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REFERRAL RECOMMENDATIONS _ ORAL MAXILLO FACIAL SURGERY

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REFERRAL RECOMMENDATIONS _ ORAL MAXILLO FACIAL SURGERY Powered By Docstoc
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                              ORAL MAXILLO FACIAL SURGERY REFERRAL RECOMMENDATIONS

    Diagnosis / Symptomatology                        Evaluation                           Management Options                          Referral Guidelines
General problems include:                Thorough history and physical             Specific treatments depend on specific     Most OFM surgical diagnoses require
                                         examination is required for determining   problem identified as below.               referral for specialist management.
   Soft tissue conditions of the face   the diagnosis. All case histories                                                    However, these guidelines are
    and oral cavity                      should include alcohol and tobacco                                                   provided (below) to give greater clarity
                                                                                   A special needs benefit is available for
   Teeth, gums and associated           use, drug and allergy history.
                                                                                   patients who have acute dental needs
                                                                                                                              in situations of the primary/secondary
    conditions                                                                                                                interface of care. Clearly, telephone/
                                                                                   and have a Community Services Card.
   Trauma facial bones                                                            Access to dental services for holders of
                                                                                                                              fax/e-mail communication would
                                                                                                                              enhance appropriate treatment.
                                                                                   Health Care Cards is through the
                                                                                                                              Cross-reference to Hospital Dental
                                                                                   Suburban Dental Health Clinics or
                                                                                                                              Surgery Referral Recommendations is
                                                                                   O.H.C.W.A.,Monash Ave. Nedlands.
                                                                                                                              also advised.




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    Diagnosis / Symptomatology                           Evaluation                          Management Options                           Referral Guidelines
Soft tissue conditions of the face and oral cavity
Congenital                                 Standard history and examination:                                                    Referral of suspected congenital
                                                                                                                                conditions should be made to dentists
                                               Radiographs.                                                                    or secondary service in the first
                                               Comment on bite, status of teeth                                                instance.
                                                and gum disease.
                                                                                                                                Tongue tie with reducing functional
                                               Comment on jaw opening                                                          impairment should be referred for
                                                (Trismus).                                                                      further treatment. Referral within the
                                               Presence of lymphadenopathy.                                                    first twelve months of life is preferable
                                               Associated neurological                                                         to late referral – Category 3.
                                                abnormality.
Infective                                  Standard history and examination:         Refer to local dentist for consideration   (See Infective – Teeth and Associated
                                               Radiographs.                         for treatment.                             Conditions.) Developing dental
                                                                                                                                infections can very quickly become
                                               Comment on bite, status of teeth                                                serious and life threatening with airway
                                                and gum disease.                                                                obstruction the main sequel. Early
                                               Comment on jaw opening                                                          referral to Dental services can prevent
                                                (Trismus).                                                                      major, expensive management.
                                               Presence of lymphadenopathy.
                                               Associated neurological
                                                abnormality.
Salivary Gland Infection:                  1.   Assess hydration of patient.         1.   Culture of purulent discharge in      Otolaryngology – referral indicated for:
Sialadenitis/Sialoithiasis                 2.   Palpate floor of mouth for stones.        mouth.                                1. Poor antibiotic response within
                                           3.   Observe for purulent discharge       2. Hydration.                                  one week of diagnosis.
                                                from salivary duct when palpating    3. Occlusal view x-ray of floor of         2. Calculi suspected on examination,
                                                gland.                                    mouth for calculi.                        x-ray or ultrasound.
                                           4.   Evaluate mass for swelling,          4. Anti-staphylococcal antibiotics:        3. Abscess formation.
                                                tenderness and inflammation.              Augmentin, Ceclor.                    4. Recurrent sialadenitis.
                                           5.   Serum amylase.                       5. Ultrasound or sialogram.                5. Hard mass present – neoplasm?
                                                                                          (Sialogram in absence of infection
                                                                                          or when cleared up with               If no response, refer to OMF or
                                                                                          antibiotics.)                         General Surgery Service – Category 2.
                                                                                     Treat with antibiotics (penicillin and
                                                                                     flucloxacillin) for four days.             Limited eye opening, facial swelling,
                                                                                                                                increasing pain, trismus, dysphagia,

