Common presentations around the lower jaw and face:
• Bleeding from the lower jaw/teeth (see also Chapter 13)
• Clicking TMJ(s)
• Deranged (change in) bite (disocclusion)/dislocation
• Fistula/sinus on the skin overlying the mandible
• Limitation of opening
• Numbness/altered sensation of the lower lip
• Painful jaw
• Swellings around the lower jaw.
Common problems and their causes
Bleeding from the lower jaw/teeth
(See also Chapter 13.)
Useful questions and what to look for
Bleeding from the lower jaw/teeth
(See also Chapter 13.)
The mandible forms the lower third of the facial skeleton and is responsible for the lower transverse facial width. It has a number of powerful muscles inserted along its length. These include the muscles of mastication (temporalis, masseter, medial, and lateral pterygoid), and the suprahyoid muscles (digastric, geniohyoid, and mylohyoid). These muscles can generate considerable biting forces and are an important cause of mandibular fracture displacement. The mandible also receives the insertion of genioglossus (which forms the bulk of the tongue). Loss of support for this muscle can place the airway at risk. Morphologically, the mandible can be considered as a U-shaped long bone articulating at each end with the skull at the TMJs. Anatomically it is divided into:
• Symphysis (in the midline)
• Parasymphysis (anterior to the premolar region)
• Body (premolar and molar region)
• Angle (third molar region)
• Ramus (from third molar to condyle)
• Condyle (neck and head).
The vertical ramus supports the condyle (which articulates with the glenoid fossa) and the coronoid process (which receives the insertion of the temporalis muscle). The condylar head is supported on a relatively slender neck—a frequent site of fracture. On the medial side of the ramus, the inferior alveolar (inferior dental—ID) nerve and vessels enter the bone via the mandibular (lingula) foramen, passing forward through the ‘ID’ canal. These provide sensory innervation and nutrition to the lower teeth. The mental nerve, a terminal branch, exits the mandible through the mental foramen in the premolar region. This provides sensation to the lower lip. Numbness of the lower lip may therefore signify fracture or pathology anywhere along the course of this nerve. High-energy blows to the side of the lower jaw can result in significant displacement of fractures involving the ID canal. This may result in stretching (or even avulsion) to the nerve itself, adversely affecting its likelihood of recovery. Make sure you record any numbness. This is a common source of litigation following injuries as well as dental treatment/surgery (notably removal of wisdom teeth).
In a healthy adult the lower jaw is around 3–4 cm in height. However, once a tooth (or teeth) has been lost, there is progressive resorption of the bone. This can weaken the bone locally, predisposing the site to fracture.
In the child, the dentition will be at various stages of development and developing tooth germs are present within the bone. While these lead to a structural weakening of the bone, this is compensated for by increased elasticity and pliability of the young mandible, compared with mature bone. As a result, relatively higher forces are required to fracture the bone in children. In the edentulous elderly jaw, continued resorption of bone leads to a significant reduction in bone height. This feature, together with age-related conditions such as osteoporosis makes the jaw highly vulnerable to fracture. In some patients the bone can literally be pencil thin, especially if they have been without teeth for many decades.
Always begin by assessing the airway, notably for obvious signs of compromise and by listening for any stridor. High-energy impacts that are sufficient enough to break the bone (particularly those resulting in comminuted or multiple-site fractures), not only put patients at risk from cervical spine injuries, but can also place the airway at risk from bleeding, swelling, and loss of tongue support. If there are airway problems, call for help and try to identify the cause.
In the absence of any urgent airway problems, start by inspecting the patient from in front. Note any lacerations, bruising, abrasions, swellings and haematomas. Look carefully under the chin—impacts here may suggest the possibility of fractures in the condylar region. The classic ‘guardsman’s’ fracture (a midline/parasymphyseal fracture, associated with bilateral fractures of the condyles) usually occurs following a faint or fall onto the chin. Bleeding from the external auditory meatus may be present, usually as a result of tearing of its anterior wall by a condylar fracture. However, it may also be a sign of a fractured skull base—be careful in your assessment.
Ask the patient to open and close their mouth and note for any limitation in mouth opening. Normal opening should be approximately four finger breadths (40 mm). Ask the patient to swallow and stick out their tongue and report if they have any pain or difficulty during this.
Then stand behind the patient and palpate the inferior border of the mandible passing from the chin to the TMJ on each side. Note any swelling, steps, and tenderness. Assess the movement of each condyle by palpating immediately in front of each tragus and then by placing a gloved finger in each auditory meatus. Ask the patient to open and close while palpating here. Gently stress the joints by pushing backward on the point of the chin with the teeth slightly apart. Then ask the patient to attempt to open their mouth against resistance by placing your hand under the lower border of their mandible. These two manoeuvres help identify fractures of the condyles. Note any areas of paraesthesia, or anaesthesia. If appropriate, assess for a displaced fracture the zygomatic arch—this may impinge on the coronoid process limiting mouth opening.
Following injury, if a fracture is thought not to be present, ‘springing’ the mandible by gently compressing the angles, should be possible without causing pain. Similarly, asking the patient to open their mouth, with increasing force against resistance at the symphysis, should also be pain free. A clinically intact jaw should be able to resist both these deformational forces without discomfort and therefore avoid unnecessary imaging.
It is also important to carefully examine inside the patients mouth (see Chapter 13). Intraoral examination requires a good light and a tongue depressor to retract the cheeks. Look for:
• Damaged, loose, missing teeth (see Chapter 13)
• Occlusal derangement, or steps in the occlusal plane.
Sublingual haematoma (submucosal blood under the tongue) is highly suggestive of a fracture involving the lingual plate of the mandible. If present, the airway should be reviewed regularly in any patient taking antiplatelet agents or anticoagulants (notably aspirin and warfarin), since continued bleeding may put the airway at risk.
Testing any suspected fracture sites can be done by grasping the mandible on each side of the suspected site and gently manipulating it to assess mobility. Check the patient’s occlusion and look for loose teeth. A normal bite will have an even and almost simultaneous contact of all the teeth. Derangement can be assessed by asking the patient to slowly bite together. Look for premature contacts and any teeth that do not come into contact. Also look for any obvious bony or soft tissue swellings.
Following injury, any missing teeth must be accounted for. If their whereabouts are unknown, request a chest and soft tissue X-ray of the neck. Similarly, if associated with a lip laceration, a soft tissue radiograph of the lips is essential.
Examination of the lower jaw for non-traumatic problems follows the same sequence. Although fractures are less likely, keep pathological fractures in mind. These can present without an obvious history of trauma.
