embolization. Embolization,

however, was associated with a signiﬁcantly higher cost.

13. Didn’t you forget to mention laboratory studies?

No. Most patients don’t need them. The exceptions are patients taking warfarin or those

patients who are hemodynamically unstable. In this case, a complete blood count, coagulation

studies, and a type and screen are most often adequate.

FOREIGN BODIES

14. How should I remove a foreign body from the ear?

The following instruments can assist in extraction: alligator forceps, right-angle probe, tissue

forceps, cyanoacrylate glue, Fraser tip suction, irrigation syringe, Adson forceps, Fogarty

biliary catheter, ear curette, water-pik, skin hook, and day hook.

If a live insect is in the external auditory canal (EAC), it should ﬁrst be killed by instilling

2% lidocaine (which is quicker and less messy than mineral oil) before removal. If the

tympanic membrane is intact and space exists between the EAC and the object, a stream of

liquid can be directed behind the foreign body to force it out. A mixture of water and isopropyl

alcohol as an irrigation solution tends to cause less swelling of organic matter and is

evaporated more quickly. Direct instrumentation or suction removes most other objects.

Cyanoacrylate glue at the end of a Q-tip or small balloon-tipped catheter can do also do the

trick. Using an aural speculum when guiding the Q-tip will prevent adherence of glue to the

external auditory structures.

15. How do patients with nasal foreign bodies present?

Unless the patient or witness reports the insertion of a foreign body, the chief complaint is

that of unilateral, malodorous nasal discharge. The discharge may be mucoid or

serosanguineous but is classically purulent.

16. Is there any special trick to removing foreign bodies from the nose?

A small Foley catheter (or commercially available Katz extractor) can be passed into the

superior affected nasal cavity. Once past the foreign body, the balloon is insufﬂated and the

device pulled out, taking the foreign body with it. Alternatively, the provider can prepare a

50/50 mixture of a topical vasoconstrictor and 4% topical lidocaine, and spray it into the

involved nostril with an atomizer or spray bottle. Nebulized epinephrine has also been used

with good results. This anesthetizes nasal mucosa and reduces congestion, facilitating

removal. When this is done, the patient can occlude the unaffected nostril and blow forcefully,

often expelling the object.

Chapter 21 NONTRAUMATIC ENT EMERGENCIES 139

If the patient is unable or unwilling to attempt this maneuver, positive-pressure insufﬂation

can be attempted. The unaffected nostril is occluded, and a quick breath is delivered through a

facemask connected to an Ambu-bag. Alternatively, a parent or caregiver can do this in direct,

mouth-to-mouth fashion. If insufﬂation maneuvers are unsuccessful, an attempt should be

made to remove the foreign body with suction or forceps. The techniques listed for ear foreign

body removal can be applied to the nose.

17. “I think I’ve got something stuck in my throat.” How is the patient with this

complaint managed?

The fact that the patient can talk is a good sign. Airway compromise must be immediately

addressed. The patient should be asked about the nature of the foreign body, duration of the

sensation, the ability to swallow liquids or solids, and the perceived location of the object.

Patient estimates of location are often surprisingly accurate.

Direct visualization can identify sharp objects, such as ﬁsh bones, that may become

impaled in the posterior pharynx or the base of the tongue. Indirect or ﬁberoptic laryngoscopy,

in conjunction with local anesthesia (e.g., nebulized lidocaine), may help localize objects stuck

in the vallecula, epiglottis, or pyriform sinus.

It is important to note that the pain of myocardial ischemia can present as a feeling of

something stuck in the throat. If the history and physical are at all suspicious for acute

coronary syndrome, consider an electrocardiogram (ECG) and troponins.

18. If the physical examination does not reveal the foreign body, what should be

done next?

Soft-tissue density lateral radiographs of the neck or chest radiographs should be obtained.

Large, sharp, angulated objects tend to lodge in the esophagus. If radiographs do not localize

the foreign body, a water-soluble radiographic contrast agent like Gastrograﬁn can be used as

part of an esophagram done under ﬂuoroscopy (by radiology). Barium should be avoided

initially because it interferes with visualization during endoscopy. Esophagoscopy should be

considered in patients with persistent symptoms or when the diagnosis is unclear.

