Common Dental Issues

A very quick guide to common issues prompting referrals to maxillofacial surgery (aka MaxFax and OMFS)

This is a surgical speciality relating to the hard and soft tissues of the head and neck; with close links to ENT and neurosurgery. To become a higher trainee in MaxFax you must be dual qualified in medicine and dentistry; SHOs are singly qualified in either. This means the SHO is often dentally qualified only and may need help with medical issues. Often in hospital ENT/MaxFax will cross cover each other out of hours.

MaxFax is quite a small speciality and not well known; so it often gets very vague referrals and a lot of questions. Generally, they are a friendly bunch so call and ask; but if it is for fillings, broken dentures etc then ask the community dental team instead

Basic anatomy/terms
cf54fb55fcbad7b83abcb61d80f41f2fAdults have 8 teeth in each quadrant of the mouth (upper and lower, left and right), each is given a number- starting from the midline 1. central incisor, 2. lateral incisor, 3. canine, 4. first premolar, 5. second premolar, 6. first molar, 7. second molar and 8. third molar (wisdom tooth). So an abbreviation of UL5 is the upper left second premolar.

If you see XLA before a tooth this means extraction under local anaesthetic, XGA- extraction under general anaesthetic. # means fracture

Baby/deciduous/primary teeth are given letters. A. Central incisor. B lateral incisor. C canine. D 1st molar. E 2nd molar

The visible part of the tooth is the crown and is made of an outer layer of enamel (hard, white), middle dentine (softer, yellow) and central pulp (contains nerves and blood vessels). The roots are covered with gingiva (gum), periodontal ligament (which holds the tooth into bone), then dentine and pulp.

Caries is tooth decay- sugar causes caries and consuming sugary foods more than 3-4 times daily results in decay eventually. The rate increases with higher rates of consumption, lack of fluoride (hence advising fluoride toothpaste), low salivary flow and poor oral hygiene

Gingivitis is gum disease; most commonly noticed as bleeding on tooth brushing. Periodontitis is more severe, and the bone and periodontal ligament has been affected; teeth become loose

Imaging
For a possible dental abscess, dental trauma or a suspected mandibular dislocation then an OPG (orthopantomogram) is the ideal investigation; for suspected mandibular fractures then request an OPG and PA mandible; for zygomatic complex fractures then facial films (each hospital has a slightly different protocol for these). If you are arranging a CT head for someone with suspected facial fractures then specify adding facial bones and mandible, as otherwise these are often not imaged. If you are not familiar with these then ask a friendly radiologist to explain, Radiopaedia has useful resources, or alternatively sit with the MaxFax SHO when they review the films and they’ll point out the anatomy/pathology

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Figure 1 PA mandible
Opg 2015 02 04
Figure 2 OPG

Xerostomia
AKA dry mouth. Has multiple causes- medications, Sjogren’s, dehydration, surgery, radiotherapy… Complications- reduced QoL, caries, infections (eg parotitis), poor oral intake, sore dentures. Management- oral hygiene, high fluoride toothpaste, sips of water, saliva replacements, surgery,

Mouth ulcers
Wide range of causes- very common, very annoying and can be very painful! Trauma, idiopathic and nutritional are common reasons Any ulcer which has been present for more than 3/52 then consider malignancy and urgently refer to OMFS. Investigations- refer to dentist/ OMFS, haematinics, coeliac serology, medications review. Symptom relief- Difflam spray/mouthwash (benzydamine), Bonjela. Other treatments- steroids, cytotoxics

Dental trauma
Do not try to re-implant baby teeth- it risks damaging the developing adult tooth
Adult teeth which have been avulsed (knocked out) can be re-implanted, but minimising extra-oral dry time is critical to prognosis. If you see this in triage then urgently call MaxFax, don’t leave them waiting hours to be seen. You can either re-implant yourself if you are comfortable to do so; or store in unsweetened milk, normal saline or the patient’s own saliva.

Candidiasis
NICE has a CKS for management of this, and local prescribing protocols vary. But look for either erythematous mucosa or white patches which can be easily wiped off leaving a bleeding base

Abscesses
Dental abscesses, particularly from lower molars have the potential to compromise a patient’s airway; or can leave the patient seriously unwell. Follow an A-E approach in your initial assessment; get early MaxFax input and consider anaesthetics.

Some particularly concerning signs are voice change, drooling, protruding tongue and swollen neck. Keep the patient nil by mouth, get IV access, take bloods and start antibiotics (usually amoxicillin and metronidazole) and keep them under observation until review- do not let them sit out in the waiting room if you are worried!

Trismus- how wide they can open their mouth- measure this in cm or the patient’s finger widths, under 1cm/1 finger is concerning

Look for broken, decayed or heavily filled teeth. Press (gently) on any teeth you are concerned by or the patient points to as the source- if the patient jumps or shouts it’s probably the source
Look for localised swellings next to teeth- a small fluctuant swelling next to the tooth may be amenable to incision and draining

Feel the floor of the mouth – it should be soft and not raised; feel under the mandible and again it should be soft- if either is abnormal then discuss.

There are various textbooks available with titles like essentials, handbook, secrets, principles etc. – I’ve not got a particular recommendation. Ask for advice early and if you get the chance then go with the MaxFax SHO when they see the patient- it’s easier to see a demonstration than learn from a book!

Dr Stef Wischhusen, BDS (Hons), MFDS RCS Ed, MbChB (Hons)

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