Approximately half of patients with a mandibular fracture will have multiple fractures present. In about 10%, three or more sites will be involved. Therefore, if you identify one fracture, look for another (cf. pelvic fractures).
• FBC: this is usually required in all cases of suspected infection and following significant blood loss. A raised WCC is a useful guide to severity of infection.
• Glucose: screen for diabetes (associated with spreading sepsis).
• ESR/CRP: this is also a useful guide to severity of infection.
• Microbiology: for any pus/discharge.
Preliminary investigations commonly include an orthopantomograph (OPT), posteroanterior (PA) mandible film, and lateral oblique films.
Indications for performing these images are as follows:
Patients presenting with a history of trauma and clinical suspicion of a fractured mandible
• Two images should be taken at 90 degrees to each other.
• An OPT requires the patient to sit or stand upright. If this is not possible, a lateral oblique film can be taken.
• If a fracture of the condylar neck is suspected, a reverse Townes view can be helpful.
• It is important that all images include the mandible in its entirety.
• If trauma is involved, then an OPT and PA mandible are required.
• If a dentoalveolar infection is suspected, the patient needs an OPT to examine the teeth and bone morphology.
• If the patient has had recent surgery, an OPT is indicated.
Limitation of mouth movement
• If trauma to the TMJ is suspected, an OPT and PA mandible should be used.
• If dislocation is suspected, an OPT must image both the condyle and glenoid fossa.
Not all patients require a CT of their mandible. Indications are generally as follows:
• Imaging complex fractures including the condylar region. With isolated condylar fractures, this may be done as an outpatient.
• Imaging the mandible and soft tissues to identify the source and extent of severe cervicofacial infections (see Chapter 5).
• Imaging the TMJ for patients with suspected joint arthropathy (usually as an outpatient).
• Imaging bone when osteomyelitis, ORN, or large cystic pathology has been identified on plain films.
• Imaging of suspected tumours (CT or MRI)
This has a limited role in lower jaw conditions. It is useful in assessing soft tissue swellings surrounding the lower jaw. This would be primarily to differentiate between solid or fluid filled swellings. Ultrasound also has a role in differentiating salivary gland swellings from lymph nodes.
Injuries to the lower jaw
Most patients will give a history of blunt injury to the face, the most common mechanism being interpersonal violence. Sports, falls, and accidents are other common causes. Common symptoms include:
• Altered bite
• Difficulty in opening and closing of the jaw.
The hallmark of a mandible fracture is a change in the bite (occlusion); however, a normal occlusion does not rule out a mandible fracture.
Other features include:
• Loosened/missing teeth
• Facial deformity
• Mobility across the fracture
• Bleeding from a tear of the overlying gingival tissue
• Sublingual haematoma (Figure 12.1)
(See also Chapter 2.) Isolated lower jaw trauma can occasionally present as an emergency.
Obstruction can be caused by displaced or broken dentures/teeth or severely displaced fractures. The commonest cause is bleeding and/or saliva, especially if the patient is intoxicated or supine. If the patient is supine, quickly decide if he/she can sit up (this is possible in most isolated low-velocity injuries—see Chapter 4), or if they need full spinal protection. Sitting up will certainly help the airway. Saliva and blood should be cleared by suction. Displaced fractures should be manually reduced if possible and supported. This usually slows the bleeding. Major bleeding is rare, but if ongoing the airway should be protected with a definitive airway.
Bilateral anterior (‘bucket handle’) or comminuted mandibular fractures can displace allowing the base of the tongue to fall back. This is much more likely when patients are supine with a reduced conscious level. Any obstruction can be initially dealt with by gently pulling the fractured bones forward. This provides only temporary relief and a definitive airway will probably be required. But it may also cause further bleeding.
Bleeding from mandibular fractures although common is not usually life-threatening. If the patient is in shock, look for another cause. Actively consider facial bleeding, in awake supine patients—they may be swallowing blood. If bleeding is obvious and significant, it must be controlled during the primary survey. Bleeding from overlying lacerations can be controlled either by pressure or by rapid placement of tacking sutures. These are placed to stem bleeding and are not intended as definitive closure.
Common fracture patterns
The periosteum is an important structure in maintaining the stability of a mandibular fracture. In young patients it is generally a strong unyielding membrane. Gross displacement of the fractures only occurs after heavy impacts. However, once the periosteum has been torn, displacement of the bones can occur under the influence of the attached muscles. High-energy mandibular fractures therefore tend to be unstable.
Common fracture patterns include those shown in Figure 12.2.
Fractures of the angle (wisdom tooth area) can be displaced by the medial pterygoid and masseteric muscles, depending on the fracture orientation (termed ‘favourable’ or ‘unfavourable’). These may pull the posterior fragment lingually, or in an upward direction. This is only important when the periosteum has been torn allowing displacement to occur. See Figures 12.3 and 12.4.
Fractures at the symphysis and parasymphysis
The mylohyoid muscle passes between the hyoid bone and the inner aspect of the mandible. With midline fractures of the symphysis, the mylohyoid and geniohyoid muscles can act as a stabilizing force. However, oblique fractures will tend to overlap due to the pull of these muscles. With bilateral parasymphyseal fractures (which result from considerable force), the periosteum is often torn and the fragments can displace under the influence of the genioglossus, so-called bucket handle fractures.
This is a common site of fracture and often occurs in association with fractures elsewhere in the jaw. The classical history is a blow or fall onto the point of the chin, where one or both condyles are fractured, often associated with a symphyseal or parasymphyseal fracture (so-called guardsman’s fracture). Beware the laceration over the chin following a fall—check the condyles carefully. On mouth opening, the jaw deviates towards the site of injury.
Condylar fractures in adults tend to occur outside the joint space, although the joint can still be damaged with long-term problems. Effusion or bleeding into the joint space can occur in the absence of a fracture, the space is distended and the patient complains of an abnormal bite. Intracapsular fractures in children are more common and can result in growth disturbances in the condyle later on. See Figure 12.5.
These are uncommon and usually follow a direct blow to the side of the face. Check for other fractures (notably the zygomatic arch). Since the ramus is heavily enveloped in muscle the fracture does not displace too much. Treatment is based on the patients bite, not the X-ray appearances.
• Pain relief is a priority and may be simply achieved by infiltration of local anaesthesia or, if possible, by an inferior dental nerve block.
• Minimize movement across the fracture site. This reduces pain, bleeding, and contamination of the fracture from oral bacteria:
• A simple method is to apply a soft neck collar but this should only be done after the cervical spine has been formally cleared.
• If possible, place a bridal wire across the fracture site. This is a loop of wire encircling the teeth either side of the fracture. Care must be taken not to avulse the teeth by over-tightening the wire.