19. If I can see a foreign body, how do I remove it?

Apply a topical spray anesthetic, such as topical benzocaine or nebulized 4% Xylocaine.

Objects that are visualized may be removed with bayonet forceps or a Kelly clamp. Smooth

objects such as coins in the esophagus for less than 24 hours can be removed by placing the

patient in Trendelenburg position (head down), passing a Foley catheter beyond the object,

expanding the balloon, and withdrawing the catheter. Due to potential complications, this

procedure is typically performed under ﬂuoroscopy by experienced radiologists.

Pharmacologic treatments for passage of esophageal foreign bodies are variably effective.

Sublingual nitroglycerin relaxes the lower esophageal sphincter and is occasionally successful

at relieving a distal obstruction, such as a food bolus. Intravenous glucagon (0.5–2.0 mg)

also relaxes the lower esophageal sphincter, allowing a distal obstruction to pass. However,

because glucagon commonly elicits vomiting, it has been associated with esophageal

perforation in this setting. Benzodiazepines may also be effective. Never use papain-containing

agents; they dissolve meat and, due to gas formation, are associated with esophageal

perforation. Sharp objects should be removed endoscopically.

KEY POINTS: ESOPHAGEAL FOREIGN BODIES

1. In the patient presenting with an esophageal foreign body sensation, esophagoscopy should

be considered with persistent symptoms or an uncertain diagnosis.

2. Because glucagon commonly elicits vomiting, it may cause esophageal perforation.

Chapter 21 NONTRAUMATIC ENT EMERGENCIES140

20. Any other pearls?

Of esophageal foreign bodies that pass through the gastrointestinal (GI) tract, 80% to 90% pass

without signiﬁcant problems. The remainder requires surgical removal. These latter objects tend

to be sharp or long (.6.5 cm) and are among the 1% that cause perforation. A special case

should be made for disk or button batteries. Because most are prone to leakage, every effort

should be made to remove them immediately if localized to the esophagus. Otherwise, their

location in the GI system should be followed with serial X-rays until elimination is conﬁrmed.

KEY POINTS: NATURAL HISTORY OF GI FOREIGN BODIES

1. Of foreign bodies, 80% to 90% pass through the gastrointestinal tract without signiﬁcant

problems.

2. The following often require surgical removal: sharp or long (.6.5 cm) objects, disk or

button batteries, and those that have not migrated on serial radiographs.

SINUSITIS

21. What is sinusitis? What are the common causes?

Sinusitis is an inﬂammation of the paranasal sinuses, which include the maxillary, ethmoid,

frontal, and sphenoid sinuses. It is the consequence of ostia occlusion, most commonly

caused by local mucosal swelling secondary to a viral upper respiratory infection. Allergies,

trauma, mechanical obstruction from tumors, foreign bodies, or abnormal anatomy may also

cause occlusion that leads to bacterial overgrowth and excess mucus production. Of all viral

upper respiratory infections, 0.5% to 5% are complicated by bacterial rhinosinusitis. When

symptoms are present less than 3 weeks, the process is characterized as acute.

22. How do I make the diagnosis?

The four most helpful signs and symptoms when diagnosing bacterial rhinosinusitis are

purulent nasal discharge, upper tooth or facial pain (especially unilateral), maxillary sinus

tenderness (unilateral), and a worsening of symptoms after initial improvement. The physical

examination is often unrewarding. Anterior rhinoscopy with a headlamp and nasal speculum

may reveal the presence of pus, foreign bodies, masses, or anatomic abnormalities.

23. Which other diagnostic studies should I pursue?

Plain ﬁlms and computed tomography (CT) are not recommended for initial diagnosis but may

be used for recurrent or chronic conditions. A single Water’s view is as sensitive as a full

sinus series. Findings may include mucosal thickening (.6 mm), air-ﬂuid levels, and

opaciﬁcation. For uncomplicated sinusitis, CT is not speciﬁc because 40% of asymptomatic

patients and 87% of patients with a recent upper respiratory infection have abnormal ﬁndings

on CT scan. However, CT can be used to diagnose intrafacial or intracranial involvement. Nasal

endoscopy is an excellent modality for identifying disease but is done only by an

otolaryngologist and rarely on an emergent basis.

