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THIRD EDITION
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2013
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Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices, or
medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer of
each product to be administered, to verify the recommended dose or formula, the method and
duration of administration, and contraindications. It is the responsibility of practitioners, relying
on their own experience and knowledge of their patients, to make diagnoses, to determine
dosages and the best treatment for each individual patient, and to take all appropriate safety
precautions.
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Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi
Using this Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
1 Evidence-based practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Assessing patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3 Human disease and patient care . . . . . . . . . . . . . . . . . . . . . . . . . 29
4 Control of pain and anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5 Infection and inflammation of the teeth and jaws . . . . . . . . . . . . . . . . . 89
6 Removal of teeth and surgical implantology . . . . . . . . . . . . . . . . . . 117
7 Diseases of bone and the maxillary sinus . . . . . . . . . . . . . . . . . . . . 147
8 Oral and maxillofacial injuries . . . . . . . . . . . . . . . . . . . . . . . . . . 177
9 Dentofacial and craniofacial anomalies . . . . . . . . . . . . . . . . . . . . . 199
10 Cysts and odontogenic tumours . . . . . . . . . . . . . . . . . . . . . . . . 213
11 Mucosal diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
12 Premalignancy and malignancy . . . . . . . . . . . . . . . . . . . . . . . . . 265
13 Salivary gland disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
14 Facial pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
15 Disorders of the temporomandibular joint . . . . . . . . . . . . . . . . . . . 327
16 Radiation protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
v
Preface
This book has been written for undergraduate and Oliver Tabbenor for reviewing many of the chap-
postgraduate clinical students to help their knowl- ters. Other areas of dentistry are dealt with in the
edge and understanding of the oral and maxil- accompanying volume of this series Master Den-
lofacial sciences. Our purpose is to present the tistry Volume Two: Restorative Dentistry, Paediatric
core knowledge of our specialties in an integrated Dentistry and Orthodontics, edited by Peter Heas-
and patient-focused way. The disciplines of oral man. We hope that the format is fresh and stimu-
surgery, dental and maxillofacial radiology, oral lating with ample opportunity for readers to assess
and maxillofacial pathology and oral medicine their knowledge.
have been brought together to provide an under- While this book will act as a core text for under-
standing of clinical problems. We have therefore graduate dental students, it will also be useful for
worked together to compile chapters, although postgraduates undertaking a Masters degree in Oral
we have each taken a lead in coordinating par- Surgery or preparing for the Membership of the
ticular chapters (Paul Coulthard, Chapters 1, Joint Dental Faculties (MJDF) or Membership in
3, 4, 6, 8, 9; Keith Horner, Chapters 2, 5, 7, 15, Oral Surgery examination of the Royal College of
16; Philip Sloan, Chapters 10, 11, 12, 13; and Surgeons in the UK or international equivalents.
Elizabeth Theaker, Chapter 14). This new edition
has been thoroughly updated since the publication Paul Coulthard
of the earlier popular text. I would like to thank 2013
Edmund Bailey, Neil Patel, Verena Toedtling and
vi
Using this Book
vii
Using this Book
viii
Using this Book
question and check that you are on schedule at Quickly plan your answer so that you can present a
time intervals during the examination. Find out if logical approach. The use of subheadings will guide
a negative marking system is to be used, such that your examiner through the essay, indicating that
marks are lost for incorrect answers, as this will you have an understanding of the breadth of the
determine whether it is worth a guess or not when question and score you points on the way. A brief
you do not know the answer. introduction to set the scene will produce a good
impression. Describe common factors first and
rare things later. Try to devote a similar amount of
Extended matching items text to each aspect of the answer. Maintain a con-
Extended matching items (EMIs) are thought to cise approach even for an essay. Finish the essay
be valuable in assessing both the level and applica- with a conclusion or summary to draw together
tion of knowledge. They may be based around a the threads of the text or describe the clinical
theme, such as a diagnosis, a set of investigations importance.
or a symptom or sign. Identify the theme, then
carefully read the introductory lead in state-
ment. Note that an option to be matched with Oral examinations
each vignette or case may be used once, more than The oral examination can induce a lot of anxiety for
once or not at all. On occasions, when more than some people but preparation and practice can alle-
one option could be correct, choose the best option viate this. Some oral examinations include presen-
available. tation of a clinical case. It can be very difficult to
know how well or not you are doing, depending on
the attitude of the examiners. The examiners usu-
Short notes ally begin with general questions and then move on
Do not waste time writing irrelevant text. Short to requests for more detailed information and con-
note questions are marked by awarding points for tinue until you reach the limit of your knowledge.
key facts. While layout is always important to allow It is useful to have preprepared initial statements
the examiner to identify these facts easily, a logical on key subjects, which might include a definition
approach is less important than for an essay. Give and a list of causes or types of pathology. This can
each section of the question the correct propor- help you to be articulate at the start of the viva
tion of time rather than spending too long on one until you settle into things.
part in an attempt to get every point. It is more There is frequently more than one answer to a
efficient to get the easiest points down for every question of patient management and it is not wrong
question rather than all for one part and none for to state this in an examination. To explain that a
another. particular area is not well supported by scientific
evidence and describe the alternative views will
be respected and appreciated. Students are often
Essays advised to lead the direction of the viva, but in
Answer the number of essays requested. It is dan- practice this may be difficult to do. In reality, the
gerous not to answer a question at all and many examiner may insist that you follow rather than
marking systems will mean that you cannot pass lead. Remain calm and polite and do not hold back
even if you answered another question rather well. on showing off what you know.
ix
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Dedication
xi
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Evidence-based practice 1
It either validates previously accepted diagnos- the outcomes of forgoing or accepting treatment.
tic tests, preventive regimens and treatments, or For example, when the consultation concerns the
replaces them with new ones that are more pow- removal of a lower wisdom tooth, the clinician
erful, more accurate, more effective and safer. The may ask the patient to compare the distress caused
strength of evidence from various study designs is by the pericoronitis with the anticipated dis-
shown in Fig. 1.1. tress of temporary pain and swelling and possible
Do not look at promotional brochures, which altered sensation. The patient should also take into
often contain unpublished material. Ignore anec- account the likelihood of future episodes of peri-
dotal evidence, such as the fact that a dental coronitis if they forgo surgery.
celebrity is using a particular product. Do not
accept the newness of a product as an argument
for changing to it as the opposite might have a good
Benefits and limitations of
scientific argument. evidence-based medicine
The aim of evidence-based medicine is to improve
clinical outcomes for patients and there is plenty of
Clinical expertise evidence that this is the case. One example is that
Clinical expertise is the ability to use clinical myocardial infarction survivors, who are prescribed
skills and past experience to rapidly identify each aspirin or beta-blockers, have lower mortality rates
patients unique oral health state and diagnosis, than those who arent prescribed these drugs.
their individual risks and benefits of potential inter- Another example would be the benefit of using
ventions and their personal values and expectations. streptomycin for pulmonary tuberculosis as dem-
onstrated by the historic Medical Research Council
trials. These are generally regarded as the first of
Patient values the modern randomised controlled trials.
Patient values are the unique preferences, con- The randomised controlled trial provides the
cerns and expectations each patient brings to a underlying basis for evidence-based medicine and
clinical encounter and which must be integrated the number of trials is growing exponentially with
into clinical decisions if they are to serve the more than 150000 listed by the Cochrane Library.
patient. It is usual practice for the clinician to However, there are limitations to evidence-based
describe the diagnosed condition or disease to the medicine. There is a shortage of consistent scien-
patient and then describe the treatment available tific evidence, difficulties in application of research
together with the harms that the treatment may evidence to individual patients and barriers to the
potentially cause. To determine the patient val- practice of high-quality care. Some clinicians mis-
ues, the clinician could go on to ask the patient understand the philosophy of evidence-based medi-
to make a value judgement about these two, that cine and incorrectly believe that it means a loss of
is, which is worse and by how much. The patient clinical freedom, or that it ignores the importance
may need to think about this or discuss it with of clinical experience and of individual values,
family members. The clinician may also describe which is not the case.
Cohort studies
Case-control studies
Cross-sectional surveys
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Evidence-based practice Chapter 1
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Master Dentistry
simple cases in one group and all the difficult cases Sample size calculation
in another. If the groups are kept as similar as possi- A clinical trial should be large enough to have a
ble at the start of the study then it will be easier to high chance of detecting, as statistically significant,
isolate and quantify the impact of the intervention. a benefit from the treatment. Many trials are too
small to be sure that no benefit exists. The authors
may conclude that the intervention had no benefit,
Blinding but if they had calculated in advance the appropri-
Ideally all patients and clinicians involved in the trial ate sample size, and recruited more participants,
should be blind to the intervention so that all groups then they may have observed an effect.
are treated equally, apart from the experimental
treatments that are being compared. If this isnt the
case then the study may be biased by patients who Inclusion and exclusion criteria
report symptoms, and clinicians who interpret them, The criteria used to determine who can enter the
influenced by their hunches and opinions about the trial and who should be excluded shouldnt be too
anticipated treatment effectiveness. It is, however, restrictive. If they are restrictive then the conclu-
not always possible to blind all trials. In surgical tri- sions can only be used to guide decisions for the
als, for example, the surgeon will be aware of which narrow group of patients who also fit the criteria.
technique of the alternatives he or she is using, but
it may be feasible to have clinicians other than the
operating surgeon who are blind to the study group, Estimate of effect
carrying out the postoperative assessments. This The estimate of effect or treatment effect is the
would be described as a single-blind trial. relationship observed between the intervention
A trial is described as double-blind when both the and outcome. There are various methods available
participants and the investigator are blind to the inter- to describe the results in clinically useful ways,
vention. Some trials require a double-dummy. This including the risk ratio and a number needed to
may be the case, for example, in an oral medicine trial treat to benefit (NNT). The risk ratio is the ratio
when two or more mouthrinse interventions need to of the risk in the intervention group to the risk in
look and taste the same. The double-blind, double- the control group. A risk ratio of 1 indicates no dif-
dummy, randomised controlled trial can also be use- ference between comparison groups. The NNT is
ful when, for example, a drug in tablet form is to be an estimate of how many people need to receive
compared with a drug in injection form. Participants a treatment before one person would experi-
in one of the study groups would receive a tablet con- ence a beneficial outcome. The NNT for 1g oral
taining the active drug together with an injection of paracetamol compared to placebo to achieve at
placebo, and the other study group would receive a least 50% relief of severe or moderate pain after
placebo tablet with an injection of the active group. surgery is about 3.8. Ibuprofen at 400mg compared
A study is described as triple-blind when the to placebo has a NNT of 2.4 and is, therefore, a
statistician who is analysing the data is blind to more effective oral analgesic.
the identification of the study group in addition to The confidence interval (CI) provides a measure
the investigator and participants. of the precision or uncertainty of study results for
making inferences about the population of patients.
As CIs indicate strength of evidence about quantities
Completeness of follow-up such as treatment benefit, they are of particular rel-
All patients entered to the study should be evance to practitioners of evidence-based medicine.
accounted for at its conclusion. Ideally no patients
should be lost to follow-up because these patients Different types of randomised
could have had outcomes that would affect the con-
clusions of the study. They may have dropped out
controlled trial
because of an adverse outcome. One way of deal-
ing with the data where there are patients who have Efficacy and effectiveness
been lost is to assign the worst-case outcome to all Efficacy refers to whether an intervention works
of those lost to follow-up. However, some consider in people who receive it. In an efficacy trial, the
that a loss of more than 20% is unacceptable. investigators completely control the administration
4
Evidence-based practice Chapter 1
of the intervention given to the participants. Sur- both interventions. This is called a cross-over trial.
gical trials comparing different surgical techniques This has been used for comparing patient satisfac-
are efficacy trials. Trials investigating analgesics for tion after provision of a conventional denture ver-
pain control after wisdom tooth surgery are often sus an implant-retained denture. Participants are
efficacy trials too, when patients are usually kept randomised to receiving a conventional denture or
on the study premises so that investigators can implant-retained denture. Then after an evaluation
ensure that the study medication is taken properly. period, those with the conventional denture receive
Even if participants go home, a high compliance is dental implants and a new or modified denture.
expected and will usually be aided by contacting Those participants with implants have the abut-
the participants by telephone to prompt this. ments only removed, so that the soft tissues heal
Effectiveness refers to whether an interven- over the implants (implants are allowed to sleep),
tion works in people to whom it has been offered. and then have a conventional denture made. In this
These effectiveness trials try to evaluate the effects way, patients can experience both interventions and
of an intervention in a similar environment to that report their satisfaction in a better way.
found in usual clinical practice. The inclusion cri- In a split-mouth design, each patient acts as
teria are likely to be less strict as the intention is his or her own control. The different treatment
to mimic the real world. Participants may accept or options are carried out on different sides of the
refuse the intervention, which is likely to already mouth. The advantage of this type of design is that
have a proven efficacy. the influence of host-related factors, such as gen-
eral health, age or oral hygiene, on the interventions
are reduced. The split-mouth design could not be
Phase I, II and III trials used for the comparison of two mouthrinses as
Trials designed for evaluation of new drugs are the effect of each could not be limited to one side
described as Phase I, II and III trials. Following the or the other, but is excellent for procedural treat-
investigation of safety and potential efficacy in ani- ments such as placement of dental implants. The
mal studies, the first human trials are conducted. intervention is randomised to the right or left side
These are known as Phase I studies and are car- of the patients mouth.
ried out with healthy volunteers as participants
and focus on safety and establishing the appropri- Bias and assessment of
ate dose level. These are followed by Phase II stud-
ies that investigate efficacy of the chosen dose or a
randomised controlled trials
dose range. Participants will be patients who have a
condition requiring the drug, for example, pain after Bias
surgery requiring an analgesic. Phase III studies are Bias in health care research refers to any process
effectiveness studies comparing the new drug with or factor that causes the results of a trial to devi-
an existing similar drug. ate away from the truth. It usually occurs uncon-
Once the new drug has been approved for mar- sciously rather than because the investigators are
keting, there is likely to be a phase of monitoring. making a deliberate attempt to falsify the conclu-
This phase is sometimes called a Phase IV trial, sions. Bias can be introduced at any stage, in the
although it is not a randomised controlled trial but planning, conducting or analysis of a trial. A bias
rather a survey. known as selection bias is described when patients
are entered into a trial such that the groups are
not properly balanced. For example, an investiga-
Parallel, cross-over and split-mouth tor may believe that a new implant system is better
design than an existing one but is anxious that it may not
When participants are exposed to only one of the actually work so well for the more complex cases.
study interventions, for example, a new analgesic If the clinician has prior knowledge as to which
or placebo, the study is described as a parallel trial implant group a particular patient will be in, then
or trial with parallel group design. An alternative he or she may present study information in such a
design, used less frequently, is when the partici- way to the complex patients that they are discour-
pant is given one intervention followed by another aged from entering the trial altogether, when they
in random order, that is, each participant receives were due to enter the new implant system group.
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Master Dentistry
This should not occur if the randomisation and allo- 1.3 Other research methods
cation procedure is good.
Bias can also occur in the publication and dis-
semination of trials. Authors are more likely to Learning objective
submit and editors are known to be more likely to
You should:
accept papers for publication when the findings are know other types of clinical study design.
positive. This is referred to as publication bias. It
would be helpful if high-quality trials were pub-
lished irrespective of the direction of their findings. A multicentre double-blind placebo controlled
trial is not the only way to answer a therapeutic
question. There are some questions that cannot be
Assessing the quality of randomised answered by randomised controlled trials, usually
controlled trials because it would be inappropriate for the investiga-
Not all published trials are perfect and so if you tor to influence the aetiology or natural history of the
want to be confident about the conclusions drawn disease. For example, we believe from observational
from a trial in guiding your clinical decision mak- studies that dental implant osseointegration is signifi-
ing, then the quality of the trial published as a cantly impaired in patients who smoke, thus reducing
paper should be assessed. The degree to which the implant success. It would not be ethical to randomise
trial has been designed, conducted and analysed patients to smoking and non-smoking groups and so
well, is described as the internal validity of the a randomised controlled trial cannot be undertaken.
trial. The precision and extent to which it is pos- We must be content with observational studies. Simi-
sible to generalise the results of the published trial larly, it may not be feasible to study an intervention
to other settings is known as the external valid- that may not show effects for many years because of
ity. There are various assessment tools available the difficulty in funding and high drop-out.
to determine the quality, although these are likely Also, some things are so obvious that there
to be modified as needed. It may, for example, be doesnt need to be a randomised controlled trial.
important to know that a trial comparing different There has never been a randomised controlled trial
analgesics for pain after wisdom tooth surgery was to show that defibrillation of the heart in ventricu-
blinded properly. However, blinding of partici- lar fibrillation saves more lives than doing nothing,
pants would not be important in a trial comparing or to demonstrate that antibiotics are beneficial in
lingual nerve protection with no protection during treating pneumonia.
wisdom tooth surgery, when measuring postopera-
tive tongue sensation, as the patient is unlikely to
introduce bias. It is necessary therefore, to con- Cohort studies
sider what parts of any assessment tool are impor-
tant and relevant to the research question being In a cohort study, two or more groups of individu-
asked. als are selected on the basis of difference in their
The outcomes measured should be meaning- exposure to a particular agent and followed up to
ful and provide direct information about benefit determine how many in each group develop a par-
or harm. Outcome measures may be described as ticular disease or other outcome.
true and surrogate outcomes. A true outcome The evidence that there is a causal, rather than
provides unequivocal evidence of tangible benefit coincidental, link between smoking and ill health
for the patient. An example in a dental implant was produced by the world-famous cohort study
trial would be the presence or absence of a func- that followed up 40000 British doctors divided
tioning implant-supported prosthesis. A surrogate into four cohorts (non-smokers and light, moderate
outcome is a predictor of the true outcome. In the and heavy smokers). The authors published their
dental implant trial, the number of surgical vis- 10-year interim results in 1964, which showed a
its required or the presence of plaque, bleeding of substantial excess in both mortality from lung can-
probing, or radiographic marginal bone changes, cer and all-cause mortality in smokers with a dose
would be described as surrogate outcomes. response relation. They went on to publish 20-year
Outcomes should be reliable, reproducible, eas- and 40-year results, with an impressive 94% follow-
ily quantifiable and affordable. up, that confirmed the dangers of smoking.
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Evidence-based practice Chapter 1
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Master Dentistry
studies, as well as an estimate of the overall result 1.5 How to read a paper
of all the studies together. The forest plot from
this review has been adopted as the logo for the
Cochrane Collaboration (Fig. 1.3). Learning objective
A systematic review in 2005 based on 139 stud- You should:
ies showed that there was no credible evidence understand the importance of critical appraisal.
that the vaccine against measles, mumps and
rubella was involved in the development of either
autism or Crohns disease, as had been published The medical and dental literature is vast and grow-
and then reported in the press. ing rapidly, so the reader should be clear about
why he or she is reading to avoid getting lost. Rea-
Box 1.1 sons may include keeping up-to-date, to find an
answer to a specific clinical question or to under-
Components of a Cochrane systematic review take research. There are many poor-quality studies
published, so once the reader has identified papers
Background.
of potential interest, it is important to assess their
Objectives.
methodological quality or critically appraise, and
Criteria for considering studies for this review.
note their clinical applicability.
Types of studies.
Types of participants.
Types of interventions.
Types of outcome measures.
Appraisal questions
Identification of studies for inclusion.
Search strategy.
When seeking to provide the best possible care for
Databases searched.
patients, clinicians need to know what works, what
Any language restrictions.
doesnt and how to distinguish between the two.
Any unpublished studies.
When reading a paper, it is useful to ask particu-
Study selection.
lar questions (see Box 1.2), but remember that it
Quality assessment. is easier to criticise the research of others than to
Data collection and analysis. undertake a perfect piece of research oneself.
Main results.
Discussion.
Reviewers conclusions for practice and research. CONSORT
The CONSORT (Consolidation of the Standards of
Reporting Trials) statement was published in 1996
Box 1.2
8
Evidence-based practice Chapter 1
by a group of biostatisticians, clinical epidemiolo- Lancet, require that papers submitted report-
gists and journal editors to help authors with the ing randomised controlled trials should adhere to
reporting of randomised clinical trials for publication the recommended presentation. The intention is
in journals. The statement consists of 22 items on a that this initiative will improve the quality of ran-
checklist (Table 1.1) and flow diagram (Fig. 1.4). domised controlled trials and their reporting in
Many journals, including the British Dental publications.
Journal, JAMA, British Medical Journal and The
Table 1.1 CONSORT checklist of items to be included when a randomised trial is reported
Introduction
Background 2 Scientific background and explanation of rationale
Methods
Participants 3 Eligibility criteria for participants and the settings and locations where data
were collected
Interventions 4 Precise details of the interventions intended for each group and how and when
they were actually administered
Objectives 5 Specific objectives and hypotheses
Outcomes 6 Clearly defined primary and secondary outcome measures
Sample size 7 How sample size was determined
Randomisation sequence 8 Method used to generate the random allocation sequence
generation
Randomisation allocation 9 Method used to implement the random allocation sequence clarifying whether
concealment the sequence was concealed until interventions were assigned
Randomisation implementation 10 Who generated the allocation sequence, who enrolled participants and who
assigned the participants to their groups
Blinding 11 Whether or not participants, those administering the interventions and those
assessing the outcomes were blinded to the group assignment
Statistical methods 12 Statistical methods used to compare groups for primary outcomes
Results
Participant flow 13 Flow of participants through each stage (a diagram is strongly recommended)
Specifically for each group, report the numbers of participants randomly
assigned, receiving intended treatment, completing the study protocol and anal-
ysed for the primary outcome
Recruitment 14 Dates defining the periods of recruitment and follow-up
Baseline data 15 Baseline demographic and clinical characteristics of each group
Numbers analysed 16 Number of participants in each group
Outcomes and estimation 17 For each primary and secondary outcome, a summary of results for each group
and the estimated effect size and its precision (e.g. 95% confidence interval)
Ancillary analyses 18 Address multiplicity by reporting any other analyses performed, including subgroup
analyses and adjusted analyses, indicating those prespecified and those exploratory
Continued
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Master Dentistry
Table 1.1 CONSORT checklist of items to be included when a randomised trial is reportedcontd
Discussion
Interpretation 20 Interpretation of the results taking into account study hypotheses, sources of
potential bias or imprecision and the dangers associated with multiplicity of
analyses and outcomes
Generalisability 21 Generalisability (external validity) of the trial findings
Overall evidence 22 General interpretation of the results in the context of current evidence
Excluded (n= )
Did not receive allocated intervention (n= ) Did not receive allocated intervention (n= )
Give reasons Give reasons
10
Evidence-based practice Chapter 1
1.6 Clinical practice guidelines Table 1.2 Levels of evidence and grades
of recommendations for therapies
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Assessing patients 2
This chapter describes the basic principles of A full and accurate history is of paramount impor-
assessing a dental patient. A history should include tance in assessment of a patient. In some cases,
significant medical and social facts as well as the the history may provide the diagnosis, while in the
dental problem. An initial extraoral examination remainder, it will give essential clues to the nature of
covers both the visual appearance of the patient the problem. The approach to history taking needs to
and features such as swellings and nerve dys- be tailored to the type of complaint being investigated.
function. Once these aspects are completed, the It is important to have a systematic approach to tak-
intraoral examination will attempt to identify ing a history. A consistent series of questions will avoid
any lumps or swellings and to differentiate these inadvertently missing an important clue. Use open
into dental and non-dental origins. Features such rather than closed (those usually eliciting a yes/no
as ulcers and motor or sensory nerve dysfunction response) questions wherever possible to avoid leading
will also be noted before the detailed examina- the patient. Record the patients own responses rather
tion of the troublesome tooth or teeth. The physi- than paraphrasing. The history will cover:
cal examination of the teeth is described. Specific
the complaint
investigations must be chosen for their suitability,
both in terms of the usefulness of the results and the history of the complaint
the medicolegal aspects of their use. For example, past dental history
both HIV testing and the use of X-rays have impli- social and family history
cations beyond the results that they provide. The medical history.
Master Dentistry
14
Assessing patients Chapter 2
a Submental
b Submandibular c d e
c Preauricular
f g
d Postauricular b
a
e Occipital
h i
f Jugulo-digastric
g Jugulo-omohyoid
h Mid jugular j k
i Midposterior cervical
j Lower jugular
k Lower posterior cervical
Fig. 2.1 Principal lymph nodes in the head and neck. The dotted lines indicate the outline of the sterno-
cleidomastoid muscle.
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Master Dentistry
V1
C2
V2
Trigeminal nerve:
V3 V1 ophthalmic division
C3 V2 maxillary division
V3 mandibular division
C2
Cervical nerve:
C4
C2C4 branches
Fig. 2.2 Cutaneous sensory innervation of the head and neck by the trigeminal and cervical nerves.
colour
the patient knows what to expect. Then repeat this
single or multiple over the symptomatic area, asking the patient to
surface texture/warmth say whether they can feel anything. Record the area
of altered sensation in the notes using a drawing.
tenderness
The degree of alteration in sensation can be
fluctuation assessed by using different probes. A teased-out
sensation/pulsation. piece of cotton wool can be used or, where anaes-
Consistency can be informative, ranging from the thesia appears to be profound, a sharp probe can be
soft swelling of a lipoma, through cartilage hard (carefully) tried.
pleomorphic adenomas and rubbery hard nodes The extent of the area of paraesthesia or anaes-
in Hodgkins disease, to the rock hard nodes of thesia will tell you the particular nerve, or branch
metastatic malignancy. Tenderness and warmth on of a nerve, involved (Fig. 2.2). This will, in turn,
palpation usually indicates an inflammatory pro- inform you about the possible location of the
cess, while neoplasms are commonly painless unless underlying lesion. For example, a patient with
secondarily infected. Fluctuation indicates the disturbed sensation of the upper lip has a lesion
presence of fluid. To assess fluctuation, place two affecting the maxillary division of the trigeminal
fingers on the swelling and press down with one fin- nerve. If this is the sole site of sensory deficit, it
ger. If fluid is present, the other finger will record suggests a lesion closer to the terminal branches of
an upward pressure. Pulsation in a swelling will this cranial nerve (e.g. in the maxillary sinus). In
indicate direct (i.e. it is a vascular lesion) or indirect contrast, if sensory deficiencies are simultaneously
involvement (i.e. in immediate contact) of an artery. present in other branches of the nerve, it suggests
that the lesion is more centrally located.
Paraesthesia/anaesthesia
The presence of sensory disturbance is usually Paralysis/motor disturbance
identified initially by the patient in the history. It While paralysis or motor disturbance may be
is important to identify the extent of the affected reported as a symptom by the patient, it may ini-
area and the degree of alteration in sensation. It is tially be identified during an examination. In the
best to use a fairly fine, but blunt-ended, instru- maxillofacial region, the motor nerves that are
ment for this at first, for example, the handle of a likely to be under consideration are the facial nerve,
dental mirror. First, run the instrument gently over the hypoglossal nerve and the nerves controlling the
what is assumed to be a normal area of skin so that muscles that move the eyes.
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Assessing patients Chapter 2
Disturbance in function of the facial nerve will Again, a systematic approach is essential to
result in effects on the muscles of facial expression. avoid being distracted by the first unusual find-
Paralysis of the lower face indicates an upper motor ing you encounter. The examination must include
neurone lesion (stroke, cerebral tumour or trauma). lips, cheeks, parotid gland orifices, buccal gingi-
Paralysis of all the facial muscles (on the affected vae, lingual gingivae and alveolar ridges in edentu-
side) indicates a lower motor neurone lesion. The lous areas, hard palate, soft palate, dorsal surface
latter is seen in a large number of conditions but, of the tongue, ventral surface of the tongue, floor
for the dentist, important causes include Bells of mouth, submandibular gland orifices and, finally,
palsy (Fig. 2.3), parotid tumours, a misplaced infe- the teeth. Different clinicians will have their own
rior dental local anaesthetic and trauma. sequence of examination, but it is the thoroughness
of the examination that is important, not the order
in which the regions of the mouth are examined.
2.3 Intraoral examination Once the general intraoral examination is com-
plete, a problem-specific examination can proceed.
Learning objectives This is tailored to the clinical problem.
You should:
be able to differentiate dental and non-dental
sources of symptoms Swelling/lump
understand the significance of features of ulcers,
such as form, site and pain The examination of an intraoral swelling or lump
be able to examine for motor and sensory nerve is essentially the same as that described above
dysfunction as part of the extraoral examination. Most oral
know how to examine a tooth. swellings are inflammatory, caused by periapical
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Fig. 2.4 Clinical photograph of a squamous cell carcinoma of the tongue. Note the raised edges and
necrotic centre.
or periodontal infections. However, the minor- The finding of an ulcer on examination may
ity of oral swellings and lumps that are non-dental necessitate taking additional history; for example,
encompasses a wide range of conditions, the details if a traumatic ulcer is suspected, direct question-
of which form a significant part of this book. ing may prompt the patient to recall the injury
(Fig. 2.5). If multiple ulcers are detected, this
may lead to further enquiries about any previous
Ulcer history of recurrent oral ulceration or specific gas-
Examination of an ulcer should include assess- trointestinal diseases. It is surprising how often
ment of eight important characteristics: ulceration is discovered that the patient is not
site
aware of. When an ulcer is found, it is vital that
a detailed record of the history and examination
single/multiple
findings is made. Any oral mucosal ulcer that does
size
not heal within 3 weeks should be considered as
shape possibly malignant and urgent referral must be
base of the ulcer arranged.
edge Certain ulcers have a tendency to occur in par-
pain ticular oral sites; for example, squamous cell carci-
time period. nomas are most common on the lower lip, in the
floor of mouth and the lateral border of the tongue.
Visual inspection is essential but palpation is also On the other hand, traumatic ulcers are most com-
an important part of the examination of an ulcer. mon on the lateral border of the tongue and buc-
Gloves must be worn for palpation and the texture cal mucosa in the occlusal plane. Ulceration on the
of the ulcer base, margin and surrounding tissues lower lip is also a common site for traumatic ulcer-
should be ascertained by gentle pressure. Malignant ation, particularly following administration of an
neoplasms tend to ulcerate, and these often feel inferior dental block or after a sports injury. Site
firm, hard or even fixed to deeper tissues. A raised is also important in diagnosis; for example, minor
margin is a suspicious finding, as is the presence of aphthae are restricted to lining mucosa and can be
necrotic, friable tissue in the ulcer base and bleed- ruled out if ulceration is occurring on the hard pal-
ing on lightly pressing (Fig. 2.4). Healing traumatic ate or gingivae.
ulcers tend to be painful on palpation and they feel Size and shape can also be helpful; for example,
soft and gelatinous. linear fissure-type ulcers may be seen in Crohns
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Assessing patients Chapter 2
Fig. 2.5 Clinical photograph of a traumatic ulcer of the lingual mucosa. Note the superficial nature of the
ulcer. Its base is covered by fibrous exudates and the surrounding area is inflamed.
disease, though aphthae are more usual. The shape the possible site of the underlying pathological pro-
of a traumatic ulcer may reveal the cause; for cess (Fig. 2.6).
example, semicircular ulcers are sometimes caused
by the patients fingernail. Bizarre persistent ulcer-
ation is sometimes a result of deliberate self-harm, Paralysis/motor disturbance
unusual habits or taking recreational drugs. In such
cases, diagnosis can be difficult as the patient may Within the oral cavity, motor disturbance is seen
deny knowledge of the causation. Minor aphthae in the tongue (owing to damage to the function of
have characteristic size and site features, which can the hypoglossal nerve) and the soft palate (owing to
distinguish them from major and herpetiform aph- lesions affecting the vagus nerve). With hypoglos-
thae (see Chapter 11). sal nerve lesions, there is deviation of the tongue
Pain, as mentioned above, is a feature of inflam- towards the affected side when attempting protru-
matory and traumatic ulcers, while in the early sion. There is also a problem with speech, with lin-
stages a malignant ulcer is often painless. Advanced gual sounds such as l, t and d affected.
malignant ulcers eventually tend to become painful
as a result of infection and involvement of adjacent
nerves. Presentation with a painful traumatic ulcer Tooth problems
is common in dentistry. The cause should be elimi-
nated if possible (e.g. smoothing or replacement Tooth problems are, of course, the most common
of an adjacent fractured restoration), symptomatic problems facing the dentist. The context is usually
treatment such as analgesic mouthwash prescribed pain or swelling. A standard method of examina-
and, most importantly, review arranged to ensure tion helps in reaching a diagnosis. You should not
that healing has occurred. simply hammer the suspect tooth with the mir-
ror handle and take a radiograph as your method
of assessment! Careful examination may establish
Paraesthesia/anaesthesia a diagnosis and therefore, avoid any need for radi-
ography or other special tests. Examination will
The principles of examination are those described involve:
above for extraoral examination. Once again, you
need good anatomical knowledge of the nerves sup- visual
plying different parts of the oral cavity to interpret probing restorations
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Master Dentistry
V2 (branch of V2 (greater
infraorbital nerve) palatine)
V2 (nasopalatine)
V2 (ASA)
V2 (PSA)
V3 (buccal)
V2 (lesser palatine)
IX (glossopharyngeal nerve)
V3 (mental)
V3 (lingual)
Fig. 2.6 Sensory innervation of the oral cavity is principally from the trigeminal nerve (V) while the glos-
sopharyngeal nerve (IX) supplies the posterior third of the tongue. NB: Taste sensation in the anterior two-
thirds of the tongue is provided by fibres of VII nerve origin passing through the lingual nerve.
assessing mobility
Pressure sensitivity should be assessed using
direct finger pressure and, when this does not
periodontal probing
evoke a response, can be supplemented by percus-
thermal tests sion, using a dental mirror handle. This will assess
pressure tests. whether periodontitis is present or not. However,
Visual examination will reveal gross caries, the if a single cusp is tender to percussion, this may be
presence of restorations, signs of tooth wear and indicative of cracked cusp syndrome.
gingivitis. A probe will allow tactile assessment of
restoration margins.
Mobility should be assessed manually. Periodon- 2.4 Special investigations
tal probing should be carried out to assess pock-
eting, the presence of calculus/overhangs and,
ultimately, bone loss.
Learning objectives
A basic test of vitality should always be per- You should:
formed, using a cotton wool pledget soaked with understand what samples can be taken for tests,
ethyl chloride (cold stimulus) and sometimes how to take and treat these materials and what
tests are available
heated gutta-percha (hot stimulus). While these are
know how to interpret the results that are returned
usually sufficient to reveal a hypersensitive tooth
know when imaging techniques would be
with pulpitis, an electrical pulp test can be used to informative and which type of imaging to choose.
assess vitality in some cases.
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Assessing patients Chapter 2
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Master Dentistry
aspiration biopsy (FNAB) can be used to obtain a The Sickledex test may be used to screen
sample of cells from a solid tumour, and is a hospi- for sickle cell anaemia prior to giving general
tal procedure. It may be facilitated by using ultra- anaesthesia in situations of urgency. The blood
sound imaging as a guide. sample should be subjected to haemoglobin
electrophoresis.
Haematological parameters of importance in
Incisional/excisional biopsy dentistry are described in Table 2.1.
Mucosal biopsy is one of the more common inves-
tigations used by dentists in primary and second-
ary care. Tissue is removed under local or general Biochemistry
anaesthesia, using sharp dissection to avoid crush- Biochemical investigations are used principally in
ing the specimen. It is fixed in at least 10 times its specialist clinics to investigate patients present-
volume of 10% neutral buffered formalin or similar ing with oral manifestations of systemic disease,
fixative. It is then forwarded to the histopathol- for example, estimation of alkaline phosphatase
ogy or specialist oral and maxillofacial pathology in Pagets disease of bone, and serum calcium to
laboratory. exclude hyperparathyroidism when a giant cell
Excisional biopsy. The entire lesion is removed granuloma is diagnosed. Biochemical estimation
and submitted for diagnosis. It is suitable for benign of cyst fluid for protein content is sometimes
polyps, papillomas, mucocoeles, epulides and other undertaken as part of the diagnosis of keratocystic
small reactive lesions. odontogenic tumour.
Incisional biopsy. A representative sample
of a larger lesion is taken for diagnosis prior to
treatment. This is a specialist procedure requir- Immunology
ing some expertise and experience. It is used for Advances in knowledge and methods in immunol-
generalised mucosal disorders such as lichen pla- ogy have resulted in a large number of laboratory
nus or for the diagnosis of other red and white immunological investigations, available in specialist
patches. An important consideration is obtaining laboratories. Sometimes diagnostic arrays of tests
a sample from an appropriate area. Non-healing are offered by the laboratory. Examples of tests in
ulcers are often investigated by incisional biopsy; dentistry include detection of antibodies against
here it is important to include the margin of the extractable nuclear antigens, including SS-A and
ulcer with some normal tissue and to obtain a suf- SS-B, for the diagnosis of Sjgrens syndrome and
ficiently large sample (normally 10mm 10mm) autoantibodies in vesiculo-bullous diseases.
to identify or exclude cancer. Sometimes fresh HIV testing should only be undertaken by spe-
tissue is required for diagnosis, for instance, in cialists and does not fall directly into the remit of
the vesiculo-bullous diseases where immunofluo- dentistry. It requires informed patient consent and
rescence is needed. Special arrangements must counselling. Dentists must be able to recognise the
be made with the laboratory when such tests are oral manifestations of immunodeficiency states and
planned. arrange proper referral.
Haematology Imaging
Patients presenting with oral manifestations of
haematological disease are normally referred for Imaging is an important special test in dentistry
specialist opinion. Full blood count and assay and oral and maxillofacial surgery. X-ray exposure
of haematinics is an important investigation for carries a quantifiable risk (see Chapter 16), X-ray
patients presenting with lingual papillary atrophy or examinations should be selected according to spe-
recurrent oral ulceration, for example. Coagulation cific selection (referral) criteria. Other imaging
studies and platelet counts may be required when investigations not using ionising radiations (ultra-
excessive bleeding is encountered. Patients on anti- sound and magnetic resonance imaging) have their
coagulant therapy should have their international place and should be used in preference to X-ray
normalised ratio (INR) checked before any surgical techniques (radiography and computed tomog-
procedure is undertaken. raphy) when they can provide the same or better
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Assessing patients Chapter 2
Haematocrit (HCT)
Male 4054 ml/dl 0.400.54
Female 3747 ml/dl 0.370.47
Mean cell volume, adults (MCV) 80101 m3 80101 fl
Mean cell haemoglobin, adults (MCH) 2731 pg/cell 1.681.92 fmol/cell
Mean cell haemoglobin concentration, adults (MCHC) 3136.5 g/dl 4.85.6 mmol/l
White cell count, adults (leukocytes; WBC) 450011000/mm3 4.011.0 109/l
Neutrophils 20007500/mm3 2.07.5 109/l
Lymphocytes 15004000/mm3 1.54.0 109/l
Monocytes 2001200/mm3 0.21.2 109/l
Eosinophils 40400/mm3 0.040.40 109/l
Platelets, adults (PLT) 150000450000/l 150400 109/l
Erythrocyte sedimentation rate, adults (ESR) 08 mm/h 08 mm/h
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Assessing patients Chapter 2
Fig. 2.8 CBCT imaging. The data are displayed in four windows, representing (clockwise from lower left) axial,
coronal, sagittal and volume-rendered (3D) images.
view in a single scan and are only appropriate for Clinical maxillofacial applications include soft
hospital or specialist practice. tissue lumps in the neck (e.g. lymph nodes) and
the salivary glands, detection of salivary calculi and
demonstration of inflammatory or obstructive dis-
Diagnostic ultrasound ease of the salivary glands.
Ultrasound uses the principle that high-frequency
(218MHz) sound waves can pass through soft
tissue but will be reflected back from tissue inter- Radioisotope imaging
faces. The echoes can be detected to produce an Radioisotope imaging is also known as nuclear med-
image. The sound is transmitted and detected by icine (Fig. 2.9). The technique uses radioisotopes
the same hand-held transducer. Imaging is real- (usually gamma ray emitters) tagged on to phar-
time, which permits its use in conjunction with maceuticals, which are usually injected into the
needle biopsy techniques. bloodstream. By choosing the radiopharmaceutical
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26
Assessing patients Chapter 2
Dr A Smith
Consultant Oral and Maxillofacial Surgeon
Anytown General Hospital
Anytown
2 January 2008
Dear Dr Smith,
Re: Mr John Doe, 24 Green Lane, Anytown. Date of birth: 25.12.40 Tel: 0123 456789
I would be grateful if you would see this 60-year-old man. He presented today complaining
of a growth from a recent extraction socket in his upper jaw. He said that this had appeared
after an extraction I carried out two weeks ago and was getting slowly bigger. He also
complains of a numb feeling on the left cheek. I had extracted /6 two weeks ago at the
request of the patient because it was loose.
Examination revealed a palpable left cervical lymph node. There was reduced sensation to
touch on the left upper lip and cheek. Intra-orally there was a mass on the left maxillary
alveolus in /6 region, about 2 by 1 cm. The mass has an irregular surface, feels indurated,
bleeds easily on palpation and looks necrotic in places. I have taken a periapical radiograph,
which shows some bone destruction at the site of the socket.
I am worried that this might be maxillary sinus malignancy and I would appreciate your
urgent opinion and management.
Mr Doe has a history of mild hypertension for which he takes a bendrofluazide tablet (2.5mg)
in the morning. Otherwise there is no other medical history of note. He is a nervous patient
generally and will probably be accompanied by his wife. Mr Doe is a non-smoker and drinks
7-8 units of alcohol per week. He can attend at any time.
Yours sincerely,
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Human disease and patient care 3
30
Human disease and patient care Chapter 3
Table 3.2Medical questionnaire incorporating the American Society of Anesthiologists classification of physical
status
to patients in whom the risk of developing endo- surgically constructed systemic or pulmonary shunt
carditis is the highest. The recommendations of or conduit.
one group (Working Party of the British Society
for Antimicrobial Chemotherapy) suggest high-risk Management
patients are those that have had or have a history of Good oral hygiene is probably the most impor-
endocarditis, cardiac valve replacement surgery or a tant factor in reducing the risk of endocarditis in
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Master Dentistry
Management Management
Blood pressure should be controlled before Arrhythmias should be controlled before
sedation/GA for elective treatment and patients sedation/GA.
should continue to take their antihypertensive Additional monitoring and supplemental oxy-
drugs up to and on the day of sedation/GA. gen therapy are required when using conscious
Blood pressure should be monitored dur- sedation techniques.
ing treatment involving conscious sedation Local anaesthetics containing adrenaline (epi-
techniques. nephrine) should be avoided in undiagnosed
For treatment under local anaesthesia, solutions arrhythmias.
containing adrenaline (epinephrine) may be used
safely providing that aspirating syringes are used Angina and myocardial infarction
to reduce the incidence of intravascular injec-
tion (which may cause hypertension, arrhythmia About 5% of patients have a myocardial infarction
or trigger angina in susceptible patients). during GA if they have already had a myocardial
infarction in the past. The death rate of myocardial
infarction associated with GA is 50%. GA is par-
Cardiac failure ticularly dangerous for patients who have had an
Diuretics are the usual treatment. Exercise toler- infarction in the previous 6 months.
ance gives useful information about the severity of
the disease. Management
Angina should be controlled before sedation/
Management GA.
Cardiac failure should be controlled before Patients may be treated using conscious seda-
sedation/GA. tion techniques but require additional monitor-
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Human disease and patient care Chapter 3
Chronic obstructive airways disease asthma are more likely to be allergic to drugs such
Chronic obstructive pulmonary disease (COPD) is as penicillin.
defined as the presence of a productive cough for
at least 3 months in 2 successive years. Fig. 3.2 Management
shows a chest radiograph of a patient with COPD. It is important to avoid GA drugs that release
A frequent cause is smoking. The severity may be histamine such as atracurium and morphine.
assessed from the patients exercise tolerance, Conscious sedation techniques may be indicated
together with drug usage and the frequency of in mild asthma to reduce anxiety and avoid an
related hospital admissions. attack.
LA may be used safely.
Management
Non-steroidal anti-inflammatory drugs
GA involves a risk of respiratory impairment.
(NSAIDs) should be prescribed only if the
Intravenous conscious sedation techniques are patient has taken the drug before on more
also likely to further compromise respiratory than one occasion without a hypersensitivity
function and should be undertaken in hospital. reaction.
LA may be used safely. The patient may be
more comfortable in a semi-supine or upright Other respiratory diseases
position, as they can become increasingly
breathless in the supine position. Upper or lower respiratory tract infections.
These do not contraindicate dental treatment
under LA or conscious sedation, although the nasal
Asthma obstruction of the common cold may make treat-
Frequency and severity of attacks and quantity of ment with an open mouth uncomfortable for the
medication give an indication of the severity of patient. Similarly, patients may find it difficult to
the disease. Asthma may occasionally be precipi- inhale nitrous oxide and oxygen. It is usually prefer-
tated by anxiety or emotional stress. Patients with able to postpone treatment, especially if the patient
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Human disease and patient care Chapter 3
for deep vein thrombosis may last only 36 months instead. Metronidazole interacts with warfarin and
but will continue for life for atrial fibrillation and should be avoided as should erythromycin which
those with mechanical prosthetic heart valves. A has unpredictable effect. Amoxycillin interferes
commonly used anticoagulant is warfarin, which less with warfarin but patients should be warned
antagonises vitamin K. Warfarin takes 36 hours or to look out for bleeding. Aspirin (acetylsalicylic
longer to peak anticoagulant effect which is mea- acid) and, to a lesser extend other NSAIDS,
sured by prolonged prothrombin time (PT) and should be avoided. The anticoagulant effect of
activated partial thromboplastin time (APTT). The warfarin is not usually affected by paracetamol.
international normalised ratio (INR) comparing the
patients PT with that of a control is increased with
warfarinisation. An INR near 1 is normal and patients Antiplatelet therapy
taking anticoagulants are usually in the range 24. Patients taking antiplatelet medication such as aspi-
rin, clopidogrel (e.g. Plavix), dipyridamole (e.g.
Management Persantin), aspirin plus dipyridamole (e.g. Asasantin
In the past, patients have had their warfarin dose Retard) will have prolonged bleeding, but for minor
adjusted to reduce the risk of bleeding during surgery this may not be clinically significant. How-
and after oral surgery, but more recently a small ever, teeth should be removed at a maximum of
clinical trial suggested that this might not be three per visit and regional nerve blocks should be
necessary and the risk of thromboembolic event avoided. An absorbable haemostatic dressing should
after withdrawal of warfarin outweighs the risk be placed to the socket that should then be sutured
of bleeding after oral surgery. Patients within the using a resorbable material. For more significant
normal range may not require any change to their surgery, the patient should be managed in a hospital
warfarin dose at all for minor surgery but should setting and the antiplatelet therapy may be stopped
be warned that there is an increased risk of bleed- before surgery in consultation with the interven-
ing after surgery. If possible, a single extraction tional cardiologist. Similarly, patients taking aspirin
should be undertaken in the first instance with plus clopidogrel should be referred to a specialist.
further extractions at subsequent visits to limit
the extent of surgery. An INR measurement
should be carried out within 24 hours of surgery
Endocrine disease
and preferably on the day of surgery.
Diabetes mellitus
Patients should receive appropriate verbal and
written information about postoperative care and Patients with diabetes mellitus are immunocompro-
how to access assistance should there be any post- mised and require early vigorous treatment of infec-
operative bleeding, as should any other patient. tions. Where surgery is being performed, patients
Local measures for haemostasis are likely to be may need antibiotic prophylaxis. It should be estab-
adequate. lished whether the patient is controlled with diet
Patients who do bleed should be transferred to alone, tablets or insulin injections. If the patient is
hospital for haematological management including not to be starved (LA or sedation), then treatment
the administration of vitamin K by slow intrave- is arranged so as to interfere least with meal times,
nous injection or fresh frozen plasma. such as within 2 hours of breakfast, and the patient
Patients undergoing more major surgery are likely is instructed to take medications and food as normal.
to require reduction in their anticoagulation and
Management
this should be done in discussion with a haema-
tologist who will advise. Similarly, haematological The patient should be reasonably well controlled
collaboration is required even for minor surgery before sedation/GA. When the patient is starved
for patients whose anticoagulation is not stable. prior to a GA, they must have their oral hypo-
glycaemic drug or insulin adjusted. Non-insulin
Intramuscular injections should be avoided in all
dependent diabetes mellitus patients can usually
patients with a haemostasis disorder or on anti-
withstand a short period of starvation but may
coagulants, and local anaesthetic regional nerve
need insulin if undergoing prolonged surgery.
blocks should be avoided if possible and infiltra-
Their oral hypoglycaemic should be stopped the
tion or intraligamentary injection techniques used
day before surgery.
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Master Dentistry
Patients with insulin-dependant diabetes mellitus screen prior to treatment and especially before
should have their long-acting insulin omitted the surgery. Patients may need vitamin K or fresh fro-
night before surgery and blood glucose moni- zen plasma to correct coagulation and, therefore,
tored. Insulin and glucose therapy is started using should be managed in hospital.
a variable-rate insulin infusion (soluble insulin Drugs. Prescribing is a problem and many drugs
50IU in 50ml normal saline by syringe driver) should be used with caution or avoided completely
and adjusted as required. The patient also should in severe hepatic disease. Paracetamol, NSAIDs
receive carbohydrate. Alternatively, the Alberti and sedatives are among these. Any drug prescrib-
regime may be used if the patient is usually well ing should include reference to a drug formulary.
controlled. This consists of an infusion of glucose It is difficult to predict the impairment of drug
10%, 500ml; human soluble insulin 10IU; and metabolism even when using liver function tests.
potassium chloride (KCl) 10ml, over 5 hours via a Cross-infection. Universal precautions for cross-
dedicated cannula. The insulin and KCl concentra- infection control mean that all patients, whether
tions are adjusted according to the results, aiming known high risk or not, should be managed in the
for a blood glucose of 610mmol/l. same way to minimise the risk of transmission of
Hypoglycaemia must be avoided as it may cause infectious agents.
brain damage. Blood glucose should be mea-
sured regularly with an automated blood glucose
measurement device because control is upset by Renal disease
surgery and anaesthesia.
The severity of renal impairment is expressed as
the glomerular filtration rate (GFR), which is usu-
Hypothyroidism and hyperthyroidism ally measured by the creatinine clearance. Fluid
There is a serious risk of arrhythmias if an balance and sodium and potassium levels may
untreated hyperthyroid patient receives a GA. be upset and platelet dysfunction (impaired pro-
duction, impaired conversion of prothrombin to
Management thrombin, and vasodilatation and poor platelet
Patients with hypothyroidism should avoid opioids, aggregation) may lead to a bleeding tendency.
sedatives and GA. They are, therefore, best treated
using LA unless well managed with thyroxine. Management
Drug doses should be reduced as drug excre-
tion may be reduced and NSAIDs should be
Hypoparathyroidism and avoided.
hyperparathyroidism Patients should receive dental treatment the
Hypoparathyroidism. This should be considered day following dialysis when any heparin is no
in patients presenting with facial paraesthesia or longer active but they are still at maximum
twitching. Other signs include delayed tooth erup- benefit from the dialysis.
tion and enamel hypoplasia. Patients who have undergone renal transplanta-
Hyperparathyroidism. This may cause oral signs, tion will be receiving immunosuppressive drugs
as described in Chapter 7. GA may be complicated and will require an increase to their steroid
by the risk of arrhythmias and sensitivity to muscle dose prior to extensive treatment or GA. They
relaxants. may also require antibiotic prophylaxis.
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Human disease and patient care Chapter 3
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CLINICAL BOX
Cause
Anxiety or pain leading to sympathetic activity but
then vagal overactivity.
Fig. 3.3 Emergency drugs in preloaded syringes.
Principles of treatment
The following minimum equipment should be Need to encourage oxygenated blood flow to
available: brain as rapidly as possible.
Portable oxygen cylinder (D size) with pressure May need to block vagal activity with atropine
reduction valve and flowmeter. and allow heart rate to increase.
Oxygen face mask with reservoir and tubing.
Anxiety.
u If the patient is unconscious, give 1mg (1 unit) u Make no attempt to put anything in the mouth or
glucagon intramuscular injection (0.5mg if less than 8 between the teeth.
years or less than 25kg). u Give oxygen (15l per minute).
u After movements have subsided, place the patient in
the recovery position and check airway.
u After full recovery, reassure and allow the patient
Cause home unless the seizure was atypical or prolonged or
Usually known diabetic and patient may recog- injury occurred.
nise symptoms themselves.
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Human disease and patient care Chapter 3
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Master Dentistry
A B
Fig. 3.4 Facial flushing and swelling, especially of eyelids and lips, in anaphylactic shock. (A) Child; (B)
same child after anaphylactic shock.
bronchospasm Cause
hypotension. Stroke results from either cerebral haemorrhage or
cerebral ischaemia unrelated to dental treatment.
Further management
Principles of treatment
Transfer to A&E.
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Human disease and patient care Chapter 3
Cause
Overdose can result from a large or too rapid an Angina
injection of benzodiazepine or can occur in a sensi- Angina is relieved by rest and nitrates:
tive patient, e.g. an elderly patient.
Glyceryl trinitrate spray 400mg metered dose
Principles of treatment (sprayed on oral mucosa or under tongue and
mouth then closed).
The action of the benzodiazepine is reversed with
Give oxygen (15l per minute).
the specific antagonist.
Allow home if the attack is mild and the patient
Further management recovers rapidly.
Maintain airway and ventilation as appropriate
while reversing effect with an antagonist. Myocardial infarction
If a myocardial infarction is suspected:
Psychiatric emergencies Transfer to A&E.
Signs and symptoms Give oxygen (15l per minute).
Unusual/bizarre/agitated/violent behaviour. Aspirin tablet 300mg chewed.
Cause Cause
Usually there is a known psychiatric illness. Angina results from reduced coronary artery
lumen diameter because of atheromatous plaques.
Principles of treatment Myocardial infarction is usually the result of
Transfer to A&E. thrombosis in a coronary artery.
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D
Fig. 3.5 Rhythms seen in cardiac arrest. (A) Ventricular fibrillation (VF); (B) ventricular tachycardia (VT) and
absent pulse; (C) asystole; (D) pulseless electrical activity (PEA). Initially there is normal QRS complex but this soon
becomes more bizarre in appearance.
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Human disease and patient care Chapter 3
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Master Dentistry
Disability (D)
Common causes of unconsciousness include profound
hypoxia, hypercapnia (raised carbon dioxide levels), cere-
bral hypoperfusion (low blood pressure) or the recent
administration of sedatives or analgesic drugs.
u Review and treat the ABCs: exclude hypoxia and low
blood pressure.
u Check the patients drug record for reversible drug-
induced causes of depressed consciousness.
u Examine the pupils (size, equality and reaction to light).
u Make a rapid initial assessment of the patients
conscious level using the AVPU method: Alert,
responds to Vocal stimuli, responds to Painful stimuli
or Unresponsive to all stimuli. A
u Measure the blood glucose to exclude
hypoglycaemia, using a glucose meter.
Exposure (E)
To assess and treat the patient properly, loosening or
removal of some of the patients clothes may be necessary.
Respect the patients dignity and minimise heat loss. This
will allow you to see any rashes (e.g. anaphylaxis) or per-
form procedures (e.g. defibrillation).
BASIC LIFE SUPPORT
u Initialpatient assessment, airway maintenance, expired
air ventilation and chest compression constitute basic
life support (BLS) or cardiopulmonary resuscitation.
u BLS is a holding operation maintaining ventilation
and circulation until treatment of the underlying cause
can be instigated.
u BLS implies that no equipment is used. Where a
simple airway or face mask is used, this is described
as basic life support with airway adjunct.
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Human disease and patient care Chapter 3
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Master Dentistry
Late complications
Inflammation of the vein (thrombophlebitis).
Inflammation of the surrounding skin
6 (cellulitis).
5
4
1
1
2
Cephalic vein
Basilic vein
2 Intramuscular route
3 Median vein 3
4 Median cubital vein The intramuscular route is used to deposit a drug
5 Median nerve into muscle. Absorption is faster than with the
6 Brachial artery
subcutaneous route because muscle is very vas-
Fig. 3.13 Cubital fossa and forearm anatomy. cular. However, systemic effect may take 1530
minutes after injection to occur. This site is there-
fore, not appropriate for drug delivery in cardiac
Complications arrest, although it is useful for other medical
There are a large number of early and late compli- emergencies.
cations associated with venous cannulation. Fortu- Intramuscular injections are generally given
nately, most of them are relatively minor. at one of five sites: mid-deltoid, gluteus medius,
gluteus minimus, rectus femoris and vastus late-
Early complications ralis (Fig. 3.14). The muscles of the buttock offer
Failed cannulation: usually as a result of push- a large injection site and are therefore, frequently
ing the needle completely through the vein; it is used for elective drug administration such as anti-
experience related. biotics and analgesics in the hospital situation.
Haematomas. However, they have the lowest drug absorption
Extravasation of fluid or drugs. rate. The vastis lateralis (anterolateral aspect of the
Damage to other local structures. middle third of the thigh) and the mid-deltoid (just
above level of axilla) sites are preferred in medical
Shearing of the cannula.
emergencies.
Fracture of the needle.
Gluteus medius
Deltoid
Gluteus maximus
Rectus femoris
Biceps
Vastus lateralis
A B
Fig. 3.14 Intramuscular injection sites in the arm (A) and buttocks (B).
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Human disease and patient care Chapter 3
Gluteus medius
Gluteus minimus
Sciatic nerve
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Master Dentistry
Q Self-assessment: questions
Multiple choice questions (True/False) b. Is most commonly caused by a shortened red
1. Intramuscular injections: cell lifespan
a. Should not be given to patients with a bleeding c. Will result in elective surgery under general
disorder anaesthesia being cancelled if the haemoglobin
concentration is less than 10g/dl (6.2mmol/l)
b. Are not appropriate for drug delivery in
emergencies because of the slow absorption d. Is not associated with oral ulceration
into the circulation by this route e. Of the sickle cell type contraindicates dental
c. Produce the fastest absorption when a gluteal treatment under general anaesthesia
muscle is used because these muscles have 5. A patient who suffers from angina:
the greatest blood flow of the muscles used a. May be safely treated using intravenous
d. Of hydrocortisone can be used to mimic sedation
cortisol secretion in patients on long-term b. Is likely to be taking daily aspirin and, therefore,
treatment with corticosteroids who may suffer may be at risk of postoperative haemorrhage
from adrenocortical suppression c. May be taking drugs that cause oral signs
e. Of vitamin K may be used in hospital for acute d. Suffers from a pressing chest pain that may
haemorrhage caused by liver disease radiate to the jaw and left arm and is not
2. Anaphylaxis: relieved by nitrates
a. Is mediated by IgE antibodies, which cause e. During dental treatment should be placed
release of histamine and other vasoactive in the supine position and given oxygen
mediators to be released immediately
b. Is most frequently caused by non-steroidal
Case history question
anti-inflammatory drugs (NSAIDs) in dentistry
Mrs Walker is an energetic 68-year-old lady. She is
c. Treatment includes administration of
fit and well apart from hypertension, which is well
intravenous fluids, using sodium chloride in the
controlled with atenolol. Two large upper anterior
first instance
composite fillings are unsightly and she has decided
d. First-line management should be the
to go ahead with the crowns that you have advised. At
immediate transfer of the patient to a hospital
the end of crown preparation treatment, you press the
accident department
auto-return button of the dental chair to sit Mrs Walker
e. Is particularly associated with antibiotics, blood up. She starts to say that she feels a little dizzy and
products, vaccines, aspirin and other NSAIDs, then loses consciousness.
heparin and neuromuscular blocking agents Discuss the management of this patient.
3. A pregnant woman:
a. Who faints should be placed in the supine
Oral examination questions
position 1. What do we mean by antibiotic prophylaxis?
b. With dental pain should be prescribed 2. How in general terms may a collapsed patient be
paracetamol rather than an NSAID diagnosed and managed?
c. Who suffers a fracture of her mandible should 3. How should a patient taking warfarin be managed
have reduction and fixation carried out using prior to dental extractions?
a conscious sedation technique and local 4. What is a common cause of faint in dentistry
anaesthesia rather than general anaesthesia and describe the underlying mechanism of the
d. May develop an aggravation of gingivitis or a collapse?
pyogenic granuloma at the gingival margin 5. Discuss the management of a patient who is an
e. Should not work in an environment where she insulin-dependent diabetic and presents with an
might be exposed to nitrous oxide acute dento-alveolar abscess.
4. Anaemia:
a. Is said to be present in an adult male if the
haemoglobin concentration is less than
13.5g/dl (8.4mmol/l) and in an adult female if
less than 11.5g/dl (7.4mmol/l)
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Human disease and patient care Chapter 3
A Self-assessment: answers
Multiple choice answers be avoided as the patient has a coagulation
1. a. True. This would cause formation of a large problem and the injection into muscle will lead
haematoma. Similarly, an inferior alveolar nerve to a haematoma.
block injection could cause bleeding into the 2. a. True. These mediators are released from mast
pterygomandibular space, which at this site cells and basophils, producing respiratory,
could be particularly dangerous as the airway circulatory, cutaneous and gastrointestinal
could be obstructed by the swelling. Infiltration effects. Increased vascular permeability and
type injections of local anaesthetic are much peripheral vasodilatation reduce venous return
safer. and cardiac output.
b. False. While not appropriate for drug b. False. The penicillin antibiotics are the most
administration in the management of cardiac common cause of anaphylaxis in dentistry.
arrest, the intramuscular route is suitable NSAIDs such as ibuprofen are recognised as
for many other medical emergencies. It is causing hypersensitivity, such as rashes, angio-
preferable to give adrenaline (epinephrine) by oedema and bronchospasm, but anaphylaxis is
the intramuscular route in anaphylaxis, for rare compared with penicillin.
example, rather than by the intravenous route, c. False. The hypotension of anaphylaxis may
when arrhythmias may lead to cardiac arrest. well need management but it is preferable
c. False. The gluteal muscles have the lowest to use a plasma substitute. Sodium chloride
absorption rate of the muscles used for will leave the vascular compartment much
intramuscular injections but are appropriate more rapidly than a macromolecular plasma
for the administration of some drugs, such as substitute substance, such as gelatin
morphine for postoperative analgesia. It would (Gelofusine or Haemaccel). It is, therefore,
only be appropriate to use this injection site in better to use a plasma substitute initially when
hospital dentistry. attempting to maintain blood pressure in shock,
d. True. Steroid cover attempts to replicate the arising in conditions such as anaphylaxis.
normal rise in cortisol that occurs in stress d. False. First-line treatment of anaphylaxis
in those patients that are unable to mount includes restoration of blood pressure by laying
this response because of adrenocortical the patient flat, the administration of oxygen
suppression. This may be accomplished by by therapy mask and adrenaline (epinephrine)
giving steroids orally or by intramuscular by intramuscular injection. This treatment must
or intravenous injection; however, steroids be carried out by the dentist as soon as the
are least well absorbed when given by diagnosis is made as death can occur within
the intramuscular route. There is some minutes. Treatment must begin while awaiting
debate about what constitutes a significant the emergency services to transfer the patient.
physiological stress in dentistry. It is likely that e. True. Anaphylactic reactions are particularly
conservative dentistry or minor surgery under associated with all of these medicinal products.
local anaesthesia do not require steroid cover. 3. a. False. Pressure on the inferior vena cava from
However, more significant surgery or a general the pregnant uterus can reduce venous return
anaesthetic does constitute a significant stress and cardiac output and cause the patient
and it is important that cover is provided. to collapse if placed supine during the third
Adrenocortical suppression may be assumed if trimester. It is important, therefore, to provide
the patient is currently taking systemic steroids dental treatment in a semi-supine position.
or has taken more than a 1 month course Management of a faint requires the patient
during the previous year. Hydrocortisone to be moved onto the left side to relieve the
100mg may be required 6 hourly for 72 hours pressure on the vena cava.
for major surgery under general anaesthesia. b. True. Most manufacturers advise avoiding
e. False. Liver disease can lead to bleeding NSAIDs during pregnancy. Drugs should
disorders, as a consequence of reduced be prescribed during pregnancy only if the
synthesis of clotting factors, reduced expected benefit to the mother is thought to
absorption of vitamin K and abnormalities of be greater than the risk to the fetus. All drugs
platelet function. Vitamin K is needed for the should be avoided if possible during the first
synthesis of factors II, VII, IX and X. Acute trimester.
haemorrhage in a patient with liver disease may c. False. General anaesthesia is best avoided
be treated with intravenous vitamin K or fresh during pregnancy and elective treatment
frozen plasma. Intramuscular injections must postponed. However, the nature of the
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Master Dentistry
emergency surgery may dictate that general if the patient is anxious, as this will minimise
anaesthesia has to be used, in which case this the activity of the sympathetic nervous system
will be safest after the first trimester and before and reduce the stress on the cardiovascular
the last month. Conscious sedation techniques system. However, angina should be controlled
using nitrous oxide or an intravenous before elective treatment. The clinician should
benzodiazepine, such as midazolam are not only proceed with methods with which he or
without risk themselves. she feels competent. Generally, patients of the
d. True. These conditions usually resolve after the American Society of Anaesthesiologists (ASA)
birth of the baby. physical status I (see Table 3.1) are suitable
e. True. The literature relating to nitrous oxide for sedation and also some status II patients,
exposure and risk to health professionals has although the latter may require referral to the
been controversial. To date, there is no direct hospital service.
evidence of any causal relationship between b. True. Angina patients are usually prescribed
chronic low-level exposure to nitrous oxide aspirin (75 or 150mg daily) to prevent future
and potential biological effects. However, every myocardial infarction, unless contraindicated
attempt should be made to reduce the level of by allergy, intolerance or active peptic
trace nitrous oxide to exposed health care staff ulceration. Low-dose aspirin antiplatelet
and women should avoid the setting during the therapy is of value in preventing arterial
first trimester. thrombosis and also protects against venous
4. a. True. These concentrations are typical of the thromboembolism. The clinical significance
lower limits of normal for adult males and of postoperative bleeding depends on the
females. severity of the surgery. Some recent research
indicates that low-dose aspirin may lengthen
b. False. The haemolytic anaemias (subdivided
the bleeding time but only within normal
into inherited and acquired types) are not
limits. It has been reported that intraoperative
the most common. Iron-deficiency anaemia
bleeding is more common but postoperative
is the most common and may result from an
haemorrhage is not.
inadequate diet or chronic blood loss through
gastrointestinal or menstrual bleeding. c. True. Calcium channel blockers reduce
myocardial contractility and may cause
c. True. While a haemoglobin concentration of
lichenoid reactions and gingival overgrowth.