• Any loose dentoalveolar fractures should be splinted.
This is possible if the patient is cooperative and has:
• A minimally displaced fracture on imaging
• With no mobility across the fracture line
• No change in occlusion
• No evidence of bleeding or infection.
Treatment involves oral analgesia, antibiotics for 1 week, and a liquid/very soft diet for 4 weeks until a stable callus has formed. Patients still need urgent follow-up but do not need admission.
For painful or more displaced fractures, intermaxillary fixation (IMF) may be applied. The upper and lower teeth are fixed together using wires or elastics. This uses the upper (uninjured) teeth for support and as a guide, to re-establish the bite and immobilize the fracture during healing. Various devices are available to achieve this. Relative contraindications include respiratory disease, the possibility of convulsions, a head injury (GCS score of ≤8), and poor patient cooperation. If the patient has no teeth (edentulous patients), modified dentures (Gunning splints) can be ligated to the jaws to achieve a similar goal. This may be possible in the emergency department, but usually patients need admission or transfer to the appropriate specialty’s department for this to be done.
This is required in displaced or mobile fractures where IMF is not suitable or cannot be undertaken. Surgical exposure of the fracture and anatomical reduction is carried out. The fracture is accurately reduced and fixed using titanium ‘mini’ plates or screws. This is now the preferred approach to most mandibular fractures, resulting in faster recovery and rehabilitation. However, there is potentially more morbidity, especially injury to the inferior alveolar nerve and tooth roots. The patient still requires a soft diet for the same period of time. Keep the patient fasted and refer to maxillofacial (or appropriate specialty).
TMJ dislocation occurs when the condyle is displaced anteriorly out of its socket, the glenoid fossa, and is prevented from returning to the correct position. It becomes trapped anterior to articular eminence. See Figure 12.6.
Spasm of the powerful masticatory muscles then prevents its relocation. It usually occurs with an audible pop at times of maximal mouth opening, i.e. yawning, or following an injury to the jaw when the mouth is open. Radiographs are not normally required unless there is a history of trauma—to make sure it is not a fracture/dislocation.
The patient will attend with a mouth that is propped open, they cannot close or move the jaw and this will be associated with drooling.
There are many ways to relocate a dislocated jaw. The trick is muscle and patient relaxation (analgesia and sedation). The TMJ is an intrinsically unstable joint and it is the spasm in the powerful masticatory muscles that prevents relocation in many cases. Relocation therefore often requires analgesia and a parenteral short-acting muscle relaxant (e.g. midazolam). Entonox is also a very good drug to use. Local anaesthesia injected directly into the muscles of mastication (both sides) is also very helpful. Whatever you use, give this plenty of time to take effect.
The patient is then sat with their back and head resting against a wall. Stand in front and place your thumb(s) inside the patient’s mouth, just posterior to the last standing mandibular teeth. Apply downward and posterior pressure from your thumb(s) and at the same time push up with your fingers on the under surface of the chin. If fully relaxed, the joint(s) should pop back into position and the mouth can fully close.
Be mindful to wrap gauze around your thumbs to avoid trauma when the patient bites down. Once reduced, place a barrel bandage around the patient’s head for 30 minutes and monitor closely if parenteral sedative or a muscle relaxant was given.
If this does not work or the jaw immediately dislocates again, refer to maxillofacial for advice.
Patients with dislocation cannot close their wide open mouths. This is a common cause of confusion. If the patient cannot open their mouth or it is only slightly open it is not a dislocation.
Infective swellings around the lower jaw and face
Acute swellings around the lower jaw are usually due to bacterial infections in the adjacent fascial spaces. These may be localized at first but they can quickly become widespread. Most often they arise from an underlying dental infection. However, there are other causes (such as infections of bone cysts, skin lesions, or the salivary glands). Infections localized only to the skin (cellulitis) may also occur. Untreated, some infections can rapidly progress and become life-threatening. Spread of infection depends on the local anatomy, particularly the point of origin of the infection (i.e. which tooth). Virulence of the organism and host resistance are also important factors.
Fascial spaces related to the mandible
The mylohyoid muscle divides the floor of the mouth into two large spaces—the sublingual space above the muscle and the submental and submandibular spaces below it.
This is a horseshoe-shaped space passing from one side of the floor of the mouth to the other. The superior limit of this space is the tongue and the inferior limit is the mylohyoid. It contains the sublingual glands and the deep lobes of the submandibular glands. It communicates posteriorly with the submandibular spaces. Swelling here is potentially very serious because of the threat to the airway. The tissues are delicate and can easily distend, pushing the tongue up and back. Usually infections here are associated with swelling in one or both submandibular spaces. They are almost always due to dental infections. When significant swelling is present, urgent decompression is required.
This is triangular in shape, bounded above by the mylohyoid muscle (medially) and mandible (laterally), and below by the deep cervical fascia. It contains lymph nodes, the superficial lobe of the submandibular gland, and blood vessels. It communicates with the sublingual space above, the superficial facial space laterally, and the deep pterygoid space and parapharyngeal spaces posteriorly. Surgical access can be made 2–3 cm below the lower border of the mandible. Skin and subcutaneous tissues are incised and sinus forceps are used to penetrate the deep cervical fascia towards the lingual side of the mandible.
This is contained by the two anterior bellies of the digastric muscles. Above is the mylohyoid muscle and below is the deep cervical fascia, covered by platysma and skin. It contains submental lymph nodes and communicates with the submandibular space. Surgical access is obtained behind the chin prominence in the neck.
This is a commonly affected space and often presents to casualty as a ‘fat face’. Infections can spread into it from both mandibular and maxillary teeth. It is bounded by the buccinator muscle anteromedially, and the masseter muscle posteromedially. Laterally is the deep fascia from the parotid capsule and the overlying platysma. The inferior boundary is the insertion of the deep fascia into the mandible, and its superior boundary the zygomatic arch. Its contents are the buccal fat pad. Posteriorly it is continuous with the pterygoid space. Surgical access is usually obtained from within the mouth. If the abscess points onto the skin, an incision can be made externally, but a scar will result.
This is bounded laterally by the temporalis facia, zygomatic arch, and masseter muscle, and medially by the medial and lateral pterygoid muscles. The temporalis muscle and mandibular ramus further divide this space into superficial and deep compartments. The superficial compartment contains the submasseteric space below and the superficial temporal space above. The deep compartment contains the superficial pterygoid space (or pterygomandibular space) below and the deep temporal space above. The superficial pterygoid space communicates with the deep pterygoid space. The superficial and deep temporal spaces together are also known as the infratemporal fossa space.