24. How is sinusitis treated?

Approximately 65% of cases of acute rhinosinusitis in adults and children will resolve

spontaneously. Most patients with a viral upper respiratory infection improve within 7 days.

Thus, antibiotics should be reserved for patients who meet the clinical criteria described

previously, and those whose symptoms have persisted for more than 7 days. The most likely

organisms are Streptococcus pneumoniae, nontypable Haemophilus inﬂuenzae, Moraxella

catarrhalis, other Streptococcus species, and anaerobes.

Chapter 21 NONTRAUMATIC ENT EMERGENCIES 141

Initial antibiotic therapy options include amoxicillin, trimethoprim-sulfamethoxazole,

amoxicillin-clavulanate, doxycycline, or azithromycin. In children, consider amoxicillin,

amoxicillin/clavulanate, cefpodoxime, or cefuroxime. Appropriate treatment duration remains

unclear; a 10-day course is most often used. The use of vasoconstrictor sprays such as

phenylephrine (Neo-Synephrine) or oxymetazoline (Afrin) offer symptomatic relief but should

not be used longer than 3 days because of the propensity for rebound edema. Antihistamines

should be avoided because they are implicated in mucosal crusting and blockage of the ostia.

Ultimately, daily nasal saline irrigation and nasal topical steroids should be encouraged before

antibiotics are prescribed.

25. Which patients need referral and admission? What are the complications?

If there is no improvement after two complete courses of antibiotics, the patient should be

referred to an otolaryngologist. Complications arising during therapy can be classiﬁed as

local, orbital, and intracranial. Patients with sinusitis who show evidence of orbital or central

nervous system involvement should be treated as medical emergencies.

Locally, mucoceles and osteomyelitis can develop. Orbital complications are the most

frequent, especially in children, and range from cellulitis to abscess formation. Cavernous

sinus thrombosis, resulting from the direct spread of infection through valveless veins, is truly

life-threatening. It is heralded by a toxic appearance, high fever, cranial nerve palsies, retinal

engorgement, and bilateral chemosis and proptosis. Other intracranial complications

demanding aggressive intensive therapy include meningitis, subdural empyema, and brain

abscess. The majority of these complications can be diagnosed by CT.

26. Any other pearls?

Yes. Check a ﬁngerstick glucose in a sick patient with sinusitis. Mucor in diabetic patients and

Aspergillus in immunocompromised patients can be life-threatening. These patients require

hospital admission and specialist consultation.

KEY POINTS: SINUSITIS

1. The four most helpful physical examination signs and symptoms when diagnosing bacterial

rhinosinusitis are purulent nasal discharge, upper tooth or facial pain (especially unilateral),

and maxillary sinus tenderness.

2. A single Water’s view is as sensitive as a full sinus series. Findings may include mucosal

thickening (.6 mm), air-ﬂuid levels, and opaciﬁcation.

3. For uncomplicated sinusitis, CT is not speciﬁc because 40% of asymptomatic patients and

87% of patients with a recent upper respiratory infection have abnormal ﬁndings on CT scan.

4. Cavernous sinus thrombosis resulting from sinusitis is heralded by a toxic appearance, high

fever, cranial nerve palsies, retinal engorgement, and bilateral chemosis and proptosis.

5. Mucor in diabetic patients and Aspergillus in immunocompromised patients can be

life-threatening.

EPIGLOTTITIS

27. How did George Washington die?

George Washington is believed to have died from epiglottitis. It is recorded that on December

14, 1799, the morning of his death, he had a severe sore throat, developed stridor and

hoarseness, and was unable to lie supine.

Chapter 21 NONTRAUMATIC ENT EMERGENCIES142

28. List the signs and symptoms of epiglottitis in adults.

Symptoms

Sore throat (100%)

Odynophagia/dysphagia (76%)

Fever (88%)

Shortness of breath (78%)

Anterior neck tenderness

Hoarseness or mufﬂed (hot potato) voice

Signs

Lymphadenopathy

Drooling

Respiratory distress

Extreme pain with palpation of the larynx

29. What is the thumbprint sign?

A ﬁnding on lateral neck radiographs caused by the presence of an edematous epiglottis.