10g/dl is less than the lower normal limit, most
anaesthetists use this figure to decide when d. False. Angina is typically an exercise-related
elective surgery should be postponed. pressing precordial chest pain, radiating to
the jaw and left arm, but it is relieved by
d. False. Oral ulceration is among several
nitrates.
oral changes that may be associated with
anaemia. Others include glossitis, sore tongue, e. False. Many patients are more comfortable
candidiasis and angular stomatitis, although it in an upright or semi-reclined position than
is important to remember that these conditions supine. Intraoral glyceryl trinitrate spray and
may have other causes. oxygen should be administered.
e. False. Of the haemoglobinopathies, Case history answer
haemoglobin S is the most clinically
The patient should be placed in the supine position
significant. The S gene is carried by 10%
again and her airway, breathing and circulation (ABC)
of patients of African origin but is also
checked. Resuscitate as appropriate. If the patient
seen in Italy, Greece, Arabia and Indian
is unconscious but breathing and has a circulation,
subcontinent. Homozygous patients usually
then provide oxygen therapy and move into the
have anaemia (610g/dl). Heterozygotes
recovery position. If the patient has fainted, then a
are almost asymptomatic and sickling only
prompt recovery could be expected. Knowledge of
occurs when oxygen tensions are low. The
the patients medication might suggest a diagnosis of
presence or absence of haemoglobin S should
postural hypotension, and the patient should recover
be determined before general anaesthesia
spontaneously within a minute or so. Atenolol is a -
in risk groups. General anaesthesia, while
adrenoceptor blocking drug commonly prescribed for
not absolutely contraindicated, will require
hypertension. As the heart and peripheral vasculature
special precautions and may even require
are less responsive to the sympathetic reflex on
exchange transfusion to raise the percentage
changing to an upright posture, the dental chair
of haemoglobin A.
should be moved slowly to allow the patient time to
5. a. True. If angina is mild. A conscious sedation
compensate.
technique may be preferable in this situation
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Control of pain and anxiety 4
The pain system during surgery, and the latter refers to pain result-
Not all noxious stimuli that activate nociceptors ing from nervous system dysfunction, such as is
are necessarily experienced as pain. While the sen- seen in postherpetic neuralgia or trigeminal neural-
sations we call pain, pricking, burning, aching or gia (Chapter 14).
stinging may have an urgent and primitive quality, Both inflammatory and neuropathic pains are
they can be modulated. For example, in situations characterised by changes in sensitivity, notably a
of crisis or emergency, or even when an individuals reduction in the intensity of the stimuli necessary
attention is simply elsewhere, noxious inputs may to initiate pain, so that stimuli that would never
trigger much less pain sensation than would other- normally produce pain begin to do so; this is called
wise be expected. It is observed that fear for sur- allodynia. There is also an exaggerated responsive-
vival in a war situation may suppress the pain of an ness to noxious stimuli, termed hyperalgesia.
inflicted injury until the individual is away from the
immediate danger of the front line. Equally, anxiety
about undergoing elective surgery may intensify the Pain control
postoperative pain experience.
The variability of human pain suggests that there Several publications including reports by the Royal
are neural mechanisms that modulate transmission College of Surgeons and College of Anaesthetists
in pain pathways and modify the individuals emo- have shown that relief of pain following surgery in
tional experience of pain. The transmission of pain the UK has been suboptimal and this issue has been
is therefore, no longer viewed as a static process recognised globally. Reasons include inadequate rec-
using exclusive pathways from peripheral tissues ognition or evaluation of pain and prescription of
through the spinal cord to the brain, but rather as inappropriate drugs and inadequate doses.
messages arising from the interplay between neuro-
nal systems, both excitatory and inhibitory, at many
levels of the central nervous system (CNS). Dental pain and pain after surgery
Analgesics should be prescribed according to their
Acute pain effectiveness and appropriate to the pain intensity
Acute pain has been described as pain of recent reported by the patient or the anticipated post-
onset and probable limited duration. It usually has operative pain intensity and taking into account
a causal relationship to injury or disease. Patients potential adverse effects and the general health of
report of pain stops long before healing has been the patient (Table 4.1). There are many clinical tri-
completed. Pain following injury or surgery would als comparing analgesic effectiveness and the most
be typical of this type of pain. effective drugs have a low NNT, where the NNT
is the number of patients who need to receive the
active drug to achieve at least 50% relief of pain
Chronic pain compared to placebo over a 46 hour treatment
Chronic pain is frequently defined as pain last- period.
ing for long periods of time; however, it is not the Acetaminophen (paracetamol) possesses anti-
duration of pain that distinguishes it from acute pyretic activity and is an effective analgesic. It
pain but rather the inability of the body to restore is considered safe because it does not have the
its physiological functions to normal homeostatic side-effects such as gastrointestinal ulceration and
levels. Chronic pain commonly persists beyond the haemorrhage, cardiorenal adverse effects or impair
time of healing of an injury and its intensity usually platelet aggregation. However, paracetamol is asso-
bears no relation to the extent of tissue damage, ciated with liver toxicity, especially in patients who
indeed there may be no clearly identifiable cause. already have compromised liver function, cirrho-
sis or hepatitis. Patients should always be warned
that many combination analgesics may contain
Inflammatory and neuropathic pain paracetamol and they should only take the analgesics
Clinical pain may be inflammatory or neuropathic recommended or prescribed. Paracetamol may be
in origin; the former refers to pain associated with administered intravenously, intraoperatively followed
peripheral tissue damage, such as that produced by oral administration after discharge home.
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Control of pain and anxiety Chapter 4
Table 4.1 Systemic pain relief after dental and surgical procedures
These adult protocols are based on evidence from postoperative pain systematic reviews. The British National Formulary and other sources contain
more extensive lists of analgesics.
Non-steroidal anti-inflammatory drugs (NSAIDs) Some patients have a sensitivity to aspirin such
inhibit cyclo-oxygenase (COX) enzyme which is that they develop cutaneous reactions. Asthmatic
crucial for the production of prostaglandins that patients are at risk of experiencing bronchospasm
mediate pain via COX-2 but also via COX-1, for gas- when exposed to aspirin and other NSAIDs. These
trointestinal mucosal protection, platelet function reactions are described as aspirin sensitivity rather
and protection of the inadequately purfused kidney. than allergy as they are not mediated via an immune
Consequently, NSAIDs are effective analgesics but reaction. It is difficult to predict sensitivity and
are also responsible for the loss of gastric protec- there is no test available. If a patient reports asthma,
tion and consequent ulceration and bleeding that can chronic rhinitis or urticaria and NSAIDs have previ-
occur and other effects. They are contraindicated in: ously been a trigger of acute bronchospasm, then they
should be avoided and paracetamol and codeine used.
the elderly
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doses to ensure therapeutic plasma levels. Ade- Pain and the mind
quate doses of analgesics should not be withheld It is well established that pain and depression are
because of misconceptions and fears on the part related, although the reasons for the association
of the prescriber. It is wrong to believe that pain is remain unclear. This has led to the unfortunate
the inevitable consequence of surgery or that the situation in the past when the dentist or other
use of opioids for acute pain in hospital will lead to clinician, who could not find an obvious cause
addiction. of the patients pain, believed that the reported
Men and women require the same analgesic pain was imaginary. It is now understood that if a
doses for pain relief, although older patients may patient reports pain then that pain is real. It is also
require smaller doses. now understood that any emotional disturbance
in a patient with pain is more likely to be a con-
sequence than a cause of the pain and it is dan-
Pre-emptive analgesia gerous to ascribe pain routinely to psychological
Sustained pain causes the pain system to become causation. Traditional concepts focused either on
sensitised and this has the effect of amplify- medical or psychological explanations for pain, but
ing the pain experience significantly. Prevention the boundaries between these are being eroded as
of pain rather than treating pain is therefore, psychogenic cause is found to have a biochemical
important and theoretically could reduce the physical basis.
analgesic requirements after surgery. However,
the evidence for the clinical advantage of giv-
ing an analgesic before pain as opposed to giving 4.2 Local anaesthesia
the same analgesic after pain is still unconvinc-
ing. Despite the debate about pre-emption, it
is important to give systemic analgesics before Learning objectives
the local anaesthetic (LA) has worn off and to
You should:
give LA during general anaesthesia (GA) to pre- understand how local anaesthetics work
vent pain in the early postoperative phase, even know the potency, speed of onset and duration of
though this may not reduce the later analgesic action of common agents
requirements. be aware of reasons for failure of anaesthesia and
complications that can occur
know the safe dosages of common local
Preoperative patient preparation anaesthetic drugs.
Most patients are anxious about postoperative pain.
Relieving this anxiety by explaining how postop-
erative pain will be dealt with has been shown to The correct selection of pain control technique
reduce the postoperative pain experienced. for patients requiring dental treatment is impor-
tant for safe and successful practice. As with other
aspects of clinical dentistry, this clinical decision
Patient-controlled analgesia making is based on knowledge and experience.
Usually intravenous (i.v.) morphine is used via an Generally patients for treatment under local anaes-
infusion pump, with a lock to limit dose for safety. thesia will be managed by the dentist in a primary
Patients given this control over their own pain relief care setting, whereas those requiring a GA will be
usually use smaller doses than would have been referred to hospital. However, there may be a few
prescribed. patients requiring local anaesthesia whose medical
history dictates that they are treated in hospital.
Patients requiring conscious sedation techniques
Route of drug administration are treated in both the primary care and hospital
The oral route is preferable but tablets, capsules setting.
or oral suspension should be chosen as appropriate By common usage, the localised loss of pain
for age and the nature of the treatment. Alternative sensation is referred to as local anaesthesia,
routes such as intramuscular, i.v. and rectal may be rather than local analgesia, which would be more
appropriate in hospital. accurate. The word anaesthesia implies loss of all
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Control of pain and anxiety Chapter 4
sensation including touch, pressure, temperature for infiltration injections and 35 minutes for infe-
and pain. rior alveolar nerve blocks).
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Master Dentistry
Mandibular ramus
Superior constrictor
Masseter muscle
A B
Fig. 4.1 Diagram of pterygomandibular space illustrating the need to inject an adequate dose of local
anaesthetic for a reliable block of inferior alveolar and lingual nerve conduction. (A) The area covered by
1ml of local anaesthetic, which is not sufficient to block conduction. (B) A full cartridge of local anaesthetic is neces-
sary to block the inferior alveolar and lingual nerve conduction.
depression and cardiovascular collapse. Accidental effects of local anaesthesia or vasoconstrictor. Injec-
i.v. injection may lead to excessively high plasma tion into an artery causes vasoconstriction and isch-
concentration. Prilocaine has low toxicity, similar aemia of the tissue area of supply.
to lidocaine, but if used in high doses may cause
methaemoglobinaemia.
Allergic. Approximately two million dental local
Complications of inferior alveolar
anaesthetic injections are administered daily nerve block
around the world. Reports of allergic reactions are Injection into the medial pterygoid muscle
extremely rare. In the past, they may have been may result in trismus as well as ineffective
associated with the preservative (methylparaben) anaesthesia.
that was included in the cartridge or antioxidant Deep injection into the parotid salivary gland
(metabisulphite) used to stabilise the adrenaline may result in blockade of the facial nerve and
in amide-type anaesthetics. If a patient gives a his- temporary facial muscle paralysis.
tory compatible with an allergic reaction (rash, The patient may experience an electric shock
swelling or bronchospasm), rather than psycho- type of sensation if the needle touches the
genic reaction or the consequences of i.v. injec- inferior alveolar nerve and the injection should
tion (tachycardia), then they should be referred only start after withdrawing the needle 1mm;
for allergy testing. Hypersensitivity reactions otherwise direct damage resulting in long-term
occur mainly with the ester-type local anaesthet- paraesthesia may result.
ics such as benzocaine, cocaine and procaine.
Latex-free plungers and seals are used by most
manufacturers.
Types of local anaesthetic drugs
Topical local anaesthetics
Local complications Topical LAs may be used on intraoral mucous
Soft-tissue trauma. Too rapid an injection or membranes prior to intraoral injections of LA or to
injection of too large a volume may tear soft tissues. reduce discomfort of minor procedures. They may
Nerve trauma. A nerve may be lacerated by a also be applied to the skin prior to venepuncture.
needle or stretched and traumatised by injection of Intraoral. Lidocaine (4%) is available as an oint-
solution into the neural sheath. Prolonged paraes- ment or gel. There are also spray formulations
thesia will result. (10% lidocaine) available for intraoral use.
Intravascular injection. Injections into a vein Skin. Lidocaine 2.5% and prilocaine 2.5% (EMLA)
may result in a haematoma and/or the systemic or 4% tetracaine (amethocaine) (AMETOP gel).
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Control of pain and anxiety Chapter 4
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Control of pain and anxiety Chapter 4
providing conscious sedation techniques or treat- totally uncooperative patient. Successful seda-
ment under local anaesthesia alone. tion requires a patient to have sufficient intellect,
insight and cooperation. Psychologically imma-
Assessment for conscious sedation ture individuals unmanageable with LA alone may
exhibit disinhibited or childish behaviour when
Indications sedated and so a GA may be needed.
Patients who are unable to provide a responsible
Psychological indications adult (over 16 years) to accompany them, escort
Anxiety may be the most obvious and common rea- them home and remain with them for the rest of
son for prescribing conscious sedation rather than the day are not suitable for treatment with intrave-
LA alone but it is important to confirm this by dis- nous sedation or GA.
cussion, rather than accept a request for sedation
from a patient who may not be aware of its implica- Dental contraindications
tions or of treatment alternatives. It may be neces- Prolonged or difficult oral surgery is a contrain-
sary to justify the selection and patient preference dication to treatment under any form of sedation
alone is not sufficient reason. Extremely anxious as this may stretch both the patient and opera-
and phobic patients may require GA for their den- tor beyond their limits of endurance. It must also
tal management or consideration of other strategies be remembered that sedation techniques do not
such as cognitive behavioral therapy (CBT). reduce surgical morbidity. Planned GA may be
preferable.
Dental indications
Moderately difficult or prolonged procedures such as Medical contraindications
dental implant surgery may be an indication for seda- Allergy. Allergy to sedatives or anaesthetics is obvi-
tion. Some patients who are happy to undergo rou- ously an absolute contraindication to the use of
tine dental treatment with a LA alone, may require these drugs, but such allergies are very rare.
sedation to accept more invasive surgical procedures. Systemic disease. Severe forms of systemic dis-
Extensive dental treatment or surgery may require GA. ease such as a recent myocardial infarct or poorly
controlled or severe hypertension or angina, may
Medical and behavioural indications be obvious contraindications for sedation for GA,
Systemic disorders such as mild angina, controlled but even hay fever or the common cold may con-
hypertension or controlled anxiety-induced asthma, traindicate inhalational sedation if there is nasal
may be an indication for the use of sedation as this obstruction.
minimises the psychological response to stress and so Respiratory disease. Chronic obstructive pulmo-
will reduce the activity of the sympathetic nervous nary diseases (COPD) such as bronchitis, emphy-
system. This may avoid, or at least reduce, the likeli- sema or bronchiectasis are contraindications. Such
hood of an angina or asthma attack or of raising the patients are particularly sensitive to the respira-
systemic blood pressure. Those with cardiorespiratory tory depression associated with benzodiazepines
compromise should receive supplemental oxygen. and anaesthetic drugs. Also, patients whose respi-
In disorders such as spasticity, multiple sclerosis or ration is driven by a low partial pressure of oxygen
parkinsonism, where a patient may be eager to coop- rather than their partial pressure of carbon dioxide
erate but physically unable to do so, benzodiazepine are likely to have their hypoxic drive removed by
sedation may be of use because of its muscle relaxant the relatively high concentration of oxygen admin-
properties. Similarly, patients with controlled epi- istered during inhalational sedation. Patients with
lepsy may benefit from the anticonvulsant property impaired cardiac function, as well as those with
of benzodiazepines. Anxiety-induced gagging is often chronic obstructive pulmonary disease may be sub-
very successfully managed with sedation. ject to hypoxic drive.
Pregnancy. Women who are, or may be preg-
Contraindications nant, should preferably not be sedated or given a
GA. Nitrous oxide inactivates vitamin B12, inhib-
Psychological and social contraindications its DNA formation and may be teratogenic. Its
It is better to admit defeat and arrange for treat- use in elective situations is therefore, contraindi-
ment under a GA than to attempt sedation of a cated, particularly during the first trimester when
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Control of pain and anxiety Chapter 4
69
Master Dentistry
Benzodiazepines
Undesirable effects
Nitrous oxide is usually regarded as a non-toxic The first benzodiazepine, chlordiazepoxide, was
anaesthetic agent, provided that it is administered synthesised at Hoffmann-La-Roche Inc. in the
with sufficient oxygen, but it does have some unde- USA in 1956. It became available as an anxiolytic
sirable effects. in 1960. Many different benzodiazepines have been
Vitamin B12 metabolism. Nitrous oxide depresses produced since.
vitamin B12 metabolism and prolonged exposure
may lead to impaired bone marrow function, result-
ing in megaloblastic anaemia. However, all reported Mechanism of action
cases have involved exposure for more than Benzodiazepines are also muscle relaxant and
24 hours. Of greater significance is a neuropathic anticonvulsant. With the discovery of gamma-
vitamin B12 deficiency, which may result in neuro- aminobutyric acid (GABA), the major inhibitory
logical damage from repeated short-term exposure. neurotransmitter in the CNS, and the development
Teratogenicity. A study in the 1970s suggested of sophisticated techniques for the localisation of
an increase in spontaneous abortion and congenital receptors, the cellular and molecular mechanisms
anomalies in female dentists and assistants heavily of action of the benzodiazepines were unravelled.
exposed to nitrous oxide (greater than 9 hours per It is now established that these drugs exert their
week). This led to recommendations of exposure pharmacological effects by facilitating the transmis-
limits for staff and scavenging of waste gas. Mul- sion of GABA in the CNS through interaction with
tiple attempts to reproduce these research results a benzodiazepineGABA receptor complex. The
have failed and a worldwide review of literature latter was discovered in 1977.
in the 1990s concluded that there was no scien- The GABA receptors, which are tetrameric pro-
tific basis for the previously established thresholds teins in the cell membranes, act as highly selec-
(25ppm in the USA and 50ppm in the UK). The tive chloride channels and, when activated, allow
scavenging of waste gas to decrease the pollution of negative chloride ions to enter the cell, which then
the surgery air, is of course, of benefit to prevent becomes inhibited. The chloride channel is continu-
the sedation of the staff. ally opening and closing and there is a constant flux
Nausea or vomiting. Both are occasionally seen of chloride ions. An agonist accelerates the process
after the administration of nitrous oxide. As the gas of ion flux. The following range of possible drug
is not known to affect the vomiting centre, this is actions based on the benzodiazepineGABA recep-
more likely a result of other causes such as patient tor complex are possible:
predisposition or hypoxia.
Agonist, e.g. midazolam.
Increased pressure in gas-containing body
spaces. The low solubility of nitrous oxide, which Partial agonist.
permits its rapid transfer from alveoli across endo- Antagonist, e.g. flumazenil.
thelium to blood and vice versa, also permits rapid Partial inverse agonist.
transfer into other air-filled body cavities. Nitrous Inverse agonist, e.g. betacarbolines.
oxide equilibrates with blood, tissue and gas-
containing spaces more rapidly than nitrogen diffuses
out into alveolar air, and there is a 35-fold difference Undesirable effects
in the blood/gas partition coefficients of the two Benzodiazepines have a very wide safety margin and
gases. Consequently, for every molecule of nitrogen a high therapeutic index but nonetheless do have
removed from air spaces, 35 molecules of nitrous some unwanted side-effects.
oxide will pass in and there will be an increase in vol- Respiratory depression. The benzodiazepines
ume of a compliant space and increase in pressure are mild respiratory depressants and although this
of a non-compliant space. Nitrous oxide may diffuse effect is usually insignificant in normal patients,
from the intestinal wall into the abdominal cavity and rapid i.v. injection of benzodiazepines can some-
cause a slight increase in abdominal girth, but this is times cause profound respiratory depression or
of no clinical significance. More seriously, an increase even apnoea. Respiratory depression is greatly
in pressure may occur in the middle ear or sinuses, increased if benzodiazepines are given together
should they be obstructed and this may result in pain. with opioids. This is a synergistic effect rather than
70
Control of pain and anxiety Chapter 4
additive effect; therefore, if both drugs are com- usually complete in 8 hours. Midazolam also offers
bined, only about one-quarter of the dose of each the advantages of deeper sedation, more potent
drug is required to cause the same effect as the anterograde amnesia and less irritation on injection; it
full dose of each drug administered alone. Unless is, therefore, the current drug of choice for i.v. seda-
extreme care is taken, such a combination is likely tion. It is water soluble, hence the minimal local irri-
to cause anaesthesia or respiratory arrest and is, tation on injection, but becomes highly lipophilic at
therefore, not recommended. physiological pH and enters the brain rapidly.
The elderly. In some elderly patients, benzodi-
azepines have caused hyperactivity, anxiety and
agitation rather than sedation because the neu- Temazepam
rotransmitter profile of individuals is subject to An alternative to diazepam for oral use is temaze-
age changes. These unwanted effects have been pam (trade names Normison and Restoril among
reversed with flumazenil. others), which has a short half-life and no active
metabolites.
Elimination
All benzodiazepines are metabolised by the liver Legal status
and excreted via the kidneys. The metabolism of The legal status of the various benzodiazepines is
midazolam involves the hydroxylation by hepatic different from country to country and consequently
microsomal oxidative mechanisms to a few metabo- it is important to be familiar with local procedures
lites. Very little intact drug is excreted unchanged for storage and dispensing.
in the urine.
Flumazenil
Diazepam The benzodiazepine antagonist flumazenil (trade
Diazepam (trade name Valium) has a half-life of names Anexate, Lanexat, Mazicon among others)
2050 hours and also has active metabolites (e.g. should be available in the area where midazolam
desmethyldiazepam) that have even longer half- injection is administered and also the recovery area.
lives and may cause a delayed sedative effect. Full The recommended initial dose is 200g adminis-
recovery may take 4872 hours. tered intravenously over 15 seconds. If the desired
Diazepam, producing less amnesia than mid- level of reversal is not obtained within 60 seconds.
azolam, may be beneficial in weaning patients off A further dose of 100g can be injected and
pharmacological sedation and is available in an repeated at 60-second intervals where necessary, up
organic preparation as Diazemuls, which is much to a maximum total dose of 1mg.
less irritant on injection than Valium. Diazepam
for injection is insoluble in water and is supplied in
propylene glycol, which is irritant to endothelium. Sedation techniques
This can lead to thrombophlebitis. Accidental intra-
arterial injection in the antecubital fossa has been The sedation technique required will vary accord-
known to cause such severe arteriole spasm that the ing to a particular patients needs. One patient
ensuing ischaemia has resulted in the loss of digits. may require oral sedation alone, while another may
require oral premedication followed by i.v. seda-
tion. Individual susceptibility to sedative agents var-
Midazolam ies widely, and a suitable dosage regimen has to be
Midazolam (trade names Hypnovel, Dormicum established for each patient. Written informed con-
and Versed among others) has a shorter half-life sent to treatment under sedation must be obtained
than diazepam; in normal subjects, it is 1.53 prior to treatment.
hours. It is, therefore, more appropriate for den-
tal sedation. It also has active metabolites (e.g.
1-hydroxymethylmidazolam glucuronide), but the Oral sedation
elimination half-life of these is so short that they are Oral sedation in child dental patients is useful
of no significance in clinical practice and recovery is but the effects are sometimes unpredictable and
71
Master Dentistry
1. Your may eat and drink up to two hours before your appoint-
ment, but this last meal should be a light one.
2. Bring with you an adult friend or relative (over 18) who will
be responsible for caring for you afterwards. You are asked
to make your own arrangements for transport home after
your treatment and this should be in a car or taxi.
3. Take your routine medicines at the usual times and discuss
any medicines you are taking, before your sedation starts.
4. Please inform us if you think that you may be pregnant.
Although you may think that you have recovered quite quickly,
the effects of your sedation may not have worn off entirely for
the rest of the day. It is important that until the next day you:
individual dose requirements vary considerably. estimating the required drug dosage and this is
Sometimes children become hostile with oral seda- sometimes difficult. It does not permit individual
tion. In adult patients, oral sedation may also be an titration of a drug against a clinical response. It is
effective way of managing anxiety and nitrazepam, usually prescribed for administration about 11.5
diazepam and temazepam are the most popular hours before dental treatment is due to start. Oral
in the UK. The preoperative and postoperative sedation may also be used the night before treat-
instructions that are given to patients having i.v. ment to permit sleep in an anxious patient who
sedation also apply to those having oral sedation may otherwise not sleep. Temazepam is available
(Fig. 4.2). as tablets, gel capsules (not in the UK) or oral
Nitrazepam has a prolonged action and may, solution.
therefore, give rise to residual effects the fol-
lowing day. Diazepam also has a long half-life but
does not interfere with dream sleep to the same Inhalation sedation
extent. Temazepam has the shortest half-life and is, Inhalation sedation is suitable for children and
therefore, preferred. It may be given in a dose of adults alike but as it is particularly successful when
1030mg for adults and is very effective at the the administration of gases is accompanied by hyp-
larger dose, producing a degree of sedation similar notic suggestion in the form of confident reassur-
to that seen with the i.v. technique. ance and encouragement, it is especially successful
Individual susceptibility has already been men- with children. This group of patients often exhibit
tioned and this is particularly a problem with oral anxiety transposed from their parents own fear of
sedation, as is the optimal timing of the dose owing dentistry. It is a very simple and safe technique and
to the variability of gastric absorption. By compari- allows for rapid sedation and equally rapid rever-
son, inhalational and i.v. sedative techniques allow sal. Special equipment is required to administer
individual titration of drug doses by the dentist nitrous oxide and oxygen at precise concentrations
at the time of treatment. Oral sedation involves and flow rates (Fig. 4.3). This equipment must be
72
Control of pain and anxiety Chapter 4
73
Master Dentistry
TLC IC VC
5
Lung volume (l)
TV
3
2 FRC ERV
1
RV
TV Tidal volume
IC Inspiratory capacity
ERV Expiratory reserve volume
FRC Functional reserve capacity
RV Residual volume
VC Vital capacity
TLC Total lung capacity
Fig. 4.4 Physiological lung volumes. Tidal volume can be increased by taking a deeper breath in or out, using
the inspiratory capacity or expiratory reserve volume, respectively. The volume of air breathed out after the largest
possible inspiration followed by the largest expiration is the vital capacity.
74
Control of pain and anxiety Chapter 4
the lower strength 5mg/5ml is more convenient anything for a 20 minute period following the
for dental conscious sedation as titration is easier. induction of sedation. Occasionally, this period is
Over 30 seconds, 2mg midazolam is administered much longer and patients are unable to remember
via an indwelling cannula with the patient in the how they got home when questioned later. The
supine position. If, after 2 minutes, sedation is not duration and quality of amnesia are difficult to
adequate, incremental doses of 0.51mg are given predict. It is for this reason that it is essential to
until the desired sedation end-point is achieved. provide instructions and advice in a written form
Adequate sedation is demonstrated by drowsiness to the patient having sedation and in advance of
and slurred speech but response to commands the appointment (see Fig. 4.2). Hallucinations,
will be maintained. Drooping of the eyelid half- some of a sexual nature, are another effect of
way across the pupil (Verrills sign), frequently benzodiazepine sedation and, although uncom-
observed with diazepam, is not usually seen with mon, may be of profound significance if the den-
midazolam. The usual dose range is 2.57.5mg tist, male or female, is unchaperoned and unable
total dose. The drug manufacturers suggest a to counter possible claims of assault. This can-
dose of approximately 0.07mg/kg body weight. not occur if the dentist always has a second per-
The final dose is, however, determined by titra- son present during treatment under i.v. sedation,
tion against response and not by calculation. The to assist with the monitoring of the patient and
elderly are more sensitive to the effects of benzo- also to be ready to assist with the management of
diazepines, and as little as 12mg midazolam in any emergency that might arise. It is important to
total may be adequate. Patients weighing less than avoid putting oneself at risk by being alone with
45kg require a reduced initial dose. Some authori- the patient during the recovery phase. It is sen-
ties recommend that all patients receive supple- sible to ask the patients escort to join them at
mental oxygen via nasal cannulae during treatment this point.
and recovery, while some use for medically com-
promised patients only. Analgesia
Benzodiazepine sedation may affect a patients per-
Venous access ception of pain but does not offer any clinically
It is important to have continuous venous access useful analgesia, and an LA must, therefore, be
during i.v. sedation as the midazolam is adminis- used where appropriate. A mouth prop is usually
tered incrementally and it also enables swift admin- necessary because of the muscle relaxation after i.v.
istration of resuscitation drugs should the need sedation.
arise. An indwelling flexible teflon cannula is less
likely to cut-out of a vein than an indwelling steel Discharge
needle. The two most convenient sites for vene- The patient should be kept under supervision until
puncture are the antecubital fossa and the dorsum at least 1 hour has elapsed from the time of the
of the hand. The latter offers the advantages of a last incremental injection (whether or not flumaze-
flat, stable, immobile surface with very little risk nil was used). They should always be accompanied
of damage to structures such as nerves or arter- home by a responsible adult who can then stay with
ies. Veins slip easily from beneath the needle and them. They should be warned not to drive or oper-
should be fixed by gentle traction of the overlying ate machinery for 8 hours and to be accessible to
skin, achieved by finger and thumb pressure beside their escort for the rest of the day (e.g. do not lock
the underlying vessel. Start the venepuncture at the bathroom doors).
junction of tributaries, if evident, as the veins will
be relatively fixed (Fig. 4.5). A normal saline flush Preoperative starvation
may be used to ensure patency and correct place- The question of whether a patient should be
ment before any drug is administered. The cannula starved or not prior to i.v. sedation is a controver-
should remain in place until recovery is complete sial one. Some operators believe that all patients
and the patient is ready to go home. should be starved from solid food for 6 hours and
clear fluids for 2 hours preoperatively (as for a
Amnesia GA) because, while the risk of laryngeal reflex
Midazolam produces good sedation and pro- impairment is small, the consequences may be
found amnesia such that the patient cannot recall grave should there be regurgitation of stomach
75
A
Fig. 4.5 Intravenous cannulation of the dorsum of the hand. (A) The cannula. (B, C) The cannulation proce-
dure. (D) Using the junction of tributaries, if this is evident, may help to stabilise veins.
76
Control of pain and anxiety Chapter 4
contents and lung aspiration. Others believe that patients, those with pre-existing respiratory insuf-
obtundment of the laryngeal reflex is so unlikely ficiency and particularly if excessive or too rapidly
to occur during the conscious sedation tech- injected doses are administered. During inhalation
niques required for dentistry that it is unneces- sedation, the movement of the reservoir bag is a
sary to starve all patients, particularly when the useful guide to respiratory rate and depth.
treatment being carried out is likely to prevent Oxygenation. For i.v. sedation, the use of a
an early return to food and drink and the patient pulse oximeter is essential. This non-invasive
may consequently remain starved for a consider- monitor can provide rapid and accurate record-
able period of time. Certainly most operators ing of arterial oxygen saturation and pulse rate,
currently prefer patients to abstain from alcohol and, therefore, provides an invaluable check of
for 24 hours prior to sedation and request that the respiratory and cardiovascular function. Pulse
the last meal before sedation should be a light oximetry is able to detect changes in oxygen-
non-fatty one. It is reasonable to starve patients ation earlier than one can by clinical observation.
from food and drink for 2 hours only prior to The saturation of haemoglobin is calculated by
treatment. Some sedationists starve their patients measuring absorption of different wavelengths of
as for a GA and infuse crystalloid solutions for haemoglobin and deoxyhaemoglobin. It is worth
rehydration purposes, but this would be unusual remembering that should the patient be anaemic
in the UK. (i.e. have less than about 10g/dl (6.3mmol/l) hae-
moglobin), the little haemoglobin present may be
very well oxygenated even though the oxygen-car-
Intranasal sedation rying capacity of the blood is much compromised.
Benzodiazepines such as midazolam may be admin- Pulse oximetry is not necessary during inhalation
istered via each nostril to the nasal mucosa as liquid sedation unless the patient has cardiorespiratory
from a syringe or as aerosol spray. It is important compromise.
not to use a large volume of liquid as this will pass Electrocardiography. Continuous electrocardio-
in to the pharynx causing coughing. The technique graphic monitoring is not normally required as it
is used by experienced sedationists for patients provides no indication of the adequacy of the cir-
who are uncooperative for intravenous administra- culation although many authorities recommend its
tion, perhaps because of special needs. use. It is certainly essential use for patients with
cardiovascular risk factors and should be used if
more than one drug is used for i.v. sedation. It is,
Monitoring sedated patients therefore, more likely to be used in the hospital
environment.
Monitoring depth of sedation and the patients Blood pressure. Intermittent monitoring of sys-
physiological variables is done clinically and electro- temic arterial pressure does not provide useful
mechanically by the dentist and the suitably trained information during sedation of patients with normal
assistant/dental nurse. preoperative pressure, although is recommended by
Sedation. The level of sedation and conscious- some authorities. It is important to use for those
ness must be monitored continuously. The patient with cardiovascular compromise.
should be relaxed, cooperative and responsive to Temperature. Monitoring of body temperature
verbal contact. Adequately sedated patients are with tympanic membrane measurement is not
sometimes described as exhibiting an expressionless necessary for conscious sedation unless lengthy.
face, as their facial muscles relax. The psychomotor Consideration should be give to the patient and
ability of patients becomes impaired and this may environment and a blanket may be required
be witnessed by asking a patient to bring a finger to whether temperature monitoring is used or not.
his or her nose. It will be observed that the move- Recovery. If patients are to be moved to a sepa-
ment is slow and inaccurate. rate area for recovery, they should not be left alone
Respiration. The rate and depth of chest and but should be supervised and monitoring should be
abdominal movements should be monitored. Any continued. The recovery area should be adequately
signs of cyanosis should be noted and acted upon. equipped for resuscitation.
Respiratory depression and even respiratory arrest The patients escort should remain with them
have occurred with midazolam, especially in elderly for the rest of the day.
77
Master Dentistry
4.4 General anaesthesia Table 4.5 Day case or inpatient general anaesthesia
Fig. 4.6 Compromised airway in patient at rest because of small mandible and soft tissues of the neck.
Risk assessment
malignancy.
Unnecessary in patients with uncomplicated angina, Is the patient in optimum physical condition for
asthma and chronic obstructive airways disease. anaesthesia? Are the anticipated benefits of sur-
gery greater than the anaesthetic and surgical risks
produced by the medical condition? The most sig-
Cervical spine X-ray nificant diseases for morbidity assessment are car-
Indication is rheumatoid arthritis with unstable diovascular: heart failure, heart valve disease or
neck (requires flexion and extension views). recent myocardial infarction.
Unnecessary in other patients. Predictors of risk are:
clinical assessment: ASA greater than class III
cardiac disease
Electrocardiogram (ECG) respiratory disease
Indications are: pulmonary abnormalities, confirmed by chest
known arrhythmias, angina, history of myocar- X-ray
dial infarction electrocardiogram abnormalities
hypertension
length and extent of surgery.
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Control of pain and anxiety Chapter 4
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Master Dentistry
82
Control of pain and anxiety Chapter 4
and provide information on the cardiac rate and of a tracheal tube is provided by detection of car-
rhythm. Pulse oximetry provides information on bon dioxide in the expired gas.
peripheral blood haemoglobin oxygen saturation.
Arterial blood pressure can be measured manu- Neuromuscular junction
ally with a stethoscope and sphygmomanom- Assessment of neuromuscular blockade provides an
eter or with automated oscillometry or directly indication of onset and recovery from muscle relax-
and provides information on cardiac output and ant drugs.
peripheral resistance. To measure blood pres-
sure directly, an arterial cannula is placed in a Body temperature
peripheral artery such as the radial artery at the General anaesthesia inhibits temperature main-
wrist. Central venous pressure may also be mea- tenance in patients and so temperature measure-
sured with a catheter via an arm vein, internal ment is important. Also, the temperature of the
jugular or subclavian with its tip in the superior theatre and fluids for replacement should be con-
vena cava. The patient may also have a urinary sidered alongside exposure of large areas of the
catheter placed so that urine output can be mea- patients body surface. Temperature probes may
sured hourly. be inserted into the nasopharynx, oesophagus or
rectum.
Respiratory system
Anaesthetic machines continuously measure air- Depth of anaesthesia
way pressure as part of the alarm system should the Bispectral index (BIS) is used in some countries to
pressure fall because the circuit becomes detached measure the depth of anaesthesia. A sensor contain-
from the patient. Capnography measures expired ing EEG electrodes is applied to the patients fore-
carbon dioxide by sampling gas and comparing with head and gives a reading between 0 and 100 with
a reference. Confirmation of the correct placement around 60 typical of general anaethesia.
Q Self-assessment: questions
Multiple choice questions (True/False) 3. The vasoconstrictor adrenaline (epinephrine)
1. Adequate analgesia: added to local anaesthetic:
a. After oral surgery is most appropriately a. Should not be used in hyperthyroid patients
provided by a non-steroidal anti-inflammatory b. Is contraindicated for use in patients with
analgesic (NSAID) ischaemic heart disease
b. After maxillofacial injury, is best provided by c. May be dangerous if used for a patient who is
opioids abusing cocaine
c. Provided by paracetamol may cause liver d. Is less safe than felypressin for use in patients
damage with heart disease
d. Provided by opioids may cause respiratory e. Interacts with tricyclic antidepressants,
depression resulting in hypertension
e. In terminal disease should be provided when 4. When using an intravenous sedative technique
necessary, rather than continuously to avoid with midazolam:
tolerance a. Airway protection is not appropriate
2. Dental local anaesthetics: b. Reversal may be accomplished with a bolus
a. Cross the placenta during pregnancy injection of 500mg flumazenil
b. May result in an immune reaction in patients c. The patient should be monitored with a pulse
allergic to latex oximeter, that is set to alarm should the oxygen
c. May be administered via the periodontal ligament saturation fall below 80%
d. Include ethyl chloride d. Supplemental oxygen therapy is not necessary
for all patients
e. Applied topically prevent the pain on injection
for inferior alveolar nerve blocks e. Slight changes in blood pressure occur
83
Master Dentistry
84
Control of pain and anxiety Chapter 4
A Self-assessment: answers
Multiple choice answers c. True. Intraligamentary or periodontal
1. a. True. As surgery causes inflammatory pain, ligament anaesthesia is most often used as
then it is beneficial to use an analgesic that is a supplementary method to conventional
also anti-inflammatory. NSAIDs act principally injection techniques. The solution is injected
by inhibiting prostaglandin production by slowly under high pressure using a specially
the enzyme cyclo-oxygenase in peripheral designed syringe. The technique may
tissues but also in part in the central nervous cause the tooth to be tender to percussion,
system. There is a mismatch between the anti- which is a consideration when used for
inflammatory potency of these drugs and their conservative dentistry but not when
analgesic activity, and many are relatively more removing the tooth.
selective for the constitutive form of cyclo- d. True. Ethyl chloride is supplied as a liquid
oxygenase, COX-1, than for the form of the in a glass container. It is sprayed onto the
enzyme that is induced in inflammation, COX-2. oral mucosa where it evaporates, cooling
It is believed that COX-1 predominates in the the surface sufficiently to cause freezing and
stomach, yielding protective prostaglandins, consequent anaesthesia. This technique has
and COX-2 is induced in inflammation, been traditionally used to anaesthetise mucosa
giving rise to pain and swelling, hence the over an abscess prior to its incision to permit
development of COX-2 inhibitors as potentially drainage. The method is technique sensitive
gastro-safe NSAIDs. and less popular now. Ethyl chloride is also
b. False. Maxillofacial trauma may be associated used on cotton wool pledgets to investigate
with head injury and opioids may interfere with the vitality of teeth.
neurological observations that are required. e. False. Topically applied local anaesthetics such
Codeine does not cause a problem and may as lidocaine produce anaesthesia of the oral
be safely used. mucosa to a depth of about 23mm, which
c. False. Paracetamol is one of the most widely is not sufficient to prevent the pain of needle
used of all drugs and, with proper use, seldom penetration through deeper tissues during an
causes adverse events or reports of serious inferior alveolar nerve block.
side-effects. Therapeutic doses of paracetamol 3. a. True. Adrenaline (epinephrine) could precipitate
are, therefore, unlikely to cause liver damage a thyroid crisis in a hyperthyroid patient.
and indeed paracetamol is commonly used However, there is no problem in patients who
for analgesia and fever in alcoholic patients. are taking thyroid replacement therapy.
However, single doses of more than ten times b. False. It is important to prevent large increases
the recommended dose are potentially toxic in heart rate in patients with ischaemic heart
and can result in hepatic cellular injury. disease as this may precipitate cardiac
d. False. Opioids used for patients who are not ischaemic pain (i.e. angina) or a myocardial
in pain, or in doses larger than necessary to infarction. However, adrenaline (epinephrine)
control pain, can depress respiration. However, in a dental cartridge of local anaesthesia is
opioids at doses used to provide adequate not absolutely contraindicated. An aspirating
analgesia do not cause respiratory depression. technique should always be used for all
e. False. The aim of pain management in terminal patients, whether they suffer from ischaemic
disease is for continuous pain relief, and this heart disease or not, and this will reduce the
is best achieved by regular rather than when likelihood of inadvertently injecting adrenaline
required administration of analgesia. Tolerance (epinephrine) intravenously. The maximum dose
may develop but should not deter from should be limited to about three cartridges,
providing effective pain relief. particularly if the heart disease is not well
controlled. The patient should be managed
2. a. True. Local anaesthetics cross the placenta by
with as much care as possible to ensure that
passive diffusion but are generally not harmful
they remain relaxed during the treatment. It is
unless excessive amounts are administered.
sometimes sensible to sedate these patients to
The drug of choice is lidocaine with adrenaline
ensure that they do not become physiologically
(epinephrine). Local anaesthetics also enter
stressed, although this should be undertaken
breast milk.
in a hospital setting. Inhalational sedation is
b. True. The local anaesthetic itself contains no particularly useful for this group of patients.
latex but the bung inside the cartridge may Adrenaline (epinephrine) should be avoided in
contain latex and this may be sufficient to patients with refractory arrhythmias and in those
provoke an allergic reaction.
85
Master Dentistry
100
97.5
Mixed venous
Haemoglobin saturation (%) 75
50
25
0
5.3 13.3 14
Oxygen pressure (kPa)
who have had a recent myocardial infarction, may be advisable to protect the oropharynx
when plain 4% prilocaine is recommended. with, for example, a butterfly sponge with a
c. True. A patient who has used cocaine in tie extraorally. When carrying out oral surgery
the 24 hours before receiving a dental local such as the removal of wisdom teeth, it is not
anaesthetic containing adrenaline (epinephrine) possible to place a barrier behind the surgical
is at risk of greatly increased adrenergic area without triggering a pharyngeal gag reflex.
responses. The tachycardia may be significant Adequate high-velocity aspiration must always
enough to lead to a cardiac arrhythmia such as be available whether or not a physical barrier is
ventricular tachycardia. employed.
d. False. High doses of felypressin may result b. False. Should reversal with flumazenil be
in vasoconstriction of the coronary vessels necessary, an initial dose of 200mg should be
and precipitate ischaemic cardiac pain. The administered intravenously over 15 seconds.
maximum dose should be limited to about If the desired level of consciousness is not
three cartridges in patients with ischaemic obtained within 60 seconds, further doses
heart disease. of 100mg may be injected every minute as
e. False. Tricyclic antidepressants prevent necessary up to a maximum total dose of
the presynaptic reuptake of noradrenaline 1mg. The usual dose required is 300600mg.
(norepinephrine) and 5-HT (serotonin) and The dose of flumazenil should be titrated
work by potentiating the effects of these against the individual response and it may be
neurotransmitters. Theoretically, exaggerated preferable to maintain a degree of sedation
adrenergic effects such as hypertension could during the early postoperative period rather
result when patients also receive adrenaline than bring about complete arousal, particularly
(epinephrine) in a dental injection. However, in very anxious patients or those with coronary
there is no evidence that this occurs in artery disease.
practice. c. False. It should be remembered that because
4. a. False. When excessive water, blood or debris of the nature of the affinity of oxygen for
are anticipated to collect in the mouth, then it haemoglobin, the relationship between the
86
Control of pain and anxiety Chapter 4
partial pressure of oxygen in blood and gas at the expense of oxygen. This may be
haemoglobin saturated is represented by a harmful and so should be prevented by the
sigmoid rather than linear graph (Fig. 4.8). administration of 100% oxygen to the patient,
This means that at the upper end of the curve, for a few minutes following treatment.
a reduction of 2% in the oxygen saturation b. True. Nitrous oxide is compressed and up
of haemoglobin represents a fall in the to four-fifths of the contents of a full cylinder
partial pressure of oxygen of about 15%. In is in the liquid state, so the valves must be
other words, small changes in haemoglobin elevated above the horizontal. The amount of
saturation represent large changes in the nitrous oxide present in a cylinder can only be
partial pressure of oxygen. However, the determined by weighing, as the gas pressure
partial pressure of oxygen has to fall to 10kPa above the level of the liquid remains constant
(75mm in figure) before the amount of oxygen as long as any liquid remains.
carried in the blood falls noticeably. Below c. True. All inhalational machines must be
an oxygen saturation of 90%, the oxygen fitted with a fail-safe system so that, should
carriage of the blood falls off drastically and the oxygen supply be cut off or the oxygen
correction of the fall is required to prevent cylinder become empty, the nitrous oxide alone
hypoxia occurring. This may be achieved by will automatically cut out, making it impossible
asking the patient to take larger breaths or by to deliver nitrous oxide alone to the patient
lifting the chin to improve the airway. However, and render them hypoxic. Machines are also
should these measures fail, then one should designed so that they cannot deliver less than
consider administering supplemental oxygen 30% oxygen.
or reversing the sedation. Some consider
d. True. Recovery is normally complete within 30
an oxygen saturation of 94% an indication
minutes of discontinuation of nitrous oxide and
of impending clinical hypoxia. Haemoglobin
patients can then leave without an escort.
provides an effective oxygen reserve, such
e. False. Nitrous oxide provides good analgesia,
that about 75% of the haemoglobin of mixed
such that the pain on injection of local
venous blood is saturated with oxygen.
anaesthesia can be prevented completely. This
d. True. It has been suggested in some reports
is particularly useful for children.
that all patients sedated intravenously should
have supplemental oxygen administered. Extended matching items answers
While this may be helpful in some situations,
EMI 1
such as sedation of elderly patients for
endoscopy, it is not necessary for all dental 1. B. Seven cartridges (2.2ml) of lidocaine is the
patients, the majority of whom are young, fit maximum recommended dose of local anaesthetic
and healthy, and where hypoxic episodes are for a healthy adult.
best prevented by careful technique rather than 2. F. The most likely explanation of the previous
universal oxygen administration. incident would be an intravascular injection
e. True. Changes in cardiovascular parameters of local anaesthetic containing adrenaline
brought about by midazolam are slight but (epinephrine). The symptoms do not resemble
can induce a decrease in mean arterial those of an allergic reaction and palpitations do
pressure, cardiac output, stroke volume and not suggest a vasovagal attack or faint during
systemic vascular resistance. It is useful to which there is a bradycardia.
have a baseline measure of systemic arterial 3. H. This limited mouth opening is likely to
blood pressure with which to compare any have resulted from inflammation in muscles
later measurement that may be required in a of mastication associated with a haematoma
sensitive patient or in an overdose situation. following an inferior alveolar nerve block. Patients
It is also an important part of the preoperative experiencing this complication need antibiotics
assessment. Arterial blood pressure if diagnosed early, so there would be no benefit
may be measured indirectly by using a in this case. Explanation of the problem and
sphygmomanometer. Semi-automatic electrical reassurance is important.
sphygmomanometers are now readily available 4. J. An upper first premolar may be anaesthetised
and inexpensive. These have a small piezo- using a buccal infiltration and greater palatine
crystal, which is positioned over the artery to block with local anaesthetic solution. Alternatively
detect arterial pulsations. an infraorbital block and greater palatine block
5. a. True. Immediately following the administration may be used.
of high concentrations of nitrous oxide, a 5. C. Bupivacaine has a long duration of action
diffusion hypoxia may occur, as both nitrogen and is, therefore, the most appropriate for
and nitrous oxide occupy space in the alveolar postoperative pain control.
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of the teeth and jaws 5
Acute pulpitis
Overview
Clinical features
The common clinical problems in dentistry are Severe, sharp pain or throbbing pain is usually
related to infections and inflammation. The most of several minutes (1015) duration. The pain is
prevalent dental diseases, dental caries and the poorly localised and often radiates away from the
periodontal diseases, are not included here. How- site of origin, but it only crosses the midline when
ever, the sequelae of these diseases are frequently anterior teeth are involved. The pain is precipi-
infection and inflammation of the bone. This chap- tated particularly by heat, but also sometimes by
ter deals with these, along with other associated cold and sweet stimuli. The symptoms are often
conditions of importance to the dentist. relieved by analgesics.
A B
Fig. 5.1 Radiograph of internal resorption in a lateral incisor as shown on (A) periapical radiograph and
(B) small volume CBCT examination.
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Fig. 5.3 Radiograph of loss of lamina dura on the Fig. 5.4 Radiograph of rarefying osteitis associ-
fractured central incisor. ated with the lower right central incisor.
the periapical inflammation is usually provoked by leukocytes and macrophages, while in the latter,
a dead and/or infected pulp) although, particularly they accumulate within a periapical granuloma. In
with multirooted teeth, some response may still be both cases, suppuration may occur, leading to the
elicited, as well as tenderness on percussion. development of a periapical abscess.
Acute periapical periodontitis may also occur
after trauma or endodontic treatment to a tooth. In
such cases, the history should lead to the diagnosis. Management
Endodontic therapy or extraction of the affected
tooth is required. In cases of post-traumatic acute
Radiology periapical periodontitis, the inflammation may
The basic radiological sign accompanying acute resolve with splinting and time.
inflammation around the apex of a tooth is
localised bone destruction. Where there is little or Chronic periapical periodontitis
no previous chronic inflammation, this will appear
as loss of the lamina dura (Fig. 5.3). Where the
(periapical granuloma)
periapical periodontal ligament was previously wid-
ened or a granuloma was present, acute inflamma- Clinical features
tion will appear as a poorly defined radiolucency, There may be few or no symptoms.
termed a rarefying osteitis (Fig. 5.4).
Radiology
Pathology The initial sign is widening of the periodontal liga-
Acute periapical periodontitis may arise de novo ment space with preservation of the radio-opaque
or develop against a background of pre-existing lamina dura (Fig. 5.5). This naturally progresses
chronic periapical periodontitis. In the former, the with time to form a rounded periapical radiolucency
periodontal ligament is infiltrated by neutrophil with a well-defined margin a granuloma (Fig. 5.6).
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Infection and inflammation of the teeth and jaws Chapter 5
Fig. 5.5 Radiograph of widened periodontal liga- Fig. 5.6 Radiograph of granuloma on a central
ment on the lateral incisor with intact lamina dura. incisor.
Ultimately, this may undergo cystic change (radicu- of Melassez, may proliferate as a result of release
lar cyst; see Chapter 10). Differentiation between of inflammatory mediators. Neutrophil infiltration
a large granuloma and a small radicular cyst is not within this epithelium may be one factor leading to
possible on purely radiological grounds, but lesions cavitation and formation of a radicular cyst.
greater than 1cm diameter are often assumed to be
cysts until histopathological diagnosis is established.
A further radiological sign frequently seen in Management
chronic periapical periodontitis is sclerosing (or Endodontic therapy or extraction of the affected
condensing) osteitis (Fig. 5.7). This appears as tooth is required. Should the lesion persist following
a fairly diffuse radio-opacity, usually around the orthograde endodontic therapy, apicectomy should
periphery of a widened periodontal ligament or a be considered (Box 5.1 and Fig. 10.12 on p. 95).
periapical granuloma.
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Fig. 5.7 Radiograph of condensing (sclerosing) osteitis relating to the grossly carious molar. The vertical
radiolucent line is a vascular channel.
for hypercementosis per se, but its recognition is Successful treatment of the periapical lesion by
obviously important if extractions are planned. endodontic therapy often arrests the resorption.
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Infection and inflammation of the teeth and jaws Chapter 5
Box 5.1
Clinical features
Early symptoms are of pain and swelling, localised
to the operculum (gum flap) overlying the crown
of the tooth (Fig. 5.12). In more severe cases the Fig. 5.10 Apicectomy of tooth and retrograde
patient may complain of limitation of mouth open- restoration.
ing and facial swelling.
On examination, there may be extraoral swell- often overerupted, upper tooth. Spread of infection
ing and lymphadenopathy. Trismus may be present. may occur to deeper tissues.
Intraoral examination will reveal a swollen, tender
operculum overlying the tooth. In chronic pericor-
onitis, pus may be seen exuding from beneath the Radiology
operculum. A frequent finding with lower third Apart from the appearance of a partially erupted,
molars is evidence of trauma from an opposing, possibly impacted, tooth (Chapter 6), there are few
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Fig. 5.13 Radiograph showing sclerosing osteitis around the follicle of the third molar. The patient had
chronic pericoronitis.
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Fig. 5.14 Histopathological section of a dental abscess showing pyogenic membrane and necrosis
(lower centre of picture).
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Infection and inflammation of the teeth and jaws Chapter 5
with an air-rotor drill. This does not require local of the head and neck is described in more detail in
anaesthesia as the tooth is non-responsive to Chapter 2.
sensitivity tests, although it is important not to
apply pressure to the tooth (as it may be exqui-
sitely tender to percussion) by cutting tooth tissue Spread of infection through tissue
slowly with a sharp bur. Alternatively, the tooth is spaces
extracted to gain adequate drainage. This may be
undertaken under regional local anaesthesia, with In addition, to spread through the lymphatic system,
or without conscious sedation, or using general infection in the soft tissues of the face also spreads
anaesthesia. along fascial and muscle planes. These potential tis-
sue spaces usually contain loose connective tissue
Spread of infection to facial and can be described anatomically (Fig. 5.15).
tissues
Floor-of-mouth tissue spaces
Lymphatic spread of infection The mylohyoid muscle divides the sublingual and
submandibular spaces, although they are continu-
The lymphatic system is frequently involved in ous around its posterior free edge (Fig. 5.16). The
infections and gives an indication as to the pattern submental space is situated below the chin and
of spread. Enlargement and tenderness of nodes, between the anterior bellies of the digastric muscles.
described as lymphadenitis, is common, although There are no restrictions on the spread of infection
inflammation of the lymphatic vessels, described as between the two submandibular spaces and the sub-
lymphangitis, may occur and can be seen as thin red mental space; consequently, it can spread across the
streaks through the skin. The lymphatic drainage neck below the inferior border of the mandible.
Buccinator
muscle
Tongue
Sublingual
space
Deep lobe of
Buccal submandibular
space salivary gland
Submandibular
space
Superficial
lobe of the
submandibular
salivary gland
Fig. 5.15 Potential tissue spaces about the floor of the mouth.
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Mylohyoid
muscle
Anterior belly
of digastric
muscle
Mandible
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Infection and inflammation of the teeth and jaws Chapter 5
Parotid Medial
salivary gland pterygoid muscle
Para-
pharyngeal
space
Parotid
space
Superior
Masseter constrictor
muscle muscle
Peritonsillar
space
Submasseteric
space
Pterygo-
mandibular
space
Buccal space
Buccinator Mylohyoid
muscle muscle
Premolars and molars show spread of infection into will be raised and the patient will have difficulty in
the buccal sulcus leading to intraoral or extraoral swallowing saliva; this pools and may be observed
spread according to the relation to the attachment running from the patients mouth. This sign indi-
of buccinator. Similarly, second mandibular molar cates the need for urgent management. Celluli-
teeth have more lingually placed roots and may, tis involving the tissue spaces on both sides of the
therefore, result in either sublingual or submandib- floor of mouth is described as Ludwigs angina.
ular spread, depending on the relative position of
the mylohyoid muscle.
Cavernous sinus thrombosis
Rarely, infection in the tissues of the face may
Cellulitis spread intracranially via the interconnecting venous
Cellulitis is a spreading infection of connective tis- system. This is more likely with the upper face via
sue typical of streptococcal organisms. It spreads the facial vein to the cavernous sinus. While rare,
through the tissue spaces as described above and cavernous sinus thrombosis is life-threatening.
usually results from virulent and invasive organisms.
The clinical features are those of a painful, diffuse,
brawny swelling. The overlying skin is red, tense Management of infections about
and shiny. There is usually an associated trismus, the face
cervical lymphadenopathy, malaise and pyrexia.
The swelling is the result of oedema rather than A clinical and radiographic examination of the
pus and may be extensive when it involves lax tis- mouth should be carried out to identify potential
sues such as in the superficial mid-face about the causes such as carious or partly erupted teeth or
eyes. Cellulitis usually develops quickly, over the retained roots.
course of hours, and may follow an inadequately The patient may need to be admitted to hospi-
managed or ignored local dental infection. tal if they are unwell or there are signs of airway
If the infection spreads to involve the floor of compromise. A differential white-cell count may
mouth and pharyngeal spaces, then the airway can indicate an increase in neutrophils. A blood glu-
be compromised. Initially, the floor of the mouth cose investigation may be carried out to exclude an
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Fig. 5.18 Postoperative photograph showing drains in right and left submandibular spaces.
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Infection and inflammation of the teeth and jaws Chapter 5
5.5 Other infections and more readily distinguished on Gram staining (Gram
positive) (Fig. 5.19). These masses may be partially
inflammations calcified and visible to the naked eye as bright yel-
low (sulphur) granules. Diagnosis is made on clini-
Learning objectives cal grounds accompanied by Gram staining, culture
You should:
and sensitivity testing performed on a sample of
know what infections of a more general character pus. This is of particular importance as it is unusual
have dental/facial implications for Actinomyces species to be the only bacteria
know the symptoms associated with these present. Within the tissues, the masses of bacte-
infections ria lie in areas of suppuration surrounded by acute
be aware of the medical conditions that predispose inflammatory cells. The adjacent granulation tissue
patients to these infections. often shows considerable fibrosis.
Management
Actinomycosis Any related dental cause is treated and swellings
are incised and drained as necessary. A 3-week
Clinical features course of penicillin is used for acute infections
Infection with Actinomyces species, most com- and a 6-week course is used for chronic infections.
monly A. israelii, may involve the cervicofacial and Alternatively, erythromycin, tetracycline or clinda-
abdominal regions as well as skin and the lungs. mycin may be used.
The cervicofacial region is, however, the most
commonly affected and acute infection here may
be indistinguishable from an acute dento-alveolar Osteomyelitis
abscess. There may be a history of trauma. Multiple
discharging sinuses are a classic sign of chronic acti- Osteomyelitis is inflammation of the medul-
nomyocosis infection. lary cavity of a bone caused by an infection. It is
quite rare but is seen particularly in those patients
whose defence against infection is compromised
Pathology because of local or systemic factors. It is a seri-
Actinomycosis is characterised by the presence of ous condition requiring urgent specialist man-
masses of the filamentous anaerobic bacteria visible agement. In contrast, localised bone infection
in sections stained with haemotoxylin and eosin but following tooth extraction is referred to as osteitis
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or dry socket, and can be managed in primary care spread of infection within the narrow spaces. By
(Chapter 6). the time the bone matrix is affected, the condition
is classified as chronic osteomyelitis.
Acute osteomyelitis
Management
Clinical features Benzylpenicillin or clindamycin and metronida-
Symptoms are pain, tenderness and swelling in the zole are normally started and altered as neces-
affected area. As such, these symptoms are essen- sary, according to the results of pus sensitivity
tially those of an acute dental infection. The man- testing. The patient may require hospital admis-
dible is affected more frequently than the maxilla. sion for incision and drainage, but it is prefer-
Where the body or lower ramus of the mandible able to limit any dentoalveolar surgery to the
is affected, an important symptom is a developing extraction of grossly mobile and non-vital teeth.
numbness over the chin as a result of inferior alveo- Antibiotics should be continued for at least
lar nerve involvement. 2 weeks after control of the acute infection.
Fig. 5.20 Radiograph of acute osteomyelitis. This occurred after extraction of the first molar.
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Infection and inflammation of the teeth and jaws Chapter 5
Fig. 5.21 Occlusal radiograph of the lower right molar region in chronic osteomyelitis. Note the bone
destruction within the jaw and sequestration lingually. Buccally there is periosteal new bone formation.
