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When to refer to a


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The controversial changes to dentists' contracts and out-of-hours dental provision has left GPs worried they will be overwhelmed with patients unable to find an NHS dentist. Mr Peter Dyer,

Dr Madelaine Storey and Dr Jane Collingwood give some practical advice

Fewer than half of all adults and two-thirds of children are currently registered with a dentist. Consequently, many patients may attempt to obtain emergency dental treatment from their GP as local services available to unregistered patients are often not well advertised.

Having established an apparent dental problem, GPs are obliged to refer the patient for any further treatment, if necessary, to a dentist or local emergency service. They should not attempt to manage a condition requiring dental skills unless they have the appropriate training and expertise.

From this month, PCTs will assume responsibility for the provision of out-of-hours dental services. Provision of these services will no longer be a requirement under NHS dentists' contracts. It is intended that out-of-hours dental services should be accessed by telephone (local helplines or NHS Direct) and subject to established triage-algorithms.

With the exception of true dental emergencies (severe haemorrhage, threatened airway or overwhelming infection), treatment within 24-48 hours is indicated for the majority of dental conditions during open-access sessions by local dentists during the working day. So again more patients may go to their GP in an attempt to get assistance earlier.

Dental abscesses

A dental abscess is a localised collection of pus associated with a tooth or the supporting structures. Symptoms are severe pain that will disturb sleep and exquisite tenderness to touch.

Signs are: tooth is usually extruded, mobile and tender to percussion; gingival swelling which may develop into a fluctuant mass with purulent exudate; facial swelling +/- cellulitis; and fever, malaise, lymphadenopathy.

No investigations are necessary in primary medical care.

Definitive treatment of a dental abscess should be provided by a dental practitioner. The following interim treatment may need to be provided when immediate access to a dental practitioner is not possible.

·Analgesia: paracetamol +/- codeine

phosphate, or NSAIDs

·Antibiotics: amoxicillin (or erythromycin if intolerant of penicillin), or metronidazole (amoxicillin and metronidazole are

generally prescribed separately)

For more information on dental prescribing go to, but as a general guide:

·Amoxicillin six years usually 250mg unless very swollen/

spreading infection 500 mg (TDS x five days)

·Metronidazole ­ generally 200mg but double dose as for amoxicillin with more

extensive swelling (TDS x five days)

Chlorhexidine mouthwash is of no value.

If the patient is systemically unwell, has severe trismus or swelling affecting the floor of their mouth, a course of oral

antibiotics is unlikely to resolve the

problem; there is a risk of developing a

compromised airway and the patient should be admitted to a maxillofacial unit for surgical management.

Wisdom teeth

Patients presenting with discomfort from the back of their lower jaw may have a condition called pericoronitis. This occurs when the flap of gum overlying a partially erupted wisdom tooth becomes inflamed. The patient may also present with trismus and a bad taste in their mouth.

If this is the first time that this has happened it can be managed with hot saltwater mouthwashes and a five-day course of metronidazole. The NICE guidelines clearly state that surgical removal of impacted wisdom teeth should be limited to those with pathology such as unrestorable caries and repeated episodes of pericoronitis.

Gum disease

Gingivitis is inflammation of the gingival tissues as a consequence of low-grade infection caused by the presence of dental plaque and may progress to periodontitis. Acute necrotising ulcerative gingivitis (ANUG) is a rare, severe form of gingivitis (see box opposite page).

The main cause of halitosis is gum disease but there may be rare occasions when it occurs with respiratory or gastrointestinal tract conditions.

Aphthous ulcers

Aphthous ulcers are common and painful occurring in clusters on most mucosal surfaces in the mouth. They range from 2-5mm in diameter, but may be larger and single.

If the ulcers are mild and infrequent, over-the-counter remedies may be sufficient. Generally if adcortyl is difficult to apply, prescribe hydrocortisone lozenges and hold these against the lesion to dissolve. Otherwise pain relief may be achieved through benzydamine mouthwash.

Generally choline salichylate dental gel is not recommended as it can cause further ulceration and long-term damage to the oral mucosa.

Frequent, painful recurrences necessitate treatment and a mouthwash is often easier for patients to manage. Betamethasone (one 500mcg tablet) dissolved in water and held in the mouth for two minutes can help and may be used three or four times a day while the ulcer lasts.