Lateral neck ﬁlms are of limited use because they are only 38% sensitive and 76% speciﬁc.

30. Name the most common organisms identiﬁed in adult epiglottitis.

The two most common organisms found are H. inﬂuenzae and beta-hemolytic streptococci. In

most cases, no organism is found pointing to a viral cause. With the introduction of the Hib

vaccine in children, the reservoir for H. inﬂuenzae has decreased dramatically so that

epiglottitis is now seen more frequently in adults.

31. How do I manage epiglottitis? What signs and symptoms indicate the need for

airway intervention?

Antibiotics should be started immediately. Use a second- or third-generation cephalosporin

active against H. inﬂuenzae and beta-hemolytic streptococci such as cefotetan or cefoxitin.

Steroids are often used but remain controversial and have not been shown to provide any

beneﬁt. It is traditionally taught that racemic epinephrine should be avoided because of the

potential for rebound edema, but there is little data to support this. Patients with symptomatic

respiratory distress, stridor, drooling, shorter duration of symptoms, and H. inﬂuenzae

bacteremia are at increased risk for airway obstruction. Patients with a respiratory rate of less

than 20 breaths per minute and no respiratory distress should be observed closely in an

intensive care unit (ICU). In patients with a respiratory rate greater than 30 breaths per

minute, moderate-to-severe respiratory distress, PCO

of greater than 45 mm Hg, or cyanosis,

consider immediate active airway intervention.

32. How is the deﬁnitive diagnosis of epiglottitis made?

The gold standard for deﬁnitive diagnosis of epiglottitis in adults is direct laryngoscopy and

visualization of the inﬂamed or edematous epiglottis. In children, the appropriateness of

direct visualization is more controversial. Some believe that any attempt at visualizing the

inﬂamed epiglottis should take place in a controlled setting, such as the operating room.

Others believe it is appropriate to use a tongue depressor or laryngoscope blade to depress

the tongue and visualize the epiglottis of a small child sitting in his or her parent’s lap. In

either case, visualization should take place only by someone experienced in the management

of pediatric airways.

OTITIS EXTERNA

33. How does otitis externa present?

The classic ﬁnding is pain with manipulation of the external ear. Cardinal symptoms are

itching, pain, and tenderness to palpation. Common signs are erythema and edema of the

auditory canal, with crusting, pus, or weeping secretions. Predisposing factors for otitis

Chapter 21 NONTRAUMATIC ENT EMERGENCIES 143

externa, also called swimmer’s ear, are excessive moisture in the ear canal and trauma

(typically from overzealous cleaning).

34. What bacteria are usually responsible?

Pseudomonas aeruginosa and Staphylococcus aureus.

35. How is it treated?

The goals for treatment are twofold: to avoid precipitants and to eradicate infection. To treat

infection, 2% acetic acid (for drying) combined with hydrocortisone (for inﬂammation) should

be placed on a wick in the ear canal. Alternatively, topical antibiotic drops can be used.

Cortisporin otic suspension works well because it has antibacterial, anti-inﬂammatory, and

drying properties, as well as a nontoxic pH.

Additionally, unlike Cortisporin solution, Cortisporin suspension can be used in the

presence of a perforated tympanic membrane. If the external ear canal is extremely inﬂamed

and narrowed, a wick can be placed to ensure drainage and instillation of medication. If otitis

media coexists, be sure to add systemic antibiotics.

36. What is malignant otitis externa?

Malignant otitis externa is a potentially lethal extension of infection of the external ear canal

into the mastoid or temporal bone. It is caused most commonly by P. aeruginosa and occurs

in patients with diabetes or other immunocompromised states. The mortality rate approaches

50%. Malignant otitis externa should be considered when, despite adequate treatment,

headache and otalgia persist. CT or magnetic resonance imaging (MRI) conﬁrms the

diagnosis. Treatment includes admission, intravenous antipseudomonal antibiotics, and

potentially surgical debridement.

PERITONSILLAR ABSCESS

37. State the typical signs and symptoms seen with peritonsillar abscess

(quinsy).

Symptoms: Fever, unilateral sore throat, odynophagia, trismus, and occasionally

referred otalgia. Patients typically have had pharyngitis for some time with recent

antibiotic treatment. Smokers, males, and those with periodontal disease are at

increased risk.