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extractions can be adopted in the maxilla. When may offer improved sensitivity over plain radio-
extraction of teeth is required in patients who have graphs, while magnetic resonance (MR) scans may
had radiotherapy to the jaws, a specialist opinion be useful in showing soft tissue involvement. Radio-
should be sought. isotope bone scans are highly sensitive but have
Surgical management of osteoradionecrosis is limited specificity.
similar to osteomyelitis. Sometimes, the changes
can be extensive, necessitating partial jaw resection
to remove all necrotic bone. Pathology
The bone often becomes black or dark green in
colour due to the products of bacterial colonies
Bisphosphonate-associated forming in the marrow spaces once the necrotic
necrosis of bone bone becomes exposed to the oral cavity. Microscop-
ically the surfaces of the non-vital bone are scalloped
Bisphosphonates are a class of drug used for treat- due to osteoclastic action. The osteocyte lacunae
ment of a variety of bone conditions, including are empty and, in the later stages, the bone matrix
osteoporosis, Pagets disease of bone, osteogenesis collagen breaks down. Granulation tissue may form
imperfecta and, as part of management of bony at the interface with vital bone and a dense chronic
metastatic disease. Their mode of action is upon active inflammatory reaction is seen. Sequestration
osteoclasts, slowing bone remodelling and turn- and transmucosal elimination are often found.
over, but they also have a prominent antiangio-
genic effect. In the past few years, there have been
increasing numbers of reports of necrosis of bone Management
in the jaws of patients being treated with these As is the case for patients who have had radiother-
drugs, principally where the more potent nitrog- apy to the head and neck, prevention of the condi-
enous drugs have been administered intravenously. tion is paramount, so as to reduce the chance of
The evidence suggests that the disease can be a late surgery being necessary. Special care should be taken
effect of bisphosphonate use, even occurring after with any patient attending the dentist who is, or has,
cessation of therapy. The aetiology of the necrosis undergone bisphosphonate treatment. Where an
of bone in the jaws is not clearly understood, but extraction or other surgical treatment is required,
seems to be related to inhibition of bone remodel- the wisest course is to refer the patient to a special-
ling, killing of osteoclasts and decreased intraosse- ist. Patients receiving intravenous bisphosphonates
ous blood flow. for metastatic bone disease are more at risk than
those receiving oral bisphosphonates for osteoporo-
sis. Modification or cessation of oral bisphosphonates
Clinical features may be considered in consultation with the treating
Patients may present with poor wound healing, soft physician and the patient. Any surgery should be
tissue breakdown and exposure of bone. There may undertaken as atraumatically as possible and patients
be superadded symptoms and signs of osteomyeli- should be reviewed regularly after surgery.
tis (see p. 104). The disease affects the mandible Management of bisphosphonate-associated
more frequently than the maxilla. The apparent necrosis of bone is essentially the same as that for
trigger for development of the condition may be an osteoradionecrosis, being a combination of antibi-
extraction, implant placement or other minor surgi- otics and careful surgery, along with cessation of
cal procedure. The criteria for diagnosis are: history bisphosphonate use. Hyperbaric oxygen therapy
of current or prior treatment using bisphosphonate may also have value. Immediate reconstruction of
drugs, exposed bone in the jaws that has been pres- any resection using non-vascularised or vascular-
ent for more than 8 weeks and no previous history ised bone may be problematic as necrotic bone may
of radiotherapy. develop at the recipient site.
Radiology Periostitis
Plain radiographic appearances are identical to
those of osteoradionecrosis (see p. 106). Cone Proliferative periostitis sometimes causes jaw swell-
beam computed tomography (CBCT) (or CT) ing and ulceration. The condition arises as a result
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of chronic irritation to the periosteum, often from swelling. The lesion, which may be mistaken for a
foreign material, which enters through an ulcer. malignant process clinically, is referred to as a veg-
Vegetable pulse material is the best-known exam- etable pulse granuloma.
ple. Leguminous grains from cooked food accu- Augmentation materials that have been
mulate under an ill-fitting denture and are forced implanted into the jaws sometimes become
into the periosteum. The resulting chronic inflam- infected and cause periostitis and osteitis. A rare
matory processes, including a foreign body reaction cause of periosteal expansion is metastatic deposi-
to the starch, cause cortical erosion and periosteal tion of carcinoma.
Q Self-assessment: questions
Multiple choice questions (True/False) b. Is indicated when surgical repair of a root
1. A dense bone island (DBI; idiopathic perforation is required
osteosclerosis): c. May be undertaken on posterior teeth
a. Is a mixed radiolucent/radio-opaque lesion d. Need not involve the removal of all the gutta-
b. Causes external bony swelling percha from the walls of the cavity in the root
end
c. Is found only in relation to teeth unresponsive
to sensitivity tests e. May be described as successful even when
there is no regeneration of periapical bone
d. Requires no treatment
e. Is also known as an enostosis Extended matching items questions
2. Periosteal new bone formation is seen in: Options:
a. Chronic osteomyelitis A. Chronic periapical periodontitis
b. Cherubism B. Cellulitis
c. Langerhans cell histiocytosis C. Acute periapical periodontitis
d. Metastatic bronchial carcinoma D. Garrs osteomyelitis
e. Pagets disease of bone E. Pericoronitis
3. Orofacial infections are: F. Acute pulpitis
a. Common following contaminated facial G. Chronic osteomyelitis
laceration H. Acute alveolar abscess
b. A common source of lost working days I. Chronic pulpitis
c. Usually of fungal or viral aetiology when J. Bisphosphonate-associated necrosis of bone
affecting the oral mucosa Lead in: Match the clinical and radiological signs
d. Best managed by prescribing an antibiotic and symptoms from the list below with the likeliest
empirically rather than waiting for the results of diagnosis above.
a culture and sensitivity investigation 1. Clinically: painful, diffuse, reddened swelling
e. Commonly the result of endogenous affecting the right side of the face, centred on the
commensal organisms cheek, causing partial closure of the eye. This
4. Penicillins: developed overnight. The previous 3 days there
a. Are the most commonly used antimicrobial had been, according to the patient, an abscess
drugs in dentistry present on UR3. The patient feels unwell and
b. Are described as being non-toxic there is lymphadenopathy present. UR3 is grossly
carious. Radiologically: UR3 has a periapical
c. Such as amoxicillin are more readily
rarefying osteitis.
absorbed from the gastrointestinal tract than
phenoxymethylpenicillin (penicillin V) 2. Clinically: a 20-year-old male presents with
pain and swelling at the back of his mouth on
d. Are more useful than metronidazole when
the right side. It has been present for a couple
anaerobic activity is required
of days. On examination, he has a tender,
e. Such as benzylpenicillin produce rapid high palpable, upper right cervical lymph node. There
plasma levels when given by the intravenous is some trismus. Intraorally, there is swelling of
route the gingivae distal to LR7. UR8 is erupted and
5. Apical surgery: traumatising this swelling when in occlusion.
a. May be carried out using a semilunar incision Radiologically: LR8 is present but mesioangularly
when the tooth is restored with a crown impacted against LR7.
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Infection and inflammation of the teeth and jaws Chapter 5
3. Clinically: a dull, throbbing pain associated with there is swelling extraorally over the left jaw and
LL6, made worse on touching and when trying some cervical lymphadenopathy. Intraorally, she
to eat. This tooth is heavily restored. It does not has a partially dentate mouth, with missing molars
respond to sensitivity testing. Radiologically: LL6 on the lower left. Her alveolar ridge distal to LL5 is
has periapical rarefying osteitis associated with swollen and a draining sinus is visible buccally. LL5
both roots. socket is still partly open. Radiologically: there is a
4. Clinically: severe, sharp pain on right side of 2 3cm area of radiolucency with a central area of
the face. Difficult to localise, but is precipitated radio-opacity located in LL5 and LL6 region.
particularly by hot drinks and comes in waves 9. Clinically: a 45-year-old male presents with a
lasting several minutes. Radiologically: there is longstanding pain and swelling related to the left
nothing unusual to see extraorally. In the mouth, lower jaw. He also says that in the last week he
there are many heavily restored teeth, but no is getting a tingling sensation in his left lower lip
obvious carious lesions. On closer examination, that aggravates him. He generally doesnt believe
using a pledget of cotton wool soaked in ethyl in dentists and he has been self-treating for 2
chloride, UR5 is hypersensitive, but it is not tender months using various herbal remedies, to no avail.
to percussion. On examination, there is swelling of the lower part
5. Clinically: pain of left side of the face that is hard of the left face overlying the body of mandible.
to localise, although LL5 is tender on touching The swelling is tender and, upon this, there is a
and eating. This has been present for a few days, localised reddened area that has crusted over.
but this morning the patient reports that the pain Intraorally, there are many carious teeth and poor
was a bit easier, although some swelling has oral hygiene. The LL6 and LL7 are little more than
arisen next to the LL5. On examination, there is retained roots. There is buccal swelling next to LL6
tenderness when palpating the left side of the and, adjacent to it, an obvious sinus in the buccal
face over the premolar region of the left mandible. sulcus. Radiologically: LL6 and LL7 roots all show
Intraorally, LL5 is grossly carious and tender to periapical radiolucency. Below these, there is a
pressure. There is fluctuant swelling in the buccal more extensive area of rarefying osteitis, within
sulcus next to LL5. The tooth does not respond which can be seen some islands of radio-opacity.
to sensitivity tests. Radiologically: LL5 has a 10. Clinically: a dull, throbbing pain that arises
periapical rarefying osteitis. spontaneously from the upper left molar region and
6. Clinically: occasional dull ache from UL1. The which usually lasts for a few hours. Occasionally
tooth is restored with a crown. No tenderness the pain is stimulated by hot drinks. The symptoms
to pressure. No soft tissue abnormality. have been occurring irregularly for some
Radiologically: round, 0.5 cm diameter periapical months. On examination, there are no extraoral
radiolucency, with loss of lamina dura, associated abnormalities and no soft tissue abnormalities
with UL1. intraorally. There are some large restorations in the
7. Clinically: an 8-year-old child presents with a firm upper left teeth, but only UL7 gives an abnormal
swelling associated with the left body of mandible. response to pulp testing. It is not tender to
He complains of occasional toothache on that percussion. Radiologically: apart from confirming
side. On examination, a hard but mild swelling can a very deep amalgam restoration in UL7, there are
be palpated, principally on the buccal aspect of no abnormal radiological findings.
the alveolus, deep in the buccal sulcus, extending
Case history questions
forwards to the canine region. He has gross
caries of his first permanent molars. LL6 is sore Case history 1
when you press on it. Radiologically: LL6 shows Mary is a 40-year-old dental phobic. She attended
a periapical condensing (sclerosing) osteitis. An 4 weeks ago as a casual patient for extraction of
occlusal radiograph, taken to assess the buccal a grossly decayed lower left first molar. She has
swelling, shows a thin layer of periosteal new reluctantly returned now complaining of awful pain
bone adjacent to the original buccal cortical on the lower left, swelling in that region and in the
margin of the mandible. submandibular region, a numb lip on the lower left and
8. Clinically: a 75-year-old woman attends a bad taste. Radiographs are taken (Fig. 5.22).
complaining of an infection in her left lower jaw Describe your assessment, likely diagnosis and
that has been present for a few weeks, since management.
she had her LL5 extracted, and which now is
Case history 2
causing her a lot of distress. She cannot wear
her lower partial denture. She suffers from severe Chris is 25 years of age. He attends your surgery
osteoporosis, having sustained several vertebral complaining that he has pain and swelling at the back
fractures over the last 5 years. On examination, of his mouth on the lower right side, a bad taste, bad
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breath and that he cannot open his mouth properly. He Case history 3
has lymphadenopathy of the right submandibular and Susan is a 55-year-old regular patient at your surgery.
cervical nodes. You know from a previous visit that he You have spent many months restoring her dentition
has a partially erupted lower third molar. with crowns, bridges and endodontic treatments. She
Describe your assessment, likely diagnosis and says that while she was away on her annual holiday
management.
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Infection and inflammation of the teeth and jaws Chapter 5
she suffered an abscess on a lower front tooth that Oral examination questions
was treated by antibiotics. While she is pain free now, 1. What is the significance of the radiological sign of
she has noticed a small spot on her chin that weeps loss of lamina dura?
fluid occasionally.
2. When would you use antibiotics to treat an
Describe your assessment, likely diagnosis and
infection of dental origin?
management.
3. What is an abscess?
Case history 4 4. Can you distinguish between a periapical
Fig. 5.23 shows a radiograph of a patient who attends granuloma and a radicular (periodontal) cyst on a
your surgery with toothache. She complained of a dull radiograph?
aching pain on the upper right, with some tenderness 5. What is pyrexia?
in the upper buccal sulcus. The pain is unaffected by 6. What is endarteritis obliterans?
thermal stimuli.
7. How may infection spread from pericoronitis of a
Describe your assessment and likely diagnosis.
lower third molar tooth?
8. What are the clinical differences between acute
pulpitis and acute periapical periodontitis?
A Self-assessment: answers
Multiple choice answers d. False. Metastatic lesions of prostate carcinoma
1. a.False. DBI has a uniform radio-opacity, very will produce a proliferative periostitis, but
much the same in density as the cortical bone bronchial carcinoma will not. Metastatic breast
at the lower border of the mandible. carcinoma sometimes stimulates new bone
formation. In such cases, the appearance
b. False. DBI is entirely within the normal
contrasts markedly with the new bone
boundaries of the jaw.
formed in osteomyelitis, being in spicules
c. False. DBI typically forms close to the roots at right angles to the bone surface. This
of teeth and is frequently joined to the lamina sunray appearance is also classically seen in
dura. However, the vitality of the teeth is osteogenic sarcoma.
irrelevant.
e. False. The bone changes in Pagets disease
d. True. frequently produce a parallel trabecular
e. True. DBI is usually seen in the premolar/ pattern and bony enlargement, but there is no
molar region of the mandible. Most periosteal new bone.
authorities consider them to be a 3. a.False. The orofacial region is well vascularised
developmental, self-limiting entity. A typical and few facial lacerations become infected.
size is around 1cm, but occasionally Similarly, few compound fractures of the
much larger ones occur. The margins are mandible become infected. Impairment of this
well defined but the shape is irregular, vascularity by radiotherapy or conditions such
with no radiolucent margin. Despite their as diabetes mellitus significantly increase the
innocuous nature, they are sometimes seen risk of infection.
in association with external root resorption.
b. True. Orofacial infections represent a
If multiple DBIs are seen in the jaws, you
significant proportion of attendances for dental
should consider familial adenomatous
care provided by general dentists and for
polyposis (Gardners syndrome) in the
hospital specialist services. Infections cause
diagnosis.
pain and disability and result in lost working
2. a.True. One or more layers of very thin bone days. Occasionally, the infections can be life-
form parallel to the periphery of the jaw as threatening; untreated, many acute infections
a late radiological feature. The thin bone is persist as chronic infections with associated
usually best identified on fine-detail intraoral morbidity.
radiographic film.
c. True. The major oral mucosal infections are
b. False. Cherubism leads to jaw enlargement, of fungal, usually candidal, or viral origin.
but not by proliferative periostitis. Other superficial mucosal surfaces of the
c. True. Langerhans cell histiocytosis has similar body such as the vagina show similar
appearances to osteomyelitis. infections.
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Infection and inflammation of the teeth and jaws Chapter 5
Of course, it is possible to think of other causes, occlusal and, sometimes, panoramic radiographs
such as a fractured root in a root-filled tooth, but and may be quite a subtle change.
the radiography provides the final confirmation of 10. I. These symptoms and signs are all typical of
the straightforward diagnosis. chronic pulpitis. The pain is not so severe as with
4. F. These symptoms and signs should be familiar acute pulpitis, although occasional acute flare-ups
to every dentist and student. The absence of may occur. An important finding is that the tooth
tenderness to percussion or any radiological signs was not tender to percussion, as that sign would
excludes an acute periapical periodontitis from the have suggested periapical inflammation.
differential diagnosis. The thermal sensitivity is a
classic sign. Case history answers
5. H. The initial symptoms fit with acute periapical Case history 1
periodontitis, a finding that is consistent with the While most patients returning with postextraction
radiological signs. The appearance of a fluctuant pain will have alveolar osteitis (dry socket), there
swelling, however, indicates a collection of pus are a number of features here that indicate that the
(abscess). diagnosis is not so straightforward.
6. A. This needs no real explanation; the radiological Assessment should begin with a thorough clinical
appearance is diagnostic. examination. Extraoral examination should include
7. D. A firm swelling in a childs jaw could, of careful palpation of lymph nodes and assessment
course, be due to several different conditions. of the numbness affecting her lip (see Chapter 2 for
The symptom of toothache and a grossly carious details on both of these). Intraoral examination should
molar make for a straightforward cause-and-effect not only involve examination of the socket but also of
relationship, but could be coincidental to the other teeth on the lower left as it is always possible
bony swelling. Similarly, the periapical condensing that the recent extraction is not the cause of the
osteitis could make for a simple diagnosis of current problem. Examine the socket; after 4 weeks, a
chronic periapical periodontitis. The key feature socket should be filled with maturing granulation tissue
here is the radiological finding of periosteal new and early bone deposition will be occurring. Clinically,
bone. This sign makes the diagnosis almost therefore, the socket should be largely closed over
certain. (although a defect is often still evident with larger
8. J. The clinical features indicate chronic molar teeth) and the mucosa should not be inflamed.
infection, but the radiological sign of a The pain, swelling and numbness affecting the mental
radiolucent area with a central radio-opacity nerve all suggest a pathological process involving the
are consistent with a sequestrum lying within bone of the mandible distal to the mental foramen.
an area of bone destruction. The history of Starting from first principles, differential diagnosis
a recent extraction provides a precipitating might include infection (osteomyelitis), fracture of
event. While chronic osteomyelitis is a suitable the mandible and malignancy in the jaw. Suitable
diagnosis, the history of severe osteoporosis radiology will now help to narrow down the differential
raises the possibility of bisphosphonate- diagnosis. The radiographs show a mixed lesion (i.e.
associated bone necrosis. Someone of this radiolucent and radio-opaque) in the mandibular body.
age with severe osteoporosis would certainly This is compatible with osteomyelitis rather than the
be offered treatment and bisphosphonates other possible diagnoses, although it is possible that a
would be the obvious choice. Bone necrosis fracture may have occurred secondary to the infection.
is more commonly associated with high-dose Management would be principally by antibiotic therapy
bisphosphonates used in management of and surgical removal of the sequestered bone. Such
metastatic malignancy, but there are numerous management would be carried out under the care of a
cases appearing in the literature of patients hospital specialist.
using oral bisphosphonates developing the Case history 2
condition.
Follow the standard assessment procedures described
9. G. The tingling lower lip should set the alarm bell
in Chapter 3 of extraoral examination, intraoral
ringing, as this sign is a feature of a significant
examination (to the degree possible where there is
problem (i.e. involvement of the ID canal by some
trismus) and appropriate special tests. The last would
pathosis). The draining extraoral and intraoral
probably be limited to extraoral radiography in this
sinuses indicate an infection, while the radiological
case, using either a lateral oblique film or a panoramic
picture fits with sequestration of bone. Together
examination (preferably by a field size collimation to
with the history of a problem over several weeks,
exclude other regions of the mouth).
these features fit with chronic osteomyelitis. No
All the symptoms suggest infection as a cause. Your
periosteal new bone was noted in the history, but
knowledge about the impacted lower third molar make
that is a feature usually only picked up on true
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Master Dentistry
acute pericoronitis a likely diagnosis. If we assume is this the first? Carry out a complete examination.
that this is the case, then your management should Test each tooth for sensitivity with a cotton wool
include the following: pledget soaked in ethyl chloride. Use gentle finger
1. Irrigate beneath the operculum using saline or pressure on each tooth, followed up by percussion if
chlorhexidine solution. there is no abnormal response. Record the responses
2. If access will allow, relieve any traumatic occlusion and note if you manage to reproduce the pain the
on the operculum by grinding the cusps of the patient is complaining of.
opposing tooth. Often the opposing tooth is a
non-functional third molar; if you expect that the Radiology
lower third molar will never erupt into function, The radiograph shows a large restoration in the molar
then the opposing tooth may be best extracted to and a post crown on the first premolar. In the premolar,
relieve the pericoronitis. the root filling looks insubstantial and there is a
3. Prescribe antibiotics (the swelling and periapical granuloma present. At the level of the end of
lymphadenopathy suggest that this is the post, there is radio-opaque material overlying the
appropriate). tooth and bone. Also at this level and further coronally,
4. Advise frequent hot salt mouthwashes. lamina dura is lost along the root surface.
5. Arrange a review appointment. In a case
as severe as this, an early (2448 hours) Likely diagnosis
appointment would be appropriate, but you The lack of any aggravation of the pain by thermal
should arrange another visit once the infection stimuli suggests that this is not pulpitis. The dull
has resolved to allow a considered assessment of aching pain, along with the tenderness in the buccal
the third molar (see Chapter 6). sulcus, suggests chronic periapical periodontitis is
a likelier diagnosis. On radiological grounds, there is
Case history 3 only one likely tooth with problems: the first premolar.
Follow the standard assessment procedures described The apical granuloma suggests chronic inflammation,
in Chapter 2 of extraoral examination, intraoral but you should bear in mind that the radiograph is a
examination and appropriate special tests. Examine snapshot in time and that the lesion could be healing
the spot on her chin carefully. The description of it as (although the poor root filling suggests otherwise). The
weeping fluid, along with the history, suggests that it interesting finding is the collection of signs around the
may be a draining sinus from a chronic dental abscess. end of the post. The radio-opaque material overlying
The lower anterior teeth should be examined the root here is probably extruded cement from when
particularly carefully. Look in the labial sulcus and the post was cemented. This at least suggests a
palpate it to identify any swelling, tender areas or perforation and may indicate a fracture of the root at
other (intraoral) sinuses. Examine the teeth and assess this level. Clinical examination might reveal mobility of
for mobility and tenderness to pressure that might the crown if a fracture were present.
indicate periapical or periodontal pathology. Periapical
Oral examination answers
radiographs of suspect teeth should be taken and
you should carefully compare these with any previous 1. Loss of lamina dura may be localised to a single
radiographs to identify deterioration in any pre-existing tooth or generalised in the dentition. Localised
periapical lesions. Occasionally it might be possible lamina dura loss, usually around a tooth apex,
to pass a gutta-percha point through an open sinus is a sign of acute inflammation (or recent
and take a radiograph. The rationale for this is that acute inflammation) of dental origin. In chronic
the radio-opaque gutta-percha will point towards inflammation, the lamina dura persists as the
the origin of the infection. Practically this can be margin of a granuloma or cyst. Lamina dura
uncomfortable and only worthwhile where there is real loss laterally on the root may occur in relation
uncertainty over the origin of the infection. to a lateral canal or, more commonly, through
Management will commence with identification of loss of periodontal attachment in periodontal
the tooth causing the problem. Once a diagnosis of disease. Generalised loss of lamina dura occurs
chronic abscess is made, appropriate treatment would in hyperparathyroidism and Pagets disease of
be endodontic therapy (orthograde or, if not possible, bone, while thinning occurs in osteoporosis and
retrograde with apicectomy). Alternatively, if this fits with Cushings syndrome.
the overall treatment plan, extraction may be preferred. 2. The primary aim in treating dental infections is to
achieve drainage of pus. The second aim is to
Case history 4 remove the cause of the infection. In many cases,
the two are achieved simultaneously by extraction
Clinical features
of a tooth or a pulpectomy. Antibiotics would be
Obtain a complete history first. How long has the pain used in dental infections if drainage of pus could
been present? Have there been previous episodes or
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Infection and inflammation of the teeth and jaws Chapter 5
not be achieved. They may also be used in addition 6. The term endarteritis obliterans is used to
to the usual surgical procedures if there is a local describe a process of internal (intimal) proliferation
or generalised predisposition to infections (e.g. within a blood vessel. It causes obliteration of
Pagets disease, immunocompromised patients). the lumen, resulting in cessation of blood flow.
3. An abscess is a pathological cavity filled with Endarteritis obliterans may arise as a result
pus and lined by a pyogenic membrane. It is a of several inflammatory processes but is an
common condition in dentistry as it may result important feature of radiation damage. Following
from periapical periodontitis, periodontal disease, irradiation, endothelial cell loss results in exposure
pericoronitis or infection of a cyst. Management of the subendothelial collagen. This prompts
involves drainage of the pus; this is usually platelet adherence, thrombosis and organisation
undertaken by extracting the associated tooth or of the lumen by fibrosis. The reduced vascular
via the root canal. supply to tissues may result in impaired wound
4. No; at least it is no better than an informed guess. healing or necrosis.
A periapical granuloma is usually no larger than 7. A pericoronal infection may spread via the
1cm in diameter. Radiolucencies greater than this lymphatic system and along tissue planes
are more likely to be cysts, but there is overlap in with serious consequences. Infection may
size around this threshold. present buccally in the vestibular sulcus or
5. Pyrexia or abnormally high body temperature is may spread lingually to the sublingual and
an important physical sign. Most pyrexias result submandibular spaces. The pharyngeal tissue
from self-limiting viral infections, characterised by spaces may also be involved. Unchecked, such
influenza-like symptoms, although in dentistry the spread may compromise the airway and on
majority will result from oral infections that require occasion necessitate advanced surgical airway
active treatment. In general, a pyrexia may result management by way of tracheostomy.
from infections, neoplasms, connective tissue 8. These differ in symptoms and signs. Acute pulpitis
diseases or other causes such as drug reactions. involves severe, sharp pain of several minutes
Pyrexia is a sign of systemic toxicity; when it duration that is precipitated mainly by hot and
is associated with a dental infection it is an cold stimuli. It is often poorly localised. Acute
indication for the prescription of an antimicrobial periapical periodontitis gives symptoms of a dull,
drug and perhaps even hospital admission throbbing ache, usually well-localised to a tooth.
depending on the seriousness. Temperature has In acute pulpitis, a tooth is not tender to pressure
been traditionally measured by placing a mercury but is hypersensitive to thermal stimuli, while in
thermometer under the tongue, into the rectum or acute periapical periodontitis, the tooth is tender
under the axilla. Electronic temperature sensors to pressure and (usually) unresponsive to thermal
are now used against the tympanic membrane as stimuli.
they provide more rapid measurement and avoid
the use of mercury. Normal temperature is in the
range 35.837.1C.
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Removal of teeth and surgical
implantology 6
CHAPTER CONTENTS
know the techniques available for extraction
Overview 117 be aware of the potential complications following
6.1 Dental extractions 117 extraction and their treatment.
6.2 Impacted and ectopic teeth 124
6.3 Preprosthetic surgery 129 Assessment for extraction
6.4 Dental implant surgery 131
Self-assessment: questions . . . . . . . . . . 139
Indications for dental extraction
Self-assessment: answers . . . . . . . . . . . 142 Teeth may require removal for many reasons
including:
Overview gross caries
pulpitis
In this chapter, the surgical treatment of teeth is periapical periodontitis
described. The indications for dental extraction are pericoronitis
listed, together with the information that must be abscess resulting from periapical periodontitis,
elicited before a tooth is extracted. Forceps and surgi- periodontal disease or pericoronitis
cal techniques of extraction are outlined and the com- fractured teeth
plications that can follow extraction are outlined with
when associated with other pathology such as a
the treatment response. The clinical and radiological
cyst, fracture of the jaw or tumour
assessment and treatment are described for impacted
and ectopic teeth, lower and upper third molars,
when misplaced, impacted or supernumerary
maxillary canines and mandibular second premolars. as part of orthodontic treatment
The final section of the chapter deals with sur- when retained (primary teeth).
gery to assist retention of conventional dentures
and the surgical placement of implants.
History and clinical examination
6.1 Dental extractions The assessment of the patient has already been
described in Chapter 2. A thorough medical his-
tory prior to any surgical procedure is obviously
Learning objectives essential. This will identify patients who may
require special preparation prior to even the sim-
You should:
understand the indications for removal of a tooth
plest dental extraction. Such patients may include
know how to complete the preoperative assessment
those taking anticoagulant medication or those
that have undergone irradiation, among many
Master Dentistry
others (Chapter 3). The information obtained will procedure may be planned appropriately. Where
also determine whether surgery should be under- a radiograph is judged to be necessary, a periapi-
taken by the general dentist or specialist and also cal view should be the first choice, although other
the choice of setting. The home circumstances films may be substituted or used in addition when
and availability of an escort may also be impor- indicated (e.g. panoramic or lateral oblique for
tant if considering conscious sedation or general lower third molar).
anaesthesia.
The history also includes questions about previ-
ous dental and surgical experience and assessment of Treatment planning
patient anxiety (Chapter 4). The sex, general build The information from the history and examination
of the patient or other factors may give an indication is used to formulate the best plan for the patient.
as to the expected ease or difficulty of the extrac- This will include measures for adequate preparation
tion. For example, an extraction is likely to be more for the procedure and also the selection of anaes-
difficult in heavily built men, elderly patients may thesia: whether local anaesthesia, conscious seda-
have more brittle teeth and Afro-Caribbeans more tion with local anaesthesia or general anaesthesia.
dense alveolar bone, while child patients may have Anticipated difficulties are better discussed with
reduced access and less cooperation. the patient before treatment rather than during
The intraoral examination should include a note treatment, when they may be perceived as excuses
of the access to and position of the tooth. The for inadequate planning or experience.
crown of a heavily restored tooth is more likely to
fracture during extraction, while endodontically
treated teeth may be more brittle.
Surgical techniques
Instrumental extraction
Radiological examination To extract a tooth from the alveolus, the periodon-
Preoperative radiographs need not be taken prior to tal attachment must be disrupted and the bony
all extractions, but there are situations when radio- dental socket enlarged to allow withdrawal of the
graphic assessment is essential to demonstrate root tooth. To achieve this, various instruments have
morphology, anatomical relationships or associated been developed:
pathology (Box 6.1). Mandibular and maxillary Elevators: curved chisel-shaped instruments
third molar teeth are known to show a wide vari- that fit the curvature of tooth roots; an elevator
ability in root morphology, and so pre-extraction has a single blade.
radiographs should always be taken. It is also essen-
Luxators: similar to elevators but finer blade.
tial to know the relationship of the inferior alveo-
Forceps: have paired blades that are hinged to
lar canal in the case of the lower third molar. Cone
permit the root to be grasped.
beam computed tomography (CBCT) is indicated
when an intimate relationship of the third molar Peritome: has a finer blade with which to sever
and the inferior alveolar nerve canal is observed on the periodontal attachment and is preferred
plain film. In general, where any difficulty is antici- where it is important not to damage the bony
pated, it would be wise to take a radiograph before support of the tooth, for example, when imme-
rather than during the extraction, so that the diately replacing a tooth with a dental implant.
There are several different forceps extraction
techniques described and some basic principles
Box 6.1 and guidance are required when learning. Forceps
are used to disrupt the periodontal attachment
Checklist of situations where a pre-extraction and dilate the bony socket either directly, by forc-
radiograph is reasonable ing the blades between tooth and bone, or by mov-
Third molars. ing the tooth root within the socket, or both. Once
Isolated (lone-standing) upper molars. this has been done, the tooth may be lifted from its
Previous history of difficult extractions. socket. The movements that are required to com-
Heavily restored (e.g. crowned, root-filled) teeth. plete the extraction may be described as a prelimi-
nary movement to sever the periodontal membrane
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Removal of teeth and surgical implantology Chapter 6
and generally dilate the socket, followed by a sec- different designs of elevator (Fig. 6.1). The most
ond movement to complete the dilation and with- commonly used are:
draw the tooth. The first movement requires that Couplands elevators: a straight blade in line
force is directed along the long axis of the tooth, with the handle; available in three sizes referred
pushing the blades of the forceps towards the root to as 1, 2 and 3
apex. This force is then maintained during the sec-
Cryers elevators: a triangular blade at right
ond movement, which is dependent on the tooth
angles to the handle; available as a right and left
root and bone morphology. If a tooth has a single
pair
round root, then it may be rotated. Where the buc-
Warwick James elevators: a small blade that is
cal bone plate is relatively thin, it may be possible
rounded at its tip rather than pointed; this is set
to distort it significantly by moving the forceps
at right angles to the tip in a right and left pair,
applied to the tooth root in a buccal direction. The
but a straight Warwick James is also available.
second movement depends on the tooth and may
be described as: It is important that elevators are used appro-
priately, with their blades between root and bone
upper incisors and canines: rotational
rather than between adjacent teeth, or else both
upper premolars: limited buccal and palatal teeth will be loosened.
upper molars: buccal There are many designs of forceps. The blades
lower incisors and canines: buccal vary in size and shape according to the root mor-
lower premolars: rotational phology of the tooth/teeth for which they are
lower molars: buccal. designed. For example, lower molar forceps incor-
porate a right angle between blades and handles,
Alternative techniques for forceps movement while the blades each have a central projection to
are advocated by some, including a figure of accommodate the bifurcation. Upper root forceps
eight movement to expand the socket for molar have narrower blades than the equivalent upper
teeth. Elevators may be used to carry out the premolar forceps.
first movement prior to completion of the extrac- It may be difficult to apply forceps to teeth that
tion with forceps. Sometimes teeth and roots may are outside of a crowded dental arch and elevators
be removed with elevators alone. There are many may be more appropriate for initiating the extraction
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Removal of teeth and surgical implantology Chapter 6
to the patient although it should be mentioned in Patients should be given a written set of postop-
advance of the procedure. erative instructions (Fig. 6.2) and these should be
The three most commonly used mucoperios- also given verbally before the patient leaves.
teal flaps used in oral surgery are the envelope
(one-sided), two-sided and three-sided flaps. The
envelope flap can be used for removal of super-
Complications of dental extractions
ficial retained roots that require little or no bone
removal as the access is limited. It can also be used Postoperative pain
palatally when the access provided is good. The Discomfort after the surgical trauma of dental
incision in an edentulous patient is made along the extractions is to be expected and may be alleviated
crest of the ridge but care must be taken when with an analgesic such as paracetamol or a non-
the mandible is atrophic to avoid the mental nerve steroidal anti-inflammatory drug (NSAID) such as
which is at risk because of its relative superficial ibuprofen (Chapter 4).
position. Severe pain after a dental extraction is unusual
The two-sided flap is used when greater access is and may indicate that another complication has
required. A relieving incision is usually made from occurred.
the anterior aspect of the flap to maximise vision.
A three-sided flap has anterior and posterior reliev-
ing incisions to provide the greatest mobility of the Postoperative swelling
flap and access (see Fig. 5.9 on p. 96). Mild inflammatory swelling may follow dental
extractions but is unusual unless the procedure was
difficult and significant surgical trauma occurred.
Postoperative care More significant swelling usually indicates
Control of postoperative pain is important (Chap- postoperative infection or presence of a haema-
ter 4). Some clinicians prescribe antibiotics if toma. Management of infection may require sys-
bone removal is necessary. There is some research temic antibiotics or drainage. A large haematoma
evidence to support the use of corticosteroids to may need to be drained. Less likely is surgical
reduce postoperative oedema and trismus. emphysema.
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Removal of teeth and surgical implantology Chapter 6
gel on ribbon gauze, although this needs to be does not respond to the stimulus and, therefore,
removed and replaced over 2 or 3 weeks. inform the operator. This may happen to a lower
anaesthetised lip when extracting an upper tooth;
the lip can be crushed between forceps and teeth if
Postoperative infection it is not rotated out of the way.
In some cases, sockets may become truly infected,
with pus, local swelling and perhaps lymphade-
nopathy. This is usually localised to the socket and Damage to nerves
can be managed in the same way as a dry socket, Paraesthesia or anaesthesia can result from damage
although antibiotics may be necessary in some to the lingual nerve and inferior alveolar nerve dur-
instances. A radiograph should be taken to exclude ing extraction of lower third molars.
the presence of a retained root or sequestered
bone (Fig. 6.3). Positive evidence of such material
in the socket indicates a need for curettage of the Opening of the maxillary sinus
socket. Creation of a communication between the oral cav-
ity and maxillary sinus, an oroantral communica-
tion (OAC), may result during extraction of upper
Osteomyelitis molar teeth. This is described in Chapter 7.
Osteomyelitis (Chapter 5) is rare but may be iden-
tified by radiological evidence of loss of the socket
lamina dura and a rarefying osteitis in the surround- Loss of tooth
ing bone, often with scattered radio-opacities repre- A whole tooth may occasionally be displaced into
senting sequestra (see Figs 5.20 and 5.21 on p. 105 the maxillary sinus, when it is managed as for dis-
and 106). placement of a root fragment, as described in
Chapter 7.
A tooth may also be lost into the infratemporal
Damage to soft tissues fossa or the tissue spaces about the jaws, but this
Crush injuries can occur to soft tissues when a local usually only occurs when mucoperiosteal flaps are
or general anaesthetic has been used and the patient raised.
Fig. 6.3 Intraoral film of a patient with persistent postextraction infection. The bone of the crest of the
socket is detached, acting as a sequestrum.
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Removal of teeth and surgical implantology Chapter 6
Impacted lower second premolars. These are root number and morphology
often lingually positioned and may have an unfa- alveolar bone level, including depth and density
vourable root morphology. follicular width
periodontal status, adjacent teeth
History and clinical examination relationship or proximity of upper teeth to the
nasal cavity or maxillary antrum
The patient may have noticed that a tooth is missing relationship or proximity of lower teeth to the
or this may not be apparent until observed at a rou- interdental canal, mental foramen, lower border
tine dental examination. It is unusual for unerupted of mandible.
teeth to cause pain unless there is associated infec-
tion. The signs and symptoms of pericoronal inflam-
mation are described in Chapter 5. Pericoronitis can Diagnosis
be associated with any impacted tooth but is of par-
ticular concern when it involves the mandibular third When documenting the diagnosis, it is important
molar because of the greater potential to spread via to state impacted tooth and the problem asso-
the tissue spaces and compromise the airway. ciated with this tooth. The mere presence of an
On examination, missing teeth should be noted impacted tooth does not in itself justify the treat-
and also any caries or mobility of adjacent teeth. ment planned for the patient. It is better, therefore
Signs of infection will include swelling, discharge, to state, for example, impacted lower third molar
trismus and tender enlarged cervical lymph nodes. and recurrent pericoronitis.
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Master Dentistry
and age of the patient may all have an influence on and its potential consequences. The symptoms
the decision making. of pericoronitis are pain, bad taste, swelling of
the pericoronal tissues and face, and restricted
mouth opening (trismus). The local infection may
Indications for removal spread, resulting in a regional lymphadenopathy,
of third molars pyrexia and malaise. Rarely the swelling may
threaten the patency of the airway and breathing.
There has been disagreement about the appropriate- The potential harms are described below under
ness of removing third molars without associated complications.
pathology in order to prevent potential development
of pathology (prophylactic removal) but there is no
controversy about the value of removing teeth that
Surgical techniques
are associated with pathology. In the UK, several
bodies have published guidelines to help clinicians Lower third molar surgery
with decision making about wisdom teeth but the The operation is described in Box 6.3. The area of
research evidence on which these are founded has bone that is removed and the path of withdrawal
been of poor quality. They have generally encour- of the tooth depends upon the type of impaction
aged a more conservative approach (retention of wis- (Fig. 6.4).
dom teeth) than found in other parts of the world,
particularly the USA. The following indications have
been suggested for the removal of wisdom teeth in Box 6.3
the National Health Service of the UK:
pericoronitis
Surgical technique for removal of lower
unrestorable caries third molar
non-treatable pupal/periapical pathology 1. A buccal mucoperiosteal flap is raised to provide
adequate access.
cellulitis/abscess/osteomyelitis 2. A lingual flap is raised and the lingual nerve is
internal/external resorption of the tooth or protected with an appropriate instrument. This
adjacent teeth aspect is controversial and some would avoid
fracture of the tooth
raising a lingual flap and restrict their approach
to the buccal only. This latter approach requires
disease of the follicle, including cyst/tumour tooth division more frequently and is carried out
tooth impeding surgery or reconstructive jaw in an attempt to reduce the incidence of lingual
surgery nerve damage and resulting sensory disturbance.
tooth involved in tumour or in field of tumour The avoidance of a lingual flap has been the
popular technique in the USA, while raising a
resection.
lingual flap and protecting the nerve, with a
The decision to remove wisdom teeth or not retractor such as a Howarth, has been common
will be based on the relative benefits and harms, in the UK.
in the context of the best research evidence, clini- 3. Bone removal may be required and this may be
cal experience and the patient values, as described undertaken with an irrigated bur in a handpiece or
a chisel. The lingual split technique involves the
in Chapter 1. Impacted third molar teeth that are
removal of a segment of lingual bone plate with
not to be removed should be kept under review to a chisel after the nerve has been protected. The
ensure that no pathological process develops. Car- advocates of this technique suggest that while
ies involving the second molar adjacent to partly temporary nerve damage may occur, permanent
erupted impacted retained wisdom teeth or cystic damage is reduced when compared with the use of
pathology may develop. The decision will therefore burs for bone removal.
take many factors into account including the caries 4. The tooth may then need to be divided before
risk in addition to general health and local factors. elevation and removal. (Fig. 6.4 shows areas of
bone removal and paths of withdrawal.)
The natural history of retained third molars has yet
5. The wound is irrigated and inspected before the
to be determined.
soft tissues are closed with an appropriate suture
Most commonly the benefits include allevia- material.
tion of the symptoms and signs of pericoronitis
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Removal of teeth and surgical implantology Chapter 6
Fig. 6.4 Examples of various types of third molar impactions. (A) Vertical impaction with unfavourable root
morphology requiring bone removal and vertical sectioning. (B) Mesioangular impaction requiring bone removal and
a mesial application point to elevate and upright to remove. (C) Horizontal impaction requiring bone removal, section-
ing of the crown to permit removal of crown and then roots in stages. (D) Distoangular impaction requiring significant
bone removal to permit elevation distally for removal without reimpaction.
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Nasopalatine
foramen
Greater palatine
arteries
Flap
B
Fig. 6.6 Surgical approach for the removal of an impacted palatal canine. (A) An incision is made about
the palatal gingival margins. Greater palatine arteries and nasopalatine foramen are shown. (B) A palatal mucoperios-
teal flap is raised to provide access to the palatal canine tooth.
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Removal of teeth and surgical implantology Chapter 6
has become apparent that the long-term success is be referred to a specialist for consideration of surgi-
not good and resorption frequently occurs, albeit cal exploration or repair of the nerve.
after some years. Coronectomy should be considered when the
radiograph or CBCT indicate that the patient is
at very high risk of inferior alveolar nerve injury
Mandibular second premolars on removal of the mandibular third molar. Coro-
It is important that the mental nerve is identified nectomy involves transection of the tooth 34mm
and protected while raising a buccal mucoperiosteal below the enamel of the crown and root retention.
flap. It is frequently necessary to divide the tooth The long-term consequences of root retention are
and remove the crown before the root can be deliv- not clear so the patient should be warned but usu-
ered by elevation. ally preferable to risk of nerve injury.
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A B C
Fig. 6.7 Fraenoplasty technique for prominent labial fraenum of the edentulous maxilla.
tissue. Small amounts of hyperplastic tissue may of a straight surgical bur into the crestal bone
be excised under local anaesthesia. Larger amounts between the central incisor teeth.
should be excised with a laser or cutting diathermy
or the defect grafted with palatal mucosa to facili-
tate haemostasis and reduce scar contracture. Alveolar ridge augmentation
Resorbed and defective alveolar ridges may be
Tori built up with bone grafts and bone substitutes
to facilitate the construction of dentures. How-
Bony prominences can be surgically reduced using a ever, these procedures are rarely performed now
bur or chisel if it is not possible to adjust the den- because they do not provide good results in the
ture to accommodate them. long term. Bone grafts resorb and bone substi-
tutes such as hydroxyapatite granules become dis-
placed. The advent of osseointegrated implants
Muscle attachments has superseded the need for much of this surgery,
although alternative techniques of bone augmenta-
Prominent muscle attachments from the facial tion prior to implant placement have developed,
muscles or tongue can displace a denture when as described below.
they contract. Surgical procedures allow these
muscles to be stripped from their bony insertions.
In some cases, it may be important to reattach a Sulcus deepening
muscle in a more favourable position. The word
fraenoplasty is used for the removal of muscle Inadequate alveolar ridge height can be treated
attachments for preprosthetic purposes (Figs 6.7 by deepening the sulcus by a vestibuloplasty pro-
and 6.8) and fraenectomy when removal is carried cedure rather than augmenting the ridge. Such
out for orthodontic purposes, as the techniques procedures may leave a raw area of soft tissue,
differ in these different situations. When carry- which can be covered by a skin or mucosal graft.
ing out a fraenectomy for orthodontic reasons The major problem with these techniques is the
such as to permit closure of a median diastema, it significant wound contracture, which reduces the
is important to excise the frenum thoroughly and sulcus height again. Many variants of the surgi-
to ensure that no muscle remnants remain in the cal procedure have been developed in an attempt
alveolar bone between the central incisor teeth to improve the long-term outcome from these
(Fig. 6.9). This usually requires the careful passing operations.
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Removal of teeth and surgical implantology Chapter 6
A B C
Fig. 6.8 Fraenoplasty for prominent lingual fraenum using a Z-plasty technique.
A B C
Fig. 6.9 Fraenectomy technique for orthodontic purposes where there is a prominent maxillary fraenum
and midline diastoma.
Nerve repositioning developed in the 1960s are now little used. Ref-
erence to implants today generally means osseo-
With atrophy of the mandible, the mental nerve integrated implants, which have superseded other
can come to lie on the ridge and denture trauma types because of their high success rate. Osseoin-
can cause significant pain. The mental foramen can tegration is the word used to describe the heal-
be surgically moved into an inferior position to alle- ing of bone around implants so there is direct
viate this problem. anchorage of the implant that is then maintained
during functional loading without the growth of
fibrous tissue at the boneimplant interface. PI
6.4 Dental implant surgery Branemark discovered osseointegration, devel-
oped its application over a number of years and
first presented his work and results in 1977.
Learning objectives Development of many dental implant designs
You should: based on the root-form model has followed, as
know the indications for dental implants has development of implants for maxillofacial
be able to assess the suitability of a patient for reconstruction and for use in orthopaedic sur-
implants gery. The aims of placing osseointegrated dental
understand the principles of implant placement and implants are:
bone augmentation techniques.
1. Replacement of dentition and supporting tis-
Cobalt chrome subperiosteal implants devel- sues to restore function and appearance.
oped in the 1940s and titanium blade implants 2 . A lveolar bone preservation.
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Fig. 6.10 Four anterior mandible implants with gingival formers after surgical exposure and prior to
restoration.
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Fig. 6.11 Cross-sectional reconstructed images of the jaws, produced from a computed tomographic
scan using dental software.
life-size cross-sectional reconstructed images of volume to place an implant. Various materials may
the jaws to be produced (Fig. 6.11). As all of a jaw be used for this augmentation.
must be scanned, even to produce just one or two Autogenous bone. Bone grafts harvested from
cross-sections, this technique is best reserved for intra- or extraoral sites of the same patient are
multiple implant placements. Radiation doses are considered to provide the material of choice but
much higher than with radiography. Artefacts may they require a donor site operation with associ-
be produced by dental restorations and errors intro- ated morbidity. Each donor site has its own advan-
duced by movement. CBCT produces high-defini- tages and disadvantages. The anterior iliac crest
tion digital images with reduced patient radiation of the hip is a popular site as it affords large bone
exposure and much reduced imaging time. This 3D volumes, whereas the calvarium is used less com-
imaging equipment has less space requirement than monly because of the clinical significance of pos-
for a conventional scanner and is available for use in sible complications, such as dural tear and epidural
primary care. Image analysis software may be used haematoma. The posterior iliac crest offers greater
for planning to allow the surgeon to virtually place volume than the anterior but the patient must be
implants with due regard for avoidance of vital struc- positioned prone during surgery so is less com-
tures and then surgical guides can be constructed to monly used. Patients should be warned of postop-
accurately transfer the plan to the patient. erative pain and reduced mobility, scar and possible
altered sensation of the lateral thigh skin when
undergoing anterior iliac crest surgery. Split rib has
Surgical techniques also been used but the bone resorbs quickly. Other
sites include scapula, radius, tibia and fibula.
Bone augmentation Intraoral sites avoid extraoral scars but offer
It may be necessary to augment the alveolus of the more limited availability of volume. The man-
maxilla or mandible if there is inadequate bone dibular symphisis (chin) (Fig. 6.12), retromolar
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Removal of teeth and surgical implantology Chapter 6
Calvarium
Maxilla
Mandible
Clavicle
Scapula
Rib
Radius
Tibia
Fibula
Fig. 6.12 Bone harvesting from the anterior mandible to augment the anterior maxillary alveolus.
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or ramus and maxillary tuberosity sites are all used. of the alveolar ridge (Fig. 6.13). Bone removal
Autogenous grafts have the advantage of being both for this sinus lift grafting technique may be
osteoconductive and osteoinductive, that is they undertaken with surgical burs or ultrasonic bone
act as a scaffold into which bone can grow from cutters.
the adjacent recipient bed and also contain undif- All bone screws and plates are removed at
ferentiated cells that convert into osteoblasts and implant placement if not before. The graft
allow osteogenesis at sites away from the recipient requires sufficient time to revascularise before
bed. When large defects require reconstruction, a implants are placed so that osseointegration can
vascularised graft such as that harvested pedicled occur but not such a prolonged time that resorp-
on the deep circumflex iliac arterial system may be tion occurs because is has no physiological stress.
required (DCIA flap). Opinions vary with surgeons placing implants
Alloplastic materials. Synthetic materials between 3 and 9 months and according to the
include hydroxyapatite, tricalcium phosphate and graft material used. Sometimes implants are
bioactive glasses. These are osteoconductive. placed at the bone grafting surgery. In this case,
Ceramics. Calcium phosphate ceramics and glass implants are retained by friction of fit with osseo-
ceramics are used, of which tricalcium phosphate integration occurring later as the bone becomes
and hydroxyapatite are the most useful clinically. revascularised.
These are biologically active, that is, they release
calcium and phosphate ions into tissue and encour- Stimulation of bone regeneration
age bone formation. However, they are mechani- Bone morphogenic proteins have been identified
cally weak. and are now produced commercially in an attempt
Allografts. Human bone grafts can be harvested to accelerate bone regeneration.
from cadavers and are available in forms such as
demineralised freeze-dried bone. The processing
activates bone morphogenic proteins, which means Guided bone regeneration (GBR)
that they are osteoinductive but may not be free GBR is the term used for directing the growth of
from the risk of infectivity. new bone using barrier membranes that exclude
Xenografts. Bone grafts harvested from another the ingrowth of fibroblasts and epithelial cells and
species such as cow (e.g. Bio-Oss). The organic permit the more slowly growing bone to do so in a
component is removed as thoroughly as possible protected space. Both resorbable and non-resorbable
during processing to remove the risk of immune membranes are available. Membranes must be bio-
response and disease transmission but may not be compatible, able to maintain space and not collapse
completely free from the risk of infectivity and so down, and fulfill their primary purpose of cell occlu-
patients should be informed appropriately. Coral sion to prevent ingrowth of connective tissue cells.
is an alternative source (e.g. Algipore). They are Guided tissue regeneration is the term used
osteoconductive. to describe growing gingival tissue using barrier
membranes.
Bone grafting techniques
Onlay grafting. Donor bone blocks may be Implant placement
attached on to the recipient site as an onlay and The technique for implant placement is outlined in
fixed in place with screws or plates. Box 6.4.
Interpositional grafting. The alveolus may be
sectioned from the basal bone and donor bone
blocks inserted between the two. Implant exposure
Sinus elevation or lift. An area of the ante- The submerged implants are usually uncovered or
rior maxillary wall is infractured into the sinus exposed at about 46 months following placement,
or removed via an intraoral approach without although it is also possible to carry out a one-stage
perforating the membrane to create a new floor implant procedure when implants are exposed at
of the sinus. The space between the alveolus and the placement surgery. The overlying soft tissue is
this new floor is then packed with graft mate- punched out or a crestal flap is raised and reposi-
rial, which indirectly increases the vertical height tioned. The implant cover screw is removed and
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Removal of teeth and surgical implantology Chapter 6
Orbit
Ethmoidal
air cells
Maxillary
sinus
Inferior
turbinate
Antral wall
infractured
Bone grafting
material
Box 6.4
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A B D
Fig. 6.15 Implant placement technique.
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Removal of teeth and surgical implantology Chapter 6
Q Self-assessment: questions
Multiple choice questions ( True/False) b. Interruption of the lamina dura (white lines) of
1. When extracting primary teeth: the interdental canal overlying the tooth
a. The same principles are applied as for c. Darkening of the root where it is crossed by the
permanent teeth interdental canal
b. General anaesthesia may be required d. Periradicular bone sclerosis
c. It is essential to protect the airway during the e. Diversion of the interdental canal.
removal of teeth under general anaesthesia 4. The surgical removal of a tooth:
to prevent blood, tooth fragments or teeth a. Rather than forceps removal is likely to make
entering the airway subsequent replacement with a dental implant
d. It is essential not to retain any roots as these less feasible
may impede the eruption of the permanent b. Will cause pain, the intensity of which will be
successor determined by the amount of bone removal
e. A surgical procedure may be required if the and overall surgical difficulty
tooth has become submerged. c. Requires that the patient be prescribed
2. When removing a lower third molar tooth: antibiotics to reduce the likelihood of
a. The patient need not be warned about possible postoperative infection
lingual nerve damage if the removal is to be by d. Always requires a radiograph as part of the
extraction with forceps surgical planning
b. Any bone removal should be undertaken with e. Should always proceed immediately in the
an irrigated bur rather than a chisel and mallet event of a failed forceps extraction.
when using local anaesthesia alone 5. Preprosthetic surgery:
c. Horizontally impacted teeth present the a. Is less frequently required now that dental
greatest surgical challenge implants can provide effective tooth
d. The relationship to the inferior alveolar canal replacement rather than dentures
can be determined by radiographic assessment b. To ensure an adequate margin of keratinised
e. General anaesthesia is usually indicated. mucosa is present about dental implants is
3. The following radiological signs are associated important for success of the implant
with an increased risk of nerve injury during third c. Can be carried out to increase the space
molar surgery: between the maxillary tuberosity and
a. Presence of an enlarged pericoronal space mandibular retromolar pad
(follicle)
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Removal of teeth and surgical implantology Chapter 6
3. The root of which tooth is most often displaced 6. Why is it contraindicated to curette a local osteitis
into the maxillary antrum during forceps (dry socket) to stimulate haemorrhage?
extraction? 7. What are dental implants?
4. When removing a lower molar tooth surgically, 8. Which oral site has the highest implant failure rate?
should you section the roots completely with a 9. Do implants require regular maintenance after
bur? placement?
5. In which anatomical areas are vertical releasing 10. What are the two most common features of a
incisions contraindicated in flap design? failed implant?
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Master Dentistry
A Self-assessment: answers
Multiple choice answers useful for the removal of distolingual bone from
1. a. True. Primary teeth are extracted following about distoangularly impacted third molars.
the same principles as for permanent teeth; c. False. Distoangular teeth are usually more
however, it is important to recognise that difficult to remove because on elevation they
the molar roots are closely associated with move distally and a significant amount of bone
the developing tooth germs, which must be removal must be anticipated.
carefully avoided. Smaller forceps help to d. True. The inferior alveolar canal may lie
facilitate this. below the roots of the third molar or may be
b. True. The use of general anaesthesia in intimately related to it. If the canal is seen
dentistry is reducing in the UK but may to converge as it crosses the root then this
be indicated for the removal of primary suggests that the root is notched by the nerve
teeth, especially when multiple teeth need or, if almost interrupted, then the nerve may
to be removed or the child is young or perforate the root.
uncooperative. e. False. The choice of anaesthesia is
c. True. Airway protection during dental determined by the anticipated difficulty of
extraction under general anaesthesia is the surgery, the patient, previous experience
afforded by placing a gauze throat pack. This is of dentistry, their level of anxiety and degree
necessary because the usual airway protective of cooperation, the medical history and the
reflexes, principally the vocal folds, do not social history. Taking all these factors into
function in unconsciousness. Even when account, the removal of a single third molar
the endotracheal intubation is used during may require general anaesthesia but does not
anaesthesia, it is still good practice to place a usually do so. Conscious sedation is a more
throat pack. likely option.
d. False. In some cases it is better to leave small 3. a. False. It is irrelevant.
fragments of root in situ rather than damage b. True. Suggests that the bony wall of the canal
the permanent successor by excessive use is disrupted in some way by the roots.
of elevators. The retention of a root fragment c. True. May indicate a groove in the root.
will not impede the eruption of the permanent d. False. Is irrelevant, although it is possible that
successor. However, thought will have to sclerotic bone might lead to a more difficult
be given to its removal at a later stage as removal of the tooth.
frequently it will come to lie in a partly erupted e. True. Particularly where there is a marked dog
position adjacent to the crown of the tooth, leg course to the canal over the root; suggests
and this may lead to caries. a close relationship.
e. True. A tooth is described as submerged 4. a. True. Generally this is true if bone removal
if the occlusal surface is at a lower level is required as part of the surgical removal
than the neighbouring teeth. The second procedure. It is important that teeth are
primary molar is the most common tooth removed as untraumatically as possible and
to become submerged and the condition is with as little bone removal as possible as this
more likely in the mandible than maxilla and may compromise implant placement, which
is often associated with a missing permanent requires sufficient bone to support the implant
successor. These submerged primary teeth adequately.
may become ankylosed and are very difficult
b. False. Bone removal will usually cause more
to remove.
pain than no bone removal, but the amount of
2. a. False. The planned extraction with forceps bone removal and the overall surgical difficulty
may become a surgical procedure involving are not good predictors of postoperative
the raising of soft tissue flaps and bone pain. More important factors are the cultural
removal. Also, it is possible to cause lingual experiences, personality and anxiety of the
nerve damage with forceps alone in the patient.
region of the lower third molar, although this
c. False. If bone is not removed then antibiotics
is rare.
are unnecessary. If bone removal is
b. True. Most patients would find it unacceptable undertaken, then many clinicians do prescribe
to have a chisel and mallet used on them when antibiotics. However, the use of a chlorhexidine
conscious. This is an effective technique when gluconate mouthrinse just before the surgery
general anaesthesia is used and particularly
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Removal of teeth and surgical implantology Chapter 6
is likely to be of more use in the prevention of use of appropriate analgesia should be adequate.
postoperative infections. Clinical examination should of course be
d. True. A radiograph is not always necessary carried out and further investigation by way of
for extractions to be undertaken with forceps. radiographic examination may be appropriate
However, if it is anticipated that a surgical should there be any reason to suspect root
approach will be necessary or a forceps retention or fracture.
extraction fails and a surgical approach must 2. I. Pain at 1 week after surgery is unlikely to be
be adopted, then a radiograph is essential. related to surgical trauma, especially if the surgery
e. False. While it is usually preferable to limit the was very simple. It is more likely that the patient is
number of surgical episodes for the patient, it experiencing pain because of dry socket (alveolar
may be necessary to investigate the cause of osteitis) or infection. As there is exposed bone
the failed extraction with forceps further before then alveolar osteitis is more likely and a dressing
proceeding. A radiograph will be required if with lidocaine would be helpful.
one is not already available. The dentist may 3. F. A patient who looks unwell as described may be
need to refer the patient to a specialist if surgically shocked and this should be investigated
further surgery beyond the skill of the dentist by checking the blood pressure and heart rate.
is required or adequate facilities are not 4. J. A radiograph should be taken to investigate the
available. possibility of a retained root or sequestered bone
5. a. True. While preprosthetic surgery referred in as these are the most common cause of such
the past to a means of improving the retention infection.
of conventional dentures, it now also refers 5. G. Suturing the dental socket will put the
to that required to facilitate soft tissue health surrounding tissues under tension and stop
about osseointegrated implants. However, the bleeding. During the extraction, the local
since the introduction of implants, significantly anaesthetic may have contained adrenaline
less preprosthetic surgery is required because (epinephrine) which reduced local bleeding.
implants have overcome many of the problems
that surgery and dentures were trying to EMI 2
address. 1. E. If there is a significant three-dimensional defect
b. True. Sufficient keratinised mucosa about to the alveolus then bone augmentation will be
implants is essential to maintain health of required to facilitate later placement of dental
the surrounding soft tissues. Non-keratinised implants. Harvesting bone from the iliac crest
mucosa about implants usually leads to of the hip provides large quantities of bone very
pocketing and peri-implantitis, which ultimately suitable for this augmentation. Some surgeons may
leads to failure of the implant. prefer to use intraoral harvesting only and there are
c. True. A hyperplastic maxillary tuberosity can regional variations around the world sometimes
be reduced in size by excising a wedge of soft dependent on training and access to facilities.
tissue. 2. D. There will be significant buccal bone loss
d. False. Mandibular tori are found as painless because of the previous endodontic surgery and
bony enlargements of the lingual plate in the the horizontal bone loss associated with this
premolar region. They are bilateral in 80% of tooth. Any implant placement is likely to require
cases. They only need surgical reduction if prior bone augmentation surgery. Bone harvested
they are interfering with the lingual flange of a from an intraoral site will usually provide the
denture and preventing adequate retention. appropriate bone volume.
e. True. An acrylic stent lined with adapted gutta- 3. G. If the patient has a gag reflex that cannot
percha may be useful especially to stabilise be reduced by restorative or behavioural
and protect a soft tissue graft; however, their means then it may be appropriate to consider
efficacy is now doubted and patients usually implant treatment to retain fixed bridgework. An
find them uncomfortable. overdenture retained by implants will be much
less bulky than a conventional denture and may
Extended matching items answers prove adequate.
EMI 1 4. F. An overdenture retained by implants will
serve the purpose of tooth replacement and
1. A. The surgical removal of third molar teeth
bone preservation but also permit closure of the
may cause postoperative pain that is severe in
oronasal fistula.
intensity. It is not unusual for some patients to
remain in pain for several days after surgery. 5. A. The fractured tooth root may be removed and
Reassuring the patient and encouraging regular a dental implant placed at the same time. This will
reduce the number of surgical episodes.
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Master Dentistry
Case history answers oligodontia may or may not be associated with other
features comprising a syndrome. The medical and
Case history 1
social history may be important in determining the
A thorough history should be taken to establish the choice of anaesthesia and extent of any treatment that
nature of the pain experienced by the patient. Is this may be required. Smoking will reduce the success
mild discomfort as a result of denture-induced trauma rate of implant treatment. A clinical examination
to the soft tissues about the partly erupted tooth would note the teeth present and their health and
or is this severe pain as a result of pericoronitis or also the dimension of the edentulous alveolar ridges.
pulpitis or even an acute abscess? A medical history A DPT radiograph would confirm that there are no
is more likely to yield positive findings in this age unerupted teeth. There are too few teeth to support
group that may be relevant to her dental management. fixed bridges. Implants would be preferable to partial
For example, non-steroidal anti-inflammatory dentures, especially in a young person. However, it
analgesics are contraindicated for her pain control and appears that the edentulous alveolar ridges are very
paracetamol or codeine would be more appropriate. narrow and undercut and it would not be feasible to
The medical history may contraindicate general place implants without significant bone grafting. Fig.
anaesthesia and the age is a relevant risk factor in 6.19 shows a corticocancellous block of iliac crest
any such decision. Does Mrs Jones live alone, is graft bone fixed in place as a buccal onlay in one of
she far from the practice and how does she travel? the edentulous spaces to widen the ridge for later
These may be relevant to the extent of treatment implant placements. The patient will obviously require
that you may wish to undertake in your practice. The referral to an implant team that is familiar with the
radiograph shows a deeply impacted lower third molar management of such problems.
tooth in an otherwise edentulous mandible. The bone
will be less flexible and more brittle than in a young Oral examination answers
person and this is going to be a difficult surgical 1. Combination syndrome is when there is excessive
procedure. The patient needs to be referred to an oral resorption of the edentulous maxilla in the anterior
surgeon. Tooth removal would involve significant bone region as a consequence of the forces generated
removal to facilitate elevation with as little effort as by the opposition of natural mandibular teeth.
possible. 2. The base of the flap should be broader than the
Case history 2 apex to ensure an adequate blood supply. The
flap should be wide enough to provide good
A history would confirm that several permanent
access to the underlying operative field. The
teeth never erupted rather than these teeth required
design should permit tension-free closure with
extraction because of caries or trauma. A family
margins over sound bone.
history of this problem may be present. Such
Fig. 6.19 Photograph showing a corticocancellous block of iliac crest graft bone fixed in place as a
buccal onlay at surgery for the patient in Case history 2.
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Removal of teeth and surgical implantology Chapter 6
3. The palatal root of the maxillary first molar tooth bone to act as abutments for prostheses. The
is most frequently dislodged into the maxillary healing process of implants is described as
antrum during forceps extraction. osseointegration and results in a relationship
4. The lingual plate is thin and undercut and so it is between implant and bone that mimics ankylosis
important not to section mandibular molar roots of a tooth to bone.
completely through to the lingual side because 8. Implants placed in the anterior maxilla are the
of the risk of sectioning the lingual nerve with the most likely to fail because only relatively short
bur. implants can be placed at this anatomical site.
5. Vertical relieving incisions are contraindicated in 9. Implants like natural teeth require regular
the palate, lingual aspect of the mandible, buccal maintenance. Plastic-tipped instruments are
aspect of mandible in the area of mental nerve available for professional cleaning as metal
and over the maxillary canine eminence. instruments would scratch the titanium surface.
6. Curetting a dry socket delays healing rather than Meticulous home care is required to be
accelerating it. Any early attempts at healing will undertaken by the patient.
be destroyed. 10. Bone loss, as demonstrated by a standardised
7. Dental implants are tooth root analogues, usually radiograph, and mobility of the implant are the
made of titanium, that are placed into alveolar most consistent features of a failed implant.