This is a rapidly spreading, tense cellulitis of the submandibular, sublingual, and submental spaces bilaterally. When advanced it is an obvious diagnosis, with gross swelling both in the neck and the mouth. Earlier infections still need to be treated seriously and need urgent referral. Ludwig’s angina is a potential airway emergency which if not diagnosed and treated quickly has a mortality rate of around 75% within the first 12–24 hours. With aggressive surgical intervention, good airway control, and antibiotics this rate has now dropped to 5%.
Usually the cause is a submandibular space infection secondary to an infected wisdom tooth. Other causes include tonsillitis, infected mandibular fractures, and submandibular sialadenitis. From the submandibular space, the infection spreads to the sublingual space around the deep lobe of the submandibular gland. It then passes to the contralateral sublingual space and thence to the other submandibular space. The submental space is also affected by lymphatic spread. Infection can also originate in the sublingual space and spread laterally to both sides. Left untreated, oedema and cellulitis spread backwards in the space between the hypoglossus and genioglossus to the epiglottis and larynx, resulting eventually in respiratory obstruction.
• Systemic upset.
• Massive firm swelling bilaterally in the neck.
• Swelling in the floor of the mouth, forcing of the tongue up onto the palate.
• A ‘hot-potato’ voice. This term is used to describe the characteristic pattern of speech, which has been likened to a person speaking with a hot potato in the mouth. It has several causes in addition to Ludwig’s angina.
• Difficulty in swallowing and drooling.
• Inability to protrude the tongue.
• Eventually this leads to difficulty breathing.
The first consideration is the airway which can rapidly obstruct. Difficulty in breathing, swallowing, or talking, and gross swelling are all indications to call for senior help (often anaesthetic) urgently. Refer to maxillofacial team urgently. Further management includes IV fluids (patients often present after a few days, having not been able to drink), IV antibiotics (e.g. penicillin and metronidazole), together with surgical drainage of the submandibular and sublingual spaces and removal of the underlying cause. If there is respiratory difficulty, give oxygen. These cases are commonly associated with self-neglect (including alcohol and smoking) and immunosuppression (e.g. diabetes)
Never underestimate these fascial space infections. They are often referred to as ‘dental abscesses’ but this terminology will put you, the anaesthetist, and theatre staff, in the wrong state of mind and a lower gear of alertness. Do not underestimate the rapidity with which these infections can come to threaten the airway. If you suspect the airway may potentially be threatened, do not ‘wait and see’ by treating with antibiotics. Get senior help and consider electively securing the airway with endotracheal intubation before draining the abscess.
Antibiotics alone will not treat these infections. They require incision and drainage.
Acute bacterial submandibular sialadenitis
The majority of these infections are secondary to a calculus (stone) in the duct. Other causes include surgical scarring or strictures secondary to radiation or other causes of chronic fibrosis. The whole gland swells up and there is malaise, pyrexia, and pain. Submandibular calculi are opaque in 80% of cases, so a radiograph may aid in the diagnosis. Antibiotics are required. If the stone is easily felt in the mouth it can be removed intraorally. If the infection leads to a collection, then incision and drainage of the submandibular space must be carried out, and the gland removed on an elective basis later. Mumps virus infection involving the submandibular gland is rare but has been reported.
This results from repeated episodes of acute sialadenitis. The structure, parenchyma, and function of the gland are gradually destroyed. The gland ends up feeling very hard to palpation. Treatment is by surgical excision.
Mumps is the commonest cause of parotid swelling, even unilaterally.
It has a peak incidence in childhood but can occur in adults. In teenagers, coxsackieviruses and echoviruses can also cause acute sialadenitis. Clinically there is pyrexia and malaise. Pain is the most striking symptom. There is diffuse swelling of the gland over the ramus, which raises the lobe of the ear, and often trismus. Treatment is supportive
‘Ascending’ infection, i.e. bacteria in saliva passing back along the ducts into the glands, can involve the parotid (and submandibular) glands. In such cases, predisposing conditions are often associated, e.g. dehydration, diabetes, or immunosuppression. Fibrosis following radiotherapy or pre-existing obstruction from a calculus or stricture may also predispose to infection.
• Tender swelling
• Discharge of pus from the duct.
If the infection is not treated early, this may develop into a chronic or recurrent infection. Progressive destruction of the gland aggravates the situation, resulting in a non-functional gland.
In the absence of an obvious abscess, management initially consists of IV antibiotics, rehydration, analgesia, and correction of any systemic conditions, e.g. diabetes. If an obstruction is found, e.g. stone, this needs to be removed to enable drainage. Gland massage, especially after meals, and ‘lemon drops’ to stimulate salivary flow, help to maintain a flushing effect and prevent stagnation of saliva. Abscesses need to be incised and drained on an urgent basis. If infection persists or continues to recur, excision of the gland may be necessary. This is best done when there is no active infection.
Spreading infection within the skin (cellulitis) is characterized by swelling, warmth, erythema, and pain. The patient may present with minimal signs initially, or they may be unwell with malaise, fatigue, chills, or a fever. Regional lymphadenopathy may also be present. Cellulitis around the lower jaw and face may be a presenting sign of an underlying deeper infection. These include:
• Dental infection (tooth or cyst)
• Skin cyst (e.g. sebaceous) infection
• Infected laceration with or without a retained foreign body
• Submandibular infection
• Untreated fracture.
In the absence of these, inflammation is confined initially to the deeper dermis and subcutaneous tissue resulting in an ill-defined red rash. Untreated this can progress to sepsis, abscess formation, or necrotizing fasciitis. The most common infecting organisms in cellulitis are group A Streptococcus followed by Staphylococcus aureus. These gain access to the dermis through a break in the skin (e.g. during shaving).
Flucloxacillin has become a mainstay of treatment due to its bactericidal effect on both commonly occurring organisms. Benzylpenicillin is particularly affective against streptococci and is also commonly prescribed. In immunocompromised individuals and children, a wider variety of bacteria may be implicated and a broader spectrum of antibiotic cover may be necessary. Oral antibiotics are sufficient for mild disease; more severe cases need admission for IV antibiotics.
Treat cellulitis in the head and neck carefully. This can rapidly deteriorate resulting in abscess formation and necrotizing fasciitis. Always consider an underlying cause (often dental infections) and the possibility of immunocompromise (diabetes and alcohol abuse especially).