Consider conditions that cause aphthous-like ulceration:

­ Systemic disorders: Behçets syndrome, Reiter's syndrome, coeliac disease, neutropaenia, HIV

­ Dietary: Iron, folate, or vitamin B12 deficiency

­ Drug reactions: Nicorandil, NSAIDs, nicotine replacement therapy, methotrexate

Any ulcer present for more than two weeks should be referred urgently to a maxillofacial department for further investigation to rule out a malignancy.

Oral candida

Symptoms of infection include pain, burning, hypersensitivity to stimuli (hot, cold, salt, spices), but the condition may be asymptomatic. Examination typically

reveals intra-oral white plaques, which may become grey-yellow, and can be wiped off to reveal a red, raw base that may bleed, or red areas on the tongue, palate or buccal mucosa. Angular stomatitis may occur.

Topical antifungals are recommended in the first instance (amphotericin, miconazole or nystatin). If treatment is not effective, review compliance, suitability of formulation, and any predisposing factors (diabetes control, steroid therapy, oral antibiotics, medication leading to a dry mouth, poor denture hygiene) or review the diagnosis. A short course of fluconazole may be necessary if topical treatments fail.

Tongue discolouration

Patients may present with a coloured coating on the upper surface of the tongue, an example of which is black hairy tongue.

This does not usually signify anything

serious and is often caused by something simple such as coffee, nicotine or mouth breathing.

Advice can be given about brushing the tongue with a toothbrush to remove the coating. Anti-fungals are unlikely to help.

Geographic tongue

This benign condition has an unknown aetiology and may be associated with a fissured tongue. The surface of the tongue develops areas of redness with a white outline rather like continents on a map. These areas change shape and may be sore.

Treatment is reassurance and the use of topical medication such as benzydamine hydrochloride or chlorhexidine.


Temporomandibular joint pain dysfunction syndrome is generally accepted to be a stress -related condition. Grinding (bruxism) or clenching teeth during sleep can lead to muscle spasm and pain in the muscles of mastication and around the temporomandibular joint which may be worse in the morning or late evening and may be associated with clicking. Occasionally jaw locking or trismus is reported.

Malocclusion is not usually a cause of TMJPDS.

Initial treatment comprises an explanation of the problem and reassurance, NSAIDS, and a soft diet. A short course of benzodiazepines could be given in the

severe, acute phases to help sleep. If the problem does not resolve the patient should be referred to a dentist, to provide a mouth splint.

When to refer or admit

· Dental abscess with spreading

facial cellulitis ­ if the patient is systemically unwell, has severe trismus, swelling affecting the floor of their mouth, or a compromised airway,

they should be admitted to a maxillofacial unit

· Facial fractures

· Uncontrolled trigeminal neuralgia

· Post extraction bleeding ­ which has not stopped after biting on handkerchief for 30 minutes while resting

· Suspected oral malignancy

Signs and symptoms Management

Gingivitis Discomfort Advise good oral hygiene (daily flossing

Bleeding when brushing teeth and twice-daily tooth brushing)

Swollen, inflamed gums Antiseptic toothpaste and mouthwash twice-daily

Or asymptomatic until condition resolves. (Chlorhexidine is the most

effective oral antiseptic, but may cause tooth staining.

Triclosan, hexetidine and phenolic/essential oil

compounds are alternatives.)

Periodontitis Halitosis As above

Foul taste in mouth

Difficulty eating

Pus and debris expressible from

gingival pockets

Loosening/loss of teeth

ANUG Malaise Refer for urgent dental assessment and management.

(Acute Fever Start treatment with an antimicrobial (metronidazole

necrotising Pain and amoxicillin), an analgesic (paracetamol or

ulcerative Rapidly progressive inflammation ibuprofen) and an antiseptic mouthwash

gingivitis) with swelling and ulceration of the (chlorhexidine, hexetidine or hydrogen peroxide)

gum and sloughing of dead tissue

Peter Dyer is consultant oral and maxillofacial surgeon and Clinical Director for Surgery,

Madeleine Storey is Senior House Officer,

Jane Collingwood is Senior House Officer,

Morecambe Bay Hospitals NHS Trust,

Lancaster, Lancashire

Competing interests

None declared

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