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Diseases of bone
and the maxillary sinus 7
Fig. 7.1 Stafne bone cavity. This radiograph shows the typical appearance of a rounded well-defined radiolu-
cency with corticated margins, below the inferior dental canal.
Fig. 7.2 Torus mandibularis. (A) Clinical appearance. (B) True occlusal radiograph of the mandible showing
bilateral protruberances of the lingual cortical bone.
Radiology
develop. As the lesion matures, so too does the
Radiology shows:
connective tissue, becoming more collagenous,
while the bone is remodelled to a lamellar pattern. enlargement of a bone
The lesional tissue merges with the adjacent normal altered trabecular pattern
tissue. generally poorly defined margins.
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Diseases of bone and the maxillary sinus Chapter 7
Fig. 7.5 Periapical radiograph of a patient with fibrous dysplasia of the right maxilla. The premolar
has lost its lamina dura and the bone has a striking appearance, with a homogeneous finely stippled trabecular
pattern.
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Master Dentistry
number and size until the lesion becomes predomi- invariably some bones in the skeleton will remain
nantly radio-opaque. A thin radiolucent line often normal while others will be at different stages of
remains around the radio-opaque centre. Teeth in the disease. Its aetiology may be viral.
the path of the lesion may be displaced or resorbed
(as is the case with any benign lesion).
Clinical features
Pagets disease affects individuals in middle and
Management old age. Males are more commonly afflicted than
Surgical enucleation of the lesion is usually adequate. females. The clinical symptoms reflect the enlarge-
ment and weakening of bone that results from
Pagets disease. Slowly growing swelling of bones
Pagets disease of bone may lead to shape changes and enlargement of the
skull and jaws (Fig. 7.6). Deformity of bones, typi-
In Pagets disease, there is abnormal formation and cally of those bearing weight, may lead to bowing
resorption of bone. It is usually polyostotic, but of legs and spinal curvature. Bone pain may occur
Fig. 7.6 Clinical picture showing lengthened maxilla due to bone expansion in a patient with Pagets disease.
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Diseases of bone and the maxillary sinus Chapter 7
and, if the skull base is affected, various neurologi- and the trabeculae of bone fuse together to give rise
cal effects may develop. to masses of dense, sclerotic bone that is relatively
In the jaws, the maxilla is affected more com- avascular. Cementum is affected by Pagets disease
monly than the mandible. In contrast to fibrous in a similar manner to bone, resulting in hyperce-
dysplasia, the disease is bilateral in the jaws. mentosis and, when bone and cementum fuse,
Spacing of teeth may develop and dentures may ankylosis.
cease to fit. Extraction of teeth may be difficult,
as a result of hypercementosis and ankylosis, and
can be complicated by excessive bleeding, infec- Radiology
tion and slow healing. Other complications of There are three stages:
Pagets disease include high-output cardiac fail- 1. Radiolucent (osteolytic): bone resorption results
ure and an increased risk of sarcoma, in particular in radiolucency and cortical thinning; the lam-
osteosarcoma. ina dura of teeth may disappear.
2 . Mixed: the bony trabecular pattern is altered
Pathology and often appears like ground glass or may
show a striking appearance of lines with few
Pagets disease can be roughly divided into three
connections (Fig. 7.8); a few radio-opaque
overlapping phases. During the first of these,
patches may appear in the bone.
osteoclastic activity predominates, normal bone
3. Radio-opaque (osteoblastic): with time, the
is resorbed and is replaced by well-vascularised
radio-opaque patches increase in number,
cellular fibrous tissue. The surface of the bone is
grow and coalesce; tooth roots often have
rimmed by giant osteoclasts resting in Howships
hypercementosis.
lacunae. As the disease progresses, this osteolysis
is accompanied by osteogenesis as new bone forms The affected bone will always enlarge. In max-
within the cellular fibrous tissue in the second illary lesions, the enlargement encroaches on the
phase of the disease. This combination of bone maxillary sinuses, often obliterating them entirely
resorption and deposition gives rise to the classic (Fig. 7.9).
mosaic appearance of bone in Pagets disease (Fig.
7.7). The basophilic reversal lines that outline the
pieces of the mosaic mark switches in activity from Management
bone resorption to bone deposition. Ultimately, in If Pagets disease is suspected, the serum alka-
the third phase, osteoblastic activity predominates line phosphatase level should be measured. This is
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Fig. 7.8 Intraoral radiograph of the mandible of an edentulous patient with Pagets disease of bone.
There are two main features to note. There is an altered trabecular pattern with an impression of linearity/parallel
lines. Mesially and distally there are densely radio-opaque areas (cotton wool radio-opacities).
Fig. 7.9 Panoramic radiograph of a patient with Pagets disease of bone. There are several dense radio-
opacities within the mandible. The largest, in the lower left third molar region, subsequently underwent infection and
sequestration.
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Diseases of bone and the maxillary sinus Chapter 7
Fig. 7.10 Granuloma. (A) A panoramic radiograph of a 20-year-old female who presented with a painless swell-
ing of the anterior mandible with displacement of teeth. (B) True occlusal radiograph of the same patient, showing
the marked buccal and lingual expansion. The expanded cortices are very thin, suggesting rapid growth.
are characterised by the presence of multinucleate common feature, with cortical thinning and some-
osteoclast-like giant cells lying in an extremely vascu- times perforation, producing a soft tissue mass.
lar stroma. The giant cells vary in size, shape, intensity Occasionally there is wispy internal calcification.
of staining and the number of nuclei that they con- Displacement of teeth often occurs but resorption
tain. The fibroblastic stroma is densely cellular and is less common (Fig. 7.10).
rich in capillaries, with which the giant cells are often
intimately related. Extravasated red blood cells and
deposits of haemosiderin may be present. Evidence of Management
dystrophic calcification and metaplastic bone forma- It is important to distinguish the GCG from hyper-
tion may also be seen. In some lesions, fibrous septa parathyroidism. This is normally done by estimating
delineate foci of giant cells. serum calcium, which is raised in hyperparathyroid-
ism. Patients with hyperparathyroidism are referred
to a physician for further investigations and treat-
Radiology ment. Surgical curettage of a GCG is usually ade-
A round or ovoid radiolucency can be seen with a quate. This treatment may need to be repeated if
well-defined, non-corticated margin. Expansion is a there is recurrence; sometimes a wider resection
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may be indicated. Radiotherapy is contraindicated, hormone replacement therapy (in women), bisphos-
as with any benign bone lesion. phonate drugs, vitamin D, fluoride and other drugs.
Osteoporosis Hyperparathyroidism
Osteoporosis is a disease characterised by a micro- Hyperparathyroidism is an endocrine abnormality in
architectural deterioration of bone structure and which there is an excessive amount of parathyroid
a low bone mineral content, leading to increased hormone (PTH). This causes bone resorption and
bone fragility and an increase in fracture risk. It is hypercalcaemia. The disease may be primary, caused
a generalised disease, the effects of which are of by excessive PTH formation by a parathyroid
greatest clinical importance in the hip, spine and tumour (usually a functioning adenoma), or second-
forearm, but which will also occur in the jaws. ary to hypocalcaemia resulting from poor diet, vita-
min D malabsorption, liver or kidney disease.
Clinical features
Osteoporosis may be primary, or may occur second- Clinical features
arily in association with other diseases or with drug This disease usually affects the middle aged and is
therapy (e.g. corticosteroid use). There is a normal more often seen in women. Hypercalcaemia leads
distribution of bone mineral density (BMD) in the to clinical symptoms through renal calculi, pep-
population and osteoporosis in a particular bone is tic ulceration, bone pain and psychiatric problems.
defined as a BMD lower than 2.5 standard devia- In the jaws, teeth may become loose or even be
tions below the mean value for a young adult of the exfoliated.
same sex. Women are more likely to suffer from
the disease. Bone mineral loss is accelerated at the
menopause or following hysterectomy. Patients may Pathology
suffer from loss of height, a developing kyphosis and Cortical bone is more severely affected than can-
greater susceptibility to fractures. In the dental con- cellous bone. The increase in osteoclastic activ-
text, there is evidence that patients with osteoporosis ity results in thinning of the cortices with loss of
may lose teeth earlier in periodontal disease and that lamina dura. Marrow is replaced by fibrovascular
modifications to implant treatment may be needed. tissue; brown tumours of hyperparathyroidism may
develop (Fig. 7.12).
Pathology
The trabeculae of cancellous bone are affected by a Radiology
combination of thinning, reduction in number and There is increased radiolucency of bone, either
discontinuities. Cortical bone undergoes endosteal generalised or localised. The earliest sign is sub-
and subperiosteal resorption and may ultimately periosteal resorption of the terminal phalanges. In
resemble cancellous bone histologically. the jaws, lamina dura of teeth is classically lost,
along with the cortex of the inferior dental canal.
There may be demineralisation of the cortex of
Radiology the lower border of the mandible. Localised fairly
There is greater radiolucency of bone and cortical well-defined radiolucencies (brown tumours) may
thinning. The vertebrae undergo compression frac- be seen throughout the skeleton but are more com-
tures. In the jaws, the cortex at the lower border of mon in facial bones than elsewhere (Fig. 7.13).
mandible becomes thinner (Fig. 7.11) and the tra-
becular pattern becomes sparse.
Management
If hyperparathyroidism is suspected, assays of
Management serum calcium, phosphate and alkaline phospha-
Management comprises medical treatment, exer- tase should be carried out by a physician. Both
cise and lifestyle advice. Medical therapies include serum and urinary calcium levels and serum PTH
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Diseases of bone and the maxillary sinus Chapter 7
Fig. 7.11 Parts of two edentulous mandibles as seen on panoramic radiographs. (A) A thick cortex
can be seen at the lower border of the jaw. (B) The thinned cortex here is typical of a patient with osteopenia or
osteoporosis.
levels are usually raised and serum phosphate levels cases is the Online Mendelian Disorders in Man
decreased. Alkaline phosphatase levels are raised in (OMIM) database (http://www.ncbi.nlm.nih.gov/
severe disease. The most frequent cause of primary sites/entrez?db=omim). A number of disorders
disease is an underlying parathyroid adenoma. have effects in the jaw bones:
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Fig. 7.12 Histopathology of the brown tumour of hyperparathyroidism, showing numerous multinucleate
giant cells.
Fig. 7.13 Brown tumours of hyperparathyroidism. There are two fairly well-defined radiolucencies in the sym-
physis and parasymphysial region of the mandible; these were brown tumours. Lamina dura is also difficult to identify
on the teeth. The radiolucency in 12 region may be inflammatory rather than related to the systemic disease.
high risk of malignant change (adenocarcinoma look blue and some patients develop dentinogen-
of the bowel). esis imperfecta; short stature is typical.
Osteogenesis imperfecta: multiple bone fractures Osteopetrosis: also known as marble bone disease,
occur after minor trauma and soft tissues are typ- the medullary cavity infills with dense bone; the
ically lax, with hernia formation; the sclera may maxillary sinus may fail to pneumatise and bone
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Diseases of bone and the maxillary sinus Chapter 7
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Fig. 7.14 Normal maxillary sinus on CBCT (clockwise, from top left: coronal, sagittal, volume-rendered
and axial). The maxillary sinus is uniformly radiolucent, representing air.
Fig. 7.15 Periapical radiograph of the left upper molar region. The normal sinus floor is seen overlying
the roots of the molars, with a vertical septum directly above the first standing molar. A curving radiolucent band
runs across the sinus: this represents the groove in the bony wall containing the posterosuperior alveolar nerve and
vessels.
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Diseases of bone and the maxillary sinus Chapter 7
propria composed of loose connective tissue, lie The main radiological finding is thickening of
mucous, seromucous and serous glands. the mucosa lining the antrum. This reduces the
size of the air space on sinus images (best seen on
CBCT images; Fig. 7.16). While the thickening is
Anomalies often even in width, lumpy (polypoid) mucosal
thickening is also seen. Occasionally the mucosal
Hypoplasia and hyperplasia of the maxillary sinuses thickening may be severe enough to exclude virtu-
are frequently seen. These anomalies may be uni- ally all air from the sinus, producing a radiologically
lateral or bilateral and are identified by chance on opaque antrum. Longstanding chronic sinusitis may
radiography. Hypoplasia can be misinterpreted on stimulate sclerosis of the bony wall of the antrum.
radiography as sinus opacity due to disease, while Destruction of bone in the walls of the sinus is very
hyperplasia that extends the anterior alveolus may unusual and should be interpreted as a sinister sign
be interpreted as a cystic lesion. (see malignancy, p. 163).
In chronic sinusitis, the antral mucosa is oede-
matous and contains a dense infiltrate of lympho-
Inflammation (sinusitis) cytes, plasma cells and macrophages. Eosinophils
are often present, especially in allergic disorders.
Chronic maxillary sinusitis Mild chronic sinusitis may be associated with
Chronic inflammation of the mucosa lining the sinus few symptoms and is very common. No treatment
is common, particularly among those living in pol- may be necessary in such cases. Where treatment
luted environments and in smokers. It is also associ- is appropriate, promoting drainage is the usual goal
ated with allergies. Symptoms and signs may be few of treatment because obstruction of the ostium is
or none, only occurring during acute exacerbations often a feature. Endoscopic surgery is the usual
of inflammation. There may be nasal stuffiness and mode of treatment. Polyps may need to be surgi-
discomfort on pressure to the infraorbital area. cally excised.
Fig. 7.16 Chronic maxillary sinusitis affecting the maxillary sinuses on CBCT. The peripheral radio-opaque
bands in both sinuses are mucosal thickening; this contrasts well with the central air space.
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Fig. 7.17 Acute maxillary sinusitis affecting the left maxillary antrum. There is an obvious fluid level in the
left sinus, along with mucosal thickening on the lateral and medial walls. The right sinus is hypoplastic, but normal.
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The tumour is usually asymptomatic and, there- imaging, a dome-shaped radio-opacity may be evi-
fore, may be discovered by chance on dental radi- dent arising from the antral floor. (It is an impor-
ography. Symptoms of sinusitis may occur if the tant principle to understand that a lesion which
osteoma obstructs normal flow of secretions into is radiolucent in bone, such as a cyst, will appear
the nose. Very large lesions may cause expansion of radio-opaque in the antrum when surrounded by
the palate or a swelling of the face. relatively less dense air.)
Osteomas may be of cancellous or compact
types. In the former, the tumour is composed of
slender trabeculae of cancellous bone with fibro- Malignancy
fatty marrow. The latter consists of dense lamellar
bone with inconspicuous marrow spaces. Symptoms of sinusitis may be early features of the
A well-defined, usually round/ovoid radio-opac- disease. Paraesthesia or anaesthesia of the infraor-
ity overlies the sinus. As osteomas may be predomi- bital nerve can occur. As the disease progresses, it
nantly compact bone (compact or ivory osteoma) may destroy the bone of the antral wall and lead to
or mainly trabecular bone (cancellous osteoma), the various signs such as oral swelling, nasal obstruction
degree of radio-opacity may vary. or eye symptoms or signs. However, importantly
Surgical excision of the tumour via a Caldwell for the dentist, alveolar bone involvement may
Luc approach is the treatment of choice. cause loosening of teeth. Occasionally, malignancy
may present with a soft tissue mass growing out of
a maxillary extraction socket (Fig. 7.19).
Odontogenic cysts and benign Squamous-cell carcinomas, displaying typical
tumours histological features, form the bulk of maxillary
sinus malignancies (approximately 80%). Adenocar-
Any odontogenic cyst or tumour involving the max- cinomas and undifferentiated carcinomas constitute
illa may secondarily involve the maxillary antrum. much of the remainder. Less-common malignant
Frequently symptoms/signs are few or are those neoplasms arising in this site are malignant mela-
usually associated with cyst/benign tumour growth noma, lymphoma and sarcoma.
(Chapter 10). If the lesion is large and has involved On dental radiographs, antral radio-opacity may
a great part of the antrum, sinusitis-like symptoms be difficult to discern without a normal antral air
may develop if the normal flow of secretions into shadow available with which it can be compared.
the nose is obstructed. On a panoramic radiograph, recognition may be eas-
Periapical radiographs may be misleading unless ier because of the comparison with the contralateral
examined carefully. A radiolucent cyst or tumour side. Where bone has become involved, the radio-
may be misinterpreted as the antrum. However, opaque lamina dura of the sinus floor may become
lamina dura will be lost from involved teeth. There indistinct or disappear altogether. At a later stage,
may be displacement and resorption of roots. On teeth may lose all supporting bone (floating teeth;
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Fig. 7.19 Antral carcinoma. Intraoral (A) and extraoral (B) views. Note loss of nasolabial fold on the right side.
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Diseases of bone and the maxillary sinus Chapter 7
Fig. 7.20 Panoramic radiograph of a patient with a squamous-cell carcinoma of the left maxillary sinus.
There is complete absence of bone supporting the upper left third molar tooth and the sinus floor is not visible.
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Fig. 7.21 Displaced root within the maxillary sinus on CBCT imaging. Note the opacity filling much of the
sinus, representing reactive inflammation. Only a few locules of air can be seen at the top of the maxillary sinus.
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Diseases of bone and the maxillary sinus Chapter 7
instrument such as a Ficklings. The intraoral wound The buccal flap, therefore, has to be advanced suf-
is closed. This surgical procedure is best carried out ficiently to achieve this and this may require incis-
under general anaesthesia and with antibiotic cover. ing the periosteum of the mucoperiosteal flap.
The bony defect in the anterior sinus wall under- Mattress sutures facilitate good closure and are
goes fibrous healing. removed after 10 days. A broad-spectrum antibi-
otic such as amoxicillin and 0.5% ephedrine nasal
drops are prescribed and the patient instructed
Oroantral communication not to blow the nose. This procedure may be
undertaken under local anaesthesia. The advance-
Oroantral communication may occur following ment of the buccal flap may result in a decrease in
displacement of a root into the antrum or simply height of the buccal sulcus. It may be difficult to
after extraction of an upper posterior tooth. A pre- achieve tension-free closure of a large extraction
requisite for its occurrence is a close relationship socket.
between tooth/root and antrum, while previous Palatal flap. Alternatively, an OAF may be closed
destruction of periapical bone by an inflammatory with a palatal flap. This may be necessary because
lesion is a predisposing factor. a buccal advancement flap has failed or is not fea-
The presence of a communication is often sible. A palatal pedicle flap is raised so as to include
missed. Careful examination of the socket may a greater palatine artery (Fig. 7.24). This is rotated
clearly show a hole into the antrum. Sometimes to close the defect and is obviously more difficult
air bubbles may be evident in the socket. Classic the more posterior is the OAF. The denuded area
features include liquids passing from the mouth of palatal bone is protected with resorbable cel-
into the nose via the antrum and air passing in the lulose such as Surgicell and heals by granulation.
opposite direction if a patient attempts to blow the A palatal flap is very much more robust than a buc-
nose. If a communication is left, it will eventually cal flap but this technique is better undertaken
epithelialise, forming an oroantral fistula (OAF). under general anaesthesia.
Symptoms of sinusitis often occur.
An intraoral film will probably reveal absence of
lamina dura from the socket. Other imaging (e.g. Fracture of the maxillary tuberosity
CBCT) may reveal nothing more than disruption of
the bony sinus floor immediately after creation of Extraction of a posterior maxillary molar, usually
a communication, but signs of sinusitis (see above) lone-standing, is the scenario in which a fracture
often develop with time. might occur. With the application of force to the
Presumably some undiagnosed OAFs close spon- forceps, an audible crack may occur and the alveo-
taneously but more often they are difficult to man- lar bone of the tuberosity is felt, or seen, to move
age. The surgical technique of choice depends on with the tooth.
the time of diagnosis, with either a buccal or a pala- A periapical or panoramic radiograph may show
tal flap used. nothing unless the fracture is displaced. If the latter
A newly created OAF should be closed imme- has occurred, discontinuity of the antral floor is the
diately. An OAF that is diagnosed later should be sign.
allowed a period of 6 weeks to close spontaneously. An OAF will inevitably be created and immedi-
The reason for this is that an attempt to close the ate closure with a buccal flap as described above
fistula earlier is likely to fail because the tissues is indicated. It is likely to be relatively straight-
are more friable during their initial healing phase forward to achieve primary closure if the frac-
and more difficult to manage. After 6 weeks, if the tured piece of bone is dissected free and removed.
OAF persists, then it should be surgically closed However, if the segment of bone is large, then one
with a buccal flap but the epithelial tract that has could consider management as per alveolar fracture
formed must be excised first. (Chapter 8). This would involve splinting the bone
Buccal advancement. A buccal flap should by means of the tooth and then removing the tooth
be used to close a newly created OAF and this surgically with care 6 weeks later when the bony
should be carried out by the dentist immediately. fracture can be assumed to have healed. However,
The intention is to completely close the fistula to if the tooth has been causing pain, this may not be
facilitate healing by primary intention (Fig. 7.23). an option.
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Buccal flap
incision
Fistula removal
excision line
Fistula
Extent of
A bony defect
Transverse
releasing
incision
Bony defect
C
Fig. 7.23 Buccal advancement procedure to close an oroantral fistula.
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Diseases of bone and the maxillary sinus Chapter 7
A B C
Fig. 7.24 The palatal flap procedure to close an oroantral fistula.
Q Self-assessment: questions
Multiple choice questions ( True/False) c. The most common source of infection is blood-
1. The following are features of osteopetrosis (marble borne streptococci
bone disease): d. May produce bony sequestra, involucrum and
a. The maxillary sinus may be obliterated on chronic sinus tracts
radiography e. May lead to amyloidosis
b. Osteomyelitis is a recognised complication 5. In the maxillary sinus:
c. Osteoclastic activity is normal a. If a posterior maxillary tooth or root is lost
d. Anaemia is uncommon because of into the sinus during extraction, a flap may be
extramedullary haemopoiesis raised immediately for retrieval
e. Dense bone fills the medullary cavities, b. Roots displaced between the bone floor and
increasing bone strength sinus lining should always be removed
2. Fibrous dysplasia: c. An established oroantral fistula should be
treated by removal of any antral polyps,
a. Can affect a single bone, the craniofacial
excision of the fistula and closure by advancing
skeleton or multiple bones
of a mucoperiosteal flap
b. Does not require surgical removal but can be
d. Spontaneous formation of an oroantral
contoured when bone deformity occurs
communication that is non-symptomatic
c. Radiographically evolves through radiolucency can be managed appropriately by asking the
to ground glass and orange peel appearances patient to refrain from blowing the nose
d. Forms a sharp, discrete margin with adjacent e. Maxillary sinusitis can result in a toothache-like
normal bone pain that is poorly localised and made worse
e. May be a feature of Albrights syndrome by tilting the head forwards.
3. Giant-cell lesions in the jaw bones: 6. Of the bone tumours:
a. May occur in renal osteodystrophy a. Osteosarcoma is the most common
b. May be treated by direct calcitonin injection malignancy found in bone
c. Can be a feature of primary b. Osteosarcoma tends to occur in two age
hyperparathyroidism peaks, juvenile and adult, except in the jaws
d. Contain cells with histological and functional where the peak age is around 25 years
features of osteoclasts c. Osteomas may be solitary or multiple in the jaws
e. May perforate the alveolus d. Sunray spicules are a typical radiographic
4. Chronic osteomyelitis: feature of cemento-ossifying fibroma
a. Is associated with sickle-cell disease e. Torus mandibularis should always be confirmed
b. Is an appropriate term to describe dry socket by undertaking trephine biopsy
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Diseases of bone and the maxillary sinus Chapter 7
a tooth was removed on the upper left side, margin with the density of bone. UR8 is visible,
because food gets stuck in there. He says he unerupted, in a high position overlying the radio-
has had sinus trouble for a few years on the opacity. UR7 roots are short and blunt-ended,
same side, and has to get antibiotics now and suggesting external resorption.
again when it gets painful. He last saw a dentist 9. A 30-year-old woman attends your practice as
3 years ago for some fillings and the extraction an emergency. She had an upper left second
of the UL6. The UL6 extraction site shows a premolar extracted at another dental practice a
substantial defect, and the patient mentions that week ago and had an awful time when the tooth
the extraction was difficult, needed stitches and broke and the dentist was poking around for
was very slow to heal. ages. She doesn t want to see that dentist again.
5. A 35-year-old woman attends as an emergency Now she is complaining of a throbbing ache and
complaining of toothache on the upper right she feels blocked up on the left cheek and sinus.
side. It is a throbbing dull ache. She says her In response to your questions, she says she has
back teeth on the upper right are tender. She not been aware of drinks passing into her nose,
feels generally unwell and asks if she has an but she has been using a straw when drinking
abscess developing. She says that she is still a to stop hot drinks going near the socket. On
bit blocked up from a cold. On examination, she examination, there is a new socket, with a clot in
has tender, palpable right upper cervical lymph place, but with evidence of substantial soft tissue
nodes. Intraorally, she has a few carious teeth trauma from the surgery. Periapical and panoramic
on the upper right, but all teeth test positively to radiographs reveal the outline of a normal socket.
sensitivity tests. There is a 3 4mm radio-opacity of tooth or bone
6. A 70-year-old woman complains of a painful density immediately above the line of the maxillary
upper left molar. On periapical radiography, apart sinus floor, just above the socket. The maxillary
from a periapical inflammatory lesion on the first sinus has a band, of soft tissue radio-opacity and
molar, you notice a dense radio-opacity at the about 10mm thick, running along its walls.
upper edge of the image, distant from the teeth.
You refer the patient for a panoramic radiograph;
Case history questions
this shows a 1-cm diameter, rounded, densely Case history 1
opaque radio-opacity overlying the middle of the A 58-year-old woman noticed that her front teeth had
left maxillary sinus. On enquiry, the patient gives become spaced and seeks advice from her dentist.
no history of sinusitis. On entering the surgery, the dentist notices that she
7. A 65-year-old man complains of an upper left has difficulty in walking and does not respond to his
molar being very loose. He also says he has been questions. She has become increasingly deaf and
suffering from what he thinks is sinusitis on the her vision has also deteriorated. On examination,
left side for a few weeks. His GP has given him the maxilla and zygoma are enlarged and there is
antibiotics for this. On examination, he mentions enlargement of the forehead.
that the left side of his upper lip has been tingling 1. What diagnosis would you suspect?
for a week or more. Intraorally, you note that his 2. What information might be gained from oral
UL7 is very loose and that the UL6 is also a little radiographs and blood tests to support this
mobile. There is a little tenderness in his buccal diagnosis?
sulcus next to these teeth. A periapical radiograph 3. What are the principal histological features of this
shows virtually no bone support on UL7 and the disorder?
bone loss extends the full depth of the alveolus,
including the apparent loss of the maxillary sinus Case history 2
floor. A 60-year-old man has been treated for a T2N0M0
8. A 24-year-old man complains of a swelling in his squamous-cell carcinoma by radical radiotherapy.
upper right buccal sulcus that has been slowly He has a history of chronic alcoholism and was a
developing for some weeks or months. There heavy smoker. Six years after treatment, he develops
are no other symptoms. On examination, there is a painful ulcer in the alveolar mucosa in the treated
nothing to see extraorally, but in his mouth there is area following minor trauma. His pain worsens and the
a definite swelling adjacent to UR7 buccally. UR8 bone became progressively exposed. He is treated by
is not visible clinically, but the swelling extends a partial mandibular resection with graft.
distally to this region. On palpation, the swelling is 1. What diagnosis is most likely?
bony hard. Radiologically, panoramic radiography 2. How does radiotherapy damage tissues and what
reveals a rounded radio-opacity at the posterior structural features might be seen in the bone?
floor of the right maxillary sinus. At the edge of
3. What changes may arise in irradiated connective
this soft tissue-density radio-opacity is a very thin
tissues 10 years after exposure?
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Diseases of bone and the maxillary sinus Chapter 7
A Self-assessment: answers
Multiple choice answers 4. a.True. Sickle-cell disease can lead to infarction
1. a.True. The medullary cavity tends to infill and and bone necrosis, followed by osteomyelitis
the maxillary sinus cannot be seen. Unerupted and bone pain in the jaws.
teeth may be present. b. False. The term osteitis is preferred for local
b. True. Infection tends to become chronic and bone infection in dry socket. It may progress to
this should be considered when extracting osteomyelitis.
teeth. Specialist opinion is advised. c. False. Staphylococcal infection is the most
c. False. Osteopetrosis is a rare genetic condition common infective agent in osteomyelitis.
where there is defective osteoclast function. d. True. Sequestra are separated fragments of
d. False. As the medullary cavity is obliterated, necrotic bone; involucrum is a bone layer
some compensation occurs by extramedullary deposited upon the cortex following periosteal
haemopoiesis, but anaemia is common and expansion. Chronic sinus tracts discharging
bone marrow transplantation is sometimes pus from the necrotic bone in the medulla to
needed. the exterior are a feature of osteomyelitis.
e. False. Despite obliteration of the medullary e. True. Amyloidosis may result from a variety
cavity, bones are fragile. of chronic inflammatory disorders where there
is increased production of serum amyloid A
2. a.True. Monostotic, craniofacial and polyostotic
precursor in the liver.
forms are recognised.
5. a.True. Depending on experience. If referral is
b. False. Surgical removal is not required, but
decided upon, then the tooth or root is X-rayed
bone recontouring may only be undertaken
before being removed surgically.
after skeletal maturity has been reached, to
avoid recurrence. b. False. If a small root produces no sinusitis
and healing is demonstrated radiographically,
c. True. These reflect increasing formation and
surgical removal may not be essential.
thickening of bone trabeculae in a fibrous
matrix; the degree of radio-opacity also c. True. After closure, antibiotic therapy is often
depends on lesional thickness. prescribed and the patient advised to refrain
from blowing the nose.
d. False. Fibrous dysplasia blends with adjacent
normal bone and this feature distinguishes this d. False. Appearance of a spontaneous oroantral
fibro-osseous lesion from ossifying fibroma. fistula may be a result of dental infection,
carcinoma of the maxillary sinus or other
e. True. Polyostotic fibrous dysplasia, skin
pathoses. Thorough investigation is essential.
pigmentation and sexual precocity are the
principal features of Albrights syndrome. e. True. The teeth related to the affected sinus
may be tender to percussion and there may be
3. a.True. Renal osteodystrophy is a complex
nasal stuffiness and discharge.
disorder secondary to chronic renal failure and
it may contain elements of hyperparathyroidism 6. a.False. The most common malignant process
and osteomalcia. Osteolytic lesions containing in bone is metastatic deposition of carcinoma.
giant-cell foci may occur in the jaws. Osteosarcoma is the most common primary
bone malignancy.
b. True. An experimental study injecting calcitonin
into giant-cell granuloma has been published. b. True. Some jaw osteosarcomas do occur in the
It is more usual to remove these lesions by juvenile age group, especially where there is a
curettage. genetic predisposition to cancer.
c. True. Giant-cell lesions may form in primary c. True. Multiple osteomas, odontomes and
hyperthyroidism as a result of parathyroid bone sclerosis may be features of Gardners
neoplasia or hyperplasia. Hyperparathyroidism syndrome (familial adenomatous polyposis
can be excluded by estimating serum calcium coli).
when a giant-cell lesion in the jaw is diagnosed d. False. Sunray spicules are a feature of
histologically. osteogenic osteosarcoma.
d. True. The osteoclasts in giant-cell granulomas e. False. Normally a diagnosis of torus
contain tartrate-resistant acid phosphatase and mandibularis can be made on purely clinical
can resorb mineralised matrix. findings. Radiographic examination is used
e. True. Giant-cell lesions may perforate the prior to biopsy when other bone lesions are
alveolus and simulate a giant-cell epulis suspected in other situations.
clinically.
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Extended matching items answers 9. J. The high degree of radiographic circumscription
is typical of ossifying fibroma when a fibro-
EMI 1
osseous lesion is diagnosed histologically. Adult
1. D. Osteosarcoma is a malignant neoplasm of and juvenile types are seen and the new bone
bone. A variety of histological patterns are known formed in the lesion may be trabecular or rounded
and a large amount of cartilage may be present. (psammomatous) in form.
Formation of osteoid by malignant osteoblasts is 10. A. Highly elevated alkaline phosphatase is a
the defining histological feature. On radiographs, good marker of Pagets disease of bone in the
the periodontal ligament may be widened, teeth appropriate clinical setting. Bone sequestration
may be displaced or resorbed and sometimes is often secondary to chronic osteomyelitis in
sunray spicules may be seen. the jaws. Bisphosphonates are used to treat
2. I. The histological features are those of a fibro- Pagets disease and also have been linked to jaw
osseous lesion. Fibrous dysplasia merges osteonecrosis.
radiographically with the surrounding bone while
ossifying fibroma is well circumscribed. Fibrous EMI 2
dysplasia can affect one bone (monostotic) or 1. F. Hypoplasia of the maxillary sinus is always
several bones (polyostotic). The affected cells discovered by chance during radiography. This
contain mutations of the GNAS gene. patient is asymptomatic and has no clinical signs
3. B. Intravenous bisphosphonates such as of disease. The absence of the line of the sinus
pamidronate (Aredia) and zoledronic acid (Zometa) floor on panoramic radiographs and increased
given to preserve bone mass in cancer have been radio-opacity is a key finding; in simple terms,
linked to osteonecrosis in the jaw. Specialist the maxilla is filled with normal trabecular bone.
advice should be sought when patients on these It has been observed, however, that the orbital
drugs need extractions. cavity may be larger in these patients, extending
4. C. Osteopetrosis is a complex genetic down into the maxilla. An opaque antrum can, of
disorder characterised by reduced osteoclast course, be caused by a multitude of conditions,
action. Infantile (lethal) and late adult (benign) and if you have any doubt about your diagnosis,
clinical patterns occur. This case fits with the you should seek a second opinion.
intermediate (childhood) pattern. Paranasal sinus 2. D. Chronic sinusitis usually gives mild symptoms,
malformations occur and the bone is sclerotic. but a dull ache in the cheeks is not unusual, along
The alveolus fractures easily when teeth are with nasal stuffiness and a postnasal drip. It is
extracted. common in smokers.
5. E. Gardners syndrome affects 1:8000 people 3. I. The round radio-opacity can be interpreted
and is characterised by polyps in the bowel that according to its characteristics of a uniform,
undergo malignant transformation. Dentists may round, soft tissue-density mass. Round radio-
identify the condition because multiple osteomas, opacities can be produced by dental cysts and
odontomes and hazy sclerosis are often found tumours, along with osteomas, but they have
in the jaws. The osteomas may be compact or different radiological characteristics.
cancellous and can occur on periosteal and 4. E. Of course, this patient may simply have been
endosteal surfaces. suffering from chronic sinusitis, but the history of a
6. F. The dental features suggest that the ascending unilateral sinus problem, apparently arising over a
ramus of the jaw on the left side continued similar time period since a difficult extraction of an
growing after the right side ceased. This is typical ipsilateral upper molar, does raise the question of
of condylar hyperplasia. As the occlusal plane an oroantral fistula. When a fistula has developed,
becomes depressed, the corresponding maxillary the classic features of an oroantral communication
teeth overerupt. (drinks passing into the sinus and nose, air
7. G. Cleidocranial dysplasia is an autosomal bubbles arising from the socket) may recede as
dominant condition. The fontanelles fail to close mucosal thickening in the sinus may partly block
and dental manifestations include multiple off the hole.
supernumerary teeth, peg teeth and retention of 5. A. The symptoms suggest an infective cause,
deciduous teeth. and the principal differential diagnosis is dental
8. H. These biopsy features may be seen in abscess and acute maxillary sinusitis. The history
central or peripheral giant-cell granuloma, of a recent cold is a strong hint. The sensitivity
and also may occur in hyperparathyroidism. testing of the teeth is important. Radiography
Serum calcium levels are typically elevated in in a dental practice is only really useful in this
hyperparathyroidism and the test may be used to context if, after clinical tests, you still think that
exclude the hyperparathyroidism when giant-cell the diagnosis is possibly a dental infection.
granuloma features are seen.
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Oral and maxillofacial injuries 8
CHAPTER CONTENTS
know how to assess and document injuries
Overview . . . . . . . . . . . . . . . . . . . . 177 be aware of the particular requirements for a child
8.1 Assessment of the injured patient . . . . . 177 patient.
Airway Disability
Endotracheal intubation Glasgow Coma Scale
Breathing
Intermittent positive
pressure ventilation
Circulation
Plasma expander
infusion via right
and left antecubital
fossae
Exposure
Exclude other injuries
or when patients are treated with sedation and the role of advanced airway management
general anaesthesia. It is important to understand: including surgical management.
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When there is a need to maintain blood pressure, respecting the patients dignity. A warming blanket
plasma expanders such as Gelofusine or Haemac- is placed and i.v. fluids are warm.
cel are better than crystalloids, such as sodium chlo-
ride, as they remain in the vascular compartment
for longer. Urinary catheterisation is required and Radiographic examination
adequate fluid replacement is monitored by docu- Once immediate life-saving measures have been
menting urine output, peripheral perfusion and tem- organised, essential radiography is undertaken. This
perature. The prognosis is better when the patient is is limited to cervical spine, chest and pelvis radio-
warm with full veins and a good urine output. Elec- graphs. The cervical spine is immobilised with a
torcardiographic (ECG) monitoring is undertaken. collar until any injury has been excluded.
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A B
C
Fig. 8.4 Examples of some dental injuries.
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Injury Management
Primary teeth
Concussion Soft diet
Crown fracture Smooth or restore (when root canal treatment may be necessary) or extract depending on extent
Root fracture Soft diet or extract if causing crown mobility
Luxation Soft diet
Intrusion Leave to erupt (when may require later pulp treatment) or extract if radiograph suggests underlying
permanent follicle involved
Extrusion Extract if more than 2 mm
Avulsion Do not re-implant
Permanent teeth
Concussion Soft diet
Enamel fracture Smooth or restore
Fracture involving dentine Protect dentine and restore
Fracture involving pulp Pulp cap (<1mm exposure) or pulpotomy (>1mm exposure) when the apex is open; pulp cap (if
immediate presentation) or pulpectomy (if later presentation) when apex is closed
Root fracture Splint (2 weeks minimum) if mobile
Apical or middle third: root treat to fracture line
Coronal third: extract coronal part of tooth and restore root after gingivectomy or orthodontic extrusion
Vertical: extract
Luxation Reposition tooth manually under local anaesthesia and splint (2 weeks) followed by root treatment as
necessary
Intrusion Leave to erupt when the apex is open or use orthodontic extrusion if apex closed, followed by root
treatment as necessary
Extrusion Reposition tooth manually under local anaesthesia and splint (2 weeks) followed by root treatment as
necessary
Avulsion Less than 1 hour since avulsion: irrigate with saline and re-implant (tooth should have been stored in
saliva, milk or water preferably); compress alveolus to reduce any fracture of the socket; splint (for
approximately 7 days) and prescribe antibiotics and chlorhexidine mouthwash; root treat as necessary
Tooth avulsed for more than 30 minutes or apex closed: root treat with calcium hydroxide
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Alternate skin sutures should ideally be because they feel safer. There is a rise in the num-
removed at 4 days and the remaining sutures at 5 ber of facial fractures following assault. Facial inju-
days to minimise scarring while maintaining wound ries incurred through domestic violence are being
support. increasingly recognised. The commonest fracture is
Antibiotics are prescribed to reduce the risk of that of the mandible.
wound infection: flucloxacillin for skin lacerations
and amoxicillin for intraoral wounds, unless con-
traindicated. Tetanus prophylaxis should be recom- Clinical presentation
mended if immunisation is not up to date.
Examination consists of the palpation of bony mar-
gins of the facial skeleton starting with the supraor-
Surgical management of burns bital rims and progressing down to the lower border
of the mandible, comparing right and left sides. The
Initial management according to ATLS. There could eyes are examined for double vision (diplopia), any
be late threat to airway due to scar contracture. restriction of movement and subconjunctival haemor-
During the initial 48 hours, the patient is hypovo- rhage. The condyles of the mandible are palpated and
laemic due to pericapillary tissue exhudation and movements of the mandible checked. Swelling, bruis-
tissue oedema. After 48 hours, the patient becomes ing and lacerations are noted together with any areas
diuretic and fluid replacement demands reduce. of altered sensation that may have resulted because
Analgesia is required and prevention of wound of damage to branches of the trigeminal nerve. Any
infection with antibiotics and dressings. The area of evidence of cerebrospinal fluid leaking from the nose
burn may require excision. Partial-thickness burns or ears is noted, as this is an important feature of a
may be best left exposed to the air when epitheli- fracture of the base of the skull. An intraoral exami-
alisation may start at 12 days. Reconstruction may nation is then carried out, looking particularly for
be with skin grafts or microvascular free tissue
transfer.
Evidence of carbon deposits in the mouth, phar-
ynx or sputum are important signs of smoke inhala-
tion that may lead to respiratory distress.
Learning objectives
You should:
know how to identify facial fractures clinically and
radiologically
know the principles of management of the different
facial fractures
know the techniques used to fix facial fractures.
Aetiology
Facial fractures may result from interpersonal
violence, road traffic accidents, falls, sport and Premature contact
industrial accident or from pathology resulting
in weakness of a bony region. There is a decline
in the number of injuries following road traffic
accidents, mainly because of the wearing of seat
belts, although this has not been as great as hoped Fig. 8.5 Altered occlusion observed in a fracture
because drivers choose to drive at greater speeds of the condyle of the mandible.
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Fig. 8.6 A step in the occlusion observed in a fracture of the parasymphysis of the mandible.
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Fig. 8.7 Subconjunctival haemorrhage associated with a fracture of the zygomatic complex.
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Oral and maxillofacial injuries Chapter 8
Condyle
Coronoid
Angle
Body
Parasymphyseal Dento-alveolar
Symphyseal
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Fig. 8.9 Gillies temporal approach for the elevation of a depressed fractures zygomatic complex.
thermoplastic material. Nasoethmoidal fractures wire placed about the neck of tooth and the two
usually require open reduction and fixation with ends twisted together to produce a tail, which
plates. The medial canthus may need fixing so that in turn can be twisted with another tail of the
the distance between the eyes is corrected. opposing arch to effect IMF. Rarely used today.
Eyelet wiring: pre-prepared wires with loops, to
Techniques for facial fracture facilitate placement of separate IMF tie wires,
management are applied to pairs of teeth.
Arch bars: these may be commercially produced
Closed reduction and indirect fixation bars that are cut to length and bent to shape
in the mandible or custom-made arch bars can be prepared for
the individual patient from dental impressions.
Acrylic splints. Hard acrylic splints applied with The bars have cleats that facilitate IMF tie
dental cement are useful for dento-alveolar frac- wires. They also allow the ready placement of
tures. Similar splints constructed from metal (cast elastic traction should that be required, which
silver) were popular in the past for the definitive is not possible with direct interdental wiring or
management of mandibular fractures. eyelets. The bars are fixed to the teeth by inter-
Intermaxillary fixation. Fixation of the mandible dental wiring.
and maxilla together (mandibularmaxillary fixa- Bonded brackets: brackets bonded to teeth
tion) is commonly referred to as IMF. The teeth are result in less soft tissue trauma; such trauma
used to check the correct reduction of the fracture can potentially be a postoperative problem with
and then used for fixation. The occlusion will, there- dental wires and arch bars.
fore, be accurately re-established and the technique
is straightforward, although it would be described as
producing non-rigid fixation. Intermaxillary fixation Disadvantages of IMF fixation
may be achieved through a variety of means: The airway is partially compromised and is
at increased risk in the event of postoperative
Direct interdental wiring: simple rapid immo- swelling, regurgitation or vomiting. Opioid
bilisation of jaws is achieved with stainless steel analgesia and other central nervous system
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Oral and maxillofacial injuries Chapter 8
A B
C D
E F
Fig. 8.10 Mini-plating of the zygomatic-frontal (Z-F) and infraorbital regions for fixation after reduction of a
fractured zygomatic complex. (A) Two-point fixation of fractured zygomatic complex. (B) Fracture of Z-F.
(C) Reduced and plated Z-F. (D) Fracture of infraorbital rim. (E) Reduced and plated infraorbital rim. (F) Wound closure.
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I I III
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Oral and maxillofacial injuries Chapter 8
Fig. 8.12 Radiograph showing bilateral severely displaced fractures of an edentulous mandible.
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Oral and maxillofacial injuries Chapter 8
blindness if the haemorrhage in the muscle cone of Orbit fractures may result in diplopia or back-
the orbit is not surgically decompressed urgently. ward displacement of the globe (enophthalmus)
Loss of smell (anosmia) may follow olfactory if there has been significant loss of the orbital
nerve damage in high-level maxillary fractures. fat and muscle into the antrum.
Q Self-assessment: questions
Multiple choice questions (True/False) 5. A 55-year-old man suffers a sharp pain in his jaw
1. Fractures involving the orbit: when eating breakfast and then notices that his
teeth dont meet properly.
a. May increase the volume of the orbit
b. Are described either as blow-out or as EMI 2. Theme: Facial injury
blow-in fractures Options:
c. May be complicated by blindness A Interdental wires
d. Always require surgical repair B Peralveolar wires
e. May cause subconjunctival haemorrhage C Suspension wires
2. Fractures of the maxilla: D Intraosseous wires
a. Are less frequent if seat belts are worn E Acrylic dental splint
b. May cause limited opening of the mandible F Circumferential wires
c. May be suspected if there is intraoral bruising G Extraoral craniomandibular fixation
d. May result in severe haemorrhage H Intermaxillary fixation
e. Can result from less force than required to I Arch bars
fracture the mandible J Titanium plates
Extended matching items questions Lead in: Select the most likely technique to be of use
from the list above for each of the following cases.
EMI 1. Theme: Facial fractures Each option can be used once, more than once or not
Options: at all.
A. Fracture of the alveolus of the mandible 1. An 8-year-old boy is involved in a cycle
B. Fracture of body of mandible accident and suffers a fracture of his premaxilla
C. Fracture of right and left mandibular condyle which is quite mobile. Fig. 8.14 shows the
D. Fracture of mandibular symphysis radiograph.
E. Comminuted fracture of the mandible 2. The anterior mandibular teeth of a 35-year-
old male are found to be mobile following an
F. Pathological fracture of the mandible
alleged assault. Radiographs show that he has a
G. Fracture of the zygomatic complex dentoalveolar fracture.
H. Le Fort I fracture of the maxilla 3. A 28-year-old male has a Le Fort level I fracture of
I. Fracture of the orbital floor his maxilla and a comminuted fracture of his right
J. Nasoethmoidal fracture zygomatic complex.
Lead in: Select the most likely type of facial fracture 4. A 45-year-old female who is fit and well suffers
from the list above for each of the following cases. Each bilateral mandibular body fractures in a domestic
option can be used once, more than once or not at all. violence incident.
1. A 19-year-old male is unable to close his front 5. An elderly edentulous female with osteoporosis
teeth together and has a laceration to his chin. falls and fractures her mandible. Her general
2. On examination of a patient involved in a road health contraindicates general anaesthesia.
traffic accident, the upper dentition together with
alveolus and palate are found to be mobile relative Case history questions
to the upper maxilla. Case history 1
3. A 22-year-old patient presents with a left A 4-year-old child has fallen against a climbing frame
enophthalmus 6 months after an alleged assault while running in a park. She has lacerated her upper
in which he sustained facial injuries. lip and loosened two upper front teeth.
4. A patient requires intermaxillary fixation rather 1. List the key points of the history and examination.
than open reduction and direct fixation with 2. Describe the principles of management.
titanium mini-plates.
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Case history 3
The patient shown in Fig. 8.15 was brought to the
accident and emergency department following an
alleged assault in which he sustained facial injuries.
What anatomical structures may be particularly
relevant to this injury and require evaluation?
Case history 4
The patient in Fig. 8.16 has undergone treatment for a
fracture to his mandible.
Describe the advantages and disadvantages of this
method of management and also of the more usual
alternative treatment.
Oral examination questions
1. What surgical techniques are available for the
management of fractures to the mandible?
2. What are some of the complications that may
arise during mandibular fracture management?
3. How may dento-alveolar fractures be managed?
4. Describe the management of a laceration to the
tongue.
5. Why is placement of a nasogastric tube
sometimes contraindicated in a patient with a
Fig. 8.14 Patient described in EMI 2.
midface fracture?
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Oral and maxillofacial injuries Chapter 8
A Self-assessment: answers
Multiple choice answers Urgent placement of anterior and posterior
1. a.True. The normal volume of an orbit is about nasal packs is one method used to control this
30ml. Fractures may increase or decrease this haemorrhage.
volume. A CT scan may report a significantly e. True. The maxilla is very fragile in an
increased orbital volume on the suspected anteroposterior direction but has strong struts
fracture side relative to the uninjured side. This transmitting the forces of mastication up to the
is clinically significant because there is more base of the skull. The force from an injury that
room for the globe in the orbit and its position is directed in a horizontal direction can cause
may change. serious damage to the maxilla. The direction
b. False. While some orbital fractures may be of the force is, therefore, important, and a
described as blow-out or blow-in, there lesser force than that necessary to fracture the
are many more common fractures that are mandible may result in fracture of the maxilla.
not described in these terms. For example, Extended matching items answers
fractures of the zygomatic complex will involve
the orbit as this bone contributes to the EMI 1
anatomy of the orbit (unless there is an isolated 1. C. A fall onto the chin resulting in bilateral
fracture of the zygomatic arch). fractured mandibular condyles has been
c. True. A haemorrhage within the muscle cone described as a guardmans fracture because
of the globe from rupture of one or more of these military personal may faint and fall forward,
the posterior short ciliary arteries may result suffering such an injury after standing still for
in a retrobulbar haemorrhage. This may follow lengthy periods of time.
injury or more often after surgical reduction of 2. H. If there is movement between the upper and
a fracture, although in less than 1% of cases. lower parts of the maxilla, the fracture is likely to
Urgent surgical decompression is required. be at the Le Fort I level.
High-dose steroids and diuretics are used while 3. I. Fracture of the orbital floor may permit
theatre is arranged. herniation of the orbital soft tissue into the
d. False. Not all orbital fractures require repair, maxillary sinus. The consequent reduction in
although this is controversial. If the fracture orbital volume leads to the globe (eyeball) moving
results in a small defect and no clinical eye backwards into the socket (enopthalmus) giving
signs, then it may not be necessary; however, an unattractive sunken appearance to the eye.
a larger defect will need to be repaired, even if 4. E. If a fracture is severely comminuted, then
there are no signs, as a late sinking back of the it may be unwise to raise the periostium from
globe (enophthalmos) may develop. the bony fragments to facilitate plating as this
e. True. Fractures of the orbit usually, but will reduce their blood supply. It may also be
not always, result in a subconjunctival difficult to plate very small fragments of bone. In
haemorrhage. There may also be an associated this situation, consideration should be given to
circumorbital ecchymosis, the classic black eye. intermaxillary fixation.
2. a.True. The wearing of seat belts significantly 5. F. Pathological fracture of the mandible can
reduces the incidence of facial injury. However, arise when the jaw bone is severely weakened
drivers may feel a sense of greater security by a pathological process or lesion (such as a
when wearing a belt and drive at greater dentigerous cyst).
speeds, thus resulting in more serious injuries
when accidents do occur. EMI 2
b. True. Displaced fractures of the maxilla can 1. E. As the fracture is mobile, the displacement
result in lengthening of the midface so that must be reduced and fixation will be required.
the patient believes that they have restricted A full-coverage acrylic dental splint made to a
mouth opening when in fact the mandible has dental impression and model is likely to be all
been forced open by the maxilla and, therefore, that is required for fixation in a young child where
cannot open any more. On examination, healing is good.
gagging of the posterior teeth will be observed. 2. E. A full-coverage acrylic splint is useful to stabilise
c. True. Haematoma present in the upper buccal dento-alveolar fractures. Alternatively the teeth
sulcus is a sign of maxillary fracture. either side of the fracture segments could be wired
d. True. Rupture of the maxillary artery in facial together (interdental wires) but this doesnt usually
trauma is rare, but when it does occur, it results offer the same three-dimensional stability and may
in severe haemorrhage into the nasopharynx. cause extrusion of teeth from their sockets.
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3. C. Suspension wires can be used to maintain a thorough examination and assessment of the
the vertical position of the fracture segments patient is undertaken, which is described as the
and are wired into an archbar. In this case, a secondary survey.
transzygomatic wire was used on the left side and 2. The oral and maxillofacial assessment will consist
a frontal wire on the right (Fig. 8.14 shows the of a thorough examination of the head and neck
postoperative radiograph). This method has been and, in particular, the orofacial region. This will
superseded by contemporary plating techniques include bony margins, condylar movement,
when possible to provide improved three- eyes, ears, any leakage of cerebrospinal fluid,
dimensional stability of bone fragments. lacerations, bruising, altered sensation and
4. I. Semi-rigid osteosyntheis with titanium plates intraoral examination. Facial radiographs will be
and screws is the contemporary technique of requested and possibly a CT scan, depending on
choice if there are no contraindications for fixation the clinical findings.
of facial fractures.
Case history 3
5. F. If the fracture is displaced then it will require
reduction and fixation, but if it really is not Cheek lacerations may involve several vital structures
possible to arrange for general anesthesia, then including the superficial temporal and facial arteries,
it may be possible to attempt placement of a parotid salivary gland and duct and the facial nerve.
Gunning type splint secured with circumferential As the external ear is also involved in this injury,
wires about the mandible. the pinna, external auditory canal and tympanic
membrane need to be examined. The hearing should
Case history answers also be evaluated.
Case history 1 Case history 4
1. A complete history is required but it is also The patient in Fig. 8.16 has been treated with
important to find out the time of the accident; any intermaxillary fixation (IMF). The more usual alternative
loss of consciousness or headache, nausea or is open reduction and internal fixation (ORIF).
vomiting since the accident; last food and drink, Advantages of indirect fixation with IMF. It is an
in case a general anaesthetic is required; and uncomplicated technique requiring minimal and cheap
tetanus status as the injury occurred outside. The equipment and can be used in severely comminuted
usual oral and facial examination is required plus infected fractures.
any evidence of an injury other than facial (facial Disadvantages of indirect fixation with IMF. There is
bony margins, eyes, bruising, etc.), depth of lip no direct visualisation of the fracture site and fragments
laceration and involvement of vermilion border, may not, therefore, be as closely apposed. Some
any missing teeth or tooth fragments, degree of movement may occur about the fracture site and this
mobility of involved teeth and any interference can increase the incidence of fibrous tissue and non-
with occlusion. union. Other important factors are: longer hospitalisation
2. The first stage in management will be reassurance is required until the patient can take on adequate oral
of the child and parents. Wound cleaning and intake, compromised oral hygiene, normal speech
closure is likely to need general anaesthesia given compromised, potential airway compromise, poor
the age of the patient, who should, therefore, be patient acceptance and delayed return to work.
admitted to hospital. Attempt to use resorbable Advantages of ORIF. These are essentially the
sutures to avoid difficulty of removal. If the opposite to the disadvantages of IMF.
primary teeth are sufficiently mobile to be a Disadvantages of ORIF. Specialised, expensive
threat to the airway when the child is sleeping, equipment is necessary and it is possible to damage
or if they are interfering with the occlusion, then tooth roots or nerves. ORIF cannot be used in a
they should be extracted at the same time as the severely comminuted or infected fracture.
laceration is sutured. Otherwise, no treatment is
indicated other than recommending a soft diet Oral examination answers
and prescribing analgesia. 1. The principles are of reduction and fixation.
Reduction may be closed and indirect or open for
Case history 2 direct fixation, usually with mini-plates.
1. Patient management priorities are according to the 2. The most common complications that arise
Advanced Trauma Life Support (ATLS) protocol. during mandibular fracture management are
The patient is simultaneously resuscitated and infection, delayed union or non-union (usually as a
examined during the primary survey (airway, consequence of infection or inadequate fixation),
breathing, circulation, disability and exposure). malocclusion, alveolar nerve damage, wound
Essential radiographs (cervical spine, chest and dehiscence and damage to teeth.
pelvis) are then taken. Once the patient is stable,
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Oral and maxillofacial injuries Chapter 8
3. Fractures of the alveolar bone are managed layers using resorbable material. One should
according to the principles of reduction and consider the airway, which may become
fixation. Finger pressure is used to reduce the compromised by haematoma or oedema, if the
fractured fragments and fixation is by suturing wound is large. Radiographic examination may
of the associated soft tissues as necessary and be necessary to identify foreign bodies such as
splinting of the teeth. tooth fragments.
4. The tongue has a rich blood supply and heals 5. Fractures of the midface may extend through
well. Very small lacerations do not need any the nasal cavity and result in tearing of the soft
treatment and heal quickly. Antibiotics should tissue in the nasopharynx. Attempting to place a
be prescribed. Closure of other lacerations is nasogastric feeding tube may further tear these
undertaken under local anaesthesia or general soft tissues or a tube could potentially enter the
anaesthesia in a small child. This is done in cranium if there is a skull fracture.
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Dentofacial and craniofacial
anomalies 9
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Dentofacial and craniofacial anomalies Chapter 9
Fig. 9.1 Deranged occlusion in a patient with severe asymmetry, caused by overgrowth of the left
mandible.
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S
S N N
SNA
SNB
Po Or Po FP Or
Ar
PTM
Ar MxP ANB
PNS
ANS ANS
A MP OP A
Su Su
Go
B B
Pg
Me Gn Me
A B
S Sella A Point A
N Nasion B Point B
Po Porion Gn Gnathion
Ar Articulare Go Gonion
PTM Pterygomaxillary fissure Me Menton
Or Orbitale Pg Pogonion
PNS Posterior nasal spine Su Subnasale
ANS Anterior nasal spine
Learning objectives
You should:
Treatment planning be able to describe a preoperative care plan and
Treatment planning usually consists of the following: preparatory treatment
know the surgical options available
Preoperative orthodontic management to move
understand the essentials of postoperative care and
teeth into a position for the best possible occlu-
after care.
sion at operation. This may involve relief of
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Dentofacial and craniofacial anomalies Chapter 9
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A Chin augmentation with sliding genioplasty Fig. 9.5 Le Fort I osteotomy technique for
advancement of the maxilla.
Postoperative care
Postoperative care involves:
airway management
analgesia
liquid or soft diet
oral hygiene: may be aided with chlorhexidine
mouthrinses
antibiotics: usually continued for several days
steroids in reducing doses.
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Dentofacial and craniofacial anomalies Chapter 9
Analgesia
Table 9.1Typical sequence of treatment for patients
Analgesia is essential for all postoperative patients. with cleft lip and palate
Bolus doses of opioids are best avoided because of
the risk of respiratory depression in a patient with Age Treatment
potential airway compromise. However, titration
Birth Initial assessment; presurgical orthodontics
of opioids to the point of analgesia will ensure the
is no longer carried out
dose is below that causing respiratory depression.
Similarly, patient-controlled analgesia (PCA) with 3 months Primary lip repair surgery; Millard and
an opioid is useful in the initial postoperative stage. Delaire are two commonly used surgical
Otherwise, non-steroidal anti-inflammatory analge- techniques
sics (NSAIDs) are the drugs of choice for surgical 918 months Surgical repair of palate, which is good for
inflammatory pain. speech development but is associated with
impaired growth of the maxilla; von Langen-
beck and Delaire are two commonly used
Follow-up surgical techniques
2 years Speech assessment
Relapse is a possibility following orthognathic sur-
gery. This is largely caused by muscle pull, espe- 35 years Lip revision surgery
cially the masseteric pterygoid muscle sling about 89 years Pre-bone graft orthodontic treatment;
the posterior mandible. Joint orthodontic and sur- speech therapy
gical review appointments are arranged to provide
monitoring. 10 years Alveolar augmentation with cancellous bone
from ileac crest, which allows maxillary
canines to erupt and provides support for
9.3 Cleft lip and palate alar base
surgery 1214 years Definitive orthodontics
16 years Nose revision surgery
The spectrum of disease severity is wide. A team commonly harvested from the anterior supe-
approach to management of cleft lip and palate is rior iliac crest by open operation or trephine.
important; this may include the oral and maxillo- Grafting of the alveolar cleft allows union of
facial surgeon, orthodontist, paedodontist, speech the alveolar segments to occur and provides
therapist, audiologist, otolaryngologist, nurses an intact alveolus for the maturation of the
and midwives. Table 9.1 shows the sequence of dentition, in particular the eruption of the
treatment. canine teeth.
Orthognathic surgery is usually required to
Surgical repair of the lip and palate is required correct the maxillary hypoplasia and class III
and a variety of techniques using soft tis- malocclusion.
sue flaps are described. The Millard rotation Nose: correction of the columella, alar carti-
advancement flap is common with the Delaire lages and bony nasal skeleton may be required
flap gaining in popularity for lip closure. Velo- and rhinoplasty is becoming more common for
pharyngeal incompetence is also corrected with adult patients.
flap surgery.
Alveolar bone grafting is undertaken dur- Palatal clefts may be acquired as a result of
ing the mixed dentition phase and is a trauma, especially gunshot wounds or because of
well-established procedure. Bone is most tumour.
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9.4 Craniofacial surgery anomaly, ranging from defects of the alveolus to the
craniosynostoses.
and osteodistraction The process involves the gradual, controlled dis-
placement of a surgical fracture. The displacement
process is referred to as transport; the gap created
Learning objectives during the displacement of the bone segment fills
You should:
with immature non-calcified bone. It is this callus
know the indications for craniofacial surgery and that is distracted and then matures during a subse-
its objectives quent fixation period. The adjacent soft tissues are
understand the technique of osteodistraction. expanded as the bone segment is transported and
this unique ability to expand soft tissues simultane-
ously with bone makes this technique invaluable.
The general aim of craniofacial surgery may be
to facilitate normal assimilation into society, as is
the case for much orthognathic surgery, but there Technique
may be secondary objectives such as the prevention . Osteotomy and placement of distraction device.
1
of visual impairment, reduction of intracranial pres- 2 . Latency period (about 1 week) after which the
sure or alleviation of respiratory impairment, which distraction device is activated.
may prompt urgent surgery. 3. Distraction period until the desired transport is
The team is likely to be larger than that involved achieved.
in the management of patients undergoing orthog- 4. Fixation period (about 4 weeks) during which
nathic surgery or cleft lip and palate surgery, the distraction device is passive and after which
described earlier. In addition, the following special- it is removed.
ties may be involved: neurosurgery, clinical genet-
ics, psychology, ophthalmology and anaesthesia. Fig. 9.6 shows an alveolar distraction device.
Craniofacial surgery is undertaken at a lim-
ited number of specialist centres to permit a high
level of expertise to develop in the management 9.5 Cosmetic facial surgery
of these rare and complex disorders. Advances
in paediatric anaesthesia and imaging techniques
have contributed to the evolution of this type of Learning objective
surgery. The craniofacial skeleton has an excel- You should:
lent healing potential and this allows large soft know the more common techniques.
tissue flaps with periosteum to be raised without
detriment. The bicoronal flap or unilateral fronto-
temporal scalp flap are standard techniques that The demand for cosmetic surgery is increasing in
provide good access to the cranial vault. Additional the developed world. The need for surgery is some-
access may be required to the upper facial skeleton times controversial when it is seen to be entirely to
using transconjunctival, blepharoplasty, paranasal produce an improved aesthetic rather than func-
or intraoral incisions. tional outcome. A rhinoplasty for a patient who has
already undergone surgical correction for a cleft
lip and palate may be more acceptable than for an
Osteodistraction techniques individual who wishes to change a racial character-
istic. Similarly, surgery to maintain a more youthful
Osteodistraction or distraction osteogenesis was appearance may be criticised. As for all surgery, the
first described in 1905 but was little used until risks and benefits must be carefully considered.
the Russian orthopaedic surgeon Ilizarov devel- Scar revision. Various Z and W plasties and local
oped its use for the elongation of tubular bones. flap techniques may be used to disguise facial scars.
The technique is applicable to many areas of the Dermabrasion. Used to remove superfically
skeleton and has more recently been used in oral embedded foreign bodies from dirty facial abrasions
and maxillofacial surgery. Osteodistraction is now and allow to heal without tattooing. Also used to
used in the surgical correction of many types of treat acne scarring.