Infected mandibular fracture
Severe infection of a mandibular fracture resulting in osteomyelitis is rare. However, localized infection still happens relatively frequently, particularly when patients have poor oral hygiene, smoke, and present late. Debilitated patients, diabetics, and patients on steroids or chemotherapy are more likely to develop infected fractures because of lowered general resistance. Commonly, these occur at the angle of the mandible, where the patient has retained third molars (wisdom teeth). Comminuted fractures of the mandible may be complicated by the formation of bone sequestra which become a potential source of infection. In some cases the sequestra may extrude spontaneously into the mouth with quite minimal symptoms, but sometimes a localized abscess forms and surgical removal of the dead bone becomes necessary. Infected fractures need urgent referral. Management involves antibiotics and stabilization of the fracture.
Osteomyelitis of the jaws is uncommon and most commonly associated with odontogenic infection (infections of the teeth). It can occur following extractions, trauma, or irradiation to the mandible. It can also occur in patients taking bisphosphonates (BRONJ). Infection is more common in the lower jaw, as the upper jaw has a relatively better blood supply. Before the antibiotic era, however, it was frequently fatal. Acute osteomyelitis is less common than chronic osteomyelitis, with patients rarely presenting with obvious suppuration. A small amount of pus exuding from around a tooth is more likely to be a periodontal abscess, but if multiple adjacent teeth are involved, mobile, and the overlying soft tissue are inflamed, there is probably acute osteomyelitis (see Figure 12.7).
These depend upon the type and extent of infection and may include:
• Pain—in acute osteomyelitis, this can be severe, throbbing, and deep seated. Chronic infection has a less intense but still deep-seated and unremitting character.
• Swelling, erythema, and tenderness. Initially soft, the swelling is secondary to inflammation and oedema. This may later progress to a firm subperiosteal abscess.
• Cervical lymphadenopathy.
• Numbness of the lower lip and jaw.
• Pyrexia, anorexia, and malaise.
• Friable granulation tissue, exposed necrotic bone, and sequestrum formation are all common in chronic infection. It is important to make sure these features are not those of a malignancy.
Usually there is an obvious cause such as a decayed tooth. This may be tender and mobile. Most patients are either malnourished or immune deficient to some extent. This condition is therefore commonly seen in smokers, diabetics, and alcoholics as well as other well-known at-risk groups.
The infection is usually a polymicrobial in nature. It is caused by a mixture of streptococci and anaerobic bacteria, which pass into the bones from the infected tooth. Haematogenous spread is rare. Osteomyelitis may also arise in an infected fracture. This tends to be chronic. Smokers are at particularly high risk of this. Actinomycosis is an unusual but specific infection, also known to occur. This results in recurrent and chronic jaw abscesses. These can discharge large amounts of pus, frequently through multiple skin sinuses, which often contains characteristically appearing bright yellow granules (referred to as ‘sulphur granules’). Consider actinomycosis in any patient with chronic bone abscesses and discharging sinuses.
Acute osteomyelitis needs urgent referral for admission, IV antibiotics, and drainage of pus. Chronic osteomyelitis may be managed as an outpatient with appropriate long-term antibiotics. If so, close follow-up is required. Any associated contributing factors should also be identified and treated if possible. Surgical debridement may be required.
Infected branchial cyst
(See Chapter 5.) Most branchial cysts present in the neck and are painless, but they may become infected and involve the upper part of the lateral neck/parotid region. These are difficult to treat and recurrence is common. If infected, refer urgently.
Infected bone cysts
These can present in a number of ways:
• Chronic jaw pain, with or without swelling
• Chronic swelling, with or without pain
• Acute fascial space infection
• Pathological fracture.
In most cases, the presence of the cyst is not apparent until plain films have been taken, although some cysts may pour pus into the oral cavity on examination, suggesting the presence of a large cavity. Management may be the same as for fascial space infections, depending on the severity of symptoms. Refer urgently if systemic symptoms are present or the cyst is large.
Non-infective swellings around the lower jaw and face
The lower jaw is particularly susceptible to ORN due to its low vascularity and greater bone density. The clinical spectrum of presentation is wide. Patients usually have a non-resolving painful mucosal ulcer with evidence of exposed bone or sequestrum. This is usually in the posterior mandibular region. There may be trismus and this usually appears 3–6 months following radiotherapy. See Figure 12.8.
At the other end of the spectrum, patients may present with an orocutaneous fistula, pathological fracture, and paraesthesia of the inferior alveolar nerve. Typically radiological appearances will include a moth eaten appearance of the bone. Management principles are based on controlling any acute superimposed infection, strict oral hygiene, analgesia, and nutritional support as well as minimal surgical debridement. In severe cases resection of the bone and reconstruction with a free tissue transfer may be required.
Bisphosphonate-related osteonecrosis of the jaw (BRONJ)
Bisphosphonates inhibit osteoclastic action and reduce bone loss in patients with multiple myeloma, bony metastasis in breast cancer, Paget’s disease of bone, and postmenopausal osteoporosis. However, osteonecrosis can occur as a serious side effect in both jaws. Patients present with pain and swelling affecting the mucosa of the jaw, which may be confused with chronic osteomyelitis, ORN or even malignancy. See Figure 12.9.
CT usually shows regions of mottled bone and sequestrum formation. Treatment usually involves meticulous oral hygiene, antibiotics and gentle debridement. Cessation of the drug, if not contraindicated may help some recovery.
Paget’s disease is a localized disorder of bone remodelling that typically begins with excessive bone resorption followed by an increase in bone formation. Usually the bone is mechanically weaker, larger, less compact, more vascular, and more susceptible to fracture than normal adult lamellar bone. Although rare for the maxilla to be involved, when it is, patients can present with bone pain associated with marked deformity. Clinical examination may reveal excessive warmth, due to hypervascularity and paraesthesia of the infraorbital nerve due to bony compression. These symptoms may be confused with chronic infection or a tumour.
This is a disorder of bone growth where normal bone is replaced with immature fibrous bone. It can occur in any part of the skeleton but the skull and face are commonly involved. Patients present with a smooth hard swelling and deformity usually in childhood or early adulthood. During rapid growth this may become painful. Two types of Fibrous dysplasia are described.
• Monostotic—involving a single bone, or adjacent bones, such as the upper and lower jaw
• Polyostotic—involving many bones.
The most severe form of polyostotic fibrous dysplasia is known as McCune–Albright syndrome, which includes endocrine diseases (precocious puberty) and skin pigmentation. Fibrous dysplasia may also be associated with neurofibromatosis. The condition is said to burn itself out during puberty but exceptions are well known. Management include bisphosphonates and surgical contouring of and cosmetic deformity.
Odontogenic myxomas are uncommon benign odontogenic tumours arising from embryonic connective tissue associated with tooth formation. It usually occurs in younger patients (10–35 years old). The lower jaw is most commonly involved. Patients generally notice a painless, slow growth in the jaw, sometimes with tooth loosening or displacement. As the tumour expands, it frequently infiltrates adjacent structures and posterior lesions are associated with infiltration of the ramus.