Signs: Limited opening of the mouth (usually cannot open more than 2.5 cm), drooling,

speaking in a mufﬂed hot potato voice, and rancid breath. Examining the oropharynx shows

erythema with a deeper redness over the affected area. There is tense swelling of the

anterior pillar and soft palate. Subsequently, the tonsil is pushed downward and toward the

midline. The uvula may be in an abnormal position, either shifted away from or lying ﬂat

against the affected side.

38. What are the treatment options for a peritonsillar abscess?

Needle aspiration followed by antibiotics is the treatment of choice, successful in 85% to 95%

of patients. The patient should be seated with his or her head resting against the bed or dental

chair headrest. Visualize the tonsils with the aid of a tongue depressor or laryngoscope (a

laryngoscope neatly provides its own light source). Topical anesthetic should be applied using

lidocaine or Cetacaine. A needle cover should be cut to provide a needle guard for an

18-gauge needle, exposing no more than 1.0 cm of the needle. The guarded needle is inserted

at the most ﬂuctuant portion of the abscess. If available, ultrasound utilizing an endocavitary

probe can help identify location of the abscess during drainage. The physician should not

penetrate deeper than 1 cm and stay medial to avoid the more lateral positioned carotid

artery. A positive aspiration is achieved if 1 mL or more of pus is obtained. If needle aspiration

fails, referral to an ENT physician is necessary for surgical incision and drainage versus

tonsillectomy.

Chapter 21 NONTRAUMATIC ENT EMERGENCIES144

39. Describe the presentation of a retropharyngeal abscess.

Common presenting symptoms of retropharyngeal abscess include fever, odynophagia, and

neck pain out of proportion to oropharyngeal ﬁndings. Patients are ill appearing and may hold

the neck in slight extension. Patients may also resist neck movement, mimicking meningitis.

40. Why is this diagnosis so concerning?

The retropharyngeal space of the neck involves three fascial layers between the paraspinal

muscles and the pharynx. Infections and abscesses located here have the potential to cause

airway compromise and offer a path of direct extension into the mediastinum.

KEY POINTS: OTHER HEAD AND NECK SOFT-TISSUE INFECTIONS

1. In the patient with respiratory compromise and suspected epiglottitis, evaluation is best

performed in a controlled environment, with someone skilled at performing an emergent

nonsurgical and surgical airway.

2. Malignant otitis externa is caused most commonly by P. aeruginosa and occurs in patients

with diabetes and immunocompromised states. The mortality rate can be greater than 50%.

3. Infections and abscesses in the retropharyngeal space can lead to airway compromise and

direct extension into the mediastinum.

41. What organisms are found in retropharyngeal and peritonsillar abscesses?

Retropharyngeal and peritonsillar abscesses have similar microbial ﬂora: anaerobes, group A

streptococci (Streptococcus pyogenes), S. aureus, and H. inﬂuenzae.

42. How is a retropharyngeal abscess diagnosed and treated?

It is sometimes visible on a soft-tissue lateral neck radiograph as an increase in soft-tissue

density best seen with the neck in slight extension. Deﬁnitive diagnosis is made by CT scan.

Advanced airway management equipment should be at the bedside while an emergent

consultation with an ENT physician is obtained. Intravenous antibiotics should be started, but

as with pus formation anywhere in the body, deﬁnitive treatment is incision and drainage. The

patient should be admitted to the ICU or taken directly to the operating room by the

appropriate service. Mediastinal involvement mandates the involvement of a cardiothoracic

surgeon.

ACKNOWLEDGMENT

The editors gratefully acknowledge the contributions of Danielle Raeburn, MD, author of this

chapter in the previous edition.

BIBLIOGRAPHY

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58:1795–1801, 1998.

4. Goddard JC, Reiter ER: Inpatient management of epistaxis: outcomes and cost. Otolaryngol Head and Neck

Surg 132:707–712, 2005.

Chapter 21 NONTRAUMATIC ENT EMERGENCIES 145

5. Herkner H, Havel C, Mullner M, et al: Active epistaxis at ED presentation is associated with arterial

hypertension. Am J Emerg Med 20:92–95, 2002.