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Dentofacial and craniofacial anomalies Chapter 9
Distraction rod
Transport plate
Distraction zone
Base plate
Laser resurfacing and ablation. Used to treat Blepharoplasty. Corrects periorbital skin wrin-
acne scarring and remove tattoos. kling and orbital fat herniation.
Collagen augmentation. To improve lip profile. Pinnaplasty. Corrects prominent ear lobes or
Liposuction. To remove excess subdermal fat and pinnae. Pressure bandage required for 57 days to
improve facial contour. prevent haematoma that could lead to hyperplastic
Rhytidectomy. To remove wrinkles by dissect- pinnae or cauliflower ears.
ing above the superficial musculoaponeurotic sys- Brow lifts. Undertaken via eyebrow, mid-brow
tem (SMAS), stretching and closure after excision incision or endoscopic approach.
of excess tissue. Dissection at this plane preserves
the facial nerve beneath. Procedure also known as
face-lift.
Q Self-assessment: questions
Multiple choice questions ( True/False) e. Should be discussed with appropriate patients
1. Mandibular orthognathic surgery: by the general dental practitioner
a. Is always undertaken via an intraoral approach 2. In patients with cleft lip and palate:
b. Is usually associated with nerve damage a. Dental abnormalities may include missing teeth
following sagittal split technique b. Speech may be described as hypernasal
c. Causes facial swelling that can be reduced c. There may be eustachian tube dysfunction
with systemic steroids d. Osseointegrated implants are contraindicated
d. Requires both preoperative and postoperative e. Childhood surgery prevents the need for later
orthodontics orthognathic surgery
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Master Dentistry
A Self-assessment: answers
Multiple choice answers
1. a.False. While the sagittal split osteotomy is
undertaken via an intraoral approach, some
types of operation may use an extraoral
approach. The vertical subsigmoid (VSS
or vertical ramus) osteotomy is such a
procedure (Fig. 9.7). This operation is less
technically difficult and less time-consuming
than the sagittal split osteotomy and results
in less inferior nerve damage. It can be
performed via an intra- or extraoral approach
and the choice is determined by the ease
of access for the type of fixation to be used
in a particular case. Usually the extraoral
approach is favoured so that mini-plates
can be used, and incisions are made in the
submandibular or retromandibular area. This
operation is less versatile than the sagittal
Fig. 9.7 Vertical subsigmoid osteotomy
split but useful for correction of asymmetry
and lengthening or shortening of the vertical technique.
part of the ramus.
b. True. The inferior alveolar nerve is at significant
risk during the sagittal split operation. Reports
suggest that about 80% of patients experience
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Dentofacial and craniofacial anomalies Chapter 9
mental paraesthesia in the immediate the normal growth and development of the
postoperative phase. A large proportion of maxilla. However, such secondary surgery is
these recover sensation, and reports of still sometimes required. In Europe, almost as
long-term paraesthesia vary between 0 and many surgical techniques as surgical specialist
24%. The incidence is increased in older units have been practised. Some childhood
patients. surgical techniques may offer superior
c. True. Many surgeons use systemic steroids outcomes over others, and current randomised
such as dexamethasone to help to reduce clinical trials evaluating the long-term results
postoperative swelling. These are given will provide us with more informed choices in
intravenously during the surgery and in the future.
reducing doses over the postoperative 3. a.True. Crouzon and Apert syndromes are
days. both familial types of craniosynostosis with
d. True. It is usual for mandibular and maxillary an autosomal dominant inheritance. They
orthognathic surgery to require orthodontic are described as among the more common
treatment to move the teeth into positions craniosynostoses, although all are rare.
to ensure a good occlusion at operation. Premature fusion of the cranial and base of
Postoperative orthodontic treatment will skull sutures results in characteristic head and
facilitate minor adjustments and ensure face morphology.
stability. Other specialists such as a restorative b. False. The growing brain causes an increase
dentist or periodontist may also be involved in intracranial pressure because of the limited
in the management of the patient requiring growth of the skull. Early surgery is indicated
orthognathic surgery. to allow normal brain development. Headaches
e. True. Patients with obvious facial skeletal are a common early sign. It is not unusual for
discrepancies should be advised by the surgery to be undertaken at 57 years of age.
dentist that surgery may be an option with This has the advantage of the child starting
the potential to improve eating, speaking or school with an improved appearance.
the appearance. The patient should then be c. True. Following suture release and skull
referred to an oral and maxillofacial surgeon reshaping, the child is observed. Further
for further investigation. Patients with lesser reshaping may be required and is carried out if
discrepancies are likely to be referred for any increase in cranial pressure is noted. The
orthodontic treatment and then, if the cranial vault and orbits are normally about 90%
discrepancy is beyond the means of such of their adult size around the time of eruption of
treatment, the orthodontist will arrange a joint the maxillary first molar teeth at about 7 years
consultation with the surgeon. of age, and so this is a good age for surgery.
2. a.True. An example of a surgical procedure to enlarge
b. True. A surgical procedure called a the cranium and orbits is shown in Fig. 9.8.
pharyngoplasty may be beneficial to reduce Orthognathic surgery in late teenage years may
hypernasal speech by narrowing the be indicated.
velopharyngeal opening. d. False. The mandible develops in the normal
c. True. Insertion of grommets is usually required way. The maxilla does not have the same
because of eustachian tube dysfunction. growth potential and a class III skeletal base
develops with class III dental occlusion.
d. False. Dental implants may well form a part of
A maxillary advancement osteotomy may,
comprehensive restorative management in the
therefore, be necessary.
adult patient. Although the aim of childhood
surgery and orthodontics treatment is to avoid e. True. Craniosynostoses are rare. Health
the need for later restorative treatment, there services are organised so that a few centres
may still be the need to replace missing teeth treat more patients; this allows expertise to
or the retention of obturators to close oronasal develop and the effectiveness of treatment
for some patients. types can be evaluated.
e. False. Adult patients with cleft lip and palate Extended matching items answers
commonly have a hypoplastic maxilla, causing
1. C. Palatal obturation or a feeding appliance may
a class III skeletal base and dental occlusion
be required to facilitate feeding in infancy.
with cross-bite. This may require correction
with orthodontic expansion followed by an 2. E. Digit sucking is common and particularly
osteotomy to advance the maxilla. The aim damaging to the developing occlusion.
of childhood surgery is to prevent the need Prolongation of the habit may result in severe,
for adult orthognathic surgery by facilitating
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potentially irreversible derangement of dental 4. E. Anterior open bite may be acquired in
occlusion. adulthood with a habit of pen or instrument
3. A. First and second arch syndromes exhibit sucking.
variable degrees of disturbed development of 5. H. Patients with class III facial skeletons frequently
ear, mid-facial, infratemporal and mandibular have a hypoplastic maxilla in addition to a
structures. prognathic mandible and consequently require
a bimaxillary osteotomy rather than mandibular
surgery alone.
Fig. 9.9 Digital panoramic topographic radiograph showing effects of hemimandibular hyperplasia.
(This is the radiograph of the patient shown in Fig. 9.5.)
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Dentofacial and craniofacial anomalies Chapter 9
immobilised, and late relapse caused by muscle that the area of greatest tension is positioned at
pull. Other complications include unfavourable the alar base. It is used for complete, incomplete
bone splits, extrusion of teeth, periodontal and narrow and wide cleft repairs. The scar
defects, temporomandibular joint dysfunction, closely resembles the philtrum of the lip on the
alveolar nerve injury, infection and non-union. cleft side.
4. A submucous cleft is characterised by a 6. Distraction osteogenesis is a relatively new
deficiency of muscle or bone beneath the technique introduced to manage orthognathic
mucosa. The palate may, therefore, appear intact discrepancies. There is a need for further
but the muscles may not function properly such investigation of this technique, in particular for
that there is, for example, difficulty in swallowing. randomised controlled trials where possible
It is often identified on investigation of abnormal to compare effectiveness and morbidity of the
nasal speech. traditional surgery with this new technique.
5. The Millard rotationadvancement flap is a Distraction osteogenesis cannot be used in
commonly used method of cleft lip repair. It is a situations where a reduction in prognathism is
modified Z-plasty placed at the top of the cleft so required.
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Cysts and odontogenic tumours 10
Non-odontogenic cysts
Nasopalatine cyst General clinical features
Nasolabial cyst
Non-epithelial cysts (not true cysts) Cysts may be detected because of clinical symp-
toms or signs (Table 10.1). Occasionally an asymp-
Solitary bone cyst
tomatic cyst may be discovered on a radiograph
Aneurysmal bone cyst
taken for another purpose. Symptoms may include:
Based on the World Health Organization 1992 classification.
swelling (Fig. 10.1)
displacement or loosening of teeth
pathogenesis:
pain (if infected).
developmental The most important clinical sign is expansion
inflammatory. of bone. In some instances, this may result in an
Box 10.1 lists the cysts found in the orofacial eggshell-like layer of periosteal new bone overlying
region using these groups. the cyst (Fig. 10.2). This can break on palpation,
giving rise to the clinical sign of eggshell cracking.
If the cyst lies within soft tissue or has perforated
Other cysts the overlying bone, then the sign of fluctuance
Cysts associated with the maxillary antrum: may be elicited by palpating with fingertips on
Benign mucosal cyst of the maxillary antrum.
each side of the swelling in two positions at right
angles to each other.
Postoperative maxillary cyst (surgical ciliated
If a cyst becomes infected, the clinical presenta-
cyst of the maxilla).
tion may be that of an abscess, the underlying cys-
Cysts of the soft tissues of the mouth, face and neck: tic lesion only becoming apparent on radiographic
Dermoid and epidermoid cysts.
examination.
Lymphoepithelial (branchial cleft) cyst.
Thyroglossal duct cyst Radiological examination:
Cysts of the salivary glands: mucous extravasa- general principles
tion cyst, mucous retention cyst, ranula.
As a basic principle, radiological examination
should commence with intraoral films of the
Odontogenic cysts affected region; for small cystic lesions, intraoral
Odontogenic cysts are lined with epithelium derived films may be all that is needed for diagnosis, while
from the following tooth development structures: for all cysts the fine detail of intraoral radiography
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Cysts and odontogenic tumours Chapter 10
Typical age
(decade at
Cyst type presentation) Sex distribution Commonest site Common clinical signs
Radicular 3rd and 4th M>F Tooth-bearing areas of Slowly enlarging swellings, fre-
jaws especially anterior quently symptomless and discovered
maxilla; most common by radiography of non-vital teeth
odontogenic cyst
Residual 4th and 5th M>F Mandibular premolar Slowly enlarging swellings, fre-
area quently symptomless
Keratocyst 2nd and 3rd M>F Angle of mandible Frequently symptomless and dis-
covered on dental examination or
radiography; tooth displacement and
occasional paraesthesia lower lip
Dentigerous 3rd and 4th M>F Mandibular 3rd molar Like keratocyst, may grow to large
followed by maxillary size before diagnosed; most discov-
canine ered on radiograph taken because of
tooth eruption failure
Eruption 1st and 2nd M>F Deciduous and perma- Smooth swelling of normal or blue-
nent teeth, most fre- coloured mucosa over erupting tooth
quently anterior to first
permanent molar
Nasopalatine 4th, 5th and 6th M>F Nasopalatine canal Swelling anterior palate or floor of nose
Nasolabial 4th and 5th F>M Nasolabial fold Swelling in soft tissue
Solitary 2nd M=F Mandible Discovered on radiograph
Aneurysmal 2nd F>M Posterior mandible Firm swelling, rapidly expanding
F, female; M, male.
Fig. 10.1 Photograph showing buccal swelling caused by residual cyst in maxilla.
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will help to clarify the relationship between lesion Margins. Peripheral cortication (radio-opaque
and teeth. For larger lesions, more extensive radi- margin) is usual except in solitary bone cysts. Scal-
ography is appropriate. Selection of films should loped margins are seen in larger lesions, particu-
take account of the value of having two views with larly keratocysts. Infection of a cyst tends to cause
differing perspectives (preferably at right angles to loss of the well-defined margin.
each other; Fig. 10.2). Shape. Most cysts grow by hydrostatic mecha-
Maxilla. Suitable views are: nisms, resulting in the round shape. Odontogenic
periapicals and oblique occlusals
keratocysts and solitary bone cysts do not grow in
this manner and have a tendency to grow through
panoramic radiograph or lateral oblique
the medullary bone rather than to expand the jaw.
occipitomental (OM)
Locularity. True locularity (multiple cavities) is
true lateral (anterior maxilla). seen occasionally in odontogenic keratocysts. How-
Mandible. Suitable views are: ever, larger cysts of most types may have a multiloc-
periapicals and true occlusals ular appearance because of ridges in the bony wall.
panoramic radiograph or lateral oblique Effects upon adjacent structures. Where a lesion
abuts another structure, such as a tooth or the infe-
posteroanterior (PA) of mandible.
rior dental canal, it may cause displacement. Roots
Computed tomography (CT) may be useful in of teeth may be resorbed. When a cyst reaches a
planning surgery of large cysts, particularly in the certain size, the cortex of the bone often becomes
posterior maxilla. thinned and expanded. In posterior maxillary
lesions, the antral floor may be raised. Perforation of
the cortical plates may be recognised as a localised
Radiological signs area of greater radiolucency overlying the lesion.
Classically, cysts appear as well-defined round or Effect on unerupted teeth. Unerupted teeth may
ovoid radiolucencies, surrounded by a well-defined become enveloped by any cyst, a feature which may
margin. lead to erroneous diagnosis as a dentigerous cyst.
Fig. 10.2 An odontogenic keratocyst of the left mandible. (A) Part of a panoramic radiograph showing
displacement of the third molar and inferior dental canal to the lower border of the mandible.
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Cysts and odontogenic tumours Chapter 10
Fig. 10.2, contd (B) Part of a posteroanterior radiograph of the same lesion.
Fig. 10.3 A radicular cyst related to a retained root of a mandibular premolar. It is easy to imagine how
the cyst has developed from the periodontal ligament and that its corticated margin is an extension of the lamina
dura on either side of the root.
The appearances are similar to those of an apical peripheral areas of the cyst capsule are approached,
granuloma, but lesions with a diameter exceeding where mature fibrous tissue replaces the granula-
10mm are more likely to be cystic (Fig. 10.3). tion tissue (Fig. 10.4).
Several features associated with inflamma-
tory odontogenic cysts may be present in the cyst
Pathology lumen, lining and capsule: cholesterol clefts, foamy
The cyst lumen is lined by a layer of simple, non- macrophages, haemosiderin and Rushtons bodies.
keratinising, squamous epithelium of variable thick-
ness, which may display areas of discontinuity
where it is replaced by granulation tissue or mural
Residual cyst
cholesterol nodules. Arcades and strands of epi-
thelium may extend into the cyst capsule, which Radiology
is composed of granulation tissue infiltrated by a The residual cyst has a well-defined, round/ovoid
mixture of acute and chronic inflammatory cells. radiolucency in an edentulous area. Occasionally
This infiltrate reduces in intensity as the more flecks of calcification may be seen.
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Cysts and odontogenic tumours Chapter 10
Pathology Pathology
The cyst is lined by a continuous layer of stratified The defining feature of a dentigerous cyst is the site
squamous epithelium of even thickness (510 cells), of attachment of the cyst to the involved tooth. This
the surface of which is corrugated. The basal-cell must be at the level of the amelocemental junction.
layer is well defined, being composed of cuboidal or The lining of the cyst is composed of a thin layer of
columnar cells that display palisading. This epithe- epithelium, either cuboidal or squamous in nature,
lium is most commonly parakeratinising, although some 25 cells thick (Fig. 10.8). This lining is of
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Fig. 10.5 Odontogenic keratocyst. The lesion is very well defined with a corticated margin. The wisdom tooth
appears displaced, as does the inferior dental canal, visible at the inferior and posterior aspects of the cyst. The
shape is not round or ovoid, but rather irregular with a separate locule below the crown of the wisdom tooth.
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Cysts and odontogenic tumours Chapter 10
Fig. 10.7 Dentigerous cyst associated with unerupted second, third and a supernumerary fourth molar
on a CBCT examination. Note the perforation of the buccal cortex on the volume-rendered view.
Fig. 10.8 Dentigerous cyst showing origin from the amelocemental junction.
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Pathology
An eruption cyst is basically a dentigerous cyst in
soft tissue over an erupting tooth. The histological
features are similar to those of the dentigerous cyst,
though reduced enamel epithelium is often seen.
Gingival cysts
Gingival cysts are commonly found in neonates
but are rarely encountered after 3 months of age.
Many appear to undergo spontaneous resolution.
White keratinous nodules are seen on the gingi-
vae and these are referred to as Bohns nodules or
Epsteins pearls. Gingival cysts arise from the den-
tal lamina and histologically are keratin contain-
ing. Many open into the oral cavity forming clefts
from which the keratin exudes. Gingival cysts are
lined by stratified squamous parakeratotic epithe-
lium. In neonates and infants, the cysts are typi-
cally between 2 and 5mm in diameter. They do not
involve bone and no treatment is required.
Gingival cysts of adults are much less common
and are found mainly in the buccal gingivae in the
mandibular premolarcanine region. The cyst typi-
cally presents as a solitary soft blue swelling within
the attached gingivae, seldom larger than 5mm in
Fig. 10.9 Nasopalatine cyst. This small example
diameter. Gingival cysts of adults are lined by a thin
could easily be mistaken for a radicular cyst, but the
cuboidal or flattened epithelium resembling dental
presence of the lamina dura of the incisors indicates that
follicle. They do not extend into bone although they
this is not the case.
may rest in a shallow depression in the cortex. They
are usually removed by excision biopsy for diagnosis. epithelium. The capsule of the cyst is fibrous and
may include the incisive canal neurovascular bundle.
Nasopalatine cyst
Nasolabial cyst
Radiology
The nasopalatine cyst appears as a well-defined, Radiology
round radiolucency in the midline of the anterior As the nasolabial cyst is a soft tissue lesion, radi-
maxilla (Fig. 10.9). Sometimes it appears to be ography may reveal nothing. However, radiogra-
heart-shaped because of superimposition of the phy will be performed to exclude other causes of
anterior nasal spine. Radiological assessment should the swelling. Bowing inwards of the anterolat-
include examination of the lamina dura of the cen- eral margin of the nasal cavity has been recorded
tral incisors (to exclude a radicular cyst) and assess- as a feature. Ultrasound examination would be an
ment of size (the nasopalatine foramen may reach a appropriate investigation.
width of as much as 10mm).
Pathology
Pathology The nasolabial cyst is lined by non-ciliated pseu-
The cyst is lined by a layer of pseudostratified cili- dostratified columnar epithelium, which is often
ated columnar epithelium and/or stratified squamous rich in mucous cells.
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Cysts and odontogenic tumours Chapter 10
Fig. 10.10 Solitary bone cyst. There is a large radiolucency in the body of the mandible that arches up
between the roots of the teeth, which appear otherwise unaffected. The lower border cortex is very thin. The inferior
dental canal is not displaced but appears to stop abruptly at the posterior end of the lesion.
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A B
Fig. 10.11 Marsupialisation. (A) An incision is made over a large cystic lesion in the maxillary alveolus. (B) The
flap is sutured to the margins of the cyst lining following excision of a window of tissue for pathological examination.
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Cysts and odontogenic tumours Chapter 10
A B C
Fig. 10.12 Enucleation of a radicular cyst. (A) A three-sided incision. (B) A semi-lunar incision to gain access
to a radicular cyst associated with a maxillary lateral incisor. (C) Oblique sectioning of the apical root to permit good
access to seal the root canal with amalgam.
Odontogenic keratocyst
Surgical management
High recurrence rates are reported (up to 60%)
of particular cysts because of technical difficulty in removing all of
the cyst lining, including projections into cancellous
Radicular cysts bone. Enucleation must be thorough. Some advo-
Large radicular cysts, or small ones that do not cate irrigating the cyst cavity with chemical fixa-
resolve following conventional endodontic treat- tives such as Carnoys solution (a fixative composed
ment, require enucleation and surgical endodontic of ethanol, chloroform and acetic acid), to cause
management to seal the root canal of the associated necrosis of any remaining remnants, and others sug-
tooth. gest excision to include a bone margin about the
Access for apical surgery is gained via a three- cyst. Annual radiographic review is recommended.
sided or a semi-lunar mucoperiosteal flap (Fig. One concern of the reclassification by WHO in
10.12). The latter avoids involvement of the gin- 2005 to keratocystic odontogenic tumour (KCOT)
gival margin, which may be important where the is that it may have encouraged some to inappropri-
tooth is restored with a crown, but does not offer ately undertake resection rather than thorough enu-
adequate access or permit closure over bone for cleation. As described above, the evidence for this
larger cysts. Bone is removed with a rosehead bur reclassification is weak and it is likely to revert to
over the tooth root apex, which is then divided odontogenic keratocyst at the next WHO edition.
with a fissure bur and removed so that the root face
may be readily visualised from the buccal aspect
(Fig. 10.12C). The cyst is enucleated in the usual Eruption cysts
way and sent for histopathological examination. Reassurance of the parents is usually the only
An access cavity is prepared in the root face and management required as these cysts frequently
restored with filler the retrograde root filling to fenestrate spontaneously and require no surgi-
seal the root canal of the tooth. Following irriga- cal intervention. Occasionally, however, they may
tion of the surgical site, wound closure is achieved require marsupialisation to expose the tooth.
with an appropriate suture material that will pro-
vide adequate wound support. If the suture mate-
rial is absorbed too early, semi-lunar flaps are likely Solitary bone cyst
to show dehiscence and three-sided flaps may cause These bone cysts are often incidental findings on
gingival recession. Follow-up with radiography to radiographs. Aspiration may reveal clear fluid or air
check bony healing is indicated. See also Chapter 5. indicating that no further intervention is necessary.
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Box 10.2
Odontogenic tumours Mesenchyme and/or odontogenic
ectomesenchyme with or without odontogenic
Benign tumours epithelium
Odontogenic epithelium with mature, fibrous Odontogenic fibroma
stroma without odontogenic mesenchyme Odontogenic myxoma
Ameloblastoma, solid/multicystic type Cementoblastoma
Ameloblastoma, extraosseous/peripheral type
Malignant tumours
Ameloblastoma, desmoplastic type
Amelobastoma, unicystic type Odontogenic carcinomas
Squamous odontogenic tumour Metastasising (malignant) ameloblastoma
Calcifying epithelial odontogenic tumour Ameloblastic carcinoma primary type
Adenomatoid odontogenic tumour Ameloblastic carcinoma secondary type
Keratocystic odontogenic tumour Ameloblastic carcinoma secondary type
(dedifferentiated), peripheral
Odontogenic epithelium with odontogenic
mesenchyme, with or without hard-tissue Primary intraosseous squamous-cell carcinoma
solid type
formation
Primary intraosseous squamous-cell carcinoma
Ameloblastic fibroma derived from keratocystic odontogenic tumour
Ameloblastic fibrodentinoma Primary intraosseous squamous-cell carcinoma
Odontoma, complex type derived from odontogenic cysts
Odontoma, compound type Clear-cell odontogenic carcinoma
Odontoameloblastoma Ghost-cell odontogenic carcinoma
Calcifying cystic odontogenic tumour
Dentinogenic ghost-cell tumour Odontogenic sarcomas
Ameloblastic fibrosarcoma
Ameloblastic fibrodentinoma and fibro-
odontosarcoma
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Cysts and odontogenic tumours Chapter 10
contain enamel or dentine because both cell types commonly at other sites in the jaws. The pattern
need to interact for dental hard tissue to form. of disease varies in populations. Ameloblastoma
Odontogenic neoplasms are rare but are most is most frequent in black Africans. The midline
likely to present to the dentist. Many appear as mandible is often involved, which is a rare site in
chance findings on radiographs. Larger tumours Caucasian people. Ameloblastoma is slow grow-
may expand the jaw, particularly the lingual plate ing and typically expands the jaw. Expansion of
in the mandible, and may displace teeth. Imag- the lingual plate is a helpful diagnostic sign in the
ing plays an important role in defining the borders mandible, because cysts rarely expand the plate.
and extent of the tumour and cone beam CT with Adjacent teeth may be displaced or the roots may
reconstruction is especially useful. While odont- undergo resorption. Pain may be a presenting fea-
omes can be diagnosed radiographically, soft tis- ture. A multilocular (soap-bubble) radiolucent
sue odontogenic tumours must be biopsied before cystic lesion is typically found on radiographs (Fig.
removal is attempted. If partly cystic, it is impor- 10.13). Pathologically ameloblastomas often show
tant to include a solid area in the biopsy sample. extensive cystic change and biopsy of a solid area in
the wall of the tumour is essential for diagnosis. In
10.6 Specific odontogenic the microscope, ameloblastoma contains islands of
odontogenic epithelium. Columnar cells resembling
tumours pre-ameloblasts are found at the periphery of the
islands. Immunohistochemical CD56 staining may
Learning objectives help to identify pre-ameloblasts. The nuclei are
polarised away from the basement membrane and
You should: there is abundant cytoplasm. Stellate reticulum-
have a good knowledge of ameloblastoma, the
most common odontogenic tumour
like cells are present in the centre of the islands.
be aware of the other odontogenic tumours.
Cystic and microcystic changes are seen microscop-
ically. Follicular and plexiform patterns are seen;
often both patterns are present.
Odontogenic epithelial tumours Variants of ameloblastoma are recognised. The
unicystic type is noteworthy because, if no extra-
Ameloblastoma is the most common odontogenic mural islands are present, it behaves as a cyst
neoplasm. It arises mostly in the posterior mandible and can be treated by enucleation rather than
but can also occur in the posterior maxilla and less resection.
Fig. 10.13 Ameloblastoma in the left lower molar region, displaying multilocularity and expansion of the
bone. Note that the upper margin of the lesion is in contact with the occlusal surfaces of the maxillary teeth.
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Fig. 10.14 Compound odontome in the lower anterior region on a CBCT examination. This shows the
typical appearance of a small mass of well-defined denticles with a radiolucent periphery. These are often identified
by radiography when investigating unerupted teeth, as in this case.
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Cysts and odontogenic tumours Chapter 10
the jaw and has a poor prognosis. Malignant odon- The inferior border of the mandible may be pre-
togenic neoplasms present with expansion of the served if not penetrated, but for large ameloblasto-
jaw, destruction of adjacent tissue, displacement of mas, hemimandibulectomy or hemimaxillectomy
teeth and sometimes pathological fracture. Second- may be required. Surgery is required because ame-
ary deposits of cancer in the jaw are more common loblastomas are relatively radioresistant. Unicystic
than primary odontogenic cancer. types without mural extension may be enucleated
without taking a margin of surrounding tissue.
10.7 Surgical management Odontomes are managed by surgical enucleation
as they are generally well encapsulated and fairly
of odontogenic tumours well separated from surrounding bone.
Odontogenic myxoma requires block resec-
Learning objective tion in most cases rather than local enucleation.
Cementoblastoma requires the removal of the
You should:
associated tooth but generally is well encapsulated
have knowledge of the surgical methods
appropriate to odontogenic tumour management. so enucleates well. Recurrence may occur in up to
one-third of cases.
Treatment for malignant odontogenic tumours
Ameloblastoma is treated by surgery with the aim is usually aggressive and may involve regional
of removing the entire neoplasm with a small mar- neck dissection followed by radiotherapy and
gin of surrounding normal tissue (block resection). chemotherapy.
Q Self-assessment: questions
Multiple choice questions (True/False) e. Has a typical recurrence rate of 20%
1. Odontogenic keratocysts: 4. Among the intraosseous cysts in the jaws:
a. The soluble protein content is greater than 40g/l a. Thinning of the bone cortex is responsible for
b. May be a feature in patients with mutation in the sign known as eggshell cracking
the gene APC b. Determination of tooth vitality is essential for
c. Are thought to enlarge by hydrostatic pressure diagnosis when any cystic lesion is related to
root apices
d. Are most common in the anterior maxilla
c. The maxillary sinus, Staphnes cavity, giant-
e. Contain creamy-white, semi-fluid material
cell granuloma, odontogenic tumours and
2. Dentigerous cyst: metastatic deposits of cancer may all present
a. Is thought to arise from cystic degeneration radiographically as cysts
between the inner and outer dental epithelial d. Odontogenic keratocysts tend to form an hour-
layers glass shape at the angle of the mandible while
b. The lining typically attaches to a tooth at the radicular cysts tend to be more rounded in
amelocemental junction shape
c. May be associated with displacement of teeth e. Both ameloblastoma and odontogenic
d. Is lined by a thin layer of epithelium, which keratocyst may be detected as multilocular
often exhibits mucous metaplasia radiolucent lesions at the angle of the
e. May expand the mandibular cortex resulting in mandible, while the odontogenic keratocyst is
eggshell cracking less likely to cause lingual plate expansion
3. Nasopalatine duct cyst: 5. Gingival cysts:
a. Is typically lined by keratinising stratified a. Are most common in the mandibular premolar
squamous epithelium region in adults
b. Results in a salty taste in the mouth, which is a b. May be multiple in neonates and are referred to
recognised presenting sign as Epsteins pearls or Bohrs nodules
c. Has a capsule that often enmeshes a c. Typically range between 1 and 3cm in
neurovascular bundle diameter
d. May cause tilting of the roots of the maxillary d. Are typically lined by keratinising squamous
central incisor teeth epithelium
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e. May extend into the underlying septal d. Is thought to enlarge by hydrostatic pressure
bone e. Occurs more commonly in relation to the root
6. Among the cysts of the soft tissues: of the maxillary central rather than lateral
a. Mucous retention mucocoele occurs more incisor tooth
commonly in the upper labial submucosa than
in the lower labial submucosa
Extended matching items questions
b. Ranulae occur principally in the floor of mouth EMI 1. Theme: Pathology of cysts in the orofacial
and soft palate region
c. Dermoid cysts in the orofacial region tend to Options:
occur in the midline, mainly either superior or A. Radicular cyst
inferior to the mylohyoid muscle B. Odontogenic keratocyst
d. Lymphoepithelial cysts occur mainly in the C. Nasopalatine duct cyst
cervical region just below the anterior margin of D. Stafne cavity
the sternocleidomastoid muscle
E. Dentigerous cyst
e. Thyroglossal tract cysts in the neck tend to
F. Paradental cyst of Craig
elevate when the patient swallows
G. Gingival cyst
7. Among the bone and antral cysts:
H. Botryoid cyst
a. The Staphne cavity is an enclosed intraosseous
cavity located below the inferior alveolar nerve I. Aneurysmal bone cyst
canal J. Solitary bone cyst
b. Aneurysmal bone cyst does not have an Lead in: Match the description from the list below that
epithelial lining is most appropriate for each diagnosis above.
c. Solitary bone cyst is unlikely to involve 1. A radiolucent lesion was found incidentally on
interdental septa in the mandible a dental panoramic radiograph in a 30-year-old
man. The cyst was located in the lower premolar
d. Mucosal cysts in the maxillary sinus tend
and molar area above the inferior alveolar
to enlarge progressively and usually require
canal and showing a scalloped outline where it
surgical removal
extended between the roots of the teeth. All teeth
e. Hyperthyroidism may result in multiple giant- in the area were vital and the lamina dura was
cell lesions resembling cysts radiographically in intact. Clear straw-coloured fluid was aspirated
the jaws from the lesion.
8. Eruption cyst: 2. A 26-year-old African patient presented with a
a. Is a dentigerous cyst in soft tissue rapidly growing lesion that expanded the maxilla.
b. Typically presents as a symptomless, blue, There was bone destruction on the radiograph
fluctuant swelling on the alveolar ridge and therefore malignancy was suspected. On
c. Must be surgically fenestrated to permit biopsy, the lesion was intraosseous and was
eruption of the associated tooth cavitated. There was profuse bleeding and a small
d. Is lined by keratinising stratified squamous biopsy of the lining was taken. The pathologist
epithelium reported osteoclast-like giant cells and granulation
e. Usually involves multiple adjacent teeth tissue with blood clot.
9. The paradental cyst: 3. A pear-shaped and well-circumscribed radiolucent
lesion with a corticated outline was found on a
a. Is also called the cyst of Craig
radiograph related to the root of an upper central
b. Occurs on the lateral aspect of third molars incisor. The tooth was not restored and proved
c. Is stimulated by pericoronitis vital on testing.
d. Arises from the epithelial rests of Malassez 4. A cyst was enucleated from the posterior
e. Has a communication with oral cavity mandible of a 38-year-old man. The pathologist
10. Radicular cyst: reported that the lining was composed of stratified
a. Alternative terms are apical inflammatory squamous epithelium that showed parakeratosis
periodontal cyst, periapical cyst, dental cyst, and basal-cell palisading. Some areas were
lateral inflammatory periodontal cyst inflamed and cholesterol nodules were
b. Rushtons bodies may be found in the lining, noted.
particularly in residual radicular cysts 5. A cyst was removed along with an unerupted
c. Cholesterol crystals are commonly found in third molar tooth. The pathologist reported a
the cyst fluid, which appears to shimmer on fibrous capsule that was myxoid in places and
aspiration as a result that was lined by a thin layer of squamous and
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cuboidal epithelium. The cyst originated from the Case history questions
amelocemental junction.
Case history 1
6. A multilocular radiolucent lesion was found in
the interdental bone between the lower first and A 35-year-old man presents with painless
second premolars. The teeth were vital and after expansion of the buccal aspect of the mandible in
enucleation the pathologist reported that the cyst the third molar area. A dental panoramic radiograph
had features of a developmental periodontal cyst reveals a multilocular radiolucent cystic lesion
lined by squamous epithelium with focal thickened extending into the horizontal and ascending ramus.
areas. The third molar is absent.
1. What is the most likely diagnosis?
7. A 1-week-old girl was referred by the paediatrician
because of white nodules on her mandibular 2. What advice might be given to the patient when
alveolar ridge. seeking informed consent for surgical removal of
this cyst?
8. A well-circumscribed radiolucent lesion with a
corticated outline was found on a radiograph 3. Describe the cytological and biochemical features
related to the root of an upper lateral incisor. of the cyst content. What are the histological
The tooth was not restored but was slightly features of the lining epithelium?
discoloured. Case history 2
9. A radiolucent lesion found incidentally on a dental
An elderly man presents with a fluctuant blue cystic
panoramic radiograph in a 30-year-old man.
swelling in the anterior mandible. He wears complete
The cyst was located in the mandible below the
dentures and recalls having had a cyst removed
inferior alveolar canal. It was roughly triangular in
from the left side of his mandible many years ago.
outline. Teeth in the area appeared vital.
Radiographs showed that the residual bone in the
10. A cyst was removed along with a partially erupted anterior mandible is extremely thin.
third molar tooth following three episodes of 1. It was felt appropriate to treat the cyst by
pericoronitis. The pathologist reported a heavily marsupialisation. What are the indications for this
inflamed fibrous capsule that was lined by a layer in the above case?The cyst lining is submitted for
of squamous epithelium that formed loops and histopathological examination and is reported as
arcades. The cyst originated from the buccal consistent with residual cyst.
aspect of the molar furcation.
2. What features may be present in the biopsy tissue?
EMI 2. Theme: Pathology of soft tissue cysts in 3. Is the history of this patient having had a previous
the orofacial region jaw cyst significant?
Options: Case history 3
A. Dermoid cyst
A 22-year-old woman presented with a rapidly
B. Thyroglossal tract cyst growing swelling expanding the ascending ramus of
C. Branchial cyst the mandible. The radiologist reported a destructive
D. Epidermal cyst radiolucent lesion and was concerned that the lesion
E. Cystic hygroma might be malignant. A biopsy was suggested. In
Lead in: Match the description from the list below that theatre, there was profuse haemorrhage on opening
is most appropriate for each diagnosis above. the lesion and a small biopsy was taken before rapid
1. A 44-year-old man presented with a swelling in closure was affected.
the midline floor of the mouth that elevated the 1. What is the most likely diagnosis? The pathologist
floor of mouth and tongue. The mucosa over the reported finding multinucleated giant cells, loose
cyst was yellowish in colour. granulation tissue and areas of tissue resembling
2. A 38-year-old man presented with a fluctuant a fibro-osseous lesion.
swelling just anterior to the border of the 2. What interpretation can be made of these
sternocleidomastoid muscle. appearances?
3. A 25-year-old man presented with an anterior 3. What approaches to treatment might be
midline cystic swelling in the neck. When he considered?
protruded his tongue the cyst elevated.
Short note questions
4. A 2-week-old child had a slow-growing cystic
cervical mass. The lesion had been diagnosed by Write short notes on:
ultrasound before the child was born. 1. Imaging methods available for cysts of the jaw.
5. A 54-year-old woman developed an unsightly cyst 2. Surgical treatment of periapical radiolucency.
on the cheek skin which oozed cheesy material. 3. A radiolucency at the anterior of the maxilla.
4. Marsupialisation as a surgical management for cysts.
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Essay questions describe the information that you would give the
1. Give an account of odontogenic cysts. patient before he consents to the operation.
2. Discuss the clinical, histopathological and Oral examination questions
radiological differential diagnoses of a
1. What features of aspirates may help in the
radiolucency at the angle of the jaw.
diagnosis of a suspected cyst?
3. Give a classification of cysts of the jaws
2. How does an intraosseous cyst cavity repair after
and describe in detail the radiological and
enucleation?
histopathological features of odontogenic
3. What are the features of a branchial cyst?
keratocyst.
4. Which odontogenic tumours may have similar
4. An edentulous man aged 60 has a large cyst
presenting features to cysts in the jaws?
in his mandible requiring enucleation. Discuss
the preoperative investigations that would be 5. How do cysts enlarge?
carried out, explaining the rationale for each, and
A Self-assessment: answers
Multiple choice answers d. True. Tilting may cause butterfly central
1. a. False. Soluble protein content may be greater incisors in children.
than 40g/l if the cyst is infected, with an e. False. Recurrence is very rare.
inflammatory exudation, but levels of 40g/l or 4. a. True. Expansion of bone to a thin layer prone
less are typical of odontogenic keratocyst. to cracking is a clinical sign.
b. False. Odontogenic keratocysts are found b. True. Radicular cysts are associated with a
in basal-cell naevus syndrome, caused by non-vital tooth.
alterations in the gene PCTH. Mutations in APC c. True. All have distinct clinical features,
cause familial adenomatous polyposis. however.
c. False. An odontogenic keratocyst enlarges by d. True. Radicular cysts are thought to grow by
displacing medullary bone in a non-uniform hydrostatic pressure rather than through the
growth pattern, suggesting that enlargement intrinsic growth characteristics of the capsule.
results from bone-resorbing factors released by e. True. This is an important diagnostic clue;
the capsule. mandibular lesions producing buccal and
d. False. Two-thirds occur at the angle of the lingual expansion are more likely to be
mandible. neoplasms than cysts.
e. True. Odontogenic keratocysts contain 5. a. True. They occur in the buccal gingivae.
keratotic squames and oily material, imparting b. True. They appear as white keratinous nodules.
a creamy-white semi-fluid texture. c. False. Gingival cysts rarely exceed 5mm in
2. a. True. Occurs after crown formation. diameter.
b. True. This is an important diagnostic feature. d. True. Many contain keratin whorls.
c. True. Associated teeth may be grossly e. False. In adults, they may rest in a shallow
displaced. depression in the cortex but they do not extend
d. True. The epithelium is even, either cuboidal or into bone in neonates or adults.
squamous and resembles enamel epithelium. 6. a. True. Mucous extravasation mucocoeles
e. True. This is caused by breaking of the thin are thought to arise from trauma that
layer of periosteal bone that forms over the cyst. tears the minor salivary gland duct wall,
3. a. False. The lining may be respiratory or allowing release of mucinous saliva into the
stratified squamous in type, reflecting the oral/ surrounding tissue. They are very rare in the
nasal cavity origin. upper lip but are common in the lower lip,
b. True. Fluid leakage is thought to account for presumably because of trauma from the teeth.
this peculiar sign. In general, it is wise to be suspicious that a
c. True. The nasopalatine neurovascular bundle persistent lump in the upper lip substance
may be damaged or even removed during may be a tumour or mucous retention
enucleation. This causes little in the way of mucocoele. Biopsy is necessary to establish
clinical problems. the diagnosis (see Ch. 13).
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are not driven by inflammation. Focally thickened 3. The cyst is expected to contain keratotic squames
epithelial plaques are often found microscopically. and the soluble protein content to be less than
7. G. Gingival cysts in a neonate are referred to as 40g/l. The lining is a relatively uniform layer of
Epsteins pearls. Gingival cysts can also occur in parakeratinising stratified squamous epithelium
adults. 510 cells in thickness. The basal cells may be
8. A. Radicular cyst (periapical, apical or dental cyst) columnar or cuboidal and form a palisaded layer.
grows by osmotic pressure and is typically rounded Orthokeratotic variants are seen. Infection may alter
and well circumscribed. The discoloration of the both the biochemical and histological features.
tooth suggests loss of vitality. Periapical inflammation Case history 2
is the stimulus. Radicular cyst occurs most frequently
in relation to upper lateral incisor teeth. 1. Extreme atrophy of the mandible may predispose
to fracture. The lower denture can be modified
9. D. Stafne cavity is in reality a developmental
to maintain patency of the cyst opening after
depression in the border of the mandible that can
marsupialisation. Local analgesia may be used,
be confused with a cyst by the unwary.
avoiding the risk of general anaesthesia in the elderly.
10. F. This distinctive cyst forms in relation to
2. Residual cysts are typically composed of a fibrous
pericoronitis and is often pouch like clinically.
capsule lined internally by stratified squamous
EMI 2 non-keratinising epithelium. Inflammation is
often not a feature as the initiating inflammatory
1. A. Dermoid cysts arise from developmental
focus has been removed. The epithelial lining is
midline skin inclusions. In the oral region, they
variable in thickness but often lacks the arcades
may be located above mylohyoid and bulge into
seen in developing cysts still related to a root
the floor of mouth or below mylohyoid where they
apex. Residual cysts frequently contain Rushtons
expand into submental soft tissue. Histological
bodies, cholesterol and haemosiderin.
examination shows the lining to resemble
epidermis and adnexal structures including hair 3. It has been suggested that some individuals are
follicles, sebaceous glands and smooth muscle cyst-prone, i.e. have a tendency to form a cyst in
are also present. response to periapical chronic inflammation.
2. C. Branchial or lymphoepithelial cysts typically Case history 3
present in the second and third decades after
1. The features suggest an aneurysmal bone cyst.
slow enlargement. They are lined by squamous
epithelium and have lymphoid tissue with 2. The loose granulation tissue and giant cells are
prominent follicles in the wall. In older patients, consistent with aneurysmal bone cyst. Often
they may be confused with cystic metastatic such cysts form in relation to another lesion, in
squamous carcinoma in a lymph node. Metastatic this case a fibro-osseous lesion. Other disorders
thyroid cancer can also mimic branchial cyst. associated with aneurysmal bone cyst in the jaws
The cyst must be carefully examined by the include haemangioma, giant-cell granuloma and
pathologist. bone tumours.
3. B. Thyroglossal tract cysts develop at any point 3. Feeding blood vessels might be identified and
from the foramen caecum to the thyroid along embolised, allowing the lesion to be removed and
the line of vestigal thyroglossal duct. Most occur the bone curretted. The pathologist must search
below the level of the hyoid bone and in people for a second pathology and all material removed
under 30 years. should be submitted.
4. E. Lymphangiomatous malformations occur in the Short note answers
cervical region as cystic masses (cystic hygroma).
1. Intraoral radiographs initially and then more
The vast majority are diagnosed in the first 2 years
extensive radiographs as necessary for large
of life.
cysts. Give examples of radiographs for imaging
5. D. Epidermal cysts are very common and occur maxillary and mandibular cysts. Mention that
anywhere on the head and neck skin and at occasionally computed tomography is useful.
other sites. They are lined by stratified squamous
2. Necessity for surgery will depend on diagnosis,
epithelium and contain oily keratinous material.
based on clinical presentation and radiography.
Case history answers Radicular cyst will require endodontic therapy with
or without surgical enucleation and apicectomy
Case history 1 with retrograde root filling. Describe the surgical
1. Odontogenic keratocyst. procedure and follow-up.
2. The patient should be advised of the risks of 3. The differential diagnosis of a radiolucency at the
possible damage to inferior dental nerve, jaw anterior of the maxilla includes: abscess, cyst,
fracture and recurrence rates of up to 40%. fibro-osseous lesion, benign and malignant bone
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Mucosal diseases 11
Overview
Normal structures
Oral mucosa shows considerable variation in its
normal structure and can be affected by a wide In order to be able to recognise mucosal abnormal-
range of conditions. The identification of oral ity, it is necessary to be familiar with normal ana-
mucosal abnormalities is important because they tomical structures that patients may notice and
can be harmless, minor primary conditions and sec- become concerned about. These include:
ondary indications of systemic disease. The situa-
tion is further complicated by the multiple causes lingual papillae, especially circumvallate and
for many mucosal lesions: for example, ulceration foliate papillae
can reflect simple trauma, a habit tic with psychi- incisive papilla and rugae, which are easily
atric implications, lichen planus, infection, gas- traumatised
trointestinal disease such as Crohns disease or a fordyce granules, which may be prominent in
side-effect of a drug. atrophic mucosa
Master Dentistry
Fig. 11.1 Frictional keratosis in a patient who habitually chewed the buccal mucosa, particularly when
stressed.
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Mucosal diseases Chapter 11
is restricted to palatal lesions. The principal fea- on the labial and buccal mucosa as a result of
tures are: mechanical trauma from the teeth or dentures
palatal mucosa appears white and crazed as a (Fig. 11.2). It is easily excised under local anal-
result of keratosis gesia but will recur unless the source of trauma is
corrected.
red spots occur through blockage of minor sali-
Histopathologically there is a core of dense
vary gland ducts
fibrous tissue covered by stratified squamous epi-
histopathology shows keratin plugs in duct
thelium. The latter often shows keratinisation,
openings
reactive to trauma. Secondary ulceration may be
reversible if smoking habit stopped
seen.
not regarded as a potentially malignant disorder.
Fig. 11.2 Leaf-like fibrous hyperplasia of the palate caused by chronic irritation from an ill-fitting upper
denture.
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Mucosal diseases Chapter 11
Fig. 11.3 Minor recurrent aphthous ulceration. Crops of ulcers up to 10mm in diameter may involve the lin-
ing mucosa.
oropharynx is affected. This causes particularly malabsorption), coeliac disease and other disor-
severe symptoms, including pain on swallowing and ders of malabsorption. Oral ulceration is addi-
gagging. tionally observed in immunological disorders.
Behets disease is a multisystem autoimmune
disorder for which RAS is one of the major diag-
Aetiology nostic criteria. Classically, it is accompanied by
The aetiology of RAS is unknown, though there genital ulceration and eye lesions (e.g. uveitis);
are strong associations with having a family his- however, the skin, joints, gastrointestinal tract,
tory of RAS, stress, smoking cessation, anae- blood vessels and central nervous system may
mia and haematinic deficiency. RAS is also seen also be affected in various combinations. Severe
in gastrointestinal disease, particularly Crohns unusual RAS is a recognised manifestation of
disease (which may involve the oral mucosa infection with the human immunodeficiency
directly or induce oral ulceration secondary to virus (HIV).
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Fig. 11.4 Herpetiform recurrent aphthous ulceration. Pinhead-sized ulcers tend to become confluent with
time.
Fig. 11.5 Major recurrent aphthous ulceration. Ulcers tend to occur in the posterior part of the oral cavity
and oropharynx.
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Fig. 11.6 Primary herpetic gingivostomatitis, showing vesicles and erythema of the palatal mucosa and
gingivae.
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Mucosal diseases Chapter 11
finger-like projections. Histologically, fronds of HIV-related gingivitis. This may resemble acute
keratotic squamous epithelium are supported by necrotising ulcerative gingivitis or present as a red
delicate fibrovascular stroma. Papillomas on the lesion, termed linear gingival erythema.
fingers can be the source of human papillomavirus, HIV-related periodontitis. This manifests as
particularly for lesions on the lips and circumoral unusual focal alveolar destruction. Severe alveolitis
skin. Orogenital transmission is also possible. Intra- and osteomyelitis with sequestration of teeth and
oral papillomas can be readily excised under local surrounding tissue may be seen in patients with
analgesia. The high risk HPV types 16 and 18 are advanced AIDS.
an important cause of oropharyngeal carcinoma Other mucosal manifestations in HIV infec-
(see Chapter 12). tion. Purpura results from thrombocytopaenia;
bacillary angiomatosis, atypical ulceration, mela-
notic pigmentation, unusual infections and multiple
Human immunodeficiency virus viral papillomas are also seen.
Initial infection by HIV may be asymptomatic or
may cause a febrile illness with diarrhoea. An oral
eruption clinically similar to primary herpetic sto- Fungal infections
matitis may occur at this time.
Numerous manifestations of established HIV Candida albicans is the most common cause of
infection are recognised. There are several with fungal infection in the oral cavity (Fig. 11.7). It
strongly associated oral manifestations. is a commensal organism carried by roughly half
Kaposis sarcoma. This is caused by human her- the population and disease is caused by oppor-
pesvirus 8 (HHV-8), which is endemic in Medi- tunistic overgrowth. Oral candidiasis has been
terranean regions. Initial mucosal lesions are flat described as the disease of the diseased. Local
brown spots, which show haemosiderin deposition or systemic predisposing factors should be iden-
and vascular proliferation on biopsy. They progress tified and corrected whenever possible (Table
into raised plaques and then nodular purplered 11.1). Diagnosis is generally based on clini-
lesions, most often found on the palate, retromo- cal features and can be confirmed by laboratory
lar areas and gingivae. Oral lesions may precede the methods using material from oral swabs, smears
appearance of skin lesions. or rinses. Where quantification is required, saliva
Hairy leukoplakia. This lesion has been associ- samples, the oral rinse or the imprint culture
ated with progression from HIV infection to AIDS techniques may be used. Other Candida sp.
(acquired immunodeficiency syndrome) as the CD4 may also cause oral infection, particularly in the
T lymphocyte count falls. It is caused by prolifera- immunocompromised.
tion of EpsteinBarr virus (HHV-4) in the lateral Treatment is based on the use of either systemic,
tongue epithelium and rarely elsewhere in the oral fluconazole, or topical antifungal agents. Nystatin is
cavity. Warty ridged or smooth white plaques are available in the form of a suspension. Patients suf-
typical: sometimes extended papillary projections are fering from xerostomia may find this or miconazole
seen. The lesion is also found in HIV-negative immu- gel more pleasant to use; similarly this gel is con-
nosuppressed patients, for example in renal trans- venient for the treatment of denture-induced sto-
plant recipients. Hairy leukoplakia has been recorded matitis as it can be applied directly to the fitting
in patients taking a variety of drugs, including steroid surface of the denture. In addition to the use of
inhalers, and HHV-4 may also be a transient mucosal an antifungal agent, the patient should be advised
infection in healthy people. No treatment is required to leave the denture out at night. Acrylic den-
and the lesion is not potentially malignant. tures should be soaked overnight in a 0.1% solu-
Erythematous candidiasis. This is a frequent tion of hypochlorite. If a cobalt chromium denture
manifestation of HIV infection. It presents as white is worn, it should be soaked for 15 minutes twice
speckles on an erythematous background. Tongue daily in chlorhexidine. These measures should erad-
and palate are frequently affected. Treatment can icate those microorganisms adherent to the den-
be a problem because of the development of resis- ture, which may be more heavily colonised than the
tant fungal strains in some patients. Hyperplastic mucosa.
and pseudomembranous forms of candidiasis are Systemic antifungal agents (e.g. flucon-
also common in HIV infection. azole) should be reserved for those cases of oral
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Fig. 11.7 Denture-related stomatitis. The oral mucosa of the denture-bearing area is erythematous, oedema-
tous and hyperplastic. Candida albicans was recovered from the fitting surface of the denture.
Lesion Characteristics
Thrush (acute pseudomembranous Friable white plaques that can be scraped off; often involves oropharynx; affects infants,
candidiasis) elderly and immunosuppressed adults
Antibiotic sore mouth Generalised erythematous and sore oral mucosa; caused by elimination of bacterial compe-
tition; related to prolonged use of wide-spectrum antibiotics
Denture-induced candidiasis Related to continuous wearing of acrylic dentures; mucosa over fitting surface appears
erythematous and oedematous; patient should improve denture hygiene and leave dentures
out at night
Chronic hyperplastic candidiasis Fixed, white, folded plaques, commonly behind the angle of the mouth; smoking and poor den-
ture hygiene are common predisposing factors; candidal hyphae invade the parakeratin layer
Erythematous candidiasis Red patchy areas, typically on palate and dorsum of tongue; associated with low CD4-cell
counts, particularly in HIV infection; may be a cause of linear gingival erythema
Angular cheilitis Crusted cracked lesions at the angle of the mouth; may be infected by Candida sp. or Staph-
ylococcus aureus; predisposing factors include anaemia and saliva spreading to skin
Median rhomboid glossitis Lozenge-shaped erythematous patch on the midline dorsal tongue; usually symptomless;
epithelial hyperplasia with neutrophils in the parakeratin layer
Mucocutaneous candidiasis Generalised chronic oral candidiasis resulting in fixed mucosal white patches; immune
defect may be detected but sometimes idiopathic; some types associated with endocrine or
thymus disease; nails often affected, other mucosal sites may also be involved
candidiasis where topical antifungal agents are In contrast to nystatin, triazole or imidazole anti-
not appropriate. There are an increasing number fungal agents, including miconazole gel, are read-
of reports of resistance to azole antifungal drugs. ily absorbed via the gastrointestinal tract thus
These drugs play a significant role in the treatment care should be taken to check for possible drug
of candidal infections in the immunocompromised. interactions.
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Fig. 11.9 Lichen planus showing erosive and superficially ulcerated lesions.
2 . Minor erosive type: areas of redness and super- Plaque lesions: white patches.
ficial ulceration. Papular lesions: small white spots, which may
3. Major erosive type: atrophy, redness and exten- join up.
sive ulceration. Annular lesions: circular arrays of white lines.
Oral lesions of various types may occur in any of Atrophic lesions: diffuse red areas.
the variants of lichen planus: Erosive lesions: extreme atrophy leading to
Reticular lesions: network or linear white bands ulceration (Fig. 11.9).
(Fig. 11.8). Bullous lesions: blood-filled blisters, rare type.
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Fig. 11.10 Lichen planus, showing the subepithelial band of lymphohistiocytic infiltrate and basal-cell
degeneration.
Skin lesions
T lymphocytes cross the basement membrane
Skin lesions are classically violaceous, itchy macules into epithelium.
and papules on the flexor surfaces. The papules show
Basal-cell liquefaction and degeneration.
distinctive white lines, termed Wickhams striae.
They may be more widespread on the trunk. Finger-
Apoptosis of basal cells results in Civatte (col-
loid) bodies.
nails may be ridged or atrophied. The scalp may be
involved, leading to hair loss. In females, the vulva Sawtooth rete processes, typical of skin
and, far less commonly, the vagina may be affected. lesions, not always seen.
Ulceration may alter the characteristic features.
Lichenoid mucositis
Lichenoid mucositis is a clinical term for condi-
tions that have similar clinical features, such as Aetiology
lichenoid reaction (drugs and restorative materials), The cause of lichen planus is not known, though
lupus erythematosus and graft-versus-host disease. it has been linked with hepatitis C infection in
Lichenoid reaction due to amalgam is increas- southern European peoples. Skin lesions tend to be
ingly recognised clinically where restorations are in transitory, while oral lesions are more persistent.
direct contact with the oral mucosa. Non-erosive lichen planus is often not symptom-
atic. Biopsy is required, however, to establish a tis-
sue diagnosis. There is an association between lichen
Histopathological features planus and oral cancer with a risk of about 1% over
Appearances vary and successful diagnosis a 10 year period. Appropriate advice about alco-
depends on adequate biopsy from a representative hol, paan and tobacco as risk factors for oral cancer
site (Fig. 11.10): should be given. Regular review is recommended.
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Fig. 11.12 Desquamative gingivitis. The atrophic, erythematous appearance can be caused by a number of
diseases. This example is cicatricial pemphigoid.
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Erythema multiforme foodstuffs and the taking of very hot drinks have
Erythema multiforme is typified by recurrent been reported, and these risk factors should be con-
bullous eruptions. Crusted haemorrhagic bul- sidered in providing advice. Some clinicians advise
lae are often seen on the lips, the oral mucosa, pricking any fresh lesions with a sterilised needle
eyes and genital area. Target lesions sometimes to release the blood and speed healing. If discom-
occur on the skin. Sites may be affected in iso- fort is experienced, the use of an analgesic mouth-
lation or in combination. In rare severe disease, wash such as benzydamine hydrochloride may be of
there may be febrile illness and hospital admis- benefit.
sion may be needed. Diagnosis is primarily made
on clinical grounds, although the oral lesions may
mimic primary herpetic gingivostomatitis. The 11.8 Granulomatous disorders
disorder is believed to be an immunologically
mediated hypersensitivity reaction. The major- Learning objectives
ity of attacks are triggered by recurrent herpetic
You should:
lesions or other infections, e.g. Mycoplasma, and
know what a granuloma is and how to investigate it
drugs or chemicals have also been implicated.
know the potential causes of granuloma.
During the acute phase, systemic steroids may be
prescribed if not contraindicated but their value
is disputed, and it is important to ensure that In pathology, a granuloma is defined as a collec-
fluid intake is maintained. Antiseptic mouthrinses tion of macrophages in tissue. Granulomatous
may be used to prevent secondary infection. It inflammation characterises a number of local and
is then important to establish the cause and pre- systemic disorders of the oral mucosa. This type
vent exposure to the causative agent if possible. of granulomatous inflammation should not be con-
Prophylactic aciclovir is generally prescribed in fused with the term granuloma when applied
the first instance to prevent recurrence even in clinically to lesions formed by vascular granula-
the absence of evidence of preceding herpetic tion tissue, such as apical granuloma and pyogenic
infection. granuloma.
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Fig. 11.13 Crohns disease, showing cobblestone mucosa and slit-like fissure ulcers.
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Fig. 11.14 White sponge naevus. The buccal mucosa appears folded and spongy.
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Fig. 11.15 Vascular epulis. Note the epithelial collarette at the base and ulcerated surface.
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Q Self-assessment: questions
Multiple choice questions ( True/False) b. Hairy leukoplakia is an AIDS-defining lesion
1. In vesiculo-bullous disorders involving the oral c. Kaposis sarcoma is caused by
cavity: cytomegalovirus
a. A positive Nikolskys sign is only found in d. HIV infection may result in salivary gland
pemphigus vulgaris lesions
b. Mucous membrane pemphigoid is typified by e. Oral candidiasis is the most common oral
subepithelial bullae manifestation of AIDS
c. Circulating autoantibodies are present at a high 6. Gingival enlargements:
titre in mucous membrane pemphigoid a. Generalised gingival overgrowth may be
d. Mucous membrane pemphigoid (MMP) is caused by tacrolimus
the most common cause of desquamative b. An epulis may occur in any part of the oral
gingivitis cavity
e. Prompt fixation of a mucosal biopsy is required c. Chronic lymphatic leukaemia is the most
for successful direct immunofluorescence frequent type of leukaemia associated with
testing gingival enlargement
2. Recurrent aphthous stomatitis (RAS): d. May be caused by an autosomal dominant
a. Affects up to 10% of the population gene
b. Usually onsets during the first 2 years of life e. Excessive gingival overgrowth in transplant
c. Is nearly always related to underlying iron, recipients should be trimmed away under local
folate or vitamin B12 deficiency anaesthesia in the dental surgery
d. Herpetiform aphthae may involve the hard 7. Mucosal manifestations of systemic disease:
palate a. Coeliac-associated recurrent oral ulceration
e. Severe aphthous stomatitis may be a feature of can be detected by testing for -gliadin
HIV infection autoantibodies
3. The oral lesions of lichen planus: b. Cobblestone mucosa, fissure ulcers and mucosal
tags are found exclusively in Crohns disease
a. Typically exhibit sawtooth rete ridges in
biopsies c. Chronic iron deficiency may be linked to the
finding of oral epithelial dysplasia in mucosal
b. On the gingiva are most commonly reticular in
biopsies
nature
d. Pyostomatitis vegetans is a manifestation of
c. Are most commonly bilateral and often
ulcerative colitis
symmetrical
e. Diffuse mucosal pigmentation may be seen in
d. Are typically associated with a subepithelial
Addisons disease
band of infiltrating B lymphocytes
8. Herpes virus infections of the oral mucosa:
e. Often improve clinically with topical
corticosteroid therapy a. Herpes simplex virus type II infections may
cause primary herpetic gingivostomatitis
4. In oral candidiasis:
b. Aciclovir cream applied twice daily is the most
a. Most pathogenic Candida species involving the
appropriate treatment for recurrent intraoral
oral cavity are dimorphic
herpes simplex infection
b. Candida species never invade the oral
c. Herpes simplex is an RNA retrovirus
epithelium
d. Herpes simplex infection may rarely cause
c. Diffuse chronic mucocutaneous candidiasis
serious gastroenteritis in neonates
may be associated with endocrine
abnormalities e. Herpangina is a clinical variant of herpes
simplex infection that results in painful vesicles
d. Miconazole can be absorbed systemically from
affecting the soft palate and oropharynx.
its oral gel preparation (Daktarin oral gel)
9. White sponge naevus:
e. Candida carriage rates are higher in smokers
than in non-smokers a. Is an autosomal recessive disorder
5. Oral manifestations of human immunodeficiency b. Is restricted to the oral mucosa
virus (HIV) infection and the acquired c. Exhibits hyperparakeratosis, spongiosis and a
immunodeficiency syndrome (AIDS): basketweave appearance in biopsies
a. Initial infection is not associated with oral d. Is caused by a mutation in the gene APC
manifestations e. Is a premalignant condition
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5. How would you manage an elderly patient with 7. Which mucosal lesions are strongly associated
submucous fibrosis? with HIV infection?
6. What are the three common histological types of 8. What are the possible oral manifestations of
epulis? leukaemia?
A Self-assessment: answers
Multiple choice answers 2. a.False. Most estimates suggest that over 20%
1. a.False. Nikolskys sign is the formation of a of the population are affected by RAS.
blister when lateral pressure is applied to skin b. False. Onset can be at any age but most
or mucosa. It is found in pemphigus, some commonly occurs at puberty.
forms of mucous membrane pemphigoid and c. False. Haematinic deficiency may be found
other vesiculo-bullous dermatoses. in up to 25% of RAS patients, in some
b. True. The antigenic targets are located in populations.
and around the hemidesmosome/basement d. True. Herpetiform and major RAS may involve
membrane complex. keratinised oral mucosa.
c. False. Sensitive detection systems are required e. True. Severe and atypical RAS has been
to detect circulating autoantibodies in MMP. reported in HIV sufferers.
Mucosal biopsy is usually performed. 3. a.False. Sawtooth rete ridges are characteristic
d. False. Lichen planus is the most common of lichen planus in skin biopsies and are found
cause of desquamative gingivitis. It may also in less than one-third of oral biopsies.
be caused by mucous membrane pemphigoid, b. True. Striae may be conspicuous or evident
pemphigus, plasma cell mucositis and allergic on close examination of gingival lesions in
reactions. desquamative gingivitis caused by lichen
e. False. Perilesional mucosa is required for planus.
direct immunofluorescence and the tissue must c. True. Solitary patches of lichenoid mucositis
be snap-frozen or submitted to the laboratory may be a reaction to dental materials.
in special transport medium.
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d. False. The subepithelial infiltrate typically 7. a.False. Testing for -gliadin antibody has been
comprises mostly T lymphocytes and histiocytes. replaced by testing for endomysial or tissue
A few B lymphocytes may be present. transglutaminase antibody. A positive result
e. True. Topical corticosteroids are often used to should trigger referral to a gastroenterologist
treat symptomatic erosive lichen planus. for further investigation.
4. a.True. Most candidal infection is caused by C. b. False. These features may be seen in orofacial
albicans; other species such as C. glabrata, granulomatosis.
C. krusei, C. tropicalis and C. parapsilosis may c. True. This is important particularly in the
cause oral infection. All are dimorphic. PlummerVinson syndrome.
b. False. In chronic hyperplastic candidiasis d. True.