These will rarely present as an emergency. Tori are painless, bilateral bony growths present on the inner aspect of the mandible, usually in the premolar region. In some patients they can grow to the size of a walnut. They have normal overlying mucosa. They are usually an incidental finding in patients with parafunctional habits, but are sometime referred as a ‘lump in the jaw’ particularly in edentulous patients where they are more noticeable.
Central haemangiomas within the mandible are extremely rare. They arise from a proliferation of vessels within the medullary cavity. They usually present as a painless, firm swelling that can be associated with a subjective sensation of pulsation. They can be locally destructive because of pressure effects and can cause mobility of surrounding teeth.
(See Chapter 11.) The differential diagnosis for any large ‘cyst’ or cavity in the bone must include AVM. Although rare, these can lead to torrential haemorrhage if breached (i.e. during a dental extraction). Contrast imaging may be required.
Temporomandibular joint dysfunction syndrome
This is a controversial topic. TMJDS is a collective term used to describe a number of related conditions affecting the joints, muscles of mastication, and associated structures. These all result in common symptoms such as pain and limited mouth opening. No single condition has been found to cause it. Although up to 70% of the general population may have at least one clinical feature of this disorder, only about 5% will actually seek treatment. Females outnumber males by at least four to one. Patients most commonly present in early adulthood. Temporomandibular dysfunction is not always progressive or destructive. It is a complex disorder involving many interacting factors including stress, anxiety, and depression. Non-surgical treatments, such as counselling, pharmacotherapy, and occlusal splint therapy, continue to be the most effective way of managing >80% of patients.
Three common temporomandibular disorders are myofascial pain and dysfunction, internal derangement, and osteoarthrosis:
• Myofascial pain and dysfunction are by far the commonest. This is primarily a muscular problem resulting from ‘parafunctional’ habits, such as clenching or bruxism (grinding teeth). Stress, anxiety, and depression are commonly associated.
• Internal derangement describes a disorder in which the articular disc is in an abnormal position, resulting in mechanical interference and restriction of movement. Disc problems can result in both limitation of mouth opening and clicking/crepitus.
• Osteoarthrosis is a localized degenerative disorder that affects mainly the articular cartilage of the joint. Usually in older age groups.
The TMJ is a synovial ‘ball and socket’ type joint. A fibrous sleeve encapsulates the joint. Between the condyle and fossa there is a fibro-cartilaginous disc, or ‘meniscus’. The muscles of mastication act directly across the TMJ to effect mandibular movements. Of note, the insertion of the lateral pterygoid is into both the condylar neck and the anterior aspect of the disc. Joint movement is complex. On opening the mouth from the closed position, there is initially a hinge-type movement for the first 1 cm. After that a forward translation is added in which the condyle moves forwards and downwards along the slope of the eminence. Very little movement occurs side to side.
Various aetiological factors have been suggested, but in reality it is likely that the condition is multifactorial:
• Parafunction, such as tooth clenching and grinding (often subconsciously or during sleep), or abnormal movements of the jaw (e.g. a swing from left to right, reversed on closing—‘chewing the cud’). Such movements often exert unbalanced loads on the joints, resulting in painful muscle spasm.
• Occlusal anomalies are a common feature and there may be a higher frequency of TMJ problems in patients with heavily restored dentitions. However, there are also plenty of patients who have abnormal bites yet do not have any TMJ symptoms.
• Poorly fitting dentures can contribute to TMJ dysfunction. Over closure of the jaws when the back teeth/dentures are severely worn down (loss of posterior support) can put a strain on the joints.
• Trauma either directly from a blow, or indirectly from stretching (e.g. for dental treatment) may cause tears or adhesions around the disc, or a synovitis resulting in pain and altered function.
• Stressful life events and impaired coping mechanisms are more frequent in patients with TMJ dysfunction, compared to non-affected control patients. Anxiety neuroses and affective disorders (particularly depression) are more common. These psychogenic factors are often considered as exacerbating factors, rather than the primary cause of temporomandibular disorders.
This is difficult and controversial. Most patients do not need to be referred and can be treated by their own doctor or dentist. Treatment options include:
• Physiotherapy and jaw exercises.
• Psychosocial and behavioural interventions (such as biofeedback techniques, cognitive behavioural therapy, hypnosis, and relaxation techniques). Reassurance plays an important role in management.
• Occlusal splints (bite plates, bite raising, or intraoral appliances) are made of acrylic and can be hard or soft. They are designed to fit over the upper or the lower teeth. Normally splints are worn during sleep.
• Medications include analgesics, benzodiazepines, and muscle relaxants.
• Botulinum toxin solution (Botox®).
• Occlusal adjustment.
• In selected cases where the joint is damaged, surgery may be indicated (arthrocentesis, arthroscopy, menisectomy, disc repositioning, condylotomy or joint replacement).
The commonest cause of a clicking joint is internal derangement. This is managed initially as for TMJDS. Osteochondral loose bodies are uncommon, but should be considered if symptoms are severe or persist. Common clinical features are pain, swelling, joint noise, and sudden onset of impaired joint movements (‘locking’). Exclude any history of trauma. In the absence of fractures these patients require outpatient follow-up for imaging (CT/MRI) to confirm the presence of a loose body. This will need to be removed.
Inability to fully open the mouth has many causes, some of which are serious. This may present acutely and is often misdiagnosed as a ‘dislocated jaw’. However, in a dislocation the problem is one of closing—the mouth is typically wide open. ‘Trismus’ is a specific term. It refers to reduced opening of the jaws caused by spasm of the muscles of mastication. This implies specific pathologies, the commonest being trauma, infection or a tumour.
Normal mouth opening ranges from 35 to 45 mm.
Causes of limitation of mouth opening
• Trismus (notably trauma, infection, or tumour)
• ‘Internal derangement’ of the TMJ (meniscus displacement or ‘locking’)
• Trauma (including an untreated depressed zygomatic arch fracture)
• Infection within and around the joint (notably parotid)
• Osteoarthritis and other types of arthritis (e.g. rheumatoid)
• Ankylosis and osteophyte formation
• Myofascial pain/TMJDS
• Radiation fibrosis
• Submucous fibrosis
• Systemic sclerosis
• Myositis ossificans
• Coronoid hyperplasia
• Psychiatric causes.
The history may give some indication of the cause. Differentiate between painless and painful restriction. Plain films, CT, or MRI may be required depending on the suspected cause.
The important thing is not to miss an occult tumour—examine the oropharynx carefully (especially the ‘coffin corner’—the deep recess between the side of the tongue and wisdom teeth).