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                                                                                                                    should be referred urgently to the OMF
                                                                                                                    Service for surgical management, IV
                                                                                                                    antibiotics etc – Category 2.
Facial Trauma, eg Lacerations   Standard plus radiology.                  Oral cavity: small lacerations leave.     Larger and contaminated lacerations,
                                                                          Contaminated lacerations, suggest         refer to Hospital Service – Category 2.
                                                                          broad spectrum antibiotics.
                                                                                                                    Significant injury should be referred to
                                                                          -0.2% Chlorhexidine mouthwash.
                                                                                                                    Secondary Hospital Service –
                                                                          Minor: managed by GP, eg                  Category 1.
                                                                          debridement and suture. Consider
                                                                          Tetanus prophylaxis and antibiotics.
Lumps and Suspected Neoplasms   Consider biopsy if skilled.                                                         Refer suspected malignancy to
                                                                                                                    Hospital ENT/OMF/ Plastics/General
                                Refer to pathology lab for FNA.
                                                                                                                    Surgery, depending on local practice –
                                                                                                                    Category 2.
Ulcers.                                                                   Refer to patient’s dentist in the first   Refer to OMF service or Oral Medicine
                                                                          instance for assessment for local         specialist if no improvement after 2
                                                                          causes and treatment.                     weeks.
   Traumatic Ulcers.                                                     Topical anaesthetic paste and 0.2%
                                                                          Chlorhexidine mouthwash may assist
                                                                          comfort and healing – leave out
                                                                          dentures.
                                                                          These should heal within 10 days. If
                                                                          not, biopsy.
   Autoimmune.                 Tend to be on unattached mucosa,          Corticosteroid spray or paste (Kenalog
                                occur singularly or as a couple and are   in Orabase).
                                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.

   Infectious/viral.           Herpes appear in clusters and on          Acyclovir ointment at first sign of
                                attached gingiva, have small white        vesicles.
                                centre and with erythematous halo.
                                Usually on palate and gums.

   Malignant.                  Often painless, unhealing ulcer, rolled   History of tobacco and alcohol abuse,     Refer to OMF – Category 2.
                                margins, firm. Usually occur on lateral   sharp teeth or dentures. Non healing
                                margin of tongue. Cervical                tooth extraction socket.

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                                    lymphadenopathy??

   Dermatological disorders (eg                        Treat painful ulcerations within these   Seek advice from Dermatologist/OMF
    Lichen Planus).                                     white patches with Kenalog in            or Hospital Dental Service.
                                                        Orabase. Persistent ulcerations are
     (See Hospital Dental Surgery                       suspicious as malignant transformation
     Referral Recommendations for                       can occur in any white, red or blue
     “white patches”.)                                  patch.




