ORAL MAXILLO FACIAL SURGERY REFERRAL RECOMMENDATIONS

Transcription

1 ORAL MAXILLO FACIAL SURGERY REFERRAL RECOMMENDATIONS Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines General problems include: Soft tissue conditions of the face and oral cavity Teeth, gums and associated conditions Trauma facial bones Thorough history and physical examination is required for determining the diagnosis. All case histories should include alcohol and tobacco use, drug and allergy history. Specific treatments depend on specific problem identified as below. A special needs benefit is available for patients who have acute dental needs and have a Community Services Card. Access to dental services for holders of Health Care Cards is through the Suburban Dental Health Clinics or O.H.C.W.A.,Monash Ave. Nedlands. Most OMF surgical diagnoses require referral for specialist management. However, these guidelines are provided (below) to give greater clarity in situations of the primary/secondary interface of care. Clearly, telephone/ fax/ communication would enhance appropriate treatment. Crossreference to Hospital Dental Surgery Referral Recommendations is also advised. Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Soft tissue conditions of the face and oral cavity Congenital Radiographs as appropriate and gum disease (Trismus) Presence of lymphadenopathy abnormality Assessment associated syndromic features Management options for congenital problems will depend on specific problems: Airway Feeding Speech Neonates / Infants with airway, feeding and speech problems urgent referral Children over 12 months who have not developed teeth should be referred to a dentist. Presence of additional teeth preventing eruption, cysts and other pathologies should be referred to the OMF service if local skills are not available. Referral within the first twelve months of life is preferable to late referral Routine.

2 Infective Developing dental infections can very quickly become serious and life threatening with airway obstruction the main sequel. Salivary Gland Infection: Sialadenitis/Sialoithiasis Assess hydration of patient. Palpate floor of mouth for stones. Observe for purulent discharge from salivary duct when palpating gland. Evaluate mass for swelling, tenderness and inflammation. Serum amylase. Early or simple infections refer to dentist Complex / recurrent / rapidly progressing infections should be referred to OMF. Culture of purulent discharge in mouth. Hydration. Occlusal view x-ray of floor of mouth for calculi. Anti-staphylococcal antibiotics: Augmentin, Ceclor. Ultrasound or sialogram. (Sialogram in absence of infection or when cleared up with antibiotics.) Treat with antibiotics (penicillin and flucloxacillin) for five days. Early referral to Dental services can prevent major, expensive management. Refer to hospital for assessment by OMF OMF/ Otolaryngology / general Surgery referral indicated for: Poor antibiotic response within one week of diagnosis. Calculi suspected on examination, x-ray or ultrasound Abscess formation Recurrent sialadenitis Hard mass present neoplasm? Limited eye opening, facial swelling, increasing pain, trismus, dysphagia, should be referred urgently to the OMF Service for inpatient surgical management, IV antibiotics

3 Lumps and Suspected Neoplasms See multidisciplinary considerations Consider biopsy if skilled, age appropriate. Refer to pathology lab for FNA Refer suspected malignancy to Hospital ENT/OMF/ Plastics/General Surgery Urgent. Ulcers Traumatic Ulcers. Autoimmune. Infectious/viral. Malignant Tend to be on unattached mucosa, occur singularly or as a couple and are larger than herpes (up to 10mm). May take 14 days to heal. Often on soft palate, ventral surface of tongue/floor of mouth and lips. Herpes appear in clusters and on attached gingiva, have small white centre and with erythematous halo. Usually on palate and gums. Often painless, unhealing ulcer, rolled margins, firm. Usually occur on lateral margin of tongue. Cervical lymphadenopathy?? Refer to patient s dentist in the first instance for assessment for local causes and treatment. Topical anaesthetic paste and 0.2% Chlorhexidine mouthwash may assist comfort and healing These should heal within 10 days. If not, biopsy. Corticosteroid spray or paste (Kenalog in Orabase). Acyclovir ointment at first sign of vesicles. Non healing tooth extraction socket. Refer to OMF service or Oral Medicine specialist if no improvement after 2 weeks. Refer to OMF Urgent.

4 Dermatological disorders (eg Lichen Planus). See Hospital Dental Surgery referral recommendations for white patches.) Teeth, gums and associated conditions Traumatic Vitality tests if done. Treat painful ulcerations within these white patches with Kenalog in Orabase. Persistent ulcerations are suspicious as malignant transformation can occur in any white, red or blue patch. Retrieve and save lost tooth and replace in socket if possible or place in milk. Significant dental fragments should be retained. Seek advice from Dermatologist/OMF or Hospital Dental Service. Traumatic teeth injuries should be referred to the dentist. Refer to Hospital OMF/Dental Services with other suspected associated injuries: o Large lacerations. o o All Urgent. Associated jaw fractures. Significant behavioural problems. Gum Disease Vitality tests if done. Teeth to be cleansed, chlorhexidine mouthwash (Savacol) and consider antibiotic. Patients with Gum Disease: Refer Dentist or Dental Hospital Clinic, Semi-urgent.

5 Trauma Facial Bones Mandible See multidisciplinary considerations Zygoma See multidisciplinary considerations Midface, ie Le Fort, I, II, III See multidisciplinary considerations Standard history and examination. Radiographs including OPG. Comment on: Mal-occlusion Swelling Trismus ability to open mouth Sensory loss Lacerations soft tissue and gums Radiographs Occipito-mental 15, 30, 45 views,c.t. Comment on: Swelling around eye Numbness over cheek Bony steps around orbit Bony protrusion intra-orally Trismus Limited eye movements Bleeding in conjunctiva and sclera History and examination. Assess airway patency and maintain. Check for cervical spine injury. Check for any lost teeth. Assess neurological status Radiographs including Occipitomental 15, 30, 45 views. CT scans if available. Comment on: Malocclusion Movement of upper jaw Movement at bridge of nose Bony steps around orbits Diplopia Refer to specialist Oral and Maxillofacial surgeon or Hospital Dental Service. Displaced fractures with mobility. Refer immediately. Undisplaced, non-mobile fractures. Refer to specialist OMF or hospital Refer to Plastics / OMF Surgeon - immediate. Displaced fractures Eye closed Undisplaced fractures Refer to hospital- immediate.

6 Degenerative conditions affecting the jaws. a. Degenerative joint disease, ie TMJ Arthritides. History and examination. Radiographs including O.P.G.,C.T. Comment on: Trismus Joint pain with radiographic evidence of bone destruction Hot, tender swelling over joint Clicking or grating of jaw joint Pain on chewing or opening wide NSAIDs for analgesia, soft diet. Limit mouth opening. Moist heat for joint and associated musculature. Refer to Oral and Maxillofacial Surgeon category depending in clinical symptoms. e.g pain Salivary Drooling / incontinence History examination Comment on neurological condition Soft tissue defects Dentition Occlusion Skin integrity Consider barrier creams to maintain skin integrity Consider medication option to reduce drooling Refer to ENT/OMF/Plastics Surgeon category depending in clinical symptoms