The TMJ contains an articular disc which overlies the condylar head and prevents direct contact between it and the glenoid fossa. The disc can sometimes displace anterior to the condyle and become trapped between it and articular eminence. If this occurs it can prevent free movement of the condyle during mouth opening. This is usually an acute event but patients may give a history of preceding joint symptoms. This condition may require outpatient referral to maxillofacial if patients have significant pain.
True joint ankylosis is unlikely to present acutely. This progressive destructive arthropathy results in loss of joint space and fusion of the condylar articular surface to the glenoid fossa. It usually occurs following untreated fractures of the condyle, or middle ear infections in childhood and is therefore uncommon in the developed world. Imaging of the TMJ (OPT) will demonstrate gross irregularity of the joint and loss of joint space. In children, severe ankylosis can result in asymmetric facial growth. This requires an outpatient referral.
This arises following radiotherapy where the irradiated fields include the TMJ or muscles of mastication. Radiotherapy to the muscles results in atrophy and fibrosis of the muscle fibres. Onset is often gradual, usually noticeable 8–12 weeks after completion of treatment. However, it can continue to develop. Without intervention, mouth opening can be reduced by up to a third after several years. Studies have demonstrated that nearly half of all patients who receive curative intent radiotherapy to the head and neck will experience some limitation of opening.
Oral submucous fibrosis
Oral submucous fibrosis is a chronic debilitating disease of the oral cavity characterized by inflammation and progressive fibrosis of the submucosal tissues. It causes progressive limitation of opening which if untreated can progress to total inability to open the mouth. The buccal mucosa is the most commonly involved site, but any part of the oral cavity can be involved, including the pharynx. The condition is well recognized for its malignant potential and is particularly associated with areca nut chewing, the main component of betel quid. It is usually associated with a marbled appearance of the buccal mucosa and the presence of taut palpable fibrous bands within it.
This is heterotopic calcification of muscle. There are two forms:
• Myositis ossificans is when calcification occurs within an injured muscle.
• Myositis ossificans progressiva (also referred to as fibrodysplasia ossificans progressiva) is a condition in which ossification can occur without injury. It is inherited.
Imaging will show hazy densities approximately 1 month after injury, and denser opacities at 2 months. Treatment is usually conservative (NSAIDs and physiotherapy). Surgical removal of the myositis ossificans is rarely required.
This is a condition of unknown aetiology but is seen in association with submucous fibrosis and TMJ ankylosis. As elongation of the coronoid process occurs, it results in progressive limitation of opening from impingement on the under-surface of the zygoma and its arch. In severe cases, the coronoid can be excised.
This is an important sign and should always be taken seriously, especially in infections. Trismus is limitation in mouth opening due to muscle spasm. Most commonly, the spasm is in the masseter muscle, but it can occur in the medial pterygoid or temporalis muscles. It is a marker indicating that any infection is advanced and it is often taken as a sign that the patient needs admission. Untreated infection will rapidly progress, eventually resulting in dysphagia and potential airway problems. Anaesthetists need to be aware of any trismus if the patient is going to theatre, as fibreoptic intubation is required.
Trismus can be graded 35–40 mm normal. Mild opening 30–35 mm, moderate 15–30 mm, and severe <15 mm.
Causes of trismus
Most causes can be considered under the headings of infection, trauma, and tumour. If you remember these three pathologies you won’t overlook serious conditions:
• Muscle spasm (following injury/infection)
• Post-surgical oedema (especially following removal of wisdom teeth)
• Recent dental treatment
• Following an inferior alveolar nerve block (usually from a haematoma in the medial pterygoid)
• Dental infections/pericoronitis/submasseteric abscess
• Peritonsillar abscess
• Cerebrovascular accident/brain injury
• Acute parotitis (e.g. mumps)
• Malignancy (intraoral and extraoral).
The most common causes will be trauma and abscesses which cause spasm of the medial pterygoid. Following injury there does not have to be a fracture. Occasionally a displaced fracture of the zygomatic arch may impinge on the movement of the coronoid process and prevent normal opening. This is not trismus, but it still requires treatment.
Oral surgery procedures
Removal of the lower molar teeth may cause trismus as a result of inflammation in the muscles of mastication, direct trauma to the masticatory apparatus, or postoperative infection. Infections require antibiotics. Following this, heat therapy, analgesics, a soft diet, and gentle jaw exercises should eventually resolve the remaining symptoms.
Inferior alveolar nerve injections
Medial pterygoid haematoma can occur following a dental injection to anaesthetize the inferior alveolar nerve. These patients will present with progressive trismus within a few days of undergoing dental treatment. Be mindful of the possibility of secondary infection. A simple haematoma is managed by prescribing NSAIDs and starting the patient on gentle jaw stretching exercises. If infection is suspected, commence antibiotics and avoid exercises. Refer severe limitation or infections to maxillofacial.
(See also Chapter 8.) These are common infections arising when infection of the tonsil spreads to the surrounding tissue. As the peritonsillar abscess increases in size it is often associated with trismus resulting from spasm of the medial pterygoid muscle. Often they can be drained in the emergency department but if they threaten the airway, general anaesthesia is required.
Neurological causes of spasticity of the muscles of mastication
Cerebrovascular accident and traumatic brain injury may result in severe trismus secondary to masseter spasticity. Many patients with severe neurological injury undergo PEG placement secondary to severe masseter spasticity. Botulinum toxin may be effective in reducing this type of trismus.
Tetanus toxin, the product of Clostridium tetani, causes muscle rigidity and spasms. This results in trismus, dysphagia, opisthotonos (severe hyperextension and spasticity), and spasms of respiratory and laryngeal muscles. Treatment is with tetanus immunoglobulin, IV antibiotics, and muscle relaxants. Patients may need intubation.
(See Chapter 13.) Oral cancer typically presents as a non-healing ulcer, with raised rolled edges. Although they can occur anywhere in the mouth, the most common locations are the floor of mouth and posterolateral tongue. The patient may have a history of risk factors, including smoking and alcohol. Any ulcer which is progressively enlarging, and persists >2 weeks, should be referred for urgent biopsy to exclude dysplasia or malignancy. Management involves further imaging to determine whether there is regional lymph node involvement or distant spread. Following review at a head and neck multidisciplinary team meeting, treatment may be curative or palliative, involving surgery, chemotherapy, and radiotherapy.
Any cancer infiltrating into the muscles of mastication (skin, parotid, sarcoma) can result in trismus.