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    Diagnosis / Symptomatology                      Evaluation                       Management Options                           Referral Guidelines
Teeth, gums and associated conditions
Congenital                              Standard history and examination:    Refer to local dentist for consideration    Children over 12 months who have not
                                         Radiographs.                       for treatment or possible referral.         developed teeth should be referred to
                                         Vitality tests if done.                                                        a dentist.
                                         Comment on bite, status of teeth                                               Presence of additional teeth preventing
                                            and gum disease.                                                             eruption, cysts and other pathologies
                                         Comment on jaw opening                                                         should be referred to the OMF service
                                            (Trismus).                                                                   if local skills are not available.
                                         Presence of lymphadenopathy.
                                         Associated neurological
                                            abnormality.
Infective                               Standard history and examination:    Refer to local dentist for consideration    No improvement after 48 hours’ dental
                                         Radiographs.                       for treatment. This may include:            management, refer to OMF.
                                         Vitality tests if done.               Drainage – through tooth or soft        Patients with limited eye opening,
                                         Comment on bite, status of teeth       tissue or extraction.                   facial swelling, increasing pain,
                                            and gum disease.                  Antibiotics (Penicillin/                  trismus, dysphagia, should be referred
                                         Comment on jaw opening                 Erythromycin) for two days and          urgently to the OMF Service for
                                            (Trismus).                           referral to local dentist.              surgical management, IV antibiotics
                                         Presence of lymphadenopathy.       Note: If a GP prescribes antibiotics        etc. Signs of severe infection, refer
                                         Associated neurological            for an infective dental condition,          immediately to OMF Service (or local
                                            abnormality.                     he/she must refer to dentist, or in         General Surgery Service, if available).
                                                                             the case of children, refer to a
                                                                             dental therapist or school dental
                                                                             service.
Traumatic                               Standard history and examination:    Retrieve and save lost tooth and               Traumatic teeth injuries should be
                                         Radiographs.                       replace in socket if possible or place in       referred to the dentist.
                                         Vitality tests if done.            milk. Significant dental fragments              Refer to Hospital OMFS Services
                                         Comment on bite, status of teeth   should be retained.                              with other suspected associated
                                            and gum disease.                                                                  injuries:
                                         Comment on jaw opening                                                               – Large lacerations.
                                            (Trismus).
                                         Presence of lymphadenopathy.                                                         – Associated jaw fractures.
                                         Associated neurological                                                              – Significant behavioural
                                            abnormality.                                                                           problems.
                                                                                                                         All Category 1.


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Lumps and Suspected Neoplasms   Standard history and examination:                                          Lumps and suspected neoplasms
                                 Radiographs.                                                             should be referred to the OMFS
                                 Vitality tests if done.                                                  Service.
                                 Comment on bite, status of teeth                                         See CPAC.
                                    and gum disease.
                                 Comment on jaw opening
                                    (Trismus).
                                 Presence of lymphadenopathy.
                                 Associated neurological
                                    abnormality.

                                NB: Long term unhealing extraction
                                socket, suspect malignancy.
Gum Disease                     Standard history and examination:    Teeth to be cleansed, chlorhexidine   Patients with Gum Disease: Refer
                                 Radiographs.                       mouthwash (Savacol) and consider      Dentist or Dental Hospital Clinic.
                                 Vitality tests if done.            antibiotic.
                                 Comment on bite, status of teeth
                                    and gum disease.
                                 Comment on jaw opening
                                    (Trismus).
                                 Presence of lymphadenopathy.
                                 Associated neurological
                                    abnormality.




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    Diagnosis / Symptomatology                 Evaluation                         Management Options                  Referral Guidelines
Trauma Facial Bones
Mandible                          Standard history and examination.                                          Refer to specialist Oral and
                                  Radiographs including OPG.                                                 Maxillofacial surgeon or Hospital
                                  Comment on:                                                                Dental Service.
                                   Mal-occlusion.                                                           Displaced fractures with mobility.
                                   Swelling.                                                                Refer immediately – Category 1.
                                   Trismus – ability to open mouth.                                         Undisplaced, non-mobile fractures.
                                   Sensory loss.                                                            Refer within 24 hours – Category 1.
                                   Lacerations soft tissue and gums.
Zygoma                            Standard history and examination:                                          Refer to Specialist Oral and
                                  Radiographs – Occipito-mental 15,                                         Maxillofacial Surgeon.
                                  30, 45 views,C.T. Comment on:
                                   Swelling around eye.                                                     Displaced fractures – Refer 12-24
                                   Numbness over cheek.                                                     hours. Eye closed – refer immediately.
                                   Bony steps around orbit.                                                 Undisplaced fractures – refer within 72
                                   Bony protrusion intra-orally.                                            hours – all Category 1.
                                   Trismus.
                                   Limited eye movements.
                                   Bleeding in conjunctiva and sclera.
Midface, ie Le Fort, I, II, III   History and examination.                                                   Refer to base hospital immediately –
                                  Assess airway patency and maintain.                                        Category 1.
                                  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.
Cysts, lumps and suspected        History and examination.                Attempt aspiration if fluctuant.   Urgent referral within 24 hours –