(candidal leukoplakia), pseudohyphae invade e. True.
the parakeratin layer. 8. a.True. However, herpes simplex type I is the
c. True. Autoimmune polyendocrinopathy more common cause.
syndrome is a rare autosomal recessive b. False. Aciclovir cream is not suitable for
disorder; it is one form of diffuse intraoral use; systemic aciclovir may be
mucocutaneous candidiasis. prescribed if necessary.
d. True. Significant systemic absorption of c. False. Herpes simplex is a DNA virus.
miconazole may occur and has been reported
d. False. It may rarely cause encephalitis.
to potentiate the action of warfarin, resulting in
e. False. Herpangina is caused by coxsackievirus A.
severe purpura.
9. a.False. White sponge naevus is an autosomal
e. True. Carriage rates are also increased in
dominant disorder.
pregnancy and in denture wearers.
b. False. It may also involve the anogenital
5. a.False. Initial HIV infection may be
region, nose and oesophagus.
asymptomatic or may be associated with a
flu-like illness, diarrhoea and a generalised c. True. Biopsy is only made if there is doubt
stomatitis. about the diagnosis.
b. False. Hairy leukoplakia is a warty plaque d. False. It is caused by mutations in the genes
caused by EpsteinBarr virus overgrowth and for keratin 4 and 13.
occurs in CD4-cell lymphopenia related to HIV e. False. Other very rare forms of hereditary white
and non-HIV disorders. patch, such as those associated with tylosis
c. False. Kaposis sarcoma is caused by and dyskeratosis congenita, are associated
human herpesvirus 8 (HHV-8), endemic in with malignancy.
Mediterranean regions. 10. a.True.
d. True. HIV infection is associated with b. False. Migratory glossitis (geographic tongue)
lymphoepithelial salivary cysts, dry mouth and is not linked to systemic disease.
malignant lymphoma. c. True. This is termed median rhomboid
e. True. glossitis.
6. a.False. Drug-induced gingival overgrowth d. False. A red, beefy tongue is seen in
(DIGO) is associated with phenytoin, haematinic deficiency.
ciclosporin and calcium-channel-blocking e. False. Black hairy tongue is not a manifestation
drugs such as nifedipine. of a syndrome. PeutzJeghers is a syndrome
b. False. An epulis is a localised swelling of the of mucocutaneous melanotic pigmentation and
gingivae. gastrointestinal polyposis.
c. False. Acute leukaemia more typically results in
Extended matching items answers
enlargement of the gingivae, through infiltration
by leukaemic cells. EMI 1
d. True. Hereditary gingival fibromatosis is known 1. B. Mucous membrane pemphigoid can
to be caused by mutation of the SOS-1 gene affect the oral cavity, conjunctive and
on chromosome 2p. genital mucosa. Testing by indirect and
e. False. Excessive bleeding has been reported direct immunofluorescence can be helpful in
and such cases are best referred for specialist establishing the diagnosis.
care.
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2. C. Dysplasia and even invasive oral cancer 4. C. White sponge naevus is caused by a mutation
can present clinically as a red patch. All such in keratin genes (often K4) and is autosomal
suspicious oral lesions should be biopsied or dominant. No treatment is needed.
referred for consultant opinion. 5. J. Traumatic ulcerative granuloma with stromal
3. I. Strawberry gingival papillae are a classical sign eosinophils (TUGSE) is caused by crush injury to
of a vasculitic disease, Wegeners granulomatosis. tongue muscle. A thick fibrinous crust is present
Ulceration may be present and prompt referral to and the deeper muscle fibres are separated by
a specialist unit is indicated. histiocytic cells and eosinophils. Clinically the
4. A. Desquamative gingivitis is a clinical term disorder can mimic carcinoma. Spontaneous
describing red atrophic-looking gums. The most resolution with conservative measures is
common underlying disease process is lichen observed.
planus, but vesiculo-bullous disorders can have 6. H. Fordyce spots are normal sebaceous glands
similar clinical appearances. that occur in oral mucosa and oesophagus. In
5. D. Plasma-cell mucositis is a rare condition that older patients or where atrophy is present they
affects the oral mucosa and that can extend can be quite prominent.
into the supraglottic larynx. Mature plasma cells 7. I. When dental amalgam enters mucosal tissue
expand connective tissue papillae and this can it can form a pigmented lesion. Corrosion leads
result in a spongy appearance. Allergy to herbal to spread of the particles with time and clinically
and leaf products may be the cause in some the lesion appears to enlarge. Other causes of
patients. discrete pigmented lesions are melanotic macules,
6. H. Dentists may see children with primary herpetic naevi and malignant melanoma.
gingivostomatitis. Small grey vesicles are typical 8. F. Stomatitis nicotina or smokers keratosis is a
but quickly break down into small ulcers. distinctive lesion of the soft palate. The red spots
7. G. Linear gingival erythema is a recognised oral represent salivary duct openings. The lesion is
manifestation of HIV infection and is variant or not premalignant. Patients often give an unreliable
erythematous candidiasis. smoking history.
8. F. Leukaemia may present with gingival swelling 9. D. Haemangiomas are blood-filled developmental
or bleeding and may be confused with chronic lesions and are common in the tongue. Blood can
periodontitis. be displaced by pressure or a fine needle can be
9. E. Over half of patients suffering from pemphigus used to sample contents to confirm the diagnosis.
present first with oral disease. Autoantibodies 10. G. Chronic hyperplastic candidosis is seen
against desmoglein 3 occur and cause suprabasal most often in denture wearers and smokers.
oral keratinocytes to separate, resulting in Candida pseudohyphae extend into the keratin
intraepithelial blisters. Testing by direct and and provoke active chronic inflammation.
indirect immunofluorescence may be helpful to Predisposing factors should be eliminated and
establish the diagnosis. systemic antifungal drugs can be prescribed if not
10. J. These histological features are typical of contraindicated clinically.
giant-cell granuloma. The differential diagnosis
Case history answers
should include central giant-cell granuloma and
hyperparathyroidism. Case history 1
1. Severe oral ulceration has been linked to
EMI 2 nicorandil therapy. This is prescribed for
1. E. Nicorandil is a drug given for intractable angina. uncontrollable angina and often cannot be
Some individuals develop deep painful and substituted.
persistent oral ulcers, often at fixed sites. 2. A full history should be obtained; full blood count
2. A. Hairy leukoplakia is caused by proliferation of and haematinics would be requested and other
EpsteinBarr virus (HHV4) in the upper layers of investigations may be needed.
the oral epithelium in immunosuppressed patients. 3. Benzydamine hydrochloride (Difflam oral rinse or
HIV infection or drugs given to prevent transplant spray) may relieve pain and carmellose sodium
rejection can predispose to HL. (Orabase or Orahesive) may be used as a protective
3. B. Minor aphthae (recurrent oral ulceration) occurs barrier. Topical steroids may be of benefit.
on lining oral mucosa. Ulcers tend to last for less
than 2 weeks and rarely exceed 5mm in size. Case history 2
They are common in children and teenagers. 1. The features suggest frictional keratosis.
Sudden onset in adult life may indicate an 2. Marked wear facets are often seen in bruxism
underlying systemic disorder. (habitual teeth grinding); a thickened band is often
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Mucosal diseases Chapter 11
seen on the lateral tongue and buccal mucosa at the 3. Hepatitis C infection has been linked with oral
level of the occlusal plane owing to chronic trauma. lichen planus.
3. Provision of a protective splint may reverse
Oral examination answers
frictional keratosis by eliminating mechanical
trauma to the mucosa and correcting uncontrolled 1. Normal racial pigmentation; extrinsic causes
jaw movements or habitual chewing. such as paan chewing, smoking, chlorhexidine
4. Classical histopathological features of frictional rinses and drugs; intrinsic causes such as
keratosis are acanthosis, hyperparakeratosis and melanin incontinence in Addisons disease,
maceration of the parakeratin layer with formation haemochromatosis and jaundice.
of bacterial plaque on its surface. Epithelial 2. Hydrocortisone oromucosal tablets, applied
maturation is regular. as directed in the British National Formulary,
betamethasone soluble tablets as a mouthwash
Case history 3 and beclometasone aerosol inhaler as an oral
1. The features strongly suggest angina bullosa spray.
haemorrhagica. 3. A representative area should be selected and the
2. Full blood count and coagulation screen to biopsy should be of adequate size and depth.
exclude a bleeding disorder. Crushing should be avoided and local anaesthetic
3. A link between inhaled steroids and angina bullosa solution must not be injected directly into the
haemorrhagica has been suggested. biopsy site. Normally biopsies are fixed in 10%
neutral buffered formalin; at least 10 times the
4. Reassure the patient and advise use a nebuliser,
volume of the biopsy must be used. The specimen
rinse out mouth after using inhaler, avoid
pot must be labelled and the request card should
excessively hot drinks and hard or rough foods.
be completed carefully, providing full clinical
Case history 4 details.
1. Miconazole nitrate (Daktarin cream) has antifungal 4. Swabs are taken to estimate growth, perform
and antistaphylococcal activity. It is also available speciation and other microbiological tests. Smears
in a combined preparation with hydrocortisone are employed for rapid detection of pseudohyphae
(Daktacort). Nystatin cream may also be used. by periodic acid-Schiff base or Gram staining;
2. Lip swelling, cobblestone mucosa, ulceration and this indicates candidal proliferation and is a good
granular gingivitis suggest a diagnosis of oral indicator of candidal infection.
Crohns disease (orofacial granulomatosis). 5. Submucous fibrosis is related to paan chewing.
3. Mucosal biopsy would show non-caseating Advice should be given to discontinue this habit
granulomas, scattered chronic inflammatory and avoid other risk factors for oral cancer.
infiltration and dilated lymphatic vessels with Regular checking of the oral cavity is advised.
lymphoedema. 6. Fibrous, vascular and giant-cell types. Other
4. It is important to investigate for Crohns disease in disorders, including primary and secondary
the gastrointestinal tract. cancers, can present as a localised gingival
swelling.
Case history 5 7. Erythematous candidiasis, hairy leukoplakia, HIV
1. Reticulated lesions of lichen planus are shown. The gingivitis, Kaposis sarcoma.
white lines are often referred to as Wickhams striae. 8. Gingival and mucosal bleeding and purpura from
2. A band-like subepithelial lymphohistiocytic thrombocytopenia; gingival enlargement caused
infiltrate, basal-cell liquefaction degeneration, by infiltration by leukaemic cells (especially
Civatte bodies and sometimes sawtooth rete in acute myeloid types); dry mouth; mucosal
processes. atrophy; and ulceration.
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Premalignancy and malignancy 12
Fig. 12.1 Submucous fibrosis showing tethering bands involving the buccal mucosa.
be reduced to only a few cell layers in thickness. iron-deficiency anaemia and difficulty in swal-
Keratinisation and chronic inflammation may be lowing because of formation of a postcricoid fold
present in some cases. Where areas of erythroplasia (oesophageal web) is known as the Patterson
and leukoplakia are present, biopsies may show epi- KellyBrown or PlummerVinson syndrome.
thelial dysplasia or even carcinoma. Chronic iron deficiency results in generalised
mucosal atrophy because iron is an essential growth
requirement for the oral epithelium. Carcinoma
Atrophic lichen planus may develop in the oesophagus and less commonly
in the oral cavity, pharynx or larynx.
Links between lichen planus and oral cancer have
been debated. Some evidence links atrophic vari-
ants of oral lichen planus, characterised by red Genetic disorders
areas of mucosal thinning and erosions, with an
increased tendency to develop oral cancer. There The rare disorders tylosis and dyskeratosis con-
are no proven associations between oral non-erosive genita predispose to the development of leukopla-
lichen planus or cutaneous lichen planus and malig- kia and oral cancer. Fanconis anaemia may also
nant transformation. Lichenoid inflammation may dispose to potentially malignant disorders and is
be found in dysplastic lesions, particularly in a high- associated with a increased risk of head and neck
risk lesion known as proliferative verrucous leuko- cancer including oral cancer.
plakia. Other forms of lichenoid mucositis, such as
lichenoid reaction and discoid lupus erythemato-
sus, may additionally be confused with lichen pla- Leukoplakia and erythroplakia
nus. Tobacco or paan use should be discouraged in
lichen planus sufferers. Patients should be advised Previously, premalignant lesions were defined as
to limit alcohol intake to guidelines. areas of morphologically altered tissue in which
cancer can arise. Various terms have been used
to describe these lesions and diagnosis is often
Sideropenic dysphagia made by exclusion. Many lesions do not prog-
ress to cancer and some even regress. It is prob-
A number of conditions can result in diffi- able that a proportion of lesions diagnosed as
culty in swallowing. The association of primary potentially malignant are actually reactive, while
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Premalignancy and malignancy Chapter 12
others do not progress within the lifetime of the exclusion of other defined disorders. A semantic
patient. Discrete white or red mucosal patches are problem exists in that diagnosis by exclusion may
referred to leukoplakia and erythroplakia respec- lump more than one disease together and depends
tively. Proliferative verrucous leukoplakia (PVL) is on which diseases are recognised as definable. The
a clinically and histologically distinctive high-risk prevalence of leukoplakia varies from 0.2% to 4%
oral lesion. and the risk factors are tobacco, paan, alcohol and
possibly candidal infection.
The risk of malignant transformation is difficult
Leukoplakia to estimate in any individual case. Lesions in the
floor of mouth and ventral tongue, and those show-
Various definitions of leukoplakia have been pro- ing evidence of epithelial dysplasia or carcinoma in
posed but it is essentially a predominantly white situ, are considered to be at high risk (Fig. 12.2).
lesion that cannot be characterised as any other Paradoxically, the risk of malignant transformation
definable lesion. Leukoplakia is a clinical diagnosis is greater in non-smokers than in smokers. Leuko-
and has a variable histology. plakia is very rare in non-smokers. The regression of
Homogeneous leukoplakias are plaque-like leukoplakia in smokers following cessation suggests
lesions with a uniform smooth or wrinkled that a proportion of lesions are reactive, whereas
surface; there is less risk of malignant leukoplakia in non-smokers may reflect a local cel-
transformation. lular genetic change that tends to be progressive.
However, there is evidence to suggest that smoking
Non-homogeneous leukoplakias tend to be
cessation in leukoplakia reduces risk, and an appro-
less circumscribed and show a greater range of
priate intervention is advised.
appearances. Proliferative verrucous leukoplakia
has a warty appearance and speckled leuko-
plakia has interspersed red areas. Heaping up Other terms for leukoplakia
of keratin, nodularity and ulceration may be
A variety of terms have been employed to describe
present. The risk of malignant transformation is
leukoplakic potentially malignant oral lesions.
greater in non-homogeneous leukoplakia. Often
these lesions are multifocal.
Sublingual keratosis. This term is applied to
leukoplakia affecting the floor of mouth and ven-
The diagnosis can only be made after careful tral tongue. One reported series described a malig-
clinical examination with representative muco- nant transformation in over 30% but this has not
sal biopsy, as these procedures are essential for been confirmed by later studies. The term is not
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Premalignancy and malignancy Chapter 12
Feature Comment
Nuclear and cellular Variation in the sizes and Second
mutation
pleomorphism shapes of cells and nuclei
Increased nuclear/ Can be quantified using
cytoplasmic ratio cytophotometry
Further 4 8
Nuclear hyperchromatism Intense staining of nuclei mutations
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Epidemiology
surgical or laser excision or drug treatment may
be considered
Global incidence and trends
regular review and observation: investigation if
signs of cancer appear. The global incidence of oral and oropharyngeal can-
cer has been estimated at over 405000 new cases
Referral to a specialist centre is usually advisable per year. Of these, over 30000 occur in the USA
for patients presenting with white or red muco- and around 4600 occur in the UK. There is marked
sal patches, or other suspicious lesions. Biopsy geographical variation in distribution, with the high-
is normally required for diagnosis and to deter- est incidence in the Indian subcontinent and south-
mine whether epithelial dysplasia is present. Some east Asia, because of the particular use of paan
patients may be followed up in primary care settings. and tobacco. Oral and oropharyngeal cancer ranks
in the top ten in prevalence tables. The incidence
of oral cancer is rising and more cases are seen in
12.3 Oral cancers younger age groups. The male to female ratio of
around 2.5:1 is also changing, with an increasing
Learning objectives oral cancer incidence in women, particularly involv-
ing the tongue.
You should:
know the epidemiology and types of oral cancers
know the clinical and pathological features of Morbidity and mortality
squamous-cell carcinoma
Overall 5-year survival for oral cancer is just over
understand the management of squamous-cell
carcinoma including its grading.
50% but depends very much on the stage at initial
diagnosis and clinical factors. Squamous-cell car-
cinoma of the lip has a better prognosis than intra-
Most oral cancers do not arise in a clinically recog- oral carcinoma. In general, prognosis is worse when
nised premalignant lesion and are diagnosed as pri- tumours arise in the more posterior parts of the
mary cancerous lesions. They are typically painless, oral cavity than in the anterior area. Midline carci-
unless infected or advanced, and often cause no nomas in the floor of the mouth and ventral tongue
symptoms. For this reason, the need to conduct a may, however, spread to both sides of the neck.
careful systematic examination for every patient Staging is a system used to describe the degree of
cannot be stressed too much. Extraoral examina- spread or tumour load and the most widely used
tion should include both visual inspection of the face TNM (tumour, lymph node, metastases) system
and neck and palpation of the neck (see Chapter 2). is described in Tables 12.2 and 12.3. Survival at
The patients head should be tilted forwards and the 5 years for TNM stage I oral carcinoma is around
lymph nodes in the neck palpated in relaxed tissue. 80%, whereas survival is reduced to 15% for stage
A routine technique should be adopted, perhaps IV. Morbidity refers to the reduction in function,
starting with the submental nodes and then mov- both physical and psychological. Again, morbid-
ing to more posterior node groups. The oral mucosa ity tends to relate to stage, as large tumours may
and oropharynx should be examined carefully. The require removal of a large amount of tissue or radi-
tongue should be protruded to detect lateral devia- cal radiotherapy. Hospital readmission is frequent
tion and then relaxed and lifted to allow exami- during treatment and, in many cases, tumours prove
nation of its ventral surface and the floor of the refractory to all forms of therapy. Quality of life can
mouth. Correct positioning and the use of good illu- be assessed and is an important measure of morbid-
mination and mirrors are important factors. When ity. Good dental health is a significant factor.
oral cancer is detected, prompt referral is essential.
The importance of attending at the hospital should
be stressed, without provoking undue anxiety. Until Types of oral cancer
a biopsy result is available, definitive diagnosis
should be avoided. Any ulcer that fails to heal within Squamous-cell carcinoma accounts for around 95%
a 3-week period should be regarded as suspicious of all oral cancers. It arises from the epithelial lin-
and the patient should be referred to a specialist. ing of the oral cavity. It is described in detail in the
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Table 12.2The TNM (tumour, lymph nodes, metastases) Table 12.3 Stage determination from TNM data
system used for determination of clinical and
pathological stage of carcinoma. The system Stage T level N level M level
now includes an assessment of clinical risk 0 Tis N0 M0
Component Features I T1 N0 M0
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intake. It is believed that carcinogens in tobacco held in the oral cavity for a considerable time and
smoke accumulate in the floor of the mouth, is habit forming. Buccal and labial cancers are com-
accounting for the increased risk of squamous car- monly associated with paan use. Other tobacco hab-
cinoma at that site. its exist, including smearing tobacco paste into the
mouth and reverse bidi smoking, which has been
Paan and other tobacco use linked to palatal cancer. In recent times, areca nut
Paan, also known as betel quid, is used throughout has become popular in southeast Asia.
the Indian subcontinent. Leaf of the betel piper vine
is used to form a rolled-up quid, into which areca Alcohol
nut is placed. Areca is thought to contain alka- Alcohol is an important cofactor when com-
loid carcinogenic precursors. In addition, tobacco, bined with smoking and is now regarded a risk
spices and slaked lime may be added. The quid is factor in its own right. It may increase epithelial
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permeability, allowing greater access of carcinogenic protein, p16, accumulates in the cells and can be
substances to the basal cells. detected in the pathology laboratory by immunos-
taining. Clinical trials have shown that p16 posi-
Ultraviolet light tive oropharyngeal cancers have a more favourable
Ultraviolet B is an important factor in lip cancer. prognosis than negative carcinomas and immunos-
Fair-skinned races in tropical latitudes are par- taining for p16 can used as a prognostic marker.
ticularly at risk from sunlight. Protection, using High-risk HPV can be additionally detected by in
measures such as sun block and wearing a wide- situ hybridisation for HPV DNA and biologically
brimmed hat, is advocated where there is high risk. active high-risk HPV can be detected by RNA in
situ hybridisation for E6 and E7 mRNA. Oral cav-
Diet ity squamous carcinoma is not routinely tested for
Evidence is accumulating that a poor diet with low HPV because of the very low frequency of HPV
antioxidant action (deficient in fresh vegetable con- involvement.
tent) is an important contributory factor.
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Fig. 12.7 A squamous-cell carcinoma of the floor of mouth showing the raised rolled borders. The
lesion was painless and the patient presented requesting new dentures.
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Fig. 12.8 Tongue deviation on thrusting the tongue outwards. The patient had a large carcinoma in the oro-
pharynx, which had tethered the tongue on the left side.
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Fig. 12.9 A squamous-cell carcinoma showing a keratin pearl and cellular pleomorphism.
(MRI) and particularly positron emission tomog- of prognosis. Pattern of invasion is more impor-
raphy (PET) scanning can help to determine the tant; tumours that invade tissue on a non-cohesive
extent of bone and soft tissue spread (Fig. 12.10). front (single cells or narrow strands) have a worse
prognosis than those that invade on a broad front.
Metastasis Anaplastic (undifferentiated) tumours have a very
Carcinoma spreads to regional lymph nodes via poor prognosis. Perineural and lymphovascular inva-
the lymphatics. The primary site is important: lip sion are also indicators of poor prognosis. As yet, no
cancers spread to the submental nodes, whereas molecular markers are in routine use for oral can-
intraoral tumours are more likely to spread to the cer. As described above, markers for high-risk HPV
cervical nodes (see Fig. 2.1, p. 15). Involved lymph are used to detect carcinomas with a more favour-
nodes become first palpable and then fixed and able prognosis in the oropharynx.
hard. With increasing tumour deposition, nodes
may become matted together or even cystic as a Staging: TNM classification
result of central necrosis. Tumours in the anterior Clinical and pathological staging refers to determi-
floor of the mouth and tongue may metastasise to nation of the extent of tumour size and spread. The
both sides of the neck. Imaging can also identify patient is examined carefully and imaging is used
suspicious nodal metastasis to help treatment plan- to aid in the detection of involved neck nodes. The
ning. Fine-needle aspiration can be used to detect TNM (Tables 12.2 and 12.3) system is widely used.
cancer in equivocal nodes. Pathological staging (pTNM) is undertaken on sur-
Distant metastasis is a relatively late event but gically resected specimens and is more accurate
spread may occur to the lungs, brain, viscera and than clinical staging.
bone. Chest radiography, isotopic bone scans and CT,
MR or PET may be used to detect distant metastasis.
Imaging of oral squamous-cell
carcinoma
Grading and staging
The role of imaging in oral cancer management
Histological grading: prognostic features includes:
Histological grading refers to those features seen
in the microscope that can be related to the bio- identifying tumour size and anatomical extent
logical behaviour of the tumour. The degree of detection of regional nodes (staging)
differentiation is not a particularly good indicator post-treatment follow-up.
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Premalignancy and malignancy Chapter 12
Plain radiographs have a very limited role to play in inflammation. Neoplastic (and inflammatory)
in assessment and management of oral squamous- nodes frequently show ring enhancement follow-
cell carcinoma. Advanced lesions on the floor of ing contrast injection. Imaging contributes to the
the mouth may cause gross bone destruction in clinical staging process not least because it shows
the adjacent mandible, but detection of early bony nodes (retropharyngeal) beyond the scope of clini-
involvement has poor sensitivity. Radioisotope cal examination.
bone scans can be used to detect such early bone
destruction. These bone scans, particularly in com-
bination with CT, lead to good diagnostic sensitivity Treatment
in detection of bone involvement. The treatment of oral cancer is usually surgery fol-
Imaging of oral squamous-cell carcinoma relies lowed by radiotherapy, whereas orophryngeal can-
upon cross-sectional techniques (i.e. CT or MRI). cers, which are more likely to be at an advanced
Thin-slice (35-mm) CT sections are usually per- stage at the time of diagnosis, are managed with
formed through the oral region and neck. Intrave- radiotherapy or chemoradiation. Surgery for oral
nous iodinated contrast is given and the scans are cancer can be disfiguring and there can be signifi-
repeated, because neoplastic lesions of the floor of cant functional side effects such that eating, drink-
the mouth and tongue base tend to enhance, which ing and speaking are affected. It is hoped that
improves the delineation between normal and development of new chemotherapy agents, new
abnormal tissues. Contrast also highlights vessels, treatment combinations and timings may increase
allowing them to be more easily distinguished from the survival and quality of life of these patients.
nodes. PET can be used to detect small depos-
its of metastatic carcinoma and can often localise Surgery
unknown primary sites. On the basis of a Cochrane review and meta-
When examining images of submandibular analysis studies, surgery is generally the preferred
and jugulodigastric nodes of the internal jugu- modality of treatment for oral cancer. Small lesions
lar chain, those nodes with a diameter exceeding may be successfully removed by laser surgery.
1.5cm are abnormal; in other parts of the neck, Radical surgery is used to remove biopsy-proven
1cm is the maximum size of normal nodes. A larger primary oral cancers. It is first necessary to
low-density centre may be seen in nodes contain- undertake a full hospital examination including
ing tumour, although this finding may also be seen imaging. This often includes examination of the
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upper aerodigestive tract under general anaesthe- issue of neck dissection where there is no clinical,
sia to exclude second primary lesions. Other tests radiological or cytological evidence of cervical nodal
are used to exclude distant metastases. Informed disease is contentious. Many centres routinely per-
patient consent and support are vital. Cases are form elective neck dissection in the clinically and
normally discussed at a meeting of all health care radiologically negative neck because occult meta-
professions involved in treatment. In the UK, all static disease may be present in around 25% of
new cancer cases are discussed at a multidisci- cases. Alternatively, dye and radioactive tracers
plinary team (MDT) meeting; elsewhere there may can be used to identify sentinel node basins in the
be tumour board meeting. The surgical operation direct drainage pathway of the tumour and individ-
aims to remove the carcinoma, with a 2 cm mar- ual nodes can then be removed and sampled thor-
gin of normal tissue beyond the clinical edge of oughly by the pathologist.
the tumour where possible. When the carcinoma
involves bone then part of the mandible or maxilla Radiotherapy
must also be removed. Reconstruction is required External beam (teletherapy) and implanted radio-
to maintain function after excision of all but the active seeds or needles (plesiotherapy) can be
smallest lesions. This may be accomplished using used to treat oral cancer. Radiotherapy can also be
local flaps or distant pedicled or microvascular free used as an adjuvant therapy, combined with sur-
flaps. The latter may include bone as well as soft gery. Acute mucositis often occurs during treat-
tissues. A large variety of flaps are available and this ment but modern methods of delivering radiation
simultaneous resection and reconstruction has revo- can be used to minimise these. Later complications
lutionised the surgical management of patients with include:
oral cancer. The emphasis is now on improving the osteoradionecrosis (see Chapter 3)
quality of the functional and aesthetic result. The pathological fracture
reconstruction may also involve the use of osseoin-
dry mouth
tegrated implants (Chapter 6).
radiation scar
Donor sites for flaps used in head and neck sur-
gery include the lower limb, the upper limb and chronic ulceration.
girdle, the anterior or posterior chest wall, the A very rare late complication is the induction of
abdominal wall, the scalp and forehead. The radial neoplasms such as osteosarcoma or angiosarcoma.
free forearm flap is one of the most commonly used
with the radial artery anastomosed to the linguofa- Chemotherapy
cial trunk or superior thyroid artery. The flap is soft Many oral and pharyngeal cancer patients receive
and pliable and good for intraoral reconstruction and targeted drug therapy and modern chemotherapy
radial bone can be manipulated to provide a curved as part of their management. Combinations of sur-
mandibular raplacement if required. However, there gery, chemotherapy and radiotherapy are increas-
is risk of radial fracture and the quality of the bone ingly employed.
is not ideal. Microvascular techniques are usually car-
ried out with the aid of loupes or an operating micro-
scope with care to avoid kinking or twisting of vessels. 12.4 Role of the dentist
A selective (removing lymph nodes at certain in prevention, detection
levels) or radical (removing nodes at all levels) and treatment
neck dissection may be needed because of possible
lymph node involvement. Neck dissection results
in some morbidity and modern surgical techniques
aim to minimise loss of function. Complications
Learning objectives
include haemorrhage, haematoma, oedema, Chyle You should:
leak, Horners sydrome and infection. Decisions understand how the general dental practitioner can
educate patients in prevention of oral cancer
regarding the patients need for postoperative
be aware of the need to look for and follow-up
radiotherapy are guided by histological evidence of
suspicious lesions
tumour spread to the nodes and, in particular, to
understand postoperative dental care for patients
the presence of extracapsular spread which a bio- with oral cancer.
logical marker of aggressive tumour behaviour. The
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Premalignancy and malignancy Chapter 12
Q Self-assessment: questions
Multiple choice questions ( True/False) e. Results in the presence of a fine fibrillary
1. Carcinoma of the lip: collagen layer in the lamina propria
a. Is equally common on the upper and lower 3. Squamous-cell carcinoma of the floor of the mouth:
vermilion borders a. Can be caused by irritation from calculus on
b. Is principally caused by smoking the lingual aspect of the teeth
c. Usually arises in angular cheilitis b. May be related to pooling of carcinogens in the
floor of the mouth
d. Has a generally better prognosis than intraoral
cancers c. Can present clinically as a white patch
e. Often arises in a field of dysplastic change d. Infiltration of the submandibular duct can
cause symptoms of obstructive sialadenitis
2. Submucous fibrosis:
e. Can metastasise to both sides of the neck
a. Typically produces thickening of the buccal
mucosa and soft palate, resulting in limited 4. The classification based on TNM (tumour, nodes,
mouth opening and difficulty in swallowing metastasis) findings:
b. Is caused by chewing betel nuts a. Is a system used for recording
histopathological grading
c. Is a hereditary disorder
b. Primary carcinoma in the floor of mouth/ventral
d. Has oral epithelium that usually shows atrophy
tongue can spread directly to level IV nodes
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c. Infiltration of adjacent structures by primary Lead in: Match the histopathology report from the
carcinoma without spread into the neck list below that is most appropriate for each diagnosis
indicates stage IV disease above.
d. Extracapsular spread of metastatic deposits in 1. Histological examination shows sheets of
lymph nodes is an indicator of poor prognosis squamous cells supported by fibrous stroma.
e. Stage I squamous-cell carcinomas have an Keratin pearls are present and there is focal
80% 5-year and 50% 10-year survival rate necrosis. The squamous cells are pleomorphic
overall. and possess hyperchromatic nuclei. Numerous
atypical mitotic figures are present. The invasive
5. Histopathological features of oral epithelial
front is non-cohesive and there is a moderate
dysplasia:
chronic inflammatory infiltrate at the invasive front.
a. Interobserver agreement of oral epithelial
2. Sections show oral mucosa. In the oral epithelium
dysplasia grade among specialist pathologists
there is basal-cell crowding and hyperplasia.
is excellent
Atypical mitotic figures are present throughout the
b. Includes all of the following: acanthosis,
thickness of the oral epithelium. The squamous
acantholysis, drop-shaped rete processes,
cells show nuclear and cellular pleomorphism,
atypical mitotic activity and increased nuclear/
and keratin whorls are present. The rete ridges are
cytoplasmic ratio.
drop shaped and individual cell keratinisation is
c. Indicate carcinoma in situ when the dysplasia present in some areas.
involves the entire thickness of the epithelium
3. Sections show buccal mucosa in which there is
d. Mild dysplasia progresses through moderate to mild epithelial atrophy with parakeratosis. The
severe dysplasia pattern of epithelial maturation is regular and
e. Dysplastic oral epithelium may be found in the overall architecture is preserved. The rete
non-smokers and non-drinkers processes are flattened and bands of hyaline
6. Of the cancers in the orofacial region: collagen best seen in Van Geison stained
a. The relative proportion of salivary cancers to sections are present in the lamina propria. A mild
adenomas is the same in minor and major chronic inflammatory infiltrate is present in the
salivary glands subepithelial tissue.
b. Malignant melanoma occurs only in the sun- 4. Histopathological examination shows sheets
exposed parts of the skin in the orofacial of polygonal cells with large nuclei possessing
region prominent eosinophilic nucleoli and abundant
c. Malignant lymphoma can arise as an basophilic cytoplasm. Nests of tumour cells are
extranodal tumour in the tissues of Waldeyers seen at the interface between the oral epithelium
ring and lamina propria. Some individual atypical
cells extend by Pagetoid spread into the oral
d. Intraoral basal-cell carcinoma most commonly
epithelium. The tumour cells are positive by
arises in the floor of the mouth and ventral
immunoperoxidase for S 100, Melan-A and HMB
tongue
45 antibody staining.
e. Kaposis sarcoma is caused by HIV (human
5. Sections of this lesion from the base of the tongue
immunodeficiency virus) infection
show islands of submucosal squamous cells with
Extended matching items questions rounded cytoplasmic outlines and basophilic
cytoplasm. Microfocal keratinisation is present
EMI 1. Theme: Histopathology of oral cancer
and comedo necrosis is seen. At the periphery
and precursor lesions of the islands the cells are often columnar and
Options: show palisading. The tumour cells exhibit marked
A. Carcinoma in situ nuclear and cellular pleomorphism in some areas
B. Basaloid squamous-cell carcinoma and there is a high mitotic rate of >15 figures per
C. Squamous-cell carcinoma high-power field.
D. Malignant melanoma 6. Sections show oral mucosa in which there is
E. Proliferative verrucous leukoplakia acanthosis and marked hyperparakeratosis
forming church spires. The basal-cell layer is
F. Spindle-cell carcinoma
crowded and there is mild cellular atypia, with
G. Oropharyngeal carcinoma occasional hyperchromatic nuclei. Overall the
H. Nasopharyngeal carcinoma degree of dysplasia can be graded as mild.
I. Submucous fibrosis Multiple levels have been examined and no
J. Erosive lichen planus invasive activity is seen.
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Premalignancy and malignancy Chapter 12
3. The patient used oral snuff (a tobacco product) 3. What factor is common to the oral premalignant
and was advised to discontinue its use. She was conditions?
surprised as snuff had been advised in a health 4. What is meant by induration?
promotion leaflet in Sweden. What is the basis for 5. What are the clinical features of a cervical lymph
advising her to discontinue snuff use and why is node involved by metastatic carcinoma?
its use advocated in Sweden?
6. What is a blind biopsy?
Oral examination questions
1. What ingredients are found in paan?
2. A patient presents with cancer in the oropharynx.
On protruding the tongue, it deviates to the left
side. What is the significance of this sign?
A Self-assessment: answers
Multiple choice answers (True/False) infiltration of the submandibular salivary duct
1. a. False. Cancer of the vermilion border affects by the carcinoma may cause obstruction of the
mainly the lower lip. salivary flow. Obstructive symptoms may be
the clinical feature leading to presentation.
b. False. The principal aetiological factor is
ultraviolet (ultraviolet B) exposure from sunlight. e. True. Particularly if the primary site is in the
anterior floor of the mouth.
c. False. Angular cheilitis is most often caused
by infection with Candida species or 4. a. False. The TNM classification is used
staphylococci and is not a precancerous lesion. for tumour staging; grading is based on
histological features.
d. True. Overall lip cancer has a better prognosis
than intraoral cancer. Early detection is a factor. b. True. Although the neck is divided into
anatomical compartments referred to as
e. True. Ultraviolet exposure is linked to solar
levels, primary oral carcinoma does not
keratosis, which is a dysplastic premalignant
necessarily spread to the first level and
lesion often affecting the lower vermilion
then onwards in sequence from one level to
border.
the next, as was once thought. It has now
2. a. True. Fibrous bands are often visible in the been established that lymphatic channels
buccal mucosa and the affected areas appear communicate directly between the floor of the
pale and thickened on examination. mouth/ventral tongue and level IV in the neck.
b. False. There is no such thing as betel nuts. For example, a carcinoma arising in the floor
Paan is basically betel vine leaf into which of the mouth can spread directly to level IV
areca nut is rolled. Paan quid is held in the without involving levels IIII.
mouth for prolonged periods. c. True. Infiltration of deep/intrinsic tongue
c. False. There is good epidemiological evidence muscle, bone and anatomical structures
linking submucous fibrosis to paan use. indicates stage IV disease.
d. True. It can be reduced to only a few cell d. True. When squamous-cell carcinoma spreads
layers in thickness. to lymph nodes in the neck, the carcinoma
e. True. Submucous fibrosis is characterised by cells travel via the lymphatic vessels to the
deposition of fine collagen fibres beneath the lymph nodes. The metastatic cancer cells are
oral epithelium. The papillary lamina propria is seen first in the subcapsular sinus within the
reduced and the abnormal collagen fibres tend node and further proliferation may be restricted
to be orientated parallel to the surface of the to the node interior. If the cancer cells are
mucosa. then seen to grow through the lymph node
3. a. False. Poor oral hygiene has been associated capsule and out into the surrounding tissue,
with oral cancer but is not considered a this is described as extracapsular spread by
causative factor. the pathologist. It is an important pathological
b. True. Particularly from tobacco smoke. feature because extracapsular spread is a
c. True. It also can appear as red patches. powerful predictor of poor prognosis.
d. True. Squamous-cell carcinoma is often e. True.
painless. In the floor of the mouth, direct
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5. a. False. Grading of oral epithelial dysplasia 6. E. The World Health Organization classification
is difficult and poor agreement even among recognises that proliferative verrucous leukoplakia
specialist pathologists is recorded. (PVL) is a high-risk lesion that often transforms
b. True. Acanthosis is diffuse hyperplasia; into cancer despite having minimal dysplasia.
acantholysis is disruption of the connections 7. F. Spindle-cell carcinoma is another recognised
between keratinocytes. variant of squamous-cell carcinoma that
c. True. Often severe epithelial dysplasia involving sometimes arises after radiation therapy. The cells
almost the entire thickness is said to amount to are lozenge- or kite-shaped and staining with
carcinoma in situ. cytokeratin antibodies is often needed to identify
d. False. Histological progression of dysplasia is their epithelial character.
not always seen and regression of dysplasia is 8. G. Some squamous carcinomas of the head
thought to occur. and neck are linked to human papilloma virus,
e. True. Oral epithelial dysplasia in non-smokers particularly type 16. HPV may account for up to
and non-drinkers causes concern clinically as 75% of oropharyngeal carcinomas.
transformation rates are reportedly higher. 9. H. Nasopharyngeal carcinoma is more common in
6. a. False. Although minor gland salivary tumours the Chinese population and is linked to Epstein
account for only ~10% of all salivary gland Barr (HHV4) infection. This type of cancer is very
tumours, the proportion of benign to malignant radiosensitive and has a good response to treatment
is approximately 55% to 45% in minor glands unless bone metastasis is present at diagnosis.
and 85% to 15% in the parotid. 10. J. These features are typical of erosive lichen
b. False. Malignant melanoma can occur in the planus. Submucous fibrosis and erosive lichen
oral mucosa, particularly in the palate and planus are regarded as premalignant conditions
gingivae. because oral epithelial atrophy predisposes to the
development of dysplasia and oral cancer.
c. True.
d. False. Basal-cell carcinoma does not arise EMI 2
in the oral mucosa. Basaloid squamous- 1. B. There is a well-established link between
cell carcinoma is a variant of squamous-cell Fanconis anaemia and oral cancer in young
carcinoma with a poor prognosis. patients.
e. False. Kaposis sarcoma is linked to human 2. A. PlummerVinson syndrome is characterised
herpesvirus 8 infection and is associated with by formation of an oesophageal web and chronic
immunodeficiency. iron deficiency anaemia. It is a premalignant oral
Extended matching items answers condition.
3. C. In the UICC, classification pT2 refers to a
EMI 1 primary tumour between 2 and 4cm in maximum
1. C. These features are typical of squamous-cell dimension. pN2b denotes multiple ipsilateral
carcinoma. involved nodes none greater than 6cm in
2. A. Carcinoma in situ is defined by cellular atypia maximum dimension.
and disturbed maturation involving the whole 4. D. Invasion of adjacent structures including bone
thickness of the oral epithelium. For clinical automatically upstages oral cancer to pT4 in the
management, severe epithelial dysplasia often UICC system.
amounts to carcinoma in situ and in some 5. I. The alar of the nose is a likely site for basal-
classifications they are combined as squamous cell carcinoma. Dentists should be alert to these
intraepithelial neoplasia grade 3 (SIN 3). common destructive tumours when performing
3. I. Submucous fibrosis is linked to paan (betel) extraoral examination.
chewing. Dense collagenous bands form in the 6. G. Leukaemia may manifest as gingival swelling
oral mucosa and there may be limitation of mouth or chronic oozing of blood from the gingivae
opening and difficulty in swallowing. Dysplasia with bruising. It may be confused with chronic
and oral cancer may arise. periodontal disease.
4. D. Malignant melanoma is an important tumour for 7. F. Adenoid cystic carcinoma typically shows
dentists to be aware of. Melanoma may arise in perineural spread and may cause facial palsy, pain
the oral mucosa or facial skin. or paraesthesia. The Swiss cheese (cribriform)
5. B. Basaloid squamous carcinoma is a histological appearance is typical on biopsy.
variant that is found most often in the base of the 8. J. Proliferation of tissue from tooth sockets can
tongue and oropharynx. It tends to be submucosal be a reactive healing response but the possibility
and ulceration may not be seen. of carcinoma should always be considered,
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Premalignancy and malignancy Chapter 12
especially in the maxilla. Imaging may be helpful 2. Erythroplakia is associated with high malignant
in diagnosing carcinoma of the maxillary sinus. transformation rates. The patient should be
9. H. Extranodal malignant non-Hodgkin lymphoma advised to give up smoking and to attend for
may involve the palate. The malignant cells will regular follow-up. Consideration might be given to
not stain with cytokeratin antibodies because removing discrete areas by laser excision.
these label epithelium. The antibody markers 3. Malignant transformation rates of up to 50%
CD20 and CD 79a indicate that the tumour is a (over many years of follow-up) are recorded in the
B-cell lymphoma. literature. Rates are hard to estimate because of
10. E. Epulides should always be submitted for the poor quality of data in the literature.
histological examination to exclude metastatic
Case history 4
deposits. Breast and other cancers may
metastasise to the gingival margin. 1. Sideropenic dysphagia (PlummerVinson or
PattersonKellyBrown syndrome).
Case history answers 2. Oral epithelial atrophy and cellular atypia have
Case history 1 been recorded.
1. Oral cancer tends to be painless until advanced 3. Sideropenic dysphagia is a premalignant
and many patients delay seeking advice until there condition and the use of oral tobacco should
is pain or oral dysfunction. Lack of awareness be discontinued as it may result in malignant
of oral cancer is common in the general public transformation. In some countries, washed oral
and in some health care professionals. When tobacco (snuff) is promoted as an alternative to
patients complain of ulceration in the mouth, oral cigarette smoking to avoid the major health risks
examination should be undertaken. of smoking such as lung cancer and vascular
disease.
2. Incisional biopsy is normally performed by taking
representative tissue of adequate size and depth Oral examination answers
from the margin of the lesion to include normal
1. Paan contains areca nut wrapped in piper betel
tissue. Many oral cancer centres prefer to see
vine leaf. Tobacco, slaked lime, spices and other
any suspected lesions and to undertake biopsy
ingredients may be added. Fresh, freeze-dried and
themselves. Sometimes imaging is undertaken
other proprietary forms are available.
first and biopsy may be done at the time of
examination under general anaesthesia to exclude 2. The tumour is on the left side; fixation of the
second primary lesions. tongue by oral cancer tends to cause the tongue
to deviate to the ipsilateral side on protrusion.
3. Sentinel node biopsy is a technique in which
the lymph node or nodes draining the tumour 3. Epithelial atrophy.
site are identified by tracing techniques. The 4. Induration is a clinical term referring to the
sentinel nodes are sampled and, if no metastatic thickening and fibrous texture of the tissues
neoplasm is found, neck dissection is avoided. invaded by carcinoma cells. It is an important sign
The technique is used only for T1 and T2 tumours to detect when palpating a suspicious ulcer.
and N0 nodes, judged clinically. 5. The neck node will be enlarged and fixed. It will
typically be non-tender unless infection is present.
Case history 2 Malignant nodes may be matted together to form
1. Examination of plasma proteins for monoclonal a craggy mass. Central necrosis may lead to
gammopathy, urine for Bence Jones protein, bone cystic change.
marrow aspiration or biopsy may be undertaken. 6. Blind biopsy is the term used to describe a
2. Renal clear-cell carcinoma, bladder or prostate are procedure in which multiple biopsies are taken
possible primary sites. (usually of the nasopharynx or tonsil) to detect
3. The patient should be referred to an oncologist. carcinoma where the primary site is not apparent
on clinical examination. It is used when patients
Case history 3 present with metastatic squamous-cell carcinoma
1. Oral epithelial dysplasia is likely to have been in the neck with no obvious primary lesion.
seen. Erythroplakia tends to show drop-shaped
rete processes and marked cellular atypia.
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Fig. 13.1 True occlusal radiograph of the floor of the mouth showing a small, well-calcified calculus
close to the orifice of the left submandibular duct.
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Fig. 13.2 Digital subtraction sialogram of a normal parotid gland. Digital subtraction removes the image of
superimposed bone, allowing a clear image of the typically fine ducts of the normal gland.
Biopsy
Biopsy of labial minor salivary lobules is sometimes
used to assess overall salivary function. Incisional
biopsies of intraoral salivary masses are undertaken
through mucosa that will be later removed as a
planned surgical procedure.
On no account should a discrete salivary gland
mass in a major gland be subjected to incisional
biopsy, this may lead to recurrence and is usu-
ally unnecessary. For example, there is a 9 in 10
chance that a single parotid mass is a pleomorphic
adenoma and so the only acceptable biopsy is a
superficial parotidectomy. This will ensure removal
of the tumour together with a surrounding margin
of normal tissue. Fine-needle aspiration or needle
core biopsy is acceptable and is without the risk
of implantation of malignant cells in the needle
tract. Frozen section may be useful at surgery for
tumours in the parotid gland that are thought likely
to be malignant, to establish whether the facial
nerve may be preserved.
Fig. 13.3 Axial ultrasound image of a parotid
gland containing a pleomorphic adenoma.
The skin surface is at the top. The lesion is mainly
hypoechoic with some areas of relatively higher echo-
genicity within. There is posterior enhancement.
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Fig. 13.4 Radioisotope scan of the salivary glands. Each image is taken with the patient facing the gamma
camera, giving a face-on image. The highly active bilobed area of activity at the bottom of each image is the thyroid
gland. In this particular patient, the problem illustrated by the quantitative study was underactivity of the right parotid.
Lt, left; Rt, right; subman., submandibular.
Extraductal obstruction
13.3 Salivary gland disorders
Extraductal obstruction is caused by disease outside
the duct wall. The most important cause is neopla-
sia, particularly squamous carcinoma in the floor of
Learning objective
the mouth or salivary neoplasms. Trauma may also
You should: lead to displacement of soft or hard tissue, result-
know the features, investigations and management ing in duct obstruction.
of salivary gland disorders.
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Fig. 13.5 An obstructive swelling of a parotid gland. (A) Extraoral view; (B) intraoral view.
gland is most frequently involved (around 80% of caused by direct contact with infected saliva
cases), followed by parotid and, rarely, minor glands. and by droplets. There is a 23 week incubation
The calculi (sialoliths) tend to be hard, yellowish and period, and fever and malaise are followed by
often have a lamellated, concentric-ring structure. sudden, painful swelling of one or both parotid
They are composed of calcium phosphates, thought glands. In adults, viraemia results in involvement
to be nucleated on microcalculi, which are com- of internal organs such as the central nervous
monly found in the major and minor glands. Salivary system and gonads. Orchitis (gonadal swelling)
calculi may form in ducts within the gland substance. occurs in around 20% of affected adult males.
Diagnosis is made on clinical grounds and bedrest
is advised. As the disease occurs in minor epidem-
Acute sialadenitis ics, infected persons should avoid contact with
those at risk. Virus is present in the saliva when
Viral sialadenitis symptoms commence and remains for approxi-
Viral sialadenitis (mumps) is an acute contagious mately 6 weeks. One episode usually confers life-
infection caused by a paramyxovirus. Spread is long immunity.
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Bacterial sialadenitis The gland may become firm and fibrotic at the end
Acute bacterial sialadenitis principally involves the stage. Pathologically there may be duct ectasia,
parotid glands and is caused by bacteria entering mucous metaplasia of duct epithelium, periductal
the ductal system against the salivary flow. Reduced fibrosis and elastosis, acinar atrophy and a chronic
flow is a common predisposing factor and is a fea- inflammatory infiltration. Interlobular fibrosis
ture of many conditions, including chronic sialad- results in fusion of the lobules. Surgical removal
enitis, Sjgrens syndrome and unwanted effects is indicated in intractable disease. On sialograms,
of drugs. Streptococcus pyogenes, Staphylococcus there are combinations of sialectasis (ductal dilata-
aureus, Haemophilus species, black-pigmented bac- tion), strictures, filling defects with calculi or stag-
teroides and other oral bacteria may be detected nant secretions and atrophy of minor salivary ducts
in mucopurulent discharge from the duct opening, (Fig. 13.7). In advanced disease, large abscess cavi-
which is an important clinical sign. It is accompa- ties may form.
nied by swelling, pain, fever and erythema of the
overlying skin. Treatment is by antibiotic therapy
and gentle massage to encourage flow. Warm, salty Relapsing parotitis
mouthrinses may be helpful, and patients should be Relapsing (recurrent) parotitis is an uncommon
advised against placing a hot-water bottle over the disorder affecting children and sometimes adults.
gland as this may lead to a pointing abscess. Typically, sialography shows normal main ducts but
punctate sialectasis peripherally. Some cases are
bilateral, suggesting a congenital duct abnormality
Chronic sialadenitis or tendency to reduced flow.
Bacterial sialadenitis
Chronic bacterial sialadenitis is related to low- Radiation sialadenitis
grade bacterial invasion through the duct system Radiation sialadenitis occurs mostly after radio-
and often follows chronic obstructive disease. therapy, particularly when given for head and neck
The submandibular salivary gland is most com- cancers. There is acinar damage and progressive
monly affected. Typically, there is recurrent, pain- fibrous replacement. Depending on dose, some
ful swelling associated with eating or drinking. The recovery may be seen. The glands are shielded
duct orifice appears inflamed and a mucopurulent where possible to avoid this unwanted effect
discharge may be seen on examination. Patients (Fig. 13.8) and techniques such as intensity mod-
may complain of a salty or foul taste in the mouth. ulated radiotherapy (IMRT) can be used to direct
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Fig. 13.7 Chronic sialadenitis of the parotid gland. The main duct has a reasonably normal diameter and
course, but beyond the point of junction with an accessory gland (seen passing vertically upwards from the main
duct), the gland is abnormal. The ducts are dilated and there is some atrophy of the peripheral ducts (compare with
Fig. 13.1). A filling defect is visible centrally, indicating the presence of a substantial mucus plug or calculus.
Fig. 13.8 A patient with radiation-related dry mouth, showing carious lesions.
radiation and spare salivary glands. See Sjgrens Dense fibrosis is also present. Kuttner tumour may
syndrome for treatment of xerostomia. be part of a generalised immune disorder that can be
treated by immunosuppressive therapy.
Chronic sclerosing sialadenitis
Also known as Kuttner tumour, this disorder pres- Sarcoidosis
ents as a firm tumour-like mass affecting the sub- Bilateral parotid swelling may be caused by chronic
mandibular gland. There are increased numbers of granulomatous inflammation, as part of the multi-
IgG4-secreting plasma cells in the gland parenchyma. system disorder sarcoidosis. Confluent sheets of
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Fig. 13.9 Histopathological section of a labial gland biopsy in a patient with Sjgrens syndrome.
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Box 13.2
Diagnosis of Sjgrens syndrome mononuclear cells; the focus score is defined by the
number of foci in 4mm2 glandular tissue.
Diagnostic criteria V Salivary gland involvement
I. Ocular symptoms Objective evidence of salivary involvement defined by
A positive patient response to at least one of the three a positive result in at least one of the following three
selected questions: diagnostic tests:
1. Have you had daily, persistent, troublesome dry 1. Salivary scintigraphy
eyes for more than 3 months? 2. Parotid sialography
2. Do you have a recurrent sensation of sand or gravel 3. Unstimulated salivary flow (1.5ml in 15 minutes)*
in the eyes?
3. Do you use tear substitutes more than three times a VI Autoantibodies
day? Presence in the serum of the following antibodies:
1. Antibodies to Ro (SS-A) or La (SS-B) antigens, or
II. Oral symptoms both.
A positive result to at least one of the three selected
questions: Classification criteria
1. Have you had a daily feeling of dry mouth for more In patients without any potentially associated disease,
than 3 months? the presence of any four of the six items (must include
2. Have you had recurrently or persistently swollen either item V or item VI) or three of the four objective
salivary glands as an adult? criteria (items III to VI) is indicative of primary Sjgrens
3. Do you frequently drink liquids to aid swallowing syndrome.
dry food? In patients with a potentially associated disease
(for instance another connective tissue disease), item
III. Ocular signs I or item II plus any two from among items IIIV is
Objective evidence of ocular involvement defined as a indicative of secondary Sjgrens syndrome.
positive result in at least one of the following two tests: Exclusion criteria
1. Schirmers test (5mm in 5 minutes)*
Past head and neck radiation treatment, pre-existing
2. Rose Bengal score (4 according to van
lymphoma, acquired immunodeficiency disease (AIDS),
Bijstervelds scoring system).
sarcoidosis, graft-versus-host disease, hepatitis C, use
IV. Histopathology of anticholinergic drugs.
*As it has been demonstrated that this test may be reduced in normal subjects older than 60 years of age, it should be excluded from the
criteria or not considered indicative for a diagnosis of Sjgrens syndrome in elderly subjects.
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as blue, fluctuant swellings, which typically have a Mucous retention mucocoele. This type occurs
relapsing history. There are two types. less frequently and tends to be found in the
Mucous extravasation mucocoele. This is the upper labial mucosa. Trauma results in duct stric-
most frequent type and it occurs in the lower labial ture and then expansion, forming a cyst lined
mucosa (Fig. 13.15), buccal mucosa and rarely at by ductal epithelium. The cyst contains clear
other sites. Trauma results in tearing of the duct, saliva, with minimal inflammatory or macrophage
with leakage of saliva into the connective tissue. A reaction.
granulation tissue capsule forms and mucin-filled, Bilateral and multiple lymphoepithelial parotid
foamy macrophages are typically seen in the cyst cysts can be a feature of HIV infection. The cysts
fluid. Chronic inflammatory infiltration is usually occur early in HIV disease and are not typically
seen also. seen in advanced AIDS. Diagnosis is based on
fine-needle aspiration and imaging. No interven-
tion is normally required but if lymphomatous
infiltration is suspected, surgical excision may be
performed.
13.4 Surgery
Learning objective
You should:
know the principles of surgery to remove salivary
glands.
Fig. 13.11 Sialogram in Sjgrens syndrome. Surgical removal of minor salivary glands is the
This patient has fairly classic radiological appearances in the treatment of choice for mucous extravasation and
parotid gland. The main ducts are fairly normal (although retention cysts and tumours. Surgery of the major
the main duct anteriorly is slightly dilated), but a striking salivary glands is carried out when there is neoplas-
feature is the presence of numerous small collections of tic disease, obstruction and sometimes in inflam-
contrast medium (snow storm) overlying the gland. matory disease.
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Minor salivary glands should be excised together with the associated lin-
gual gland. If large in size, then this may be more
Excision of a cyst with associated glands and duct readily performed under general anaesthesia.
may be undertaken under local anaesthesia. Swell- Cryosurgery, in which subzero cooling is used
ings thought to be tumours because of their history, to destroy tissues, may be used to remove small
site and appearance require wider excision. Ranu- cysts. The probe of a liquid nitrogen apparatus is
lae (mucocoeles arising from the sublingual gland) placed on the cyst for two to five cycles of about
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30 seconds at 100C. The extreme cold results in patient supine and the head turned to the oppo-
an acute inflammatory response and tissue damage. site side and extended. The skin is prepared and
The technique, which is very simple to use, results the submandibular incision made 2.5cm below
in significant postoperative swelling but excellent the mandible to avoid the facial nerve (Fig. 13.16).
healing without a surgical scar. The disadvantage During dissection, vessels are identified and ligated
is that there is no histopathological examination. before the gland is removed. A vacuum drain is
Cryosurgery may also be used for small vascular placed to minimise haematoma formation and the
lesions such as haemangiomas. wound is closed with sutures.
An alternative to surgery for calculus removal
is radiologically-guided retrieval of the calculus
Submandibular salivary gland through the duct orifice using a basket retrieval
catheter. This works best with small, freely moving
Surgical removal of a calculus from the anterior calculi. Lithotripsy and balloon dilation may also be
part of the duct of the submandibular salivary used and 70% of obstructed glands can be treated
gland may be undertaken under local anaesthe- conservatively.
sia. A suture is placed about the duct behind the
calculus to prevent it moving back into the gland
and then the duct is dissected and opened via an Parotid salivary gland
intraoral approach. The calculus is removed and the
duct sutured open to prevent stricture. Should the A calculus in the anterior part of the parotid
calculus be sited more proximally, then removal of salivary duct may be removed by an intraoral
the gland may be necessary. In the case of surgi- approach under local anaesthesia, again with a
cal removal of the submandibular gland for this or suture placed behind to prevent the calculus slip-
another reason, the patient is advised of the follow- ping back into the gland. In the case of a calculus
ing risks of the operation: sited further back, or non-malignant disease in the
Possible facial nerve damage resulting in weak- superficial lobe, the glandular tissue superficial
ness of the lower lip. to the facial nerve may be removed (superficial
parotidectomy), thus preserving the nerve. In the
Possible lingual nerve damage resulting in lin-
case of a malignant tumour, the whole gland may
gual paraesthesia.
be removed (total parotidectomy) with sacrifice of
Surgical removal of the submandibular gland the nerve. Non-malignant disease occurring in the
is undertaken under general anaesthesia with the deep lobe will require removal of the whole gland
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Submandibular duct
(Whartons duct)
Lingual nerve
Hyoglossal nerve
Sublingual gland
Submandibular gland
(deep lobe) Mylohyoid muscle
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with preservation of the nerve. A patient under- Surgery is undertaken under general anaesthesia
going parotidectomy is advised of the risks of the with the patient supine and the head turned to the
operation: opposite side. The skin is prepared and a preau-
Possible facial weakness or expected facial ricular incision made and extended behind the ear
paralysis depending on the type of surgery lobe over the mastoid process and down to the sub-
planned. mandibular area (Fig. 13.17). A skin flap is raised
to expose the gland and the facial nerve trunk. An
Numbness of the ear on the side of surgery as
electric nerve stimulator may be used to help to
the great auricular nerve has to be divided dur-
identify the nerve if the patient has not been given
ing surgery.
a muscle relaxant drug as part of the anaesthetic
Much less likely complications are: technique at this stage. The gland may then be dis-
sweating around the ear when the patient eats sected above the nerve and removed. A vacuum
because of regrowth of secretomotor parasym- drain is placed and the wound closed.
pathetic nerve fibres (Freys syndrome) As with the submandibular gland, under certain
salivary fistula. circumstances calculi may be removed via the duct
orifice by consevative methods.
Q Self-assessment: questions
Multiple choice questions ( True/False) d. Salivary duct antibody is the most useful
1. Mumps (epidemic parotitis): diagnostic immunotest for Sjgrens syndrome
a. Is caused by an adenovirus e. Polyclonal B-cell expansion is a feature of
Sjgrens syndrome
b. Is transmitted by droplets spread from infected
saliva 5. Dry mouth:
c. In adults may involve the central nervous a. Caused by reduced salivary flow can be inferred
system, pancreas, testes and ovaries when the resting rate falls below 5ml/min
d. Bilateral parotid involvement is more common b. Can be a feature of cystic fibrosis
than unilateral involvement c. Typically is associated with cervical or root
e. Recurrent attacks are not uncommon caries
2. The following are likely causes of a localised d. May be caused by anxiety
swelling in the upper labial submucosa: e. Is an uncommon unwanted effect of drug
a. Mucous extravasation mucocoele therapy
b. Mucous retention mucocoele 6. Radiation effects on the salivary glands:
c. Basal-cell adenoma a. Are more apparent in mucous acini than serous
acini
d. Capillary haemangioma
b. Some recovery is possible
e. Warthins tumour
c. Include fibrosis after high exposure
3. Adenoid cystic carcinoma:
d. Can cause duct ectasia and squamous
a. May arise in the paranasal sinuses
metaplasia
b. Arises from the adenoids
e. Include endarteritis obliterans
c. Has a progressively worse survival at 5, 10 and
7. Bilateral parotid swelling may be a feature of:
20 years, respectively
a. Sarcoidosis
d. Often exhibits perineural spread
b. Warthins tumour
e. Has microcystic spaces containing basement
membrane-like material c. Primary Sjgrens syndrome
4. In Sjgrens syndrome: d. HIV (human immunodeficiency virus) infection
a. Secondary Sjgrens syndrome comprises e. Chronic lymphocytic leukaemia (CLL)
dry eyes, dry mouth and a connective tissue 8. Salivary calculi (sialoliths):
(autoimmune) disorder a. Of very small size (microliths) are commonly
b. Uptake of 99 m[Tc]-pertechnate by salivary found in the major glands
glands is increased in Sjgrens syndrome b. Form around nanobacteria that infect the ducts
c. Fatigue syndrome is associated with Sjgrens
syndrome
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c. Can result in the submandibular saliva being myoepithelial cells were present in some areas
supersaturated with respect to calcium and and islands of squamous cells were also present.
phosphate ions The tumour was enclosed by an intact pseudo-
d. May be forced into the submandibular gland capsule formed by compressed fibrous tissue into
from the anterior duct during removal under which tumour pseudopodia extended.
local anaesthesia 3. A 15-year-old girl presented with a relapsing
e. May not give rise to symptoms swelling on the lower labial mucosa. The
9. Pleomorphic salivary adenoma: pathologist reported that the lesion was a cyst
that was lined internally by granulation tissue. The
a. Carcinoma arising in pleomorphic salivary
lumen contained foamy macrophages.
adenoma has a worse prognosis than
mucoepidermoid carcinoma 4. An elderly man presented with bilateral swellings
of the parotid gland. On ultrasound, the tumours
b. May contain myxoid and chondroid stroma
were cystic and were up to 3cm in diameter. A
c. May contain plasmacytoid or spindle-shaped
fine-needle aspirate showed lymphocytes and
myoepithelial cells
clusters of oncocytes. Following the aspiration,
d. May arise in the maxillary sinus and nasal the gland became painful but after 2 weeks the
septum tumour had reduced in size considerably.
e. Shows marked nuclear and cellular 5. A 62-year-old woman developed a rapidly growing
pleomorphism swelling of the left parotid gland which was
10. Mucous extravasation mucocoele: fixed to skin. A biopsy was reported as showing
a. Most commonly occurs in the buccal mucosa multiple patterns of carcinoma, including salivary
b. Has a granulation tissue capsule duct carcinoma. Hyaline and myxoid scar tissue
c. Often contains foamy macrophages was also present.
d. May undergo spontaneous resolution 6. A 42-year-old woman presented with a parotid
tumour. A needle core biopsy showed a tumour
e. Tends to have a relapsing clinical course
composed of cells with hyperchromatic, angular
Extended matching items questions nuclei and scant basophilic cytoplasm. The
features were those of adenoid cystic carcinoma.
EMI 1. Theme: Salivary gland disorders
A worrying sign of salivary malignancy was
Options: present.