6. Kucik CJ, Clenney T: Management of epistaxis. Am Fam Physician 71:305–311, 2005.

7. Lee SS, Schwartz RH, Bahadori RS: Retropharyngeal abscess: epiglottitis of the new millennium. J Pediatr

138:435–437, 2001.

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medicine: concepts and clinical practice, ed 5, St. Louis, 2002, Mosby, pp 928–938.

9. Rabago Z, Zgierska A, Mundt M, et al: Efﬁcacy of daily hypertonic saline irrigation among patients with

sinusitis. J Fam Practice 70:1049–1055, 2002.

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70:1642–1645, 2004.

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146

DENTAL AND ORAL SURGICAL EMERGENCIES

CHAPTER 22

Richard D. Zallen, DDS, MD, and Valerie N. Byrnside, DDS

1. When should an emergent dental or oral surgical consultation be

obtained?

Facial swelling associated with tooth pain

Avulsed tooth

Alveolar housing fractures

Refractory bleeding from tooth extraction

Facial fractures

2. How are teeth numbered?

In adults, teeth are numbered starting from the upper right third molar (number 1) and

continuing around the teeth to the upper left third molar (number 16). From here the

numbering continues when you drop down to the lower left third molar (number 17)

and continues around to the lower right third molar (number 32). (See Table 22-1.)

In children, the 20 deciduous teeth (baby teeth) are lettered starting on the upper

right second molar (A) and continuing around the teeth to the upper left second molar

(J). From here the lettering continues on the lower left second molar (K) and continues

around to the lower right second molar (T). (See Table 22-2.)

Children between the ages of 6 and 13 are in a mixed dentition stage with some

adult and some deciduous teeth. Their teeth are numbered and lettered as the previous

descriptions.

3. Describe the different types of tooth fractures. Which require treatment?

The two basic types are fractures of the crown and fractures of the root. Ellis classiﬁed

tooth fractures for anterior teeth as I, II, III, and IV (Fig. 22-1). An Ellis class I fracture

involves the enamel only and does not require emergent treatment. An Ellis class II

fracture involves the enamel and dentin. An Ellis class III fracture involves the enamel,

dentin, and pulp. Ellis class II and III fractures require placement of calcium hydroxide

(Dycal). An Ellis class IV fracture involves the root of the tooth and may require

extraction, root canal therapy, splinting with dental resin, ligature wire, or Erich arch bars

depending on the level of fracture.

4. How should an avulsed tooth be transported?

The best transport medium is the socket from which the tooth came if the tooth can be

gently rinsed off and replaced. If this is not possible, Hank’s balanced salt solution (EMT

Tooth Saver) is the next best transport medium. If no transport solution is available, milk

can be used or a wet handkerchief. The patient’s (or caregiver) saliva or saline may also

be used, but these can be damaging to the periodontal ligament that is adherent to the

root surface.

Chapter 22 DENTAL AND ORAL SURGICAL EMERGENCIES 147

Maxillary right quadrant Maxillary left quadrant

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Third

molar

Second

molar

First

molar

Second

premolar

First

premolar

Cuspid Lateral

incisor

Central

incisor

Central

incisor

Lateral

incisor

Cuspid First

premolar

Second

premolar

First

molar

Second

molar

Third

molar

32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17

Third

molar

Second

molar

First

molar

Second

premolar

First

premolar

Cuspid Lateral

incisor

Central

incisor

Central

incisor

Lateral

incisor

Cuspid First

premolar

Second

premolar

First

molar

Second

molar

Third

molar

Mandibular right quadrant Mandibular left quadrant

TABLE 22-1. UNIVERSAL NUMBERING SYSTEM FOR PERMANENT TEETH

Maxillary right quadrant Maxillary left quadrant

A B C D E F G H I J

Second molar First molar Cuspid Lateral

incisor

Central

incisor

Central

incisor

Lateral

incisor

Cuspid First molar Second molar

T S R Q P O N M L k

Second molar First molar Cuspid Lateral

incisor

Central

incisor

Central

incisor

Lateral

incisor

Cuspid First molar Second molar

Mandibular right quadrant Mandibular left quadrant

TABLE 22-2. UNIVERSAL LETTERING SYSTEM FOR PRIMARY TEETH