Referring to the on-call oral and maxillofacial surgery team – what, when and how to refer emergency conditions

Post-extraction pain

For patients who seek care for post-operative discomfort, a thorough history will direct the clinician toward the source of pain. Prolonged pain following extraction should prompt the clinician toward considering a retained root fragment, dry socket, pulpal/peri-apical pathology from adjacent/opposing teeth, osteomyelitis (particularly in immunocompromised patients), infection, or fracture of the alveolar segment. Exposure of root dentine on the distal aspect of mandibular second molars following lower third molar (L3M) removal can result in dentine hypersensitivity.

When to refer

When there is persistent pain following an extraction, when all other odontogenic causes have been excluded, or a non-healing socket (Figure 1).

Localized alveolar osteitis (Dry socket)

Dry socket is a common post-extraction complication associated with traumatic extractions.² Risk factors include the use of the oral contraceptive pill, mandibular extractions, bone removal, previous dry socket and smoking. Patients report a dull, throbbing ache 3–4 days following the extraction. There is pronounced halitosis from the site, and there may be exposed bone. Management is irrigation with saline and gently dressing the site with an obtundent dressing (eg Alveogyl™). Use of chlorhexidine for debridement is not advised due to reports of anaphylaxis occurring following socket irrigation.³ Resolution of symptoms can take up to 10 days and repeated dressings may be required in this interim. Prolonged pain, or repeated post-operative pain appointments, point towards an alternative diagnosis (as discussed previously) or that the patient is smoking. Antibiotics are not recommended for the treatment of dry socket.

Cervicofacial infections

In a dental setting, this condition most commonly presents as the result of an infection from an odontogenic source or the major salivary glands, with spread to the surrounding tissue spaces. Patients may report trismus, suggesting the spread of infection/inflammation to the muscles of mastication, which is an indication for immediate referral to the on-call OMFS team (Figure 2). A raised floor of the mouth suggests infection of the sublingual space and warrants immediate referral to prevent complete occlusion of the airway. There may also be pronounced facial swelling which is warm to touch. These patients require incision and drainage and administration of intravenous antibiotics in the hospital. Patients who have a spreading infection may be pyrexic and appear flushed and tachycardic, warranting immediate referral to the on-call OMFS team. Table 1 outlines the signs and symptoms of infection affecting the spaces in the head and neck.

In all cases of spreading infection, sepsis remains a potentially fatal complication. As of 2016, sepsis is defined as, ‘life-threatening organ dysfunction caused by a dysregulated host response to an infection’.⁵ Traditionally, patients were assessed using the systemic inflammatory response syndrome (SIRS) criteria (of which some can be easily observed/performed in the dental chair as described in Table 2). However, the National Institute for Health and Clinical Excellence (NICE) have published its own guidelines on the early recognition and diagnosis of sepsis using a risk stratification tool,⁷ classing patients as low risk, moderate to high risk or high risk. This tool is extensive but not all the parameters are readily measurable or identifiable in a primary care dental setting.

Persistent haemorrhage from an extraction socket/biopsy site

Bleeding following an extraction or biopsy can be concerning for patients. Taking a thorough history should identify bleeding conditions and anticoagulant medication.

Bleeding can be classed as primary (ie at the time of surgery), reactionary (ie up to 3 hours after the procedure) and secondary (up to two weeks following the procedure).⁸

Many patients take medications which affect their ability to stop bleeding: aspirin and clopidogrel are well known culprits. Warfarin is commonly used in patients with atrial fibrillation and valve replacements; although recently, an increasing number of patients use novel oral anticoagulants (NOACs) which require less frequent monitoring and have fewer interactions with other medications compared to warfarin.⁹ NOACs currently licensed for use in the UK are dabigatran etexilate, rivaroxaban, apixaban and edoxaban.¹⁰ There is no chairside test available to measure NOAC activity, nor is there a reversal agent available to primary care clinicians. Guidelines for management of anticoagulated patients are available via the Scottish Clinical Dental Effectiveness Programme (SDCEP) website.¹¹

In all cases, adequate lighting and suction is required to identify the source of bleeding. Initially, clean, moist gauze should be applied to the area, and firm pressure applied for 10 minutes. Failing this, administration of local anaesthetic (containing a vasoconstrictor) and placement of a haemostatic agent (eg Surgicel®) into the depths of an extraction site and use of a resorbable suture (eg Vicryl Rapide™) can be used to approximate the gingivae (Figure 3).