A. Mucous extravasation mucocoele 7. A 13-year-old boy presented with a swelling of
B. Mucous retention mucocoele the right parotid gland that had steadily enlarged
C. Heerfordts syndrome and which had not improved after a course
D. Warthins tumour of antibiotics. Ultrasound showed a fairly well
E. Pleomorphic adenoma circumscribed cystic tumour which was removed.
F. Facial nerve palsy due to perineural invasion The pathologist reported that the tumour
contained goblet cells, squamous cells, clear cells
G. Salivary lymphoepithelial lesion
and intermediate cells.
H. Sialosis
8. An overweight 56-year-old man developed type
I. Carcinoma in pleomorphic adenoma II diabetes. His parotid glands became enlarged
J. Mucoepidermoid carcinoma over a 2-year period and he felt that his mouth
Lead in: Match the case from the list below that is was too full of saliva. The dentist noticed that he
most appropriate for each diagnosis above. had acid erosion on the palatal surfaces of his
1. A 55-year-old woman presented to her dentist upper anterior teeth.
with carious cavities that had occurred since her 9. A 70-year-old patient who suffered from
last check-up. The patient had noticed that her Sjgrens syndrome for many years experienced
mouth was dry and, on examination, her parotid enlargement of one of her parotid glands. A
glands were enlarged. At the dental hospital, her superficial parotidectomy was performed and the
consultant performed a needle core biopsy, which pathologist reported that the parotid parenchyma
was reported as containing confluent sheets of was expanded by a lymphoid infiltrate and
non-caseating granulomas. She was referred on to epimyoepithelial islands were present.
an ophthalamic specialist who found that she had 10. A 15-year-old girl presented with a relapsing
uveitis on slit-lamp examination. swelling on the upper labial mucosa. The
2. A longstanding tumour was removed from pathologist reported that the lesion was a cyst
the parotid gland. The pathologist reported that was lined internally by ductal epithelium. The
that the tumour was composed of sheets, lumen was filled with mucoid fluid and a small
strands and islands of ductal cells separated lamellated calculus was present.
by myxochondroid tumour. Plasmacytoid
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EMI 2. Theme: Salivary gland disorders who undertook some investigations and subsequently
Options: performed a superficial parotidectomy. The
A. Xerostomia histopathologist reported the nodule as a pleomorphic
salivary adenoma.
B. Hypersalivation
1. Which investigations are available to the oral and
C. Cystic HIV salivary disease maxillofacial surgeon for preoperative diagnosis of
D. Canalicular adenoma a lump in the parotid gland?
E. Obstuctive sialadenitis 2. What is the rationale of undertaking a superficial
F. Mumps parotidectomy for this benign neoplasm?
G. Relapsing childhood parotitis 3. What are the key histopathological features of
H. Acute bacterial sialadenitis pleomorphic salivary adenoma?
I. Ranula 4. Why is it advantageous to remove this benign
J. Sialoblastoma neoplasm as soon as practicable after diagnosis?
Lead in: Match the case from the list below that is Case history 2
most appropriate for each diagnosis above.
A 9-year-old boy presents with unilateral parotid
1. A 21-week-old infant developed an enlarging
swelling of a few days duration. He had suffered a
mass in her right parotid gland that encroached
previous similar episode, which was thought to be
onto the sternomastoid and elevated the ear.
mumps although not entirely typical. Antibiotic therapy
2. A dentist noticed that one of his 60-year-old
was prescribed and the swelling subsided within a
patients developed fresh carious lesions between
few days. The symptoms recurred a few weeks later
each visit and had recently developed cervical
and again after 3 months. His mother mentioned at
cavities in the anterior incisor teeth.
that time that he occasionally made a funny face by
3. A 7-year-old boy experienced facial swelling and blowing out his cheeks.
a febrile illness. His mother described his face as 1. What is the most likely diagnosis?
being out like a box and thought that he had a
2. Sialography is avoided in children unless essential;
dental abscess.
what features would be expected in a patient with
4. A 57-year-old patient developed a fluctuant this disorder?
swelling in the floor of the mouth that was
3. How should the condition be managed?
translucent on transillumination.
5. A 60-year-old man developed a cystic lump in the Case history 3
submucosa of the upper lip. Smaller lumps were A 73-year-old woman with a long history of Sjgrens
found adjacent the main lesion and were removed. syndrome developed rapid enlargement of the left
6. A 32-year-old man presented with pain and parotid gland. She suffered from rheumatoid arthritis.
swelling under the angle of the mandible at meal The swelling had been present for 5 weeks before she
times. Afterwards there was an unpleasant taste in attended her dentist. On examination, the left parotid
the mouth. gland is enlarged and feels both thickened and firm
7. A 78-year-old man complained of producing too on bimanual palpation. Ipsilateral non-tender cervical
much saliva. It leaked onto his pillow and he was lymph nodes are also palpable.
constantly swallowing. 1. Does the patient suffer from primary or secondary
8. A 28-year-old man developed gross bilateral parotid Sjgrens syndrome?
swelling. On imaging, he had multiple cystic changes 2. What is the most likely cause of the recent parotid
and a fine-needle aspirate showed lymphoid cells. swelling?
9. A 14-year-old girl presented with acute parotid 3. How may this diagnosis be confirmed?
swelling and pain. She had experienced two
previous attacks, one on the other side. Case history 4
10. A 37-year-old man experienced pain and swelling A 38-year-old woman presents with swelling and
of his right parotid gland 2 days after blowing up a pain for 3 days involving the left parotid gland. On
balloon. examination, the overlying skin appears erythematous
and the gland is tender on palpation. A mucopurulent
Case history questions discharge from the left parotid duct is seen. A
Case history 1 diagnosis of acute bacterial sialadenitis is made and
a swab of the discharge was sent to the microbiology
A 24-year-old woman attended for dental care. She
department.
mentioned that she had found a small lump just in
1. Which investigations on the swab should be
front of her left ear. On examination, there was a
requested?
freely moveable, rubbery nodule, 1cm in diameter,
2. Which bacterial agents are most likely to be
just below and anterior to the tragus of the left ear.
involved?
She was referred to an oral and maxillofacial surgeon
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3. Which predisposing factors may be present? throughout the meal. He noticed an unpleasant
4. How should the case be managed? taste in the mouth for some time after eating, as the
swelling subsided.
Case history 5 1. What is the most likely diagnosis?
A 34-year-old man working as a chef complains 2. Which features should be looked for particularly
that his face is swollen at the angles of the jaw, on examination?
making him look like a hamster! He is obese and has 3. How may imaging help to provide useful clinical
recently been found to be diabetic. On examination, information?
there is bilateral, symmetrical enlargement of the 4. Which histopathological features might be
parotid glands. They are not tender and a copious expected in the submandibular salivary gland?
flow of clear saliva could be obtained from the
ducts. Oral examination questions
1. What diagnosis is most likely? 1. Suggest some common causes of dry mouth.
2. Which predisposing factors can be associated 2. What types of tumour commonly affect the
with this disorder? salivary glands?
3. What histopathological features are seen in this 3. What are the possible causes of obstruction of the
condition? submandibular salivary gland?
Case history 6 4. What are the possible complications of the
surgical removal of a parotid salivary gland?
A 47-year-old man presents with intermittent pain and
swelling in the left submandibular area for 4 months. 5. What is a labial gland biopsy? How is it
Symptoms were worst just before eating and persisted undertaken?
A Self-assessment: answers
Multiple choice answers c. True. Basal cell, trabecular and canalicular
1. a.False. Mumps is caused by a paramyxovirus. adenomas are found in the upper lip. Some may
It is difficult to detect this directly but the show cystic change and some are multifocal.
virus can be grown from throat swabs or d. True. The lips are richly vascular, and vascular
saliva. Serology will show a rise in antibody malformations are not uncommon in the
titre between acute and convalescent submucosa. They typically blanche on pressure
specimens. and may be pulsatile.
b. True. Direct contact and droplet spread from e. False. Warthins tumour (adenolymphoma) is a
saliva are the principal routes of transmission. parotid lesion, though ectopic examples have
Virus is present in saliva during the prodromal been described.
phase and for about a week after resolution of 3. a.True. Adenoid cystic carcinoma can arise in
the sialadenitis. the paranasal sinuses, including the maxillary
c. True. Orchitis is the most common sinus, lacrimal gland, trachea and in more
manifestation. It is thought to occur in distant glandular tissues.
about 20% of adult mumps in males and b. False. The word adenoids is a lay term for
has been linked to infertility. Meningitis and nasopharyngeal tonsillar tissue or thickened
meningoencephalitis are rare complications. nasal/antral mucosa.
d. True. Bilateral parotitis is seen in around c. True. In a meta-analysis of survival data, survival
70% of cases. Submandibular glands are rates were quoted at approximately 75% at 5
occasionally involved also, resulting in a box- years, 40% at 10 years and 15% at 20 years.
like facies. d. True. Perineural invasion often leads to palsy,
e. False. Long-lasting immunity is generally pain or paraesthesia as presenting signs.
conferred and recurrent infection is extremely e. True. The microcystic spaces impart the Swiss-
rare. cheese appearance. They contain connective
2. a.False. Mucous extravasation mucocoeles tissue mucin, which stains with Alcian blue. It
are common in the lower lip, especially in the includes basement membrane constituents.
occlusal plane, but are very rare in the upper 4. a.False. Some textbooks do give this definition,
lip. but most clinicians recognise that either dry
b. True. Mucous retention mucocoeles tend to mouth or dry eyes with a connective tissue
occur in the upper lip and buccal mucosa, disorder can be defined as secondary Sjgrens
most commonly in older patients. syndrome.
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Salivary gland disease Chapter 13
b. False. Scintiscanning can be used but uptake e. True. Sometimes calculi are found incidentally
is decreased. on routine examination. Treatment may not be
c. True. This is common. necessary.
d. False. Antibodies against extractable nuclear 9. a.True. Carcinoma arising in pleomorphic
antigens are the most sensitive and specific adenoma is a very aggressive neoplasm;
indicators, particularly Ro and La. mucoepidermoid carcinoma has a range of
e. True. Polyclonal B-cell expansion may result clinical behaviour.
from loss of T-cell regulation. b. True. Both loose (myxoid) tissue and cartilage-
5. a.False. The lower limit of normal resting salivary like (chondroid) tissue can occur in the stroma.
flow is approximately 0.1ml/min. c. True. Plasmacytoid (hyaline) myoepithelial cells
b. True. Cystic fibrosis is a genetic disorder are a key feature.
where secretion is abnormal. d. True.
c. True. Preventive advice should be given to those e. False. Pleomorphic in pleomorphic salivary
with xerostomia as increased caries rates are seen. adenoma refers to the variety of features which
d. True. It is a consequence of adrenergic may be encountered; it is cytologically bland.
hormone release. 10. a.False. It is most common in the lower labial
e. False. Unwanted effects of drug therapy are mucosa.
one of the most common causes of dry mouth. b. True. It occurs around saliva that leaks from a
Patients must not be advised to discontinue tear in a salivary duct into connective tissue.
their medication but the responsible physician c. True. They occur in cyst and fluid.
may be contacted for advice. d. True. However, they can relapse.
6. a.False. Both mucous and serous acini are e. True.
equally sensitive.
b. True. Some recovery of function is possible Extended matching items answers
after low-dose irradiation. EMI 1
c. True. This can cause stricture of the duct. 1. C. Sarcoidosis is a chronic granulomatous condition
d. True. Particularly when head and neck cancers that may affect the parotid and cause uveitis. Facial
are treated. nerve palsy and fever may be present. This is
e. True. This is proliferation of the intimal layer Heerfordts syndrome (uveoparotid fever).
and results in narrowing or obliteration of the 2. E. Pleomorphic adenoma is sometimes referred to
vascular lumen. as mixed tumour because the neoplasms contain
7. a.True. Sarcoidosis is a multisystem chronic both epithelial ductal and myxochondroid stromal
granulomatous inflammatory disorder that can elements. The hyaline plasmacytoid myoepithelial
involve the salivary glands and cause swelling cell is a characteristic feature.
and dry mouth. Parotitis, facial palsy, uveitis in 3. A. Mucous extravasation mucocoele is most
sarcoidosis is known as Heerfordt syndrome. common on the lower lip. The duct of a minor
b. True. Up to 10% of Warthins tumour are salivary gland is ruptured by trauma. Saliva leaks
bilateral cases. out and granulation tissue walls this off forming a
c. True. cyst. Foamy macrophages are commonly present.
d. True. Bilateral lymphoepithelial cysts of the 4. D. Warthins tumours are benign and typically
parotid gland, Sjgren-like syndrome and present in the parotid gland. There is a strong link
malignant lymphoma may occur. with smoking and 10% are bilateral.
e. True. CLL may infiltrate any organ. Bilateral 5. I. Carcinoma can arise from pleomorphic
parotid enlargement and dry mouth are rare adenoma, usually after several years. Multiple
manifestations. patterns of carcinoma are suggestive of this
8. a.True. Microcalculi are commonly seen diagnosis. Often a ghost or scarred remnant of
histologically. the original pleomorphic adenoma can be found
embedded in the tumour.
b. False. It has been claimed that renal calculi
form around nanobacteria but even the 6. F. Facial nerve palsy is a sign of malignancy when
existence of these organisms is debatable. a salivary tumour is present in the parotid gland.
c. True. The saliva will be in dynamic equilibrium with 7. J. Mucoepidermoid carcinoma tends to occur
the calcium- and phosphate-containing calculi. in a younger age group than other salivary
cancers. The features in this case suggest a low-
d. True. A suture may be placed to avoid this
grade carcinoma. High-grade mucoepidermoid
well-recognised hazard.
carcinoma is more infiltrative and tends to be solid.
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8. H. Sialosis is caused by salivary acinar 9. G. Relapsing childhood parotitis is an unusual
hyperplasia and is known to occur in a variety condition characterised by duct ectasia. Acute
of disorders including diabetes, alcoholism, episodes are managed by antibiotic therapy, warm
sympathomimetic drug use, obesity and endocrine mouthrinses and gentle massage. The condition
disorders. The acid erosion of the palatal enamel often resolves after puberty.
suggests bulimia which is also a cause of sialosis. 10. H. Acute parotitis is caused by oral bacteria
9. G. Sjgrens syndrome is an autoimmune that ascend the parotid duct. The gland should
condition in which B cells accumulate in the be gently pressed and mucopurulent saliva
salivary tissue. As the condition advances, the from the parotid papilla sampled for microbial
salivary acini are destroyed, the ducts form analysis. Broad-spectrum antibiotics may be
epimyoepithelial islands and lymphoid cells useful in combination with gentle massage and
accumulate. This lesion is termed a salivary mouthrinses.
lymphoepithelial lesion (SLEL). It is known that
SLEL can progress to malignant lymphoma. Case history answers
10. B. Mucous retention mucocoele is less common Case history 1
that extravasation cyst and tends to occur in the 1. History and clinical examination including
upper lip. The duct is blocked, sometimes by palpation of the swelling are most informative.
calculus and the duct expands to produce an Ultrasound, sialography, computed tomography,
epithelial lined cyst. magnetic resonance imaging and positron
emission tomography are useful imaging
EMI 2
modalities. Fine-needle aspiration biopsy (FNAB)
1. J. Sialoblastoma is a rare salivary tumour that or narrow-cutting core biopsy can be used for
presents in the neonatal period. pathological diagnosis. Final tumour diagnosis is
2. A. Caries is a feature of xerostomia (dry mouth) sometimes made after excision biopsy.
due to loss of buffering power and the protective 2. Pleomorphic salivary adenoma cells tend to
effect of saliva on enamel. Patients sometimes do extend into the capsule surrounding the tumour
not complain of dry mouth clinically even when and enucleation may be followed by multifocal
it is severe. Xerostomia is a common unwanted recurrence. Extracapsular dissection, superficial
effect of drugs, but may also be caused by parotidectomy or other procedures aim to remove
underlying diseases such as Sjgrens syndrome. the adenoma with a margin of normal tissue to
3. F. Mumps virus causes swelling of the parotid and avoid this problem.
submandibular glands. Unilateral disease can be 3. Key histopathological features are sheets, strands
confused with dental abscess when carious teeth and islands of ductal epithelial and myoepithelial
are present. cells; myxoid or chondroid stroma; plasmacytoid
4. I. The term ranula is used to describe a mucous (hyaline) myoepithelial cells; cytological blandness;
extravasation mucocoele arising from the main extracapsular extension; and variability in
submandibular duct. appearance.
5. D. Canalicular adenoma is a salivary neoplasm 4. Early removal of pleomorphic adenoma is
typically found in the upper lip. It shows a loose advised (a) to reduce morbidity; (b) to avoid the
structure with beading of the tumour cell strands. risk of malignant transformation; and (c) to allow
Multiple tumours may be present. thorough histopathological sampling for diagnosis.
6. E. Obstructive sialadenitis is most commonly seen
in the submandibular gland but the parotid may Case history 2
also be affected. Calculus forms in the main duct 1. The most likely diagnosis is recurrent childhood
and chronic infection may contribute to progressive sialadenitis.
fibrosis and loss of functional elements. 2. Childhood sialadenitis is characterised by main
7. B. Hypersalivation (ptyalism) is a sensation of duct ectasia and strictures with destruction of
producing too much saliva. Many patients with secretory tissue.
this complaint have normal flow rates on testing. 3. Acute episodes of infection may necessitate
Sometimes the condition is due to drooling antibiotic therapy; gentle external massage may
because of loss of muscle action and surgery help to encourage salivary flow. Habits such
can help. as inflating the cheeks should be discouraged,
8. C. Bilateral multicystic salivary disease is a as infection arises from bacteria ascending the
recognised manifestation of HIV infection. ducts.
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Salivary gland disease Chapter 13
Case history 3 The floor of the mouth may be dried with gauze
1. Secondary Sjgrens syndrome; around 10% and salivary flow observed from the duct orifice.
of patients with rheumatoid arthritis have been A sialogogue, such as chewing a citric acid tablet,
estimated to have Sjgrens syndrome. may reproduce the signs and symptoms. Turbid
saliva suggests infection and should be sampled
2. Malignant lymphoma. There is a progression from
for microbiological analysis.
B-cell infiltration, through lymphoepithelial lesion
to malignant lymphoma in some cases. Low-grade 3. Occlusal radiography with exposure adjustment
B-cell lymphoma is the most common type. Acute for soft tissue may reveal radio-opaque calculus
infection or obstruction may also cause sudden in the submandibular duct. The second imaging
swelling of the parotid gland. investigation is sialography, which sometimes
dislodges the calculus.
3. Imaging studies may reveal a space-occupying
mass but biopsy is needed if malignant lymphoma 4. Obstructed glands may recover following removal
is suspected. of calculus. In chronic obstructive sialadenitis, it
may be necessary to remove the submandibular
Case history 4 gland. Principal histopathological features are
1. Culture and sensitivity. duct ectasia with mucous metaplasia, inter- and
intralobular fibrosis, acinar atrophy, acinar loss
2. Streptococcus pyogenes, Staphylococcus aureus,
and chronic inflammatory infiltration. Intraglandular
Haemophilus species and other normal oral flora
calculus may form.
may be isolated.
3. Reduced salivary flow such as in chronic Oral examination answers
sialadenitis, HIV infection, Sjgrens syndrome, 1. Unwanted effects of drugs, Sjgrens syndrome,
obstructive disease, postirradiation changes and anxiety, mouth breathing, dehydration,
side effects of drugs. uncontrolled diabetes mellitus and generalised
4. Antibiotic therapy should follow current chronic inflammatory or neoplastic disorders.
guidelines, such as those in the British National 2. Pleomorphic adenoma is the most common
Formulary, taking into account the microbiology tumour; other less-rare types are Warthins tumour,
findings. Patients should be advised to avoid adenoid cystic carcinoma, acinic-cell carcinoma
applying heat to the gland and should gently and mucoepidermoid carcinoma.
massage the gland by placing two fingers over
3. These can be classified as extraductal (e.g.
the angle of the mandible and gently moving
pressure from an adjacent tumour or displaced
upwards and forwards. Warm salt mouthrinses
anatomical structure), ductal (e.g. fibrous stricture
may also help. Review should be arranged and
of the duct wall) and intraductal (e.g. calculus,
proper assessment undertaken when the acute
mucous plug).
symptoms have subsided.
4. Facial nerve weakness or palsy, loss of sensation
Case history 5 of the ear, Freys syndrome (gustatory sweating),
1. Sialosis (acinar hypertrophy). salivary fistula and cosmetic defect.
2. Drugs, alcoholism, diabetes, liver cirrhosis, 5. Labial gland biopsy is taken to provide a sample
metabolic and hormonal disturbances, bulimia. for histological assessment of salivary tissue,
avoiding parotid biopsy. It is used most often as
3. Enlargement of secretory acinar cells with
a diagnostic procedure in Sjgrens syndrome.
cytoplasm packed with zymogen granules.
Under local anaesthesia, a 1-cm vertical or
Case history 6 horizontal incision is made in the lower labial
1. Obstructive sialadenitis owing to calculus mucosa, and 1012 lobules removed. There must
formation. Other causes of obstruction should be no disease in the overlying mucosa. Care
also be considered. must be taken to avoid damage to the labial
neurovascular bundles.
2. Calculus in the submandibular duct may be visible
but is more often detected by bimanual palpation.
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Facial pain 14
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Facial pain Chapter 14
the so-called trigger zone but this is not invariably alternative. Should the dose of carbamazepine be
the case. Activities of daily living, for example wash- limited, the antiepileptic lamotrigine may be added
ing the face, shaving, putting on make-up, eating, or used an alternative.
speaking and exposure to cold may all induce pain.
Associated signs and symptoms. The absence
of associated signs and symptoms of sensory or Surgical management
motor deficit is important. Neurological assessment Although the evidence base for surgical interven-
can play a significant role in differentiating between tions is weak, microvascular decompression (MVD)
CTN and STN. Trigeminal sensory deficits may be appears to have the best outcome and is emerging as
a feature of the latter. The patients medical history the preferred option in those patients who are fit for
may already have revealed the existence of a struc- open surgery. In this procedure, the offending blood
tural abnormality vessel is lifted away from the trigeminal root and
permanently repositioned. In comparison to periph-
eral destructive procedures such as neurectomy or
Special investigations central destructive procedures such as percutaneous
Magnetic resonance imaging (MRI) is now consid- radiofrequency thermocoagulation, MVD has a low
ered mandatory. In some cases, it demonstrates rate of complications. It is, however, important that
the intimate, potentially causative, relationship MVD is performed sooner rather than later as suc-
between the trigeminal root and an adjacent blood cess declines with duration of trigeminal neuralgia
vessel. MRI is of particular value in excluding pos- symptoms. This is leading to a change in approach
terior cranial fossa lesions and, to some extent, with clinicians raising the awareness of patients to
multiple sclerosis. the possibility of surgical intervention much earlier
in the medical treatment phase rather than as a last
resort. Gamma knife stereotactic surgery provides
Medical management an alternative to MVD in those patients for whom
The therapy of choice is carbamazepine. Reduction surgery is contraindicated. Other central procedures
or complete resolution of symptoms following its include retrogasserian glycerol injection, compres-
use is considered to be virtually diagnostic of tri- sion or radiofrequency thermocoagulation. The
geminal neuralgia. However, it should be prescribed above procedures have largely replaced peripheral
cautiously, starting at a dose of 100mg twice or treatment options although local anaesthetic injected
three times daily and increasing slowly until the into the trigger zone will provide temporary relief
patients symptoms are controlled. This is usually of symptoms (bupivacaine has a longer duration of
achieved at between 200 and 400mg three times action) and is useful in confirming the diagnosis.
daily. Gradual increase in dosage is important as
elderly patients are particularly susceptible to car-
bamazepines many side-effects. Some of these, Glossopharyngeal neuralgia
for example nausea, ataxia and dizziness, make
taking carbamazepine completely unacceptable Glossopharyngeal neuralgia is an extremely uncom-
to the patient or significantly limit its dose. Oth- mon condition.
ers, including leucopenia, thrombocytopenia and
skin reactions, necessitate its withdrawal; patients
should be informed of the signs and symptoms of Clinical presentation
these conditions when the drug is prescribed. Full Nature. There is sharp, stabbing, episodic, elec-
blood count, liver and renal function tests should tric shock-like pain. Pain may be so severe that the
ideally be carried out prior to its prescription and at patient tries to keep their tongue still and avoids
regular intervals during at least the first months of swallowing.
treatment. Individuals of Han Chinese or Thai ori- Duration. Usually of seconds duration. Spontane-
gin should be tested for HLA-B* 1502 allele and, ous remission of symptoms can occur but both this
if positive, carbamazepine should not be prescribed and their recurrence are unpredictable.
as a result of the risk of development of Stevens Site. The pain is localised to the posterolateral
Johnson syndrome. If withdrawal of carbamazepine tongue and fauces but felt within the ear on the
proves to be necessary, oxcarbazepine provides an affected side.
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may be localised by the patient to a particular tooth postherpetic neuralgia develops, its medical man-
or teeth. agement is difficult. Conventional non-steroidal
Associated signs and symptoms. The devel- anti-inflammatory agents are largely ineffective,
opment of clinical signs of herpes zoster within as is carbamazepine. There is evidence to sup-
a few days of the onset of the pain confirms the port the use of tricyclic antidepressants and gaba-
diagnosis. pentin these along with pregabalin and topical
lidocaine have been advised as first-line treat-
ment. Strong opiods and capsaicin may also be of
Special investigations benefit.
Vitality testing, bitewing and periapical radiographs
should be carried out when the pain is localised to
the teeth to exclude dental pathology. Surgical management
Local anaesthetic blockade of the stellate ganglion
using bupivacaine may produce short-term relief in
Medical management some patients.
Appropriate treatment of herpes zoster (Chapter 11).
Clinical presentation
Sex. More common in females than males.
Migraine
Age. Usually over 50 years.
Nature. An intense, unpleasant, burning pain. Clinical presentation
Duration. May be present continually. By defini- Sex. Migraine is more common in females than
tion, symptoms must have been present for at least males.
3 months. Age. Wide age range from childhood onwards.
Site. The pain is localised to the area of the Nature. Intense, severe, persistent aching pain.
distribution of the division(s) of the trigeminal Duration. Usually of hours or days.
nerve involved in the preceding episode of herpes Site. The pain is usually unilateral but may not
zoster. always affect the same side of the head. Certain
Accompanying signs and symptoms. History variants are centered on the eye.
and possibly scars of herpes zoster. The severity of Initiating factors. A variety of stimuli may
the pain may lead to anxiety and depression. induce the headache, for example certain food-
stuffs (e.g. chocolate, bananas), alcohol, stress,
hormonal changes during the menstrual cycle, the
Special investigations contraceptive pill or noise.
Investigations may have been carried out previously Associated signs and symptoms. In classic
to confirm the diagnosis of herpes zoster but infec- migraine, the headache is preceded by an aura,
tion is often diagnosed on clinical grounds alone. which may include nausea, vomiting, visual distur-
bances (photophobia, flashing lights) and other dis-
turbances of sensory and/or motor function.
Medical management
There is evidence that prevention or ameliora-
tion of postherpetic neuralgia can be achieved Special investigations
by the use of antiviral drugs such as famciclovir CT and MRI do not contribute directly to the diag-
to treat the preceding herpes zoster infection. If nosis of migraine but, where signs and symptoms
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are atypical, are important in excluding the pres- such as calcium channel blockers (e.g. verapamil)
ence of intracranial lesions. may be taken as prophylaxis.
reduced. Relapses occur and long-term therapy may Medical history. The medical history may reveal
be required (36 years). other conditions such as irritable bowel syndrome,
back pain, pelvic pain and fibromyalgia. In some
patients, there may be a history of depression and/
14.4 Persistent idiopathic facial or anxiety; patients may be reluctant to disclose
pain (atypical orofacial pain) these conditions directly, if at all, but the patients
drug history can be informative.
Learning objectives Social history. The patients social history is a sig-
nificant but difficult area. The fruitfulness of this
You should: area of inquiry depends very much on the quality
understand that persistent idiopathic facial pain is a
of the dentists communication skills the ability
diagnosis based on a particular set of symptoms
to create the appropriate conditions for disclosure
know the features of atypical odontalgia
of such information. A patient may well expect to
understand the relevance of a history of stress in
some patients. be asked about their smoking habits but be less will-
ing to divulge details concerning their personal cir-
cumstances during a consultation with their dentist.
Persistent idiopathic facial pain Sources of stress and distress should be identified:
(atypical facial pain) for example, bereavement, significant illness of, or
anxiety about, family or friends, job loss, breakdown
The term idiopathic can foster the belief that this of relationships, an unhappy home and/or work life,
diagnosis is reached simply by excluding other fear of serious illness. The impact of the patients
causes of facial pain. However, persistent idiopathic pain on their daily life should also be explored along
facial pain results in a particular constellation of with their concerns and beliefs about their symp-
symptoms, which form the basis of its diagnosis. toms if these have not already been addressed.
and their usefulness in the management of persistent implicated and are supported by varying degrees
idiopathic facial pain is accepted. Encouraging results of evidence.
have also been obtained using psychotherapeutic
approaches such as cognitive behavioural therapy.
Therefore, for some patients, involvement of a psy- Clinical presentation
chologist and/or psychiatrist in their assessment and Sex. More common in females than males.
management may be appropriate. Age. Usually over 50 years.
Nature. A burning sensation. The patient may
describe the mucosa as feeling as if it has been
Atypical odontalgia scalded or sprinkled with pepper.
Duration. Present on a daily basis often for a con-
Atypical odontalgia can be thought of as the dental siderable period of time (months or years). Symp-
equivalent of persistent idiopathic facial pain. The toms tend to increase in severity as the day goes on
characteristics of the pain and those patients who but do not disturb sleep.
experience it are broadly similar; all that differs is Site. The burning sensation most commonly
the site of the pain. The patient localises the pain affects the tongue, lips and hard palate either sin-
to a tooth or group of teeth that are clinically and gly or in combination. In terms of single sites, the
radiographically normal. In some cases, the patient tongue is most commonly affected. Type 3 BMS
may have already have undergone dental treatment often affects unusual sites such as the throat or
in an attempt to alleviate their symptoms, including floor of mouth.
the extraction of one or more teeth, with no or Initiating/ameliorating factors. There are no
only temporary relief of symptoms, which now clear initiating, ameliorating or exacerbating fac-
affect the extraction site and/or adjacent teeth. tors. However, patients may report that the burn-
It is clearly important to resist extracting healthy ing sensation is not present when they are eating or
teeth in such patients. occupied and is noticed more when they are at rest.
Analgesics are usually ineffective.
Associated symptoms. Alterations in taste sensa-
14.5 Burning mouth syndrome tion (dysgeusia), subjective oral dryness.
Duration. Many patients give a history of consult-
ing several general dental and medical practitioners,
Learning objectives specialist physicians and surgeons.
You should:
know the clinical presentation of burning mouth
syndrome Clinical examination
know which conditions have similar symptoms and
Significant findings in the patients medical and
need to be excluded
social history might be similar to those discussed
understand the link with stress and anxiety in some
patients. above under atypical facial pain.
A careful clinical examination is important to
detect any local causes for the patients symptoms,
Burning mouth syndrome (BMS; glossodynia, for example signs of conditions such as erythema
glossopyrosis, oral dysaesthesia) is characterised migrans, glossitis, lichen planus and candidiasis;
by a burning sensation affecting the oral mucosa evidence of parafunctional habits such as bruxism,
present in an individual in whom other local and tooth clenching or tongue thrusting; assessment of
systemic causes of such a sensation have been the design of the patients dentures, particularly
excluded as far as is possible (e.g. dry mouth, with respect to adequacy of freeway space and
incorrectly designed dentures, diabetes, anae- positioning of the teeth with respect to the tongue
mia). The aetiology and pathogenesis of burn- space; and dry mouth.
ing mouth syndrome remain uncertain although
there is growing evidence that it is neuropathic in
nature; changes in the oral environment, abnor- Special investigations
malities of the peripheral and/or central nervous Investigations are targeted at detecting any causes
systems and psychosocial issues have all been of burning sensations affecting the oral mucosa.
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Facial pain Chapter 14
A full blood count and haematinics to diagnose about resolution of symptoms, the diagnosis of
anaemia and/or deficiency of iron, folate or vita- burning mouth syndrome is confirmed. In a propor-
min B12 should be carried out. The presence of tion of patients with BMS, resolution or reduction
candidal infection should be excluded by the use, in symptoms occurs following confirmation and
at the very least, of swabs and smears but ideally discussion of their diagnosis, including reassurance
by a more quantitative method such as oral rinse with respect to the non-neoplastic nature of the
or saliva sample. The presence and degree of oral cause of their symptoms, exploration of their possi-
dryness should be assessed by sialometry. Blood ble relationship to stress and anxiety and exclusion
glucose and glycosylated haemoglobin should be of local and systemic causes. In other cases, symp-
measured for possible diabetes. While patients may toms persist but patients are able to come to terms
attribute their symptoms to allergic reactions, most with them once they are convinced of the absence
commonly to dental materials, in the absence of a of a serious underlying cause.
clear history or clinical signs current evidence does Unfortunately many of the treatments cur-
not justify the routine use of allergy testing, such as rently in use for BMS have not been subjected to
patch tests, in this group of patients. randomised controlled trials in this context. The
therapeutic approach follows that employed for neu-
ropathic pain, thus antidepressants drawn from the
Medical management tricyclic group (e.g. amitriptyline or nortriptyline)
Any possible local and systemic causes of burning are widely used to good effect as are gabapentin and
sensations affecting the mouth detected on exami- pregabalin. However, stronger evidence exists for the
nation or following special investigations should use of serotonin reuptake inhibitors (e.g. paroxetine).
be treated. Where no such causes are detected or Cognitive behavioural therapy does provide an evi-
where their successful treatment does not bring dence-based alternative to systemic drug treatment.
Q Self-assessment: questions
Multiple choice questions ( True/False) 4. Postherpetic neuralgia:
1. In irreversible pulpitis, the pain normally: a. Is the only type of facial pain associated with
a. Is exacerbated by biting down on the affected herpes zoster infections
tooth b. Is well controlled by the use of carbamazepine
b. Is poorly localised c. Is an invariable consequence of herpes zoster
c. Is of short, less than 10 minutes, duration infections
d. Does not respond to simple analgesics such as d. Is never accompanied by facial palsy
paracetamol 5. Atypical facial pain:
2. Trigeminal neuralgia: a. Is more strongly associated with depression
a. Is normally treated with carbamazepine than anxiety
b. Can be a presenting symptom of multiple b. May be alleviated by simple reassurance
sclerosis c. May be caused by anaemia
c. Usually crosses the midline of the face d. Is a diagnosis of exclusion
d. Only occurs in response to touching a trigger Extended matching items questions
point
Options:
e. Does not wake the affected individual from
A. Trigeminal neuralgia (classical trigeminal neuralgia;
sleep
CTN)
3. Giant-cell arteritis normally:
B. Atypical facial pain
a. Occurs most commonly in men
C. Giant-cell arteritis
b. Affects only the temporal artery
D. Postherpetic neuralgia
c. Results in a slightly elevated ESR
E. Cluster headache
d. Can be treated successfully with systemic
F. Short-lasting unilateral neuralgiform headache
steroids
attacks with conjunctival injection and tearing
e. Causes blindness (SUNCT)
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Master Dentistry
G. Classical migraine without aura couple of times each month and gives a 6-month
H. Glossopharyngeal neuralgia history. The pain is normally present for between
I. Trigeminal neuralgia (symptomatic trigeminal 12 and 48 hours and makes it very difficult for her
neuralgia; STN) to concentrate on anything. She occasionally feels
nauseous when the pain is present and tries to
J. Burning mouth syndrome
avoid situations that she knows will be noisy.
Lead in: Match the case history from the list below
7. A 71-year-old woman attends your surgery
that is most appropriate for each diagnosis above.
complaining of a sharp pain which affects the
1. A 33-year-old man complains of an intense
back of her tongue and the area just beneath
aching pain which occurs once a day and lasts
the angle of her jaw, always on the left-hand
for about an hour. He outlines the affected area
side alone. The pain lasts for about a minute and
which extends upwards from his right cheek to
comes on when she swallows or chews. Her lower
his forehead. The episodes of intense pain have
left first and second molar teeth are present and
been going on for about a week. His nose feels
restored but they appear sound, are vital and are
blocked and runs when the pain is present. He
not tender to percussion.
experienced similar symptoms about 3 months
ago which lasted for a couple of weeks and 8. A 65-year-old woman presents with a throbbing
resolved spontaneously. pain affecting her left temple. The headache
began about a week ago and is accompanied by
2. A 36-year-old woman gives a 2-week history of
pain in the muscles around her jaw joint on eating.
a sharp pain lasting for a few seconds which
She has no previous history of facial pain or
comes on when she touches the left-hand side
headache. Intraoral examination is unremarkable.
of her upper lip. One burst of pain can follow
There is no evidence of dental pathology or
immediately after the preceding one. When you
parafunctional habits.
are taking her history, she mentions that about
a month ago she consulted her GMP about a 9. An 80-year-old woman who moved into residential
deterioration in hearing affecting her left ear. care 3 months ago is brought to your surgery. The
elderly lady is complaining of an intense burning
3. A 58-year-old man gave a history of a stabbing
sensation affecting the right-hand side of her
pain affecting his left temple. Each burst of pain
face which has been present for at least the past
lasts for about 4 minutes and he can experience
3 months. The lower part of her face is spared.
three of these each waking hour. He is concerned
Nothing seems to make it better or worse. The
that he may have developed an infection in his left
patient is a poor historian and the carer knows little
eye, which looks red.
of her history before she came to live at the care
4. A 62-year-old woman gives a history of a sharp pain
home. On examination, you notice some scarring
lasting for a few seconds whenever she touches the
of the skin of her right cheek and forehead but nil
skin over her lower jaw. It is making it difficult for
else of note. The patient was recently prescribed a
her to carry out daily activities like washing her face
low dose of amitriptyline for anxiety by her GP and
or eating. The pain is confined to the left-hand side.
this seems to have helped a little with the pain.
Once an episode of pain is complete she can be
10. A 56-year-old woman complains of a burning
pain free for about an hour, even if she touches her
sensation affecting her tongue. It is present on a
face in the area affected by the pain. She has been
more or less continuous basis and gets worse as
taking paracetamol at regular intervals but this has
the day goes on. Her GP prescribed a mouthwash
made no difference to the pain.
for her but this has not been of any benefit. She
5. A 65-year-old woman complained of a deep-
is edentulous but leaving her dentures out makes
seated aching sensation affecting the right-hand
no difference to the pain. Her medical history is
side of her face from her top jaw up to her
unremarkable and, on examination, her tongue
forehead. She has suffered from the pain on a
appears completely normal.
more or less continuous basis for about
4 years. There are no exacerbating or ameliorating Case history questions
factors. Analgesics have proved ineffective. Her
Case history 1
GP referred her to an ENT consultant who carried
out an MRI to check for sinus problems. She A 50-year-old partially dentate male experiences a
has also been seen by two other dentists and sharp pain from his teeth whenever he consumes cold
had root canal treatment on several teeth, two foods and on exposure to cold air. The pain lasts only
of which have subsequently been extracted. On for as long as the stimulus is present. On examination,
examination, you detect no abnormalities. generalised gingival recession is present.
6. A 25-year-old woman complains of episodes of 1. What is a likely diagnosis?
aching pain affecting her right or left forehead, 2. What elements in the patients history indicate this
temple and cheek. She experiences these a diagnosis?
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Facial pain Chapter 14
3. What would be the relevant findings on been seen by an otolaryngologist to have her sinuses
examination? checked; no abnormalities had been detected. In
4. Are further investigations appropriate and, if so, addition, a previous dentist had referred her to a local
what? oral and maxillofacial surgeon, who had not detected
5. What would be a treatment plan? any abnormality but had arranged for her to be seen
by a neurologist who had carried out a CT scan, which
Case history 2 was normal. On extraoral examination, there was
A 25-year-old female attends the surgery complaining no tenderness of the muscles of mastication and no
of pain on eating or clenching her teeth. She localises abnormality intraorally. The patients remaining teeth
the pain to her upper right first permanent molar. On appeared sound.
examination intraorally, this tooth appears sound; 1. What is a likely diagnosis?
however, the lower right first permanent molar has 2. What elements in the patients history indicate this
a large mesialocclusaldistal (MOD) amalgam. The diagnosis?
latter tooth is tender to percussion (TTP). 3. What would be the relevant findings on
1. What is a likely diagnosis? examination?
2. What elements in the patients history indicate this 4. Are further investigations appropriate and, if so,
diagnosis? what?
3. What would be the relevant findings on 5. What would be a treatment plan?
examination?
4. Are further investigations appropriate and, if so,
Case history 5
what? A 36-year-old male complains of an aching pain
5. What would be a treatment plan? affecting the right-hand side of his maxilla. The pain
seems to arise from his teeth, particularly those
Case history 3 towards the back of his mouth in his upper jaw.
A 65-year-old man complains of a sharp pain affecting About 2 years previously he had experienced some
his right cheek. The pain is of short duration but discomfort in the same area but this had only come
extremely severe, like being stabbed with a needle or on after eating cold foods and had lasted for about
an electric shock. When he was at rest, the pain rarely 15 minutes. His current symptoms do not seem to
occurred. It was more likely to come on when he was be brought on by anything. Each episode of pain
speaking or eating. Washing his face and shaving were lasts for about an hour and is relieved by taking
particularly problematical. The pain never crosses the paracetamol. On examination intraorally, the patients
midline. The patient is generally fit and well although upper and lower molars on the right-hand side are
he gave a history of a recent deep-vein thrombosis heavily restored but not tender to percussion. Electric
and now takes warfarin. On examination, the pain is pulp testing shows a reduced response from his
induced when the patients left cheek is touched. The upper right first permanent molar compared with the
patient is edentulous. corresponding tooth on the left-hand side.
1. What is a likely diagnosis? 1. What is a likely diagnosis?
2. What elements in the patients history indicate this 2. What elements in the patients history indicate this
diagnosis? diagnosis?
3. What would be the relevant findings on 3. What would be the relevant findings on
examination? examination?
4. Are further investigations appropriate and, if so, 4. Are further investigations appropriate and, if so,
what? what?
5. What would be a treatment plan? 5. What would be a treatment plan?
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which she is taking lisinopril; she is otherwise fit and her diabetes was diagnosed 5 years ago, she has not
well. The patient is edentulous; her current dentures drunk any alcohol; prior to this she had consumed
are 2 months old and replaced the previous set, which between 4 and 5 units per week. There was a family
she had used for the past 20 years. She has recently history of type II diabetes. She expresses concern that
taken early retirement and lives with her husband, who her symptoms might indicate that she was developing
continues to work. She is a lifelong non-smoker. Since oral cancer.
A Self-assessment: answers
Multiple choice answers e. False. Patients suffering from trigeminal
1. a. False. The pain associated with irreversible neuralgia may give a history of being woken
pulpitis normally arises spontaneously and from sleep by their pain.
is not induced or exacerbated by applying 3. a. False. Giant-cell arteritis affects females more
pressure to the affected tooth. However, lying commonly than males.
down and hot stimuli may induce/exacerbate b. False. While the term temporal arteritis is
the pain. often used, the vasculitis which it describes
b. True. As with reversible pulpitis, the pain of has the capacity to affect large, medium-sized
irreversible pulpitis is usually poorly localised and small arteries in the craniofacial region
by the affected individual but does not normally in general and is believed to form part of a
cross the midline unless upper or lower anterior spectrum of disease culminating in polymyalgia
teeth are affected. rheumatica.
c. False. The pain of irreversible pulpitis is usually c. False. Giant-cell arteritis is normally
long lasting and present for hours rather than characterised by the presence of an elevated
minutes. ESR of the order of 40mm h1 or greater,
d. False. Non-opiate analgesics such as although in 20% of cases the ESR may be
paracetamol are normally effective in controlling within normal limits.
the pain associated with irreversible pulpitis. d. True. Systemic steroids are initially prescribed
2. a. True. Carbamazepine is the drug of at high dose, typically 4060mg prednisolone
choice for the medical management of daily. Maintenance therapy at a lower dose,
trigeminal neuralgia but the role of surgery e.g. 7.510mg, may be continued for several
in the treatment of this condition should years to prevent relapse.
not be overlooked. The latter provides a e. True. Ischaemia of the optic nerve secondary
valuable alternative in those patients where to involvement of the ciliary arteries may lead
pharmacotherapy is precluded, ineffective or to blindness if treatment is not commenced
poorly tolerated. promptly.
b. True. Trigeminal neuralgia predominantly 4. a. False. In some individuals, preherpetic
affects individuals over the age of 50 years. neuralgia, which may mimic dental pain,
Its occurrence in a younger individual raises precedes the development of the vesiculo-
the possibility of multiple sclerosis. Similarly bullous lesions which characterise herpes
this association should also be borne in mind zoster.
when investigating the cause of facial pain in a b. False. Postherpetic neuralgia is a difficult
person known to suffer from multiple sclerosis. condition to treat effectively. Carbamazepine
c. False. One of the diagnostic features is largely ineffective, however some benefit
of trigeminal neuralgia is the anatomical may be derived from the use of tricyclic
distribution of the pain which is confined to the antidepressants or gabapentin.
area innervated by the affected division(s) of c. False. Postherpetic neuralgia has a variable
the trigeminal nerve. incidence, the likelihood of its occurrence
d. False. While pain triggered by touching increases with age and it is more likely to affect
a particular area of the face/oral mucosa women than men. Approximately 50% of those
is a classical feature of trigeminal affected will continue to experience symptoms
neuralgia, episodes of pain may also occur for longer than 3 months.
spontaneously. The clinical presentation of d. False. Ramsay Hunt syndrome is characterised
trigeminal neuralgia does not always meet the by herpes zoster affecting the external auditory
typical diagnostic criteria.
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Facial pain Chapter 14
meatus and pharynx accompanied by an has been present and stable for several years,
ipsilateral facial palsy. without exacerbating or ameliorating factors and
5. a. True. Depression is more strongly associated unresponsive to analgesics is strongly suggestive
with atypical facial pain than anxiety; the of atypical facial pain. The absence of positive
reverse appears to be the case in burning findings on examination and investigation is
mouth syndrome. characteristic. MRI is often performed although
b. True. Just as in burning mouth syndrome, rationale for this is unclear; its prime purpose
simple reassurance accompanied by is to provide reassurance to both clinician and
supportive listening plays a significant role in patient of the absence of significant associated
the management of atypical facial pain. pathology. However, the history of this patient at
this stage makes that extremely unlikely.
c. False. There is no evidence to support an
association between anaemia and atypical 6. G. This pain is episodic but episodes have a long
facial pain. duration compared to all the other conditions
and are not clustered. It has affected either side
d. False. While the exclusion of other causes
of the face/head. Accompanying nausea and
of facial pain is important when making a
phonophobia are indicative of migraine.
diagnosis of atypical facial pain, the latter does
have characteristic features which contribute to 7. H. While the tongue is commonly affected in
its diagnosis, e.g. non-anatomical distribution; burning mouth syndrome, the pain is of too
description of a gripping, vice-like relentless short a duration and is described as sharp. The
pain; maxilla affected more commonly then the involvement of the area just below the angle of
mandible. the jaw and pain on chewing might suggest dental
pathology but the teeth are sound and not TTP.
Extended matching items answers Similarly, were it not for the involvement of the
1. E. Pain is unilateral, severe and has occurred tongue, a diagnosis of TN might be considered.
previously but age and duration of pain make However, taking into account the sites affected,
CTN unlikely, however could be atypical variant or the nature of the pain and when it is experienced,
STN. Associated nasal congestion and rhinorrhea the diagnosis is glossopharyngeal neuralgia.
is significant and not usually associated with TN. 8. C. The recent onset of unilateral pain of this
Therefore, on balance E, but MRI scan indicated nature in this site without any previous history
in view of suspicion atypical or STN. should immediately raise the possibility of giant-
2. I. The clinical features are strongly suggestive of cell arteritis. The patient is in the right age group
TN. The patients age is a cause for concern as (usually = 50 years). The accompanying pain in
CTN would be extremely unusual in someone of the muscles of mastication on chewing could
her age. The absence of a refractory period after represent temporomandibular joint dysfunction but
triggering of the pain is also somewhat atypical. is entirely consistent with giant-cell arteritis.
Therefore STN should be seriously considered. 9. D. Some elements of the history continuous pain,
The presence of ipsilateral hearing loss raises no exacerbating or ameliorating factors, some
further concerns as to the possibility of a central benefit from amitriptyline are compatible with a
lesion being present. Even if the patient were in diagnosis of atypical facial pain. The pain does,
the usual age group for CTN, this would raise the however, have a reasonably well-defined anatomical
possibility of STN. distribution apparently sparing the area innervated
3. F. On first reading, this case has many of the by the mandibular division of the trigeminal nerve.
features of trigeminal neuralgia. The 4 minute The intense burning quality of the pain is also
duration of the pain is possibly longer than one suggestive of postherpetic neuralgia and the
might normally expect for TN and the ophthalmic presence of scarring on the skin of the patients face
is the least commonly affected division of the reinforces this by providing evidence of previous
trigeminal nerve. The presence of conjunctival skin lesions possibly related to herpes zoster.
infection shifts the balance in favour of SUNCT 10. J. The duration and nature of the pain exclude H.
but an overlap is recognised between the two The absence of mucosal abnormality and the fact
conditions. MRI indicated. that the symptoms persist even when the denture
4. A. The patient gives a classic description including is not worn point to J. The lack of response to
distribution of pain, trigger zone and a refractory topical agents is not unusual. The patients normal
period after stimulation. While CTN is highly likely, medical history seems to rule out systemic factors
MRI is obligatory to exclude STN and assess such as anaemia and diabetes but it would be
possibility of DREZ compression. prudent to carry out appropriate blood tests.
Candidal infection can be excluded by performing
5. B. Although the pain is unilateral, the patients
appropriate microbiological investigations and dry
description of a continuous aching pain which
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mouth by sialometry, although the normal findings 3. No abnormality was detected at examination
on examination make both of these unlikely. including the temporomandibular joint and the
muscles of mastication.
Case history answers 4. Vitality testing of remaining teeth should be
Case history 1 carried out, following up any significant findings
1. Dentine sensitivity. with bitewing and periapical radiography.
2. Sharp pain, tooth related, cold stimuli, lasts for as 5. The diagnosis should be discussed with the
long as the stimulus is present. patient: cause uncertain, medically unexplained
3. Gingival recession. symptoms; further dental treatment of no benefit;
suggest referral to oral medicine consultant for
4. No further investigations.
confirmation of diagnosis.
5. Advise use of a toothpaste for sensitive teeth.
Treatment options: leave things as they are,
Apply a sealant to exposed cervical dentine.
pharmacotherapy (e.g. tricyclic antidepressants),
Check toothbrushing technique.
psychotherapy (helping the patient to live with the
Case history 2 pain).
1. Periapical periodontitis affecting the lower right Case history 5
first permanent molar. 1. Possible reversible (acute) pulpitis 2 years
2. Pain on eating and clenching teeth together. The previously and now irreversible (chronic) pulpitis.
pain is well localised but there may be confusion 2. Initial symptoms induced by cold stimuli and of
over whether the pain is coming from an upper or relatively short (15 minutes) duration; the onset of
a lower tooth. the current symptoms is spontaneous and they
3. Suggested tooth is sound, but the opposing tooth have a long duration (more than 1 hour).
is heavily restored and TTP. 3. Heavily restored teeth; reduced vitality but not
4. Vitality testing and periapical radiograph of lower tender to percussion.
right first permanent molar. 4. Bitewing radiograph of right-hand side shows
5. Endodontic treatment or extraction. recurrent caries in the upper right first permanent
molar.
Case history 3
5. Removal of the restoration in the upper right
1. Trigeminal neuralgia. first permanent molar, excavation of caries and
2. Severe pain, like being stabbed with a needle or placement of temporary dressing.
an electric shock; provoked by movement of the
face and touching the face; confined to the left Essay answer
cheek and never crosses the midline. Your essay should include the following information.
3. Pain is induced by touching the patients left 1. Definition of BMS. A burning sensation affecting
cheek; patient is edentulous. the oral mucosa in the absence of clinically
4. No other investigations. detectable lesions.
5. Consider prescription of carbamazepine but 2. History of the complaint. The age and sex of
check for possible drug interactions. Metabolism the patient, the affected site and the pattern of
of warfarin is accelerated by carbamazepine, pain are all appropriate to this diagnosis. Brief
reducing its anticoagulant effects. Contact the discussion of the usual sites affected in BMS and
patients medical practitioner and inform of the different pain patterns experienced.
the diagnosis; liaise with respect to treatment 3. Clinical examination. No abnormality is detected
and referral to a neurologist. Monitoring and extra- or intraorally. Various oral mucosal
adjustment of anticoagulant therapy will be disorders can give rise to a burning sensation;
necessary if carbamazepine is prescribed. good examples would be lichen planus, erythema
migrans, candidiasis, glossitis.
Case history 4
4. Medical history. Type II diabetes controlled by
1. Atypical facial pain. diet alone? Is control adequate? Poorly controlled
2. Long history but non-progressive; extraction diabetes may result in dry mouth and an increased
of teeth in the affected area; relentless, some susceptibility to oral candidiasis. Both of these
variation in severity but always present; may give rise to a burning sensation. There is no
no exacerbating or ameliorating factors; suggestion of anaemia or nutritional deficiency in
analgesics ineffective; extensively investigated the medical history but it has been suggested that
(otolaryngology, oral and maxillofacial and these may cause BMS-like symptoms.
neurology referrals). Medication. The patient is taking lisinopril, an
angiotensin-converting enzyme, the side-effects
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Facial pain Chapter 14
of which can include dry mouth and a burning her dentures out? Allergy to dental materials
sensation affecting the oral mucosa. Explore has been suggested as a cause of BMS-like
the temporal relationship between the onset of symptoms but evidence to support this is
symptoms and the commencement of medication. weak. It is accepted that denture design faults
5. Further investigations. Suggest special (e.g. adequacy of freeway) can result in such
investigations to exclude issues arising from symptoms. There is no evidence of denture
the medical history: sialometry, isolation and stomatitis on clinical examination.
quantification of Candida species, full blood 7. Social history. Onset of BMS symptoms may be
count, haematinics, random blood sugar and associated with stressful events or changes of
glycosylated haemoglobin. lifestyle. Patient has recently retired.
6. Dental history. Provision of a new full set of 8. Additional information. The patient expresses
dentures coincides with the onset of symptoms. anxiety concerning the possibility of oral cancer.
Do the symptoms resolve/improve if she leaves Such anxieties may exacerbate or cause BMS.
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Disorders of the
temporomandibular joint 15
G
A
H
C
B I
E
Rotation Translation
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Disorders of the temporomandibular joint Chapter 15
Fig. 15.3 Magnetic resonance image of a TMJ. The disc can be seen as the darker structure between the
condylar head and the temporal bone.
Radiology
Most clinical problems related to the TMJ are
caused by muscular parafunction (e.g. bruxism) or
internal disc derangements. Neither is likely to be
associated with any relevant bony abnormalities.
Consequently, radiography is not normally indicated
unless there is any suggestion of bony abnormality,
such as might be the case in rheumatoid arthritis
or osteoarthrosis. Many panoramic X-ray machines
allow specific images of the condyles to be taken
without unnecessary radiography of the rest of the
jaws. The only radiographic projection to show the
whole joint is the transcranial oblique lateral view.
A clinical diagnosis of suspected internal derange-
ment might lead to a requirement for imaging of the
disc. This is done by magnetic resonance imaging
(MRI) (Fig. 15.3). TMJ arthrography (Fig. 15.4) is
mainly of historical interest, but may occasionally be
used where patients are unsuitable for MR examina-
tion, e.g. because of severe claustrophobia.
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Pain/dysfunction
Internal derangement
The most common TMJ disorder is pain or
dysfunction. The articular disc normally sits above the anterior
aspect of the condylar head, with the disc poste-
Clinical features rior attachment lying within 10 of the vertical (Fig.
15.5). A disc may be anterior to this normal posi-
Symptoms are a combination of: tion in asymptomatic individuals, suggesting that
headache
an anterior disc position is a normal variant. Thus,
limitation/deviation of jaw opening an internal derangement is best thought of as an
Closed Open
A B
Fig. 15.5 The normal articular disc in the closed and open positions (A) and in an arthrogram showing
the maximal opening (B).
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Disorders of the temporomandibular joint Chapter 15
Clinical features
Radiology Reduction in opening.
No abnormalities are apparent on plain radiographs. In unilateral cases, lasting deviation on opening.
MR imaging shows the displaced disc in a closed/ No click.
rest position (Fig. 15.6B). Pain may be present in front of the ear.
Closed Open
B
A Open (post-click)
Fig. 15.6 A displaced disc with reduction showing the movement diagrammatically (A) and on MR
in closed and open positions (B). On the open MR scan, the disc now lies above the condyle in a normal
position.
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B
A Closed Open
Fig. 15.7 A displaced disc without reduction showing the movement diagrammatically (A) and on MR in
closed and open positions (B). Note that the disc is crumpled up in front of the condyle and the limited anterior
translator movement of the condyle.
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Disorders of the temporomandibular joint Chapter 15
Clinical features
Pain localised to the TMJ region.
Radiology
Plain films show erosions of the articular surfaces
of the condyle and, less commonly seen, of the
mandibular fossa. Sclerosis of the bone and mar-
ginal bony proliferation (lipping or osteophytes)
are seen (Fig. 15.8) and narrowing of the radio-
graphic joint space. Bony proliferations may break
away and be seen as loose bodies in the joint space.
Management
Explanation and reassurance.
Anti-inflammatory drugs.
Physiotherapy.
Fig. 15.8 Radiograph of osteoarthrosis showing
Restore deficiencies in the posterior occlusion marginal bony proliferation (lipping).
to reduce loading on TMJs.
Intra-articular steroid injections (advanced disease).
Surgery (advanced disease; final option) to Radiology
smooth irregular condylar head where there are Radiology demonstrates reduction in bone density
osteophytes or irregularities. in the TMJ. There is marked erosion of the con-
dylar head and articular fossa and narrowing of the
joint space.
Rheumatoid arthritis In long-standing disease, there is:
destruction of entire condyle
Rheumatoid arthritis is a disorder associated with
anterior open bite
synovial membrane inflammation in several joints.
secondary osteoarthrosis
The TMJs are involved in approximately half of
affected individuals. Villous synovitis leads to the ankylosis.
formation of synovial granulomatous tissue (pan-
nus) that involves fibrocartilage and the underlying Management
bone. The pannus releases enzymes that cause car- Analgesics/anti-inflammatory drugs.
tilage/bone destruction. Steroids.
Physiotherapy.
Clinical features
Pain over TMJs.
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Trauma
Management
Trauma may have a number of effects upon the Manual manipulation to reduce the dislocation
TMJ. Fractures are discussed in Chapter 8 (Fig. 15.9). Intravenous sedation with midazolam
provides muscle relaxation and greatly facilitates
this manoeuvre. The patient should avoid wide
Effusion mouth opening for some days and use the hand to
prevent this when yawning.
Effusion is influx of fluid into the joint, usually
either bleeding following trauma or inflammatory
exudate. It is important to differentiate this from Ankylosis
septic (infective) arthritis.
Fusion across a TMJ may occur as a result of
trauma, mastoid infection or juvenile chronic
Clinical features arthritis. Surgical treatment is by joint replacement
Pain over joint.
with a prosthetic joint unless the patients facial
Swelling over joint. development is not yet complete, when a costo-
Limitation of movement. chondral (rib) graft is used in an attempt to provide
Sensation of a blocked ear. a bony replacement that may grow.
Difficulty in occluding posterior teeth.
Radiology
There is a widened joint space.
Management
Anti-inflammatory drugs.
Dislocation
In dislocation of the TMJ, the condyle is abnormally
positioned outside the mandibular fossa but within the
joint capsule. Dislocation may occur during trauma or
be caused by failure of muscular coordination.
Clinical features
Inability to close the jaw.
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Disorders of the temporomandibular joint Chapter 15
Q Self-assessment: questions
Multiple choice questions (True/False) I. Rheumatoid arthritis
1. The following contribute to mouth opening: J. Joint dislocation
a. Medial pterygoid muscle Lead in: Select the most likely diagnosis from the list
b. Lateral pterygoid muscle above for each of the following cases. Each option
can be used once, more than once or not at all.
c. Masseter muscle
1. An 11-year-old patient, following trauma to the
d. Temporalis muscle jaw as an infant, developed a worsening facial
e. Stylomandibular ligament asymmetry and now has extreme limitation of
2. The following radiographs/imaging methods can opening. He has no other joint problems in the
be used to measure joint space width: body.
a. Panoramic radiograph 2. A 25-year-old male has just had a blow to the
b. Transpharyngeal radiograph face playing rugby. He complains of pain over
c. Transcranial oblique lateral radiograph his right TMJ and limitation of jaw movement. On
d. Transorbital (Zimmer) radiograph examination, there is no gross facial asymmetry.
There is a tender swelling over the affected joint
e. Cone beam CT (CBCT) or computed
and the ipsilateral posterior teeth dont seem to
tomography (CT)
occlude completely.
3. Condylar hyperplasia:
3. A 25-year-old woman complains of an annoying
a. Is a developmental disorder click in her left TMJ on opening and closing. On
b. Is an inflammatory disorder examination, there is no facial asymmetry when
c. Is assessed using radioisotope imaging the jaw is closed, but a transient deviation of
d. Is usually self-limiting the jaw during opening and closing the mouth.
e. Causes ankylosis Maximal opening is normal.
4. Erosion of the condyle may occur in: 4. A 45-year-old woman with a long history of TMJ
a. Pain/dysfunction trouble complains of dull pain and grating sounds
over her right TMJ. The symptoms are sometimes
b. Internal derangement
worse after a meal, but her jaw is also stiff in the
c. Psoriasis morning with some difficulty in opening.
d. Synovial chondromatosis (SC) 5. A 35-year-old woman with a long history of
e. Dislocation clicking and occasional pain from her right TMJ
5. Deviation to the left side on opening could be presents with an acute event, consisting of limited
caused by: opening, deviation of the jaw towards the affected
a. Right TMJ disc anterior displacement without side on attempted opening and pain localised to
reduction the joint region. These symptoms were present
b. Left TMJ disc anterior displacement without upon waking up in the morning and have been
reduction unchanged since. She mentions that the click that
c. Right TMJ effusion has always been there is no longer present.
d. Left TMJ effusion 6. An 18-year-old male student complains of aching
jaw joints, headaches and limitation of mouth
e. Bony ankylosis
opening over the previous 2 weeks. There is
Extended matching items questions no history of trauma or of previous TMJ-related
symptoms. On examination, the reduced opening
EMI 1 is confirmed, with a path of opening that is
Options: rather irregular. There is tenderness over the
A. Osteoarthrosis TMJ regions and of the muscles of mastication
B. Pain/dysfunction syndrome bilaterally. There are inconsistent jaw sounds but
C. Joint effusion no predictable click in either joint.
D. Fracture of condylar neck 7. A 9-year-old boy has a 3-year history of right
E. Ankylosis TMJ pain and tenderness. Recently, symptoms
have developed bilaterally. On examination, the
F. Juvenile chronic arthritis
mandible appears rather underdeveloped, there
G. Internal derangement: anterior displacement with
is an asymmetry with the right side appearing
reduction
relatively small and there is an anterior open bite.
H. Internal derangement: anterior displacement Enquiry indicates that he has symptoms in other
without reduction joints in the body.
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Disorders of the temporomandibular joint Chapter 15
5. What are the indications and contraindications for 7. What are the uses of arthroscopy in managing
TMJ arthrography? TMJ disorders?
6. How would you examine the lateral pterygoid 8. When might you use a soft bite guard for a patient
muscle when assessing a patient with a TMJ with TMJ problems?
disorder?