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neoplasms affecting jaws                Radiographs including local teeth     Diagnostic, FNAB.                         Category 2.
                                        periapicals and O.P.G..
                                        Comment on:
                                         Swelling of jaw buccal and/or
                                            lingual.
                                         Hard bony expansion.
                                         Loss of lip sensation.
                                         Tooth mobility.
                                         Fluctuation.
                                         Unhealing ulceration.
                                         Change of bony density on
                                            radiographs.
Infective processes of the jaws         History and examination.              Airway threatened – establish and refer      Urgent referral to Oral and
                                        Radiographs including .O.P.G.         immediately.                                  Maxillofacial Surgeon or General
                                        Comment on:                                                                         Surgeon – Category 2.
                                         Acute/chronic pain.                                                              Acute and chronic infections –
                                                                              Commence IV antibiotics.
                                         Tender to palpation.
                                                                               Penicillin Q6h 1g IV.                       refer within 24 hours.
                                         Red, hot, swollen.
                                                                               Flucloxicillin Q6h 1g IV.
                                         Trismus.
                                                                               Analgesia – avoid NSAIDs.
                                         Malaise.
                                                                               Metronidazole 500mg IV tds.
                                         Degree of dysphagia.
                                         Tongue swelling and decreasing
                                            mobility.Hard swelling floor of
                                            mouth.
Degenerative conditions affecting the   History and examination.              NSAIDs for analgesia, soft diet.          Refer to Oral and Maxillofacial
jaws.                                                                         Limit mouth opening.                      Surgeon within 7-10 days – Category
                                        Radiographs including O.P.G.,C.T.
                                                                              Moist heat for joint and associated       2.
a. Degenerative joint disease, ie       Comment on:
     TMJ Arthritides.                    Trismus.                            musculature.
                                         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
b.   Alveolar Ridge Resorption.         History and examination.                 Leave dentures out as much as         Refer to General Dental Practitioner –
     Atrophy of jaws.                   Radiographs including O.P.G.              possible.                             Category 4.
                                        Comment on:                              Soft diet.
                                         Loose dentures.
                                         Painful ulcers under dentures.         Topical analgesics.
                                         Large mucosal growths under            Treat oral thrush if present.

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                                     denture.
                                    Oral thrush.
Chronic Osteomyelitis            History and examination.                      Culture pus.?Actinomycosis.               Refer to Specialist Oral Maxillofacial
                                 Radiographs including OPG.                    Antibiotics.                              Surgeon – Category 3.
                                 Comment on:                                   Chlorhexidine Mouthwash.
                                  Pain.                                       Analgesia.
                                  Constant discharge despite                  Soft diet.
                                     antibiotics.Skin sinus.
                                  Radiographic lucency, pathological
                                     #.
                                  PH radiotherapy (ORN)

Degenerative – Xerostomia (Dry   Patient complains of dry,                  Consider role of existing medication in       Refer to OMF or Hospital Dental
Mouth)                           uncomfortable mouth with difficulty with   producing xerostomia.                         Service – Category 4.
                                 speech and swallowing.                     Sugar free chewing gum.
                                 Condition may be isolated or               Artificial saliva.
                                 associated with rheumatic disease, eg      Trial with pilocarpine – it is important to
                                 Sjogrens or PH radiotherapy to             measure salivary flow prior to trial.
                                 jaws/neck. Medicines,dry mouth more
                                 common in older age group.




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