Oro-antral communication (OAC) and displacement of teeth/roots/implants into the maxillary sinus

The proximity of the sinus floor to upper premolar and molar teeth makes communication between the mouth and maxillary sinus a risk during extraction of these teeth, particularly if there is associated apical pathology.¹³ OAC can be identified directly through the extraction socket or through the presence of bubbles from the socket. The patient may complain of fluid exiting the nose post-operatively. If the communication is small, then it is likely to heal spontaneously,^14,15 whereas larger communications are likely to require closure with a local flap. In these instances, the patient should be commenced on an ‘antral regimen’ consisting of oral antibiotics, steam inhalations, nasal decongestants and avoiding nose blowing for two weeks.

Formation of an oro-antral fistula (OAF) is when an OAC has become epithelialized, which requires formal excision and closure in a semi-elective setting.

Teeth or roots displaced into the sinus usually occur after an attempt at retrieving roots from a broken-down molar or premolar tooth (Figure 4). Radiographic confirmation with two different views is required to locate the root fragment. Retrieval can sometimes be achieved via the socket itself, but this is not always feasible.

Dento-alveolar trauma

Trauma to the dentition is associated with interpersonal violence, unbroken falls, sporting injuries and road traffic accidents (RTAs). Injuries can be extensive, affecting a combination of enamel, dentine, pulp and periodontal tissues. The diagnosis and management of these injuries are beyond the remit of this paper. However, many of these injuries can safely be treated in primary care. With all patients (particularly paediatric patients), it is necessary to establish signs of non-accidental injury (NAI). It is important to share your safeguarding concerns and to document your actions. If there is suspicion of head injury (Table 4), the patient should be referred immediately to an emergency department.

Nerve injury

Inferior Dental nerve (ID nerve) damage is associated with L3M extraction, but can occur following implant placement in the lower molar region and intraneural anaesthetic administration. To overcome the risks associated with intraneural ID nerve injection, there is reported success in the use of mandibular buccal articaine (4%) infiltrations over ID nerve blocks.¹⁶ A meta-analysis examining the use of articaine (4%) over lidocaine (2%) has reported that the former agent is more effective when used as an infiltration.¹⁷ However, its use for block anaesthesia remains controversial due to its reported increased neurotoxicity over lidocaine and prilocaine.¹⁸

Lingual nerve damage can follow L3M extractions and intraneural anaesthetic administration. Patients will complain of altered sensation to the anterior two-thirds of the tongue and possibly a loss of taste. If a lingual retraction technique is used for L3M removal, careful sub-periosteal placement of instruments against the lingual bone is essential. The mental, nasopalatine and greater palatine nerves can be implicated should mucosal relieving incisions and/or bone removal occur near their respective foramina. Neuropathy caused by implant placement warrants immediate removal of the implant.¹⁹

Fracture of the maxillary tuberosity

This complication is associated with extraction of upper third molar teeth and upper lone standing molars. Radiographic signs hinting toward tuberosity fracture include multiple divergent roots, ankylosed roots, curved roots and roots with hypercementosis (Figure 5). Tearing of the palatal mucosa perioperatively is a sign of tuberosity fracture and therefore close inspection of the palatal tissues is essential to identifying this complication. If confident, one can carefully dissect the palatal tissues from the dento-alveolar segment and continue to deliver the tooth. However, if there is uncertainty surrounding the size of the fracture, the procedure should be abandoned and the soft tissues re-approximated and the tooth splinted. Tuberosities which have been removed may create an OAC which will require closure.

Dislocated mandible

Dislocations can occur during yawning and prolonged dental treatment. Reduction of the dislocation is achieved by placing protected thumbs on the mandibular molars bilaterally, and performing a simultaneous downward and backward movement.

Hypochlorite extrusion

Extrusion of sodium hypochlorite into the peri-radicular tissues can be extremely uncomfortable. This complication usually occurs because of irrigation under high pressure which has breached beyond the apical constriction. The patient may present with sudden swelling in the surrounding tissues accompanied with erythema. Intraorally, necrosis and ulceration of the tissues may be present.²⁰ In primary care, immediate irrigation with saline or water is advised. Analgesia and cold compress over the affected area can help in alleviating symptoms.

Fracture of the mandible

A fractured mandible is a common presentation to the on-call OMFS team but may initially present in dental practice. Their aetiology includes interpersonal violence, RTAs and falls. Less commonly, mandible fracture can occur during an extraction. Signs and symptoms include pain over the affected fracture site, gingival tears, malocclusion and altered sensation to the lower lip and chin.

Conclusion

This paper has aimed to outline some of the common conditions which can present to the primary care clinician, highlighting their management and prevention.

Many of the conditions discussed can be initially managed in a primary care setting before being referred onward to secondary care. Furthermore, many conditions can be treated in primary care with further advice sought from clinicians in a secondary care/specialist setting. It is the primary care clinician's responsibility in these instances to reassure patients suitably and communicate effectively to patients and the referee to ensure the optimum outcome.