A Self-assessment: answers
Multiple choice answers 3. a.True. Condylar hyperplasia is a developmental
1. a.False. It helps in closing the mouth. anomaly causing excessive growth of the
condyle, leading to a developing facial
b. True. Only the lateral pterygoid muscle is a
asymmetry, enlargement of the condyle and
mouth opener. In fact it has two parts: its
sometimes deformity of the condylar head.
lower head is active in opening, protrusion and
It usually arises before age 20 years and is
lateral movements, while its upper head has
commoner in males.
activity during mouth closing.
b. False.
c. False. It helps in closing the mouth.
c. True. Radioisotope bone scanning (using 99
d. False. It helps in closing the mouth. mTc-labelled methylene bisphosphonate as the
e. False. The stylomandibular ligament extends radiopharmaceutical) is used to assess activity
from the styloid process on the skull base to in the condyle; ideally surgery is carried out
the angle of the mandible; its role is probably when the activity is reduced to background
to limit movement of the mandible but it has no level.
active role to play.
d. True. The jaw on the affected side often shows
2. a.False. Panoramic radiographs are taken with an increase in height of the ramus and body.
the jaw protruded and, therefore, cannot show There may be a posterior open bite on the
any information about joint space width. affected side but often there is compensatory
b. False. The transpharyngeal radiograph is taken maxillary alveolar overgrowth. Treatment is
with the mouth open. ideally by orthognathic surgery, but this should
c. True. A closed transcranial oblique lateral be delayed until the condition has stopped
radiograph is the only radiograph that shows developing.
joint space width. However, the angulation e. False. Ankylosis is not associated with the
used means that it is the joint space width in condition.
the lateral part of the joint that is demonstrated. 4. a.False. Erosion of the condylar head is a fairly
d. False. This rarely used anteroposterior non-specific feature. It is most commonly seen
radiograph is taken with the mouth open. The in osteoarthrosis.
X-ray source has to be positioned close to the b. True. Erosion in internal derangements
eye and consequently gives a high dose to the represents advanced disease with progression
lens. to osteoarthrosis.
e. True. CT can give measurements of joint space c. True. Psoriasis is a seronegative systemic
width. However, conventional axial scans arthritis. Radiologically and clinically it is similar
must be reassembled in a two-dimensional to rheumatoid arthritis.
reconstruction to make measurement easier, so
d. True. SC is a rare disorder where there is
fine sections are best. Direct sagittal scanning
formation of multiple cartilagenous and
is preferable.
osseocartilagenous nodules in the synovial
Joint space narrowing is a sign of osteoarthrosis. membrane of joints. These nodules can detach
However, it is important to remember that imaging and become loose in the joint spaces. Patients
should not be carried out just to ensure that all with SC have variable symptoms ranging from
pathological findings have been demonstrated. The none to pain, swelling, joint noises and trismus.
purpose of imaging is to aid in diagnosis and to make Treatment is by surgery to remove the nodules
a contribution to management. If you have established and resect the abnormal synovial membrane.
the diagnosis clinically and know what treatment you
e. False. There is no association with erosions.
are going to do, then the presence/absence of joint
space narrowing is irrelevant!
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5. a.False. Deviation occurs towards the affected The event usually arises suddenly, during eating,
side. yawning or, as here, appears on waking from
b. True. Any limitation on TMJ movement will lead sleep.
to deviation of the jaw towards the affected 6. B. The muscle tenderness, the headaches and jaw
side. limitation all fit with this diagnosis. The absence
c. False. This would cause deviation to the right. of any click, either current or historical, goes
d. True. Effusion will limit movement, causing against a diagnosis of internal derangement.
deviation to the left. 7. F. The age of the patient tends to give this one
e. False. Bony ankylosis would not show this sign away, as does the evidence of multiple joint
because true ankylosis will prevent all but a involvement. Almost half of patients with this
tiny degree of jaw movement. condition will have TMJ involvement and most
will ultimately have bilateral disease. Retrognathia
Extended matching items answers and anterior open bite are prominent features
EMI 1 because of destruction of the normal condylar
growth centre. Asymmetry is also fairly common,
1. E. The problem is localised to a single joint in reflecting differential degrees of involvement of the
the body and has a clear relationship to trauma joints.
when an infant, so ankylosis seems a likely
8. J. The features are certain to be dislocation,
diagnosis and juvenile chronic arthritis seems
because of the sudden onset during yawning and
unlikely. Bony ankylosis means that mandibular
the occlusal effects. Patients who dislocate their
movement is essentially non-existent, although
jaw in this way may suffer recurrent events, as in
a few millimetres of movement may be observed
this case. The anterior open bite, with gagging
through flexing of the bone. Sometimes, however,
on the posterior teeth, is also seen in bilateral
the ankylosis is due to fibrous union of the joint
condylar fractures, but in the absence of trauma
components, and a little greater movement may
this would not be in the differential diagnosis
be possible. Radiography should be able to
here. The only other possible diagnosis would be
differentiate the two types.
an acute internal derangement problem, where
2. C. Trauma has precipitated this problem, so the the condylar head had passed anterior to a lax
differential diagnosis is essentially between C, D interarticular disc and could not reduce back to
and J. In this case the occlusion is a helpful clue. allow closure; such an event would be unlikely to
If there was a unilateral fracture of the condylar occur bilaterally.
neck, then there would probably be a posterior
9. D. This scenario fits well with a fractured neck of
open bite on the contralateral side. Dislocation
condyle. The key factor that helps differentiate this
is usually bilateral and gives an anterior open
case from other trauma-associated TMJ problems
bite. Effusion, apart from other local signs of
is the occlusion. As discussed in Chapter 8,
inflammation, tends to produce difficulty in
a fracture at this site will lead to an altered
bringing the posterior teeth together, but no
occlusion due to the likely displacement of the
dramatic change in the occlusion. Of course, if
condylar fragment and the consequent upward
there is any doubt, radiography should be used as
movement of the ipsilateral ramus.
a help.
10. I. The symptoms might suggest pain/dysfunction
3. G. Reciprocal clicking is the essential sign of
or anterior disc displacement without reduction.
anterior disc displacement with reduction. In
The absence of a previous click, however, would
the absence of other symptoms, such as pain,
tend to exclude the latter diagnosis. The clues
difficulty in eating, etc., this can be seen as
here are the problems with other joints and the
normal variation rather than disease.
complaint about the bite. In rheumatoid arthritis,
4. A. This condition is more common in older destruction of the articulating surface of the
patients and in women. It may follow on from condyles may occur, leading to a superior position
an internal derangement or after trauma. The of the condyles in the fossae. This may lead to an
condition comes and goes and may gradually altered occlusion and anterior open bite.
burn out. Management should, therefore, be
aimed at symptomatic relief. In some respects, EMI 2
the symptoms in this patient could be consistent 1. A is the simplest choice. Radiological findings
with rheumatoid arthritis, but the absence of other in osteoarthrosis include sclerosis, joint space
joints with disease makes this most unlikely. narrowing, flattening of the articulating surfaces
5. H. Patients with a reducing disc (disc and osteophyte formation. B is of historical
displacement with reduction) sometimes present interest, while C needs special equipment that
with a sudden event of inability to open their dentists would not have.
mouth (disc displacement without reduction).
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Disorders of the temporomandibular joint Chapter 15
2. F. As there is nothing to image in this condition, would be appropriate and a muscle relaxant
and as the provisional diagnosis is reached on drug could be prescribed. Benzodiazepine
clinical evidence, no imaging is required. drugs are used for their muscle relaxant effects.
3. F or A. This diagnosis is often reached on clinical The form may be diazepam 5mg at night, or
evidence and radiology can do nothing to improve temazepam elixir (10mg in 5ml) at night. Review
the treatment. In reality, however, some imaging the patient after 1 month. Longer review might
may be needed to confirm that there is no fracture be useful, particularly if there has been some
and, in such cases, a panoramic radiograph may improvement, as spontaneous resolution can
be sufficient. occur. In the absence of any improvement, it
4. A and D. When evaluating fractures, it is may be appropriate to consider disc imaging
de rigueur to have two images at different and manipulation of the jaw under general
angulations, and this pair offers a 90 difference. anaesthesia.
It is becoming increasingly common for G or H Case history 2
to be used in this situation; while either provide
excellent images of the TMJ, they also deliver 1. The symptoms and signs suggest that the
higher radiation doses than A and D, and relative diagnosis is osteoarthrosis.
cost/benefit has not been evaluated. 2. First, take a radiograph of the affected TMJ
5. A followed by G or H. Once the diagnosis has to confirm the diagnosis by identification
been made using clinical information and A, of the radiological signs of the disease. A
cross-sectional imaging is appropriate to aid the transpharyngeal view or a panoramic (TMJ
surgeon in planning intervention. programme) radiograph would be reasonable.
Alternatively, a transcranial film might be useful
6. A and E. The lateral cephalometric radiograph
to examine the joint space. Mrs Johnson is
may be important as a means of recording
concerned about the effect this condition is
and monitoring objectively the facial changes
having on her life. Therefore, it is worth attempting
associated with this condition.
treatment. Reassure the patient and describe the
7. F. So long as no treatment is needed and the nature of the condition. Examine the mouth and
clinical features are clear, imaging is not going to assess whether there is a satisfactory posterior
change management. occlusion. Prescribe a non-steroidal anti-
8. J or occasionally I. Here, intervention is likely, inflammatory drug. An appropriate prescription
so imaging of the meniscus position is required. would be 400mg ibuprofen three times a day
Magnetic resonance imaging is the preferred after food for 1 month. This should not be
method for this, although a few centres will still prescribed for patients with any history of peptic
perform arthrography. ulceration or asthma, during pregnancy or for
9. A and possibly E. A may show the characteristic patients with kidney or liver disorders. A course
erosion of the condylar heads and assist in of physiotherapy would be valuable. Review after
confirming diagnosis. E would be appropriate if 1 month. In the absence of improvement, refer
there is evidence of a changing occlusion, as was to a specialist clinic. The specialist may consider
the case with juvenile chronic arthritis. intra-articular steroid injection or, as a last resort,
10. A. The radiograph is used to confirm that the surgery.
condylar heads lie anterior to the articular
eminences. Case history 3
1. There is a clear link to the traumatic incident and
Case history answers the differential diagnosis is a joint effusion or a
Case history 1 fracture of the right condylar neck.
1. The previous history of clicking suggests that 2. Check the occlusion. An effusion would either
there was, in the past, a displaced disc in the have no effect on the occlusion or cause a
right TMJ that could reduce when opening. The difficulty in approximating the posterior teeth on
change in symptoms, with loss of the click and the affected side. A fractured condylar neck is
limitation of opening with late deviation, is typical often associated with premature contact between
of a non-reducing disc displacement. A displaced the posterior teeth on the ipsilateral side and a
disc without reduction is usually preceded by a posterior open bite on the contralateral side. Take a
reducing disc. radiograph. A panoramic film is a valuable imaging
method for suspected mandibular fractures. This
2. Describe the problem to Amanda and try to
might be supplemented by other views (e.g. a
reassure her. Treatment should be carried out
reverse Townes view) if the panoramic suggests
in conjunction with her doctor, unless you are a
a fracture. An effusion would probably not give
hospital practitioner. A referral for physiotherapy
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Master Dentistry
any radiological signs on a panoramic view. If 4. No. The majority of patients with TMJ disorders
the diagnosis is joint effusion, then reassurance, have pain/dysfunction or an internal derangement.
resting the joint and use of anti-inflammatory drugs Neither have radiological signs. A panoramic
on a short-term basis would probably suffice. If a radiograph is often taken as a check for other
fracture is confirmed, then the patient should be pathology. This is unsupportable as radiographic
referred to a hospital oral and maxillofacial surgeon. screening using panoramic radiographs has no
If the occlusion is normal, then management scientific basis. A radiograph (a panoramic may be
would be conservative, that is, the same as for an the best choice) is indicated where the suspected
effusion. If the occlusion is abnormal, this would diagnosis is osteoarthrosis and after trauma when
indicate a 2-week period of intermaxillary fixation a fracture is a possible diagnosis.
(IMF) or, on occasion, open reduction and fixation. 5. The main indication for arthrography would be an
internal disc derangement that has not resolved
Case history 4
following conservative treatment and where
1. The symptoms and signs are consistent with pain/ either manipulation under general anaesthesia
dysfunction syndrome. or surgery is being contemplated. Generally
2. Reassure the patient and explain that this magnetic resonance imaging is preferred to
is a common condition. Point out that pain/ arthrography but is often less readily accessed.
dysfunction may spontaneously subside but Contraindications include local infection and
may recur. Advise jaw rest, soft diet, the use of iodine allergy. Very anxious patients and needle
anti-inflammatory drugs and construct a soft phobics may not be appropriate candidates for
bite guard. Consider referral for a course of arthrography.
physiotherapy. Review. 6. Lateral pterygoid muscle is not accessible for
direct examination. Some authorities suggest
Oral examination answers
palpation behind the maxillary tuberosity as a
1. Clicking of the jaw is a result of an atypical method of direct examination but it is of dubious
disc position, usually an anterior displacement. value, particularly as anyone would find palpation
Magnetic resonance imaging studies of normal here uncomfortable. The muscle is best assessed
individuals show that a substantial proportion by measuring the response to opening the jaw
have an anterior disc position. Therefore, the against the resistance of the operators hand.
presence of a jaw click is not in itself abnormal Place your hand under the patients chin and ask
and there should be no attempt to treat it unless them to open against it. If there is muscle spasm,
there are other symptoms or signs. there will be preauricular pain on attempted
2. Bruxism is associated with the following: opening. This procedure can be repeated with
tooth attrition with unusual wear facets lateral movements.
tooth sensitivity, particularly of anterior teeth 7. Arthroscopy is a minimally invasive surgical
frequent fracture/replacement of restorations technique in which an instrument is passed into
scalloping of the lateral border of the tongue the upper joint space, permitting direct imaging
via a camera and surgical procedures to be
ridging of the cheek mucosa along the occlusal
performed. Lavage, biopsy and sectioning of
plane.
adhesions can be performed.
3. No. However, 3040% of patients attending for a
8. A soft bite guard is a useful first-line treatment
TMJ disorder will also have a mental disorder. The
for patients with pain/dysfunction syndrome. Its
most common disorder is a depressive illness. It
method of action is not understood, but it may
is possible that when people become depressed
work as a habit breaker in parafunction or simply
they become more aware of physical symptoms.
as an absorber of occlusal forces. It is usually
worn at night for 6 weeks.
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Radiation protection 16
A
Tungsten Tungsten
filament target
Fig. 16.1 An X-ray tube insert from a dental X-ray set (A) and a diagram (B) showing the structure
and the direction of electron flow (arrow).
The first two result in absorption of all or part of Somatic effects can be:
the X-ray photon energy and ionisation of an atom. tissue effects (formerly known as determinis-
In a living cell, ionisation can have damaging tic effects): e.g. cataract formation, loss of fer-
effects. We are particularly concerned if the DNA tility, erythema of the skin, radiation sickness
of a cell is damaged. This may occur by a direct
stochastic effects: tumour induction (also
interaction of X-ray photons with the DNA or indi-
occurs in genetic effects).
rectly when a photon disrupts a water molecule
into reactive radicals that go on to damage DNA. All tissue effects have threshold doses below
which they do not occur. Above the threshold dose,
the effect is certain to occur. In dental radiography,
Somatic and genetic effects these thresholds should never be reached. The risk
of X-rays from dental radiography is for stochastic effects.
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Radiation protection Chapter 16
Aft
Fig. 16.2 The effect of filtration on the X-ray beam. Low-energy photons predominate in the unfiltered
spectrum. Filtration removes proportionately more of these weak X-rays, resulting in a filtered beam with a higher
mean energy at the expense of a loss of intensity.
Fig. 16.3 An X-ray set with rectangular collimation. This beam restriction method results in a dose reduction
to patients of about 65% compared with conventional 6-cm-diameter round beams.
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Radiation protection Chapter 16
Table 16.2Intervals between bitewing examinations in orthodontic assessment when clinically indi-
indicated by caries risk category cated (no screening)
preoperative assessment of third molars, unless
Interval (months) by caries risk category other adequate radiographs are available
when mandibular fracture is suspected.
Low Moderate High
as part of implant dentistry planning, unless
Child 1218 12 6 other adequate radiographs are available
Adult 24 or greater 12 6 Routine screening of all new patients is never
justifiable; research has shown that the majority
of patients who receive a screening panoramic
and molar regions, providing geometrically accu- radiograph receive no diagnostic benefit from the
rate images. Where periodontal probing depths examination.
exceed 5mm, then vertical bitewing radiographs
are appropriate. Selection of CBCT examinations
Cone beam computed tomography (CBCT) is a
Selection of periapical radiographs relatively new technology and its capabilities are
Periapical radiographs are indicated in the following changing as equipment is refined. Despite this, one
situations: general principle can be stated: that CBCT should
When dictated by localised symptoms/signs only be used when the question for which imag-
(pain, swelling and tenderness of a tooth). ing is required cannot be answered adequately by
lower-dose conventional (traditional) radiography.
Prior to the extraction of erupted third molars,
This view reflects the status quo in which radiation
retained roots, lone-standing upper molars or
doses and economic costs associated with CBCT are
where there is reasonable clinical suspicion that
usually higher than with conventional radiography.
problems may arise. The fashion of routine pre-
Artefact, arising from most metals (usually
extraction radiographs has arisen in the absence
dental restorations) in the scan degrade the image
of any scientific evidence of benefit.
quality significantly throughout that axial plane,
Prior to preparation of a tooth for a crown or
producing radiating dark bands. This is one reason
bridge retainer.
why CBCT should not be used as a method of car-
In endodontics, where basic guidelines suggest ies detection, as the artefacts can mimic radiolu-
radiograph(s) at the following stages: cency. Similarly, metal posts in roots may produce
preoperative the same effect. Detailed, evidence-based selection
working length estimation criteria for CBCT have been developed recently for
master cone position (precondensation) Europe (see Further reading section).
postcondensation
at 1 year after treatment completion. Dose limitation
Dental trauma.
Patient doses in dental radiography can be mini-
This list is not exhaustive. Where there is any mised by considering the following:
localised dental or alveolar problem, a periapical Operating potential (kilovoltage): for intraoral
radiograph may be appropriate. radiography, a minimum of 50kV is set and
6570kV is recommended. This is often fixed on
Selection of panoramic radiographs
dental intraoral X-ray sets but is usually used to
In terms of image quality, panoramic radiogra- control exposures on panoramic X-ray equipment.
phy is inferior to good intraoral radiographs. Con-
Tube current-exposure time product (mAs).
sequently, for most dental diagnostic uses, it is a
The current (mA) is often fixed on dental intra-
second best imaging technique. Possible situations
oral X-ray sets, while the exposure time(s) is
where it may be useful include:
often fixed for panoramic and CBCT machines.
where a bony lesion or unerupted tooth is of AC/DC generation of X-rays: DC (constant
a size or position that precludes its complete potential) generators lead to fewer low-energy
demonstration on intraoral radiographs (dose-producing) X-ray photons.
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Master Dentistry
Filtration: aluminium filters absorb low-energy used). For CBCT equipment, the choice of
X-ray photons. image receptor is out of the control of
Collimation: on intraoral X-ray sets, the beam the operator, although this will influence
can be restricted to a rectangle of 4cm radiation dose.
by 3cm, leading to a substantial dose reduction Lead shielding of patients: the only requirement
over the conventional 6-cm-diameter round to use a lead apron is when a pregnant woman
beam; all new equipment should be fitted is being examined using a technique involving a
with rectangular collimation and it should be beam that would pass through the fetus. Thy-
retrofitted on older equipment; on panoramic roid shielding can be used if that organ lies in
machines, selective field size collimation facili- the primary beam of X-rays.
ties may be available. For CBCT equipment,
there should be a choice of fields of view and
Quality assurance
examinations must use the smallest that is com-
patible with the clinical situation if this provides A poor-quality image means that the patient
less radiation dose to the patient. receives reduced, or no, benefit from the risk of the
Image receptor speed: for intraoral radiogra- X-ray examination. Even in the best hands, radio-
phy, digital systems may offer some reduction graphs may be produced that are rejects. A qual-
in mAs (and hence dose) compared with film. ity standard of no greater than 10% of radiographs
Where film is used, E- or F-speed films should (5% for CBCT images) being non-diagnostic has
be used. For digital panoramic equipment, this been set for general dental practice. Good quality
factor is out of the control of the operator, but of radiographs can be addressed by attention to all
for film-based panoramic radiography, a rare- of the criteria listed in Table 16.3.
earth screen/film combination should be used A quality assurance programme of regular
(a combination of ISO speed 400 or better is checks, cleaning and servicing should be established
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Radiation protection Chapter 16
to maintain high standards and to fulfil the legal used where distance is not feasible as protection.
requirement. Because of higher scatter doses often seen with
CBCT equipment, it is more likely that barriers
will be required.
Protection of staff
While practitioners rightly consider the wellbe- Workload
ing of patients first, the needs of dental staff and While it is probably impossible for a member of den-
the public (who are not patients) should not tal staff to receive a dose approaching the limits set
be ignored. Dentists and ancillary staff may be by law for workers, radiation dose monitoring has
exposed many times each day to X-rays if staff pro- been recommended for anyone taking more than
tection is not ensured. The following are the impor- 100 intraoral or 50 panoramic radiographs per week.
tant considerations.
Local rules
Position Every dental practice must have a set of local rules
For intraoral radiography, nobody except the for radiation safety. By reading these and adhering
patient should be within the controlled area (Fig. to them, radiation safety of staff should be assured.
16.4) unless specific guidance has been received
from a medical physics expert/radiation protec-
tion adviser. This controlled area has a strict defi- Good practice guidelines
nition; however, safety should be adequate outside Guidelines on the safe use of radiation are pro-
an area of radius 2m centred on the patient and, duced by the UK Department of Health, but are
for intraoral radiography, never in line of the pri- also available from the European Commission and
mary beam. Barriers of suitable material may be the International Atomic Energy Agency.
X-ray set
Primary
beam
Wall
Fig. 16.4 The controlled area for an intraoral X-ray set. The primary beam would be unacceptably intense
for many metres and we rely on walls to attenuate the X-ray beam to an acceptable level. While this diagram is two-
dimensional, remember that the controlled area extends above and below the patient and X-ray set. Ceiling and floor
materials may not provide an adequate barrier to limit the controlled area.
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Master Dentistry
Q Self-assessment: questions
Multiple choice questions (True/False) c. Equivalent to that from a set of posterior
1. The following are ionising radiation: bitewing radiographs
a X-rays d. Always 324Sv (microsieverts)
b. Radiowaves e. Associated with a risk of cancer typically higher
than that from a lateral cephalogram
c. Microwaves
4. A lower radiation dose for a periapical radiograph
d. Gamma rays
can be achieved by:
e. Cosmic rays
a. Using a 50-kV X-ray set rather than a 70-kV
2. The following are everyday risks to patients in X-ray set
dental radiography:
b. Using a constant potential (DC) X-ray set rather
a. Tissue (deterministic) effects than a pulsating potential (AC) X-ray set
b. Somatic stochastic effects c. Using a lead apron
c. Genetic stochastic effects d. Using D-speed film
d. Salivary gland cancer e. Using a digital radiography system
e. Cataract formation
3. The dose of radiation from a panoramic Extended matching items questions
radiograph is: EMI 1
a. About the same as 13 days of background Options:
radiation A. Old film stock
b. Much less than the dose from a chest B. Too low an X-ray exposure
radiograph
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Radiation protection Chapter 16
C. The radiographic cassette leaks light 1. A patient has gingivitis and probing suggests
D. Poor patient positioning some early loss of periodontal attachment
E. Light fogging during automatic processing throughout the mouth.
F. Poor film/screen contact 2. A patient presents with a symptomatic internal
disc derangement of a temporomandibular joint
G. Incorrect processing
that has proved unresponsive to conservative
H. Patient movement during exposure
treatment.
I. Static electricity discharge
3. A patient presents with recurrent, severe, sharp
J. Excessive X-ray exposure toothache of 10 minutes duration, precipitated
Lead in: Poor-quality radiographs lead to the need for by hot stimuli. The causative tooth is difficult to
repeat exposures, thus increasing radiation dose to localise clinically.
patients. Match each panoramic radiographic film fault 4. A 14-year-old patient has a retained deciduous
below to the diagnosis (cause of the fault) above. maxillary canine and no sign of the permanent
There may be more than one possible cause for some successor.
film faults.
5. A patient presents with a painless, clicking
1. Localised areas of black (high density) along the
temporomandibular joint.
edge of the radiograph.
6. A patient presents with an acute pericoronitis
2. Areas of the radiograph show blurring (reduced
on an erupting wisdom tooth. This is the first
image sharpness).
occasion it has occurred.
3. Lower border of mandible is distorted (up and
7. A 12-year-old patient who has mild crowding,
down shape).
a Class I malocclusion and a skeletal Class 1
4. Low density and contrast throughout the image. pattern wants and seems suitable for orthodontic
5. Wide front teeth. treatment using a simple upper removable
6. Uniformly dark, low-contrast image. appliance.
7. Narrow, matchstick front teeth. 8. A patient requires endosseous implants in the
8. A mixture of small black spots and thin zig-zag posterior maxilla.
lines over the image. 9. A patient presents with a large, painless hard bony
9. The film steadily increases in density and loses swelling in the lower first molar region.
contrast from one end to the other. 10. A 12-year-old patient, with Index of Orthodontic
10. All radiographs show low contrast and, notably, Treatment Need (Dental Health Component) >4
metal restorations look grey. and a severe Class 2 skeletal pattern requires
and seems suitable for upper and lower fixed
EMI 2 appliances.
Options:
A. Bitewing examination Essay questions
B. Periapical radiograph(s) 1. The risk to patients from dental radiography is so
C. Occlusal radiograph(s) low as to be negligible. Discuss.
D. Panoramic radiograph 2. How would you carry out radiographic quality
assurance in a dental practice?
E. Lateral cephalometric radiograph
F. CT or CBCT examination Oral examination questions
G. Magnetic resonance imaging 1. When should you use a lead apron in dental
H. Radioisotope imaging radiography?
I. Ultrasound examination 2. Where should the operator stand when exposing a
J. No radiological investigation needed patient for an intraoral radiograph?
Lead in: One of the simplest means of radiation 3. How would you respond to a patient who
protection of patients is the use of referral (selection) expressed concern about the X-ray exposure from
criteria to select the appropriate radiological a dental radiograph?
investigation, thus minimising X-ray examinations that 4. How would you improve the risk/benefit when
do not alter management of the patients problem. exposing a patient for a panoramic radiograph?
Select the most likely radiological investigation(s) from 5. Why are X-rays considered to be dangerous?
the list above that would be appropriate to the case 6. How do you assess when a patient should have a
histories below. More than one investigation may be set of bitewing radiographs?
appropriate for some cases.
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Master Dentistry
A Self-assessment: answers
Multiple choice answers c. True. Using the dose ranges given in this
1. a. True. These are produced by bombarding a chapter, two bitewing films might be around
positively charged target with electrons. the same level of dose as a panoramic
radiograph. However, the ranges involved
b. False. Low frequency and, therefore, have
mean that this may not always be the case.
insufficient energy to ionise atoms.
d. False. The dose range given assumes
c. False. Low frequency and, therefore, have
good practice and up-to-date equipment.
insufficient energy to ionise atoms.
Many older machines with higher doses are
d. True. Naturally occurring radiation from used in dental practices, and the common
radioactive materials. practice of overexposing to compensate for
e. True. Cosmic rays come from outer space underdevelopment during processing means
but contribute a substantial part of our natural that doses may be considerably higher.
background radiation. All of these radiations e. True. Looking at the figures quoted in the text
are electromagnetic (EM) radiation. EM of this chapter, you will see that the risk from
radiation exists as photons, tiny packets of a panoramic radiograph is typically an order
energy with a waveform (they have a frequency of magnitude greater than that of a lateral
and a wavelength). The higher the frequency is, cephalogram.
the greater the energy in each photon. X-rays,
4. a. False. Lower voltages give a higher proportion
gamma rays and cosmic rays are all high-
of weaker X-rays. Weak X-rays are more
frequency EM radiation and can ionise atoms.
likely to undergo absorption (photoelectric
2. a. False. These effects have threshold doses interactions) in the patients tissues.
considerably higher than that which might be
b. True. A DC X-ray set produces a smaller
received during dental radiography. They may,
proportion of weak X-rays.
however, occur during radiotherapy.
c. False. Using standard good practice
b. True. These effects (tumour induction) have no
technique (paralleling technique and
threshold dose. However, the risk is believed to
rectangular collimation), none of the primary
be directly related to the dose. With low doses
beam should be directed towards the
associated with dental radiography, the risk is low.
trunk of the patient. Scattered radiation
c. False. It is generally accepted that gonadal is principally internal and would be
doses in dental radiography are so low as unobstructed by a lead apron.
to be negligible. This is particularly plausible
d. False. This is the slower of the two intraoral
when considering panoramic radiography (the
film speeds usually available.
beam is highly collimated and is angled slightly
upwards) and intraoral radiography using film e. True. Both types of digital intraoral system
holders (paralleling techniques) and rectangular (CCD-based and photostimulable phosphors)
collimation. can produce a periapical radiograph using a
substantially lower X-ray exposure.
d. True. There is published evidence of an
association between dental radiography and Extended matching items answers
salivary gland (and brain) tumours. However,
this work refers back to a time of higher
EMI 1
radiation doses and it must be remembered 1. C. Old cassettes may get damaged during years
that the risks are small. of use and start to leak light. Light fogs the film,
e. False. Cataract formation is a tissue leading to irregular areas of black at the edge of
(deterministic) effect that should never occur as the radiograph in a position corresponding to the
a consequence of dental radiography. leak. This fault will occur on every radiograph.
3. a. True. The annual average dose to the UK 2. F. Radiographic cassettes contain a light-sensitive
citizen from all forms of radiation is 2600Sv film sandwiched between two intensifying screens.
(microsieverts). The doses from dental The intensifying screens fluoresce when exposed
radiography can be related to this. Using to X-rays and this produces the image on the
the doses given in the text of this chapter, a radiograph. A sharp image is only produced if the
panoramic radiograph would be equivalent to components are squeezed tightly together. Poor
approximately this number of days. contact between films and screens (usually due to
cassette damage) leads to all or parts of the image
b. False. Doses from chest radiography vary
losing sharpness, without distortion of shape.
but a typical range is 2040Sv, in the same
general range as panoramic radiographs.
350
Radiation protection Chapter 16
351
Master Dentistry
8. F. In this anatomical situation, it would be sensible 2. The essay plan would cover:
to obtain cross-sectional images, which can be Definition. Quality assurance (QA) can
obtained using either conventional CT or CBCT, be defined as the organised effort of staff to
in order to define accurately the available bone ensure the consistent production of high-quality
quantity and the anatomical relationship of the radiographs at the lowest possible cost with
maxillary sinus. Most implantologists would have minimum exposure of patients and personnel
already taken D for such patients as part of the to radiation. QA is an essential component of
decision-making process about whether implants radiation protection.
were appropriate. Identifying problems. Begin with a
9. D and C would be the first-choice radiographs. staff meeting to discuss issues related to
The occlusal view would be a true occlusal, radiography and try to instil an appreciation
giving an image at a right angle to the panoramic of the importance of good quality in diagnosis
radiograph. In a dental practice situation with and radiation protection. Try to identify any
limited radiological facilities, B might be the only existing known problems by discussion.
radiographic option. F might be used, in a hospital Audit film quality to see whether you reach
context, depending on the specific circumstances. the quality standard of no more than 10%
10. D and E. The panoramic radiograph is ideal unsatisfactory radiographs (or 5% for CBCT).
for viewing the developing dentition. British Carry out a film reject analysis to identify the
Orthodontic Society guidelines (reproduced principal problems. For example, if pale low-
in European guidelines, referenced in Further contrast radiographs are a problem then this
reading) give clear guidance as to when a could be caused by poor exposure selection,
cephalometric radiograph is useful in orthodontic a faulty X-ray machine or, where film is used,
treatment. This patient satisfies the criteria for underdevelopment. If the main problem is
cephalometric examination. blurred panoramic radiographs, then examine
the films to determine whether this is caused
Essay answers by positioning faults, movement or poor
1. The essay plan would cover: intensifying screen/film contact.
Define the risk. Exposure to X-rays carries with Action. Address first the problems identified
it risks. X-rays are ionising radiation that cause by film reject analysis. For example, if a major
ionisation of atoms by photoelectric and Compton problem was underdevelopment of film, make
interactions. Ionisation can damage important a fresh start with processing by cleaning the
molecules such as DNA in cells, leading to cell processing tanks and using fresh solutions.
death or mutations. With dental radiography, Monitor processing times and check developer
the risk is of somatic stochastic effects (tumour temperature.
induction). The chance of these effects is directly QA programme. Establish a programme of
related to dose; there is no threshold dose below regular checks. In your essay answer, give a
which they are sure not to occur. possible programme. There is no correct make-
Quantify the risk. Risks are related to doses. up of a QA programme as this would be tailored
Doses in dental radiography are variable, to the particular dental practice, but demonstrate
depending on many factors, but typical ranges are that you understand the principles:
<2Sv for an intraoral radiograph and 324Sv
for extraoral. These relate to cancer risks in a Daily activities
30-year-old adult which are typically less than 1 Maintain a log of film quality
per million. Doses are a fraction of annual average
Check developer temperature and process test film
exposures to the UK population and risks are less
using test object
than those of dying from other causes, such as
accidents at work. Risks are higher in children, Clean X-ray viewer
who are, therefore, a group of greater concern. Clean darkroom work surfaces.
Is risk negligible? It is important to remember
that radiography is not a normal part of Weekly activities
someones life. It is an additional risk. It is Check film stock
something carried out by clinicians to a patient Clean intensifying screens.
and a tangible benefit must be demonstrable.
However low the risk, every effort must be made to Two-weekly activities
maximise the benefit and minimise the risk through
Change developer and process reference film.
justification, dose limitation and quality assurance.
352
Radiation protection Chapter 16
353
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Index
Page numbers ending in b, f and t refer to Boxes, Figures and Tables respectively.
Index
Analgesia (Continued) ATLS see Advanced Trauma Life Sup- Black hairy tongue, 250
pre-emptive, 62 port (ATLS) Bleeding disorders, 34
preoperative preparation, 62 Atrophic lichen planus, 266 Blepharoplasty, 207
questions and answers, 8388 Atypical facial pain, questions and Blinding, RCTs, 4
systemic, 5962 see also Conscious answers, 319, 323 Blisters
sedation Atypical odontalgia, 318 intraepithelial, 252
Analgesic mouthwash, lichen planus Augmentation, collagen, 207 subepithelial, 251252
management, 250251 Auscultation, TMJ examination, 328 Blood glucose, general anaesthesia, 80
Anaphylaxis, 4344, 44f Autoantibodies, Sjgrens syndrome Blood pressure, conscious sedation
questions and answers, 5455 diagnosis, 295 monitoring, 77
see also Allergies Autogenous bone grafts, 134136, Body dysmorphic disorder (BDD),
Aneurysmal bone cysts, 223 135f 200
clinical features, 215t Automated external defibrillator Body fractures, mandible, 187f
surgery, 226 (AED), 39, 50 Body temperature
Angina, 3233, 45 AVPU method, 180 conscious sedation monitoring, 77
questions and answers, 54, 56 Avulsion, 181f, 183 general anaesthesia monitoring, 83
Angina bullosa haemorrhagica, 253 Bonded brackets, mandible fracture
Angle fractures, mandible, 187f management, 188190
Angular cheilitis, 246t, 247
Ankylosis, TMJ disorders, 334
B Bone, healing, 148
Bone cysts
Antibacterial drugs, benzodiazepine Bacterial infections aneurysmal see Aneurysmal bone
interactions, 68t patient assessment, 21 cysts
Antibiotics sialadenitis, 293, 294f see also questions and answers, 230, 233
chronic osteomyelitis, 106 specific infections Bone disease, 147159
cysts, 223224 Barbiturates, 69 alveolar loss, 132
facial soft tissue injuries, 184 Basic airway management, 46b48b, benign fibro-osseous lesions, 148
questions and answers, 54, 57 49f cysts see above
Anticoagulants, 3435, 38 Basic life support, 46b48b fractures see Facial fractures
Antihistamines, benzodiazepine Basilic vein, 52f genetic disorders, 157159
interactions, 68t BDD (body dysmorphic disorder), questions and answers, 169, 173
Antihypertensives, benzodiazepine 200 tumours see Bone tumours see also
interactions, 68t Behavioural indications, conscious under osteo; specific diseases/
Antiplatelet therapy, 35 sedation, 67 disorders
Antipsychotics, benzodiazepine Bells palsy, 17f Bone grafts
interactions, 68t Benign migratory glossitis, 255 alveolar, 204
Antrum Benign tumours autogenous, 134136, 135f
cysts, questions and answers, 230, odontogenic tumours, 226b dental implant surgery, 136
233 salivary glands, 297, 300f maxillary orthognathic surgery, 204
inflammation, 165 Benzodiazepine(s), 6971 Bone mineral density (BMD), osteopo-
mucosal cysts, 162, 163f drug interactions, 68t rosis, 156
Apicectomy, 95b, 95f mechanism of action, 70 Bone screws, mandible/maxilla fracture
questions and answers, 108, 112 overdose, 4445 management, 191
Appraisal questions, scientific papers, 8 side effects, 7071 Bone tumours, 159, 159b
APTT (activated partial thromboplastin Benzydamine hydrochloride, lichen benign tumours, 162163
time), 3435 planus management, 250251 malignancy, 163165
Arch bars, mandible fracture Benzylpenicillin, acute osteomyelitis, odontogenic cysts, 163
management, 188190 104 osteoma, 162163
Arrhythmias, 32 Bias, RCTs, 56 questions and answers, 169, 173
Arthrography, TMJ, 329, 329f Biceps muscle, 52f squamous cell carcinomas, 275276,
Arthroscopy, TMJ, 329330 Biochemical investigations, patient 277f
Articaine, 63, 65 assessment, 22 Brachial artery, 52f
ASA (American Society of Anesthe- Biodegradable plates, mandible/maxilla intravenous access, 51
siologists), classification of physical fracture management, 191 Breathing (B), 178f, 179
status, 2930, 30t31t Biodegradable screws, mandible/ medical emergencies, 46b48b, 47f
Aspergillosis, 247 maxilla fracture management, 191 British Dental Journal, 9
Aspiration, cyst surgery, 223224 Biopsies British Medical Journal (BMJ), 9
Aspiration biopsy, patient assessment, excisional, 22 Brow lifts, 207
2122 incisional, 22 Buccal advancement, oroantral
Aspirin Bisphosphonate(s), dental implant communication, 167, 168f
medical emergencies, 39 surgery, 133 Buccal space, 99f, 100, 101f
sensitivity to, 61 Bisphosphonate-associated necrosis of Buccinator muscle, 99f, 101f
Asthma, 33 bone, 107 Bullous pemphigoid, 252
acute, 43 Bisphosphonate-associated necrosis of Bupivacaine, 63, 65
Asymmetry the jaw (BONJ), 133 Burning mouth syndrome (BMS),
craniofacial anomalies, 201 Bitewing radiographs, radiation 318319
salivary gland disease, 288 protection, 344345, 345t Burns, surgery, 184
356
Index
C Chronic pain, 60
Chronic periapical inflammation
Congenital heart disease, 3032
Connective tissue neoplasms, 239
Calculi (periapical granuloma), 89b, 9293, Conscious sedation, 6677
questions and answers, 303304, 307 93f94f administration routes, 6667
salivary gland radiology, 288 Chronic pulpitis, 9091, 90f91f assessment, 6768
CaldwellLuc surgical procedure, Chronic sclerosing sialadenitis, 294 associated methods, 66
166167, 166f Chronic sialadenitis, 293295 contraindications, 6768
Cancers see Malignancies bacterial sialadenitis, 293, 294f pregnancy, 39
Candida albicans infection see chronic sclerosing sialadenitis, 294 drugs, 69 see also specific drugs
Candidiasis radiation sialadenitis, 293294, 294f indications, 67
Candidiasis, 245, 246f, 246t relapsing parotitis, 293 Indicator of Sedation Need, 69t
acute pseudomembranous candidia- sarcoiditis, 294295 inhalation, 7274, 73f see also
sis (thrush), 246t sialosis, 295 Nitrous oxide
chronic hyperplastic, 246t, 247 Circulation (C), 178f, 179180 intranasal, 77
denture-induced, 246t medical emergencies, 46b48b intravenous see Intravenous
erythematous candidiasis, 245 Circumandibular wiring, mandible conscious sedation
leukoplakia, 268 fracture management, 190 monitoring, 77
mucocutaneous, 246t Classical trigeminal neuralgia, 312 oral, 7172
questions and answers, 257, 261 Cleft lip/palate, 199 risk avoidance, 6667
Canines, maxilla see Maxillary canines incidence, 199, 199b techniques, 7177
Capsule, TMJ, 328 questions and answers, 207, 209 CONSORT, scientific papers, 89, 8b,
Cardiac arrest, 49 surgery, 205, 205t 9t10t, 10f
Cardiac failure, 32 Clindamycin, acute osteomyelitis, 104 Contraceptive pill, 38
Cardiorespiratory arrest, 4651 Clinical expertise, evidence-based Controls, RCTs, 3
Cardiovascular disease, general medicine, 2 COPD (chronic obstructive airway
anaesthesia risk assessment, 81 Clinical practice guidelines, 11, 11t disease), 33, 33f
Cardiovascular system problems, 11 Coronoid fractures, mandible, 187f
disease relevance, 30 see also specific Closed reduction, facial fracture Cosmetic facial surgery, 206207
diseases/disorders management, 188190 collagen augmentation, 207
general anaesthesia monitoring, 8283 Clotting dysfunction, hepatic disease, 36 dermabrasion, 206
physical examination, 30 Clotting studies, general anaesthesia, 80 laser abrasion, 207
Casecontrol studies, 7 Cluster headaches, 316 laser resurfacing, 207
Case reports, 7 Cochrane Collaboration, 2f, 78, 8b liposuction, 207
Cavernous sinus thrombosis, 101 Cochrane Library, 1 rhytidectomy, 207
CBCT see Cone beam computed Cognitive behavioral therapy (CBT), 66 scar revision, 206
tomography (CBCT) Cohort studies, 6 Couplands elevators, 119, 119f
CBT (cognitive behavioral therapy), 66 Cold sores (herpes labials), 244 Coxsackie virus infection, 244
Cellular pleomorphism, squamous cell Collagen augmentation, 207 Cranial defects, 132
carcinomas, 270 Collimation, radiation protection, 346 Cranial/temporal arteritis (giant-cell
Cellulitis, 101 Complaint, history taking, 14 arteritis), 316317
Cementoblastoma, 228 Compromised airways, general Craniofacial anomalies, 199212
Cemento-ossifying fibroma, 151152 anaesthesia, 79, 79f aetiology, 199
Central giant-cell granuloma see Giant- Computed tomography (CT), 2225, 24f clinical examination, 200, 201f
cell granuloma (GCG) bone squamous cell carcinomas, clinical management, 200202
Cephalic vein, 52f 275276 congenital anomalies, 199202
intravenous access, 51 dental implant surgery imaging, diagnosis, 201202
Cephalometric analysis, 201, 202f 133134, 134f history, 200
Ceramics, implant surgery, 136 glossopharyngeal neuralgia, 314 intraoral examination, 200
Cervical lymphadenopathy, 98 maxillary sinus diseases, 159, 160f investigations, 201
Cervical nerve, 16f salivary gland masses, 289 treatment, 202 see also Orthognathic
Cervical spine x-ray, general squamous cell carcinomas, 277 surgery
anaesthesia, 80 trauma, 180 Craniofacial surgery, osteodistraction, 206
Chemotherapy, squamous cell Concussion, 181f, 183 C-reactive protein (CRP), 316
carcinomas, 278 Condylar hyperplasia, questions and Crohns disease
Chest compression, 46b48b answers, 335, 337 granulomatous disorders, 254, 254f
Chest x-ray, 80 Condyle fractures, mandible, 187f recurrent aphthous stomatitis, 241
Child abuse, 181 Cone beam computed tomography Cross-infections
Children, craniofacial anomalies, 200 (CBCT), 2425, 25f hepatic disease, 36
Choking and aspiration, 41 bisphosphonate-associated necrosis HIV infection, 37
Chronic hyperplastic candidiasis, 246t, of bone, 107 Cross-over randomised controlled
247 dental extractions, 117 trials, 5
Chronic infections, 102 impacted teeth, 125 Cross-sectional surveys, 7
Chronic maxillary sinusitis, 161, 161f maxillary sinus diseases, 159, 160f Cross-sectional tomography, dental
Chronic obstructive airway disease oroantral communication, 167 implant surgery imaging, 133
(COPD), 33, 33f radiation protection, 345 CRP (C-reactive protein), 316
Chronic osteomyelitis, 104, 105f Confidence intervals, 4 Cryers elevators, 119, 119f
357
Index
Cryosurgery, minor salivary glands, Dental extractions (Continued) Digastric muscle, 100f
300301 questions and answers, 139140, Diplopia, facial fractures, 184185
CT see Computed tomography (CT) 142143 Direct interdental wiring, mandible
Cubital fossa, anatomy, 52f radiological examination, 118, 118b fracture management, 188
Cystic fibrosis, 34 techniques, 118121 see also specific Disability (D), 178f, 180
Cysts, 213214 techniques medical emergencies, 46b48b
antibiotics, 223224 third molars, 126 Disc displacement without reduction,
classification, 213214, 214b treatment planning, 118 see also 331332, 332f
clinical features, 214, 215t, Surgical extraction Disc displacement with reduction, 331,
216f217f Dental implant surgery, 131139 331f
examination, 214216 assessment, 132134 Discrete melanin-pigmented lesions,
growth of, 213 bone augmentation, 134136 250251
infection, 214 bone grafting techniques, 136 Dislocation, TMJ disorders, 334
questions and answers, 229230, clinical examination, 133 Distraction osteogenesis, questions and
232233 delayed placement, 138 answers, 208, 211
radiology, 214216, 216f217f guided bone regeneration, 136 DNA, ionising radiation effects, 342
surgery, 223226 imaging, 133134 Domestic violence, 181
aspiration, 223224 immediate placement, 138 Dopaminergic drugs, benzodiazepine
enucleation, 224 implant exposure, 136138 interactions, 68t
marsupialisation, 224, 224f see implant loading, 138 Dose limitation, radiation protection,
also specific types implant placement, 136, 137b, 345346
137f138f Double-blinding, 4
indications, 132f DPAS (diastase periodic acid-Schiff s
D postoperative care, 138
presurgical investigations, 133134
base), 268
DPT (dental panoramic tomography),
DBIs (dense bone islands), questions questions and answers, 140, 143 125
and answers, 108, 111 soft tissue surgery, 138 Drainage, facial infection management,
Deep vein thrombosis (DVT), antico- techniques, 134139 102, 102f
agulant therapy, 3435 timing, 138139 Drug abuse, general anaesthesia assess-
Defibrillation, 4951, 50f Dental indications, conscious sedation, ment, 78
Deltoid muscle, 52f 67 Drug-related ulceration, 240
Dense bone islands (DBIs), questions Dental injuries, 181f, 182183 Drugs see Medications
and answers, 108, 111 complications, 192 Dry mouth
Dental contraindications, conscious management, 182t, 183 questions and answers, 303, 307
sedation, 67 Dental pain, analgesia, 6062, 61t salivary gland disease, 288
Dental extractions, 117124 Dental panoramic tomography (DPT), Dry socket (alveolar osteitis), dental
assessment, 117118 125 extraction complications, 122123
clinical examination, 117118 Dentigerous cysts, 219220, 221f Duct obstruction, salivary gland radiol-
complications, 121124 clinical features, 215t ogy, 289, 290f
dry socket (alveolar osteitis), questions and answers, 229, 232 Duct wall thickening, salivary gland
122123 Dento-alveolar fractures disease, 291
excessive bleeding, 122 management, 186 Duration, trigeminal neuralgia, 312
jaw fracture, 124 mandible, 187f Dysaesthesia, 318319
mandible dislocation, 124 trauma, radiology, 185 Dysphagia, sideropenic, 266
maxillary sinus opening, 123 Dentofacial anomalies, 199212
maxillary tuberosity fracture, diagnosis, 202b
124
nerve damage, 123
questions and answers, 207211
see also Craniofacial anomalies
E
osteomyelitis, 123 Denture-induced candidiasis, 246t Early diagnosis, malignancies, 279
postoperative infections, 123, Denture intolerance, 132 ECG see Electrocardiography (ECG)
123f Denture irritation hyperplasia, 239 Effusion, TMJ disorders, 334
postoperative pain, 121 preprosthetic surgery, 129130 Electrocardiography (ECG)
postoperative swelling, 121 Dentures, acrylic, 245246 conscious sedation monitoring, 77
questions and answers, 140, 143 Depth of anaesthesia, general general anaesthesia, 80
soft tissue damage, 123 anaesthesia monitoring, 83 Elevators, 118119, 119f
surgical emphysema, 124 Dermabrasion, 206 Emergency surgery, general anaesthesia,
tooth airway displacement, 124 Dermatitis herpetiformis, 252 8182
tooth fracture, 122 Developmental abnormalities, dental Employer (legal person), radiation pro-
tooth fragment loss, 124 implant surgery, 132 tection responsibilities, 348
tooth loss, 123 Diabetes mellitus, 3536 Endocrine disease
trismus, 122 questions and answers, 54, 57 relevance, 3536 see also specific
eye protection, 120 Diastase periodic acid-Schiff s base diseases/disorders
history taking, 117118 (DPAS), 268 Enucleation
indications, 117 Diazepam (Valium), 7172 cyst surgery, 224
instrumental extraction, 118120 Diet, squamous cell carcinoma, 273 nasopalatine cysts, 224
patient instructions, 121f Diffuse oral melanosis, 251 radicular cysts, 225f
358
Index
359
Index
360
Index
361
Index
362
Index
Mucous extravascular mucocoele Nitrous oxide (Continued) Oral cavity, sensory innervation, 14
questions and answers, 304, 307 intravenous see Intravenous Oral contraceptive pill, 38
salivary gland, 299, 301f conscious sedation Oral dysaesthesia, 318319
Mucous membrane pemphigoid, 251 questions and answers, 87 Orbit fracture, 185
252, 252f side effects, 70 management, 187
Mucous retention mucocoele, salivary NNT (number needed to treat), 4 questions and answers, 193, 195
gland, 299 Nociception, 59 Orchitis, 292
Multidisciplinary teams, squamous cell Non-accidental injury (NAI), 181 Organic disease, psychiatric disorders,
carcinoma treatment, 277278 Non-epithelial cysts, 214b 38
Mumps see Viral sialadenitis (mumps) Non-Hodgkins lymphomas, 34 ORIF (open reduction and internal
Muscle attachments Non-homogeneous leukoplakia, 267 fixation), 186187
nerve repositioning, 131 Non-odontogenic cysts, 214b Oroantral communication, 167
preprosthetic surgery, 130, Nonsteroidal anti-inflammatory drugs Oroantral fissure (OAF), 167
130f131f (NSAIDs), 61 Orofacial granulomatosis, 254
Muscle disease, conscious sedation Nose, cleft lip/palate surgery, 205 Orofacial infections, questions and
contraindications, 68 NSAIDs (nonsteroidal anti- answers, 108, 111
MVD (microvascular decompression), inflammatory drugs), 61 Orofacial pain see Facial pain
313 Nuclear pleomorphism, squamous cell Orthognathic surgery, 202205
Mylohyoid muscle, 100f101f carcinomas, 270 cleft lip/palate surgery, 205
Myocardial infarction, 3233, 4546 Number needed to treat (NNT), 4 follow-up, 205
mandible, 203, 203f
maxilla, 203, 204f
N O postoperative care, 204205
preoperative care, 203
NAI (non-accidental injury), 181 OAF (oroantral fissure), 167 preoperative planning, 203
Nasal bone fracture, 185 Obesity, conscious sedation contraindi- Osteitis, rarefying, 92, 92f
management, 187188 cations, 68 Osteoarthrosis, TMJ disorders, 332
radiology, 186 Observations, physical examination, 30 333, 333f
Nasoethmoidal bone fracture, 185 Occipital lymph node, 15f Osteoblasts, 147148
management, 187188 Octapressin (felypressin), 65 Osteoclasts, 147148
radiology, 186 Odontalgia, atypical, 318 Osteodistraction
Nasolabial cysts, 222 Odontogenic keratocysts, 163, 214 craniofacial surgery, 206
clinical features, 215t questions and answers, 229, 232 questions and answers, 208, 211
Nasopalatine cysts, 222, 222f Odontogenic myxoma, 228 Osteogenesis imperfecta, 158
clinical features, 215t surgery, 229 Osteoma, 162163
enucleation, 224 Odontogenic tumours, 226227, 226b Osteomyelitis, 103104
questions and answers, 229, 232 benign tumours, 226b acute, 104106, 104f
Nasopharyngeal airways, 204 classification, 226227 chronic, 104, 105f
Nature, trigeminal neuralgia, 312 epithelial, 226227, 227f dental extraction complications, 123
Nausea and vomiting, nitrous oxide side malignant tumours, 226b, 228229 Garrs, 106
effects, 70 mesenchymal, 226228 questions and answers, 169, 173
Neck dissection, squamous cell carci- mixed, 226228, 228f Osteopetrosis, 158159
noma treatment, 278 questions and answers, 229230, questions and answers, 169, 173
Needle cricothyroidectomy, 49, 179, 232233 Osteoporosis, 156, 157f
179f surgery, 229 see also specific tumours Osteoradionecrosis, 106107
Needle fracture, intramuscular access Odontomes, 228, 228f Osteosclerosis, questions and answers,
complications, 53 surgery, 229 108, 111
Nerve block, inferior alveolar, 64 Oncogenes, 269270 Oxygen, medical emergencies, 3940
Nerve repositioning, muscle attach- Open reduction and internal fixation Oxygenation, conscious sedation moni-
ments, 131 (ORIF), 186187 toring, 77
Nerve trauma Operating potential, radiation
dental extraction complications, protection, 345
123
facial fracture complications, 192
Operator, radiation protection
responsibilities, 348
P
local anaesthesia, 64 Opioids, 61 Paan
Neuralgias, 312315 benzodiazepine interactions, 68t squamous cell carcinomas, 272
Neurological disorders, 37 Oral administration, medications, 51 submucous fibrosis, 265266
Neuromuscular junctions, general Oral cancer, 270278 Pagets disease, 152154
anaesthesia monitoring, 83 epidemiology, 270 clinical features, 152153, 152f
Neuropathic pain, 60 extraoral complications, 270 hypercementosis, 9394
Neuroses, 38 incidence, 270 management, 153154
Nitrazepam, 72 lymph nodes, 270 pathology, 153, 153f
Nitrous oxide, 6970 morbidity, 270 radiology, 153
administration, 73, 73f mortality, 270 Pain, 59
elimination, 69 staging, 270, 271t acute, 60
individual susceptibility, 73 types, 270271 see also specific types chronic, 60
363
Index
364
Index
Proton pump inhibitors (PPIs), 61 Radicular cysts, 217218, 218f219f Referrer, radiation protection responsi-
Psychiatric disorders, 3738 clinical features, 215t bilities, 348
conscious sedation contraindica- questions and answers, 230, 233 Relapsing parotitis, 293
tions, 68 surgery, 225 Relaxation training, 66
pain, 62 enucleation, 225, 225f Renal diseases, 36
Psychiatric emergencies, 45 Radiography, 2223, 24t Residual cysts, 218219
Psychogenic complications, local anaes- bitewing, radiation protection, clinical features, 215t
thesia, 63 344345, 345t Respiration, conscious sedation moni-
Psychological disease contrast investigations, 23 toring, 77
conscious sedation contraindica- lateral cephalometric, 133 Respiratory depression, benzodiazepine
tions, 67 periapical see Periapical radiographs side effects, 7071
psychiatric disorders, 38 radiation protection see Radiation Respiratory disease
Psychoses, 38 protection conscious sedation contraindica-
PT (prothrombin time), anticoagulant squamous cell carcinomas, 277 tions, 67
therapy, 3435 see also X-rays general anaesthesia risk assessment,
Pterygoid hamulus, 147 Radioisotope imaging, 2526, 26f 81
Pterygomandibular space, 101f salivary gland function abnormali- Respiratory system
Pulmonary function tests, general ties, 289 disease relevance, 3334
anaesthesia, 80 Radiolucent (osteolytic) radiology, general anaesthesia monitoring,
Pulmonary tuberculosis, 34 Pagets disease, 153 83
Pulpitis, 8991 Radio-opaque (osteoblastic) radiology, Retained teeth removal, 129
acute, 8990 Pagets disease, 153 Retrobulbar haemorrhage, 192193
chronic, 9091, 90f91f Radiotherapy, 37 Rheumatic heart disease, 3032
pathology, 91 radiation protection see Radiation Rheumatoid arthritis, TMJ disorders,
questions and answers, 319, 322 protection 333
PV (plasma viscosity), giant-cell squamous cell carcinomas, 278 Rhytidectomy, 207
arteritis (cranial/temporal arteritis), Randomised controlled trials (RCTs), Roots, sinus displacement, 165167,
316 26, 3f 166f
PVL (proliferative verrucous leukopla- allocation concealment, 34
kia), 268 assessment, 6
bias, 56
blinding, 4
S
Q components, 3
cross-over trials, 5
Salbutamol, 39
Salivary gland(s)
Quality assurance, radiation protection, effect estimation, 4 anatomy, 287
346347 effectiveness, 45 extraoral examination, 15
Questions, medical history, 2930 efficacy, 45 surgery, 299303 see also specific
exclusion criteria, 4 glands
follow-up, 4 Salivary gland disease, 287310
R inclusion criteria, 4
parallel trials, 5
biopsy, 290
clinical examination, 288
Radiation see Ionising radiation phase I trials, 5 cysts, 298299, 301f
Radiation dose, questions and answers, phase II trials, 5 history, 288
348, 350 phase III trials, 5 investigations, 288290
Radiation protection, 344348 randomisation, 34 obstructive disorders, 291292,
administration of, 348 sample size calculations, 4 292f
doses, 342344, 344t split-mouth trials, 5 duct wall thickening, 291
patient protection, 344347 types, 45 see also specific types extraductal obstruction, 291
bitewing radiographs, 344345, Rarefying osteitis, 92, 92f intraductal obstruction, 291292,
345t RAS see Recurrent aphthous stomatitis 293f
CBCT, 345 (RAS) questions and answers, 303304,
dose limitation, 345346 RCTs see Randomised controlled trials 306307
panoramic radiographs, 345 (RCTs) radiology, 288289
periapical radiographs, 345 Recovery, conscious sedation monitor- calculus, 288
quality assurance, 346347, ing, 77 duct obstruction, 289, 290f
346t Rectus femoris, 52f function abnormalities, 289
questions and answers, 348353 Recurrent aphthous stomatitis (RAS), masses, 289, 290f
responsibilities, 348 240243 sialometry, 288
staff protection, 347 aetiology, 241 tumours, 296298, 299f
good practice guidelines, 347 diagnosis, 242243 benign tumours, 297, 300f
local rules, 347 herpetiform, 240, 242f malignant tumours, 297298,
position, 347, 347f major, 240241, 242f 300f
workload, 347 management, 243 Salivary lymphoepithelial lesion
Radiation protection adviser, 348 minor, 240, 241f (SLEL), 295
Radiation protection supervisor, 348 questions and answers, 257, 260 Salivary stimulants, 296
Radiation sialadenitis, 293294, 294f Referrals, malignancies, 279 Salivary substitutes, 296
365
Index
Sample size calculations, RCTs, 4 Social history Submandibular lymph node, 15f
Sarcoiditis, 294295 conscious sedation contraindica- Submandibular salivary gland, 99f
Sarcoidosis, granulomatous disorders, tions, 67 anatomy, 287
254 general anaesthesia assessment, 78 calculus, 288, 289f
Scars history taking, 14 surgery, 301, 302f
facial soft tissue injuries, 192 persistent idiopathic facial pain Submandibular space, 99f
revision, 206 (atypical facial pain), 317 Submasseteric space, 101f
Schirmers test, 295, 297f physical examination, 30 Submental lymph node, 15f
Sciatic nerve damage, 53, 53f Socket capillaries, haemostasis, 122 Submucous cleft, questions and
Scientific papers, 89 Soft tissue(s) answers, 208, 211
appraisal questions, 8 gunshot wound management, 191 Submucous fibrosis, 265266, 266f
CONSORT, 89, 8b, 9t10t, 10f trauma see Soft-tissue trauma questions and answers, 279, 283
Sclerosing sialadenitis, chronic, 294 Soft tissue cysts, questions and Sulcus deepening, preprosthetic sur-
Screening, malignancies, 279 answers, 230, 232233 gery, 130
Screws, biodegradable, 191 Soft-tissue trauma Sumatriptan, 316
Second premolars dental extraction complications, 123 Superficial parotidectomy, 301303
impacted teeth, 125126 local anaesthesia, 64 Superior constrictor muscle, 101f
surgical extraction, 129 Solitary bone cysts, 223, 223f Supernumerary teeth, surgical extrac-
Sedation see Conscious sedation clinical features, 215t tion, 129
Sensory innervation surgery, 225 Surgery
head and neck, 16f Sonography see Ultrasound burns, 184
oral cavity, 14 Specialised mucosa, 237 craniofacial anomalies, 202
Shape, cyst radiology, 216 Splints minor salivary glands, 299303
Shotguns, 191 acrylic, 188 salivary glands, 299303
Sialadenitis dental injuries management, 183 squamous cell carcinomas, 277278
acute see Acute sialadenitis dento-alveolar fractures, 186 Surgical emphysema, 124
chronic see Chronic sialadenitis Split-mouth randomised controlled Surgical extraction, 120, 120b
chronic sclerosing, 294 trials, 5 anatomical risk factors, 120
radiation, 293294, 294f Sponge naevus, questions and answers, flap design, 120121
Sialography 257, 261 postoperative care, 121
salivary gland duct obstruction, 289, Squamous cell carcinomas (SCCs), questions and answers, 139, 142
290f 270278 Surrogate outcomes, RCTs, 6
Sjgrens syndrome diagnosis, 299f aetiology, 271273 Suspension wires, 190
Sialometry alcohol, 272273 Suxamethonium apnoea, 78
salivary gland disease, 288 diet, 273 Swellings/lumps
Sjgrens syndrome diagnosis, 295, paan, 272 extraoral examination, 1516
297f tobacco smoking, 271272 intraoral examination, 1719
Sialosis, 295 ultraviolet light, 273 salivary gland disease, 288
Sickle cell anaemia, 34 virus infections, 273 Symphyseal fractures, mandible, 187f
Sickledex test, 22 bone, 163, 165f Symptomatic trigeminal neuralgia,
Sickle test, 79 clinical features, 273274, 312
Sideropenic dysphagia, 266 273f275f Syncope (fainting), 4041
Sinusitis, 161162 grading and staging, 276 questions and answers, 54, 57
acute maxillary, 162, 162f imaging, 276277 Syphilis, 243
bone tumours, 163, 164f pathology, 274276 Syphilitic leukoplakia, 243, 268
chronic maxillary, 161, 161f bone invasion, 275276, 277f Systematic reviews, 78
Site, trigeminal neuralgia, 312 histopathology, 274275, 276f Systemic approach, history taking, 13
Sjgrens syndrome, 295296, 296f metastases, 276 Systemic disease, conscious sedation
associated autoimmune disease, questions and answers, 279, 283 contraindications, 67
287b, 295 treatment, 277278
diagnosis, 295, 297f, 298b chemotherapy, 278
Schirmers test, 295, 297f
sialogram, 299f
radiotherapy, 278
surgery, 277278
T
management, 296 Stafnes cavity, 147, 148f Taste disorders, impacted teeth treat-
questions and answers, 303, Steroid drugs, 38 ment, 129
306307 recurrent aphthous stomatitis man- Teeth
Skin lesions, lichen planus, 249 agement, 243 airway displacement, 124
Skin sutures, facial soft tissue injuries, Stomatitis nicotina see Smokers palatal fracture, 122
184 keratosis intraoral examination, 1920
SLEL (salivary lymphoepithelial Stroke, 44 loss, 123
lesion), 295 Subcutaneous drug administration, 53 trauma, radiology, 185
Smokers palatal keratosis, 238239 complications, 53 Temazepam, 7172
Smoking Subepithelial blisters, 251252 Temporomandibular joint (TMJ)
dental implant surgery, 133 Sublingual keratosis, 267268 anatomy, 327328, 328f
general anaesthesia assessment, Sublingual space, 99f arthroscopy, 329330
78 Subluxation, 181f, 183 clinical examination, 328
366
Index
367
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