Bleeding from the lower jaw (non-traumatic)
(See also Chapter 13.) Bleeding from the gums and the mouth in general can be a common symptom. The commonest cause is local inflammation caused by inadequate tooth-brushing—‘gingivitis’. However, gingival bleeding may be a marker of an underlying systemic disease and recognition of this fact is important for early diagnosis and management. Certain medical conditions and drugs are known to affect the gingivae. Where oral hygiene is very good consider these other causes. Rare causes include vitamin K deficiency and scurvy.
Often the cause of bleeding gums is obvious and easily treated. Treatment of infection involves removing the cause—either plaque in the case of gingivitis, or treatment of a dental infection (root canal therapy, extraction). The patient’s dentist can treat and advise on oral hygiene/arrange for the patient to see a hygienist.
The hormonal changes that are associated with pregnancy will reverse following delivery, but during the pregnancy excellent oral hygiene should be maintained. Local gingival bleeding may also be associated with a pregnancy epulis. This may need to be surgically removed if troublesome, although they usually regress after delivery.
Drug-related gingival bleeding must be managed in close association with the physician who prescribed the medication. Simply stopping any drug thought to be the cause of bleeding may have adverse effects that are potentially far worse for the patient. The degree of urgency in altering a prescription is related to the severity of gingival bleeding as well as the presence of bleeding from other sites (e.g. nasal mucosa and GI tract). In the case of some drugs, immediate reversal is possible (e.g. warfarin), whereas for others it is not.
Idiopathic thrombocytopenic purpura
This is thought to be an autoimmune disorder and probably the most common cause of thrombocytopenia. Close liaison with a haematologist is essential. Regional local anaesthetic blocks may be contra-indicated if the platelet count is <30 × 109/L. The vast majority of cases can be adequately managed by the administration of corticosteroids. If a major surgical procedure is required, platelet transfusions and/or the use of immunoglobulins may be necessary.
It is not uncommon for leukaemias, especially the acute types, to present with oral signs and symptoms. These include:
• Bleeding gums—a hyperplastic gingivitis (red, spongy, fragile gums), which bleed spontaneously.
• Infection—the gingivae are highly susceptible to infection. Secondary acute ulcerative gingivitis may be seen.
• Localized masses of leukaemic infiltrates.
• Candida/herpes simplex virus.
Occasionally persistent bleeding following minor injuries is the presenting sign of an underlying clotting disorder such as haemophilia. Bleeding sockets following dental extractions are rarely life-threatening. However, in the presence of significant co-morbid disease (e.g. in the elderly with poor cardiovascular reserve), a continually bleeding socket may quickly become a problem. You will need to decide whether it is sufficient to simply deal with the local problem, or whether it is necessary to investigate further.
Most cases need only simple reassurance and getting the patient to bite firmly on a clean handkerchief or gauze swab placed over the wound for at least 20 minutes. In the vast majority of cases bleeding settles and no further action is required other than care of the airway, if necessary using gentle suction. If bleeding persists, rinse the mouth out to clear any clots and look for the bleeding site. Depending on where the problem is this can be dealt with by further suturing or packing the wound with a haemostatic dressing, such as Surgicel®. Other measures include antifibrinolytic agents, such as tranexamic acid. Patients rarely need to go to theatre. If all else fails, patients need to be admitted for bed rest and investigations for bleeding disorders or liver disease.
(See Chapter 13.) Oral cancer is described elsewhere. Ulcers can occasionally bleed. Tumours invading bone can present with bleeding. Bleeding from the throat is a poor prognostic sign, indicating a deeply invasive cancer. These all need urgent referral.
Cutaneous sinuses and fistulae overlying the lower jaw
A sinus is an abnormal, blind-ending tract, opening onto an epithelial surface.
This is not restricted to skin only, but includes any epithelial surface, including mucosa (mouth, pharynx, anus, rectum, vagina, etc.), intestinal epithelium, bronchial epithelium, bladder epithelium, and so on. A fistula is an abnormal communication between two such epithelial surfaces. In the lower jaw the two most common causes of these are infection and tumour. Causes include:
• Dental abscesses
• Chronically infected dental root
• Chronic osteomyelitis
• Foreign body in the skin
• Ingrowing hair
• Infected osteosynthesis plate
• Necrotic lymph node
• Underlying tumour
• Furuncles and carbuncles
• Jaw cysts.
Clinically a sinus on the skin appears as a small opening, sometimes with surrounding induration. There is often a chronic discharge of pus from the sinus. A fistula may occur if the abscess drains both intra-orally and onto the skin. A microbiological swab should be taken from any discharge. If there is no obvious dental or jaw pathology, consider actinomycosis. Clinically, this is presents as ‘sulphur granules’ discharging onto the skin, although they are not always present.
Pain in the lower jaw
This is a short-lasting diffuse pain due to exposed dentine that is provoked by local stimuli (hot, cold, touch). The pain can be sharp or dull and is usually mild to moderate in intensity, lasting less than a second to minutes. Treatment is usually with a dressing or restoration and simple analgesics.
This is a pain due to inflammation of the dental pulp provoked by local stimuli. It can vary from a sharp, poorly localized, dull ache, to throbbing pain which can be severe. Pain can last minutes or hours, with episodes that may continue for several days. Treatment requires removal of the pulp or extraction of the tooth and analgesics (e.g. NSAIDs and paracetamol).
This is a severe throbbing pain in the tooth and jaw without major pathology. Often described as a severe continuous throbbing pain, it may vary from mild to intense pain, especially with hot or cold stimuli. It may be widespread or well localized and may move from tooth to tooth. It may last a few minutes to several hours. This is often a symptom of hypochondriacal psychosis or depression and there is often excessive concern with oral hygiene. Counselling, avoidance of unnecessary dental treatments or extractions, and sometimes antidepressants are required.
For these patients prevention is better than cure. NSAIDs are good for relieving bone pain. They may be given perioperatively as ‘pre-emptive’ analgesia and then continued postoperatively to minimize discomfort. Short-acting opioids, such as IV fentanyl, are commonly used for perioperative analgesia. Many analgesic regimens exist.
This is localized inflammation of the cortical bone of a socket following dental extraction, most commonly the lower wisdom teeth. Typically, the patient complains of severe dull throbbing pain, around 4–5 days after surgery and often has a bad taste in the mouth. Pain is often exquisite, with inflammation, exposed bone and halitosis. They are multiple predisposing factors:
• Mandibular extractions
• Difficult extraction
• Pre-existing infection
• Poor blood supply (e.g. Paget’s disease, following radiotherapy)
• Smoking—nicotine is a vasoconstrictor
• Systemic disorders (e.g. diabetes)
• Oral contraceptives.
Herpes zoster (shingles)
This is an acute herpetic infection in any dermatome, commonly the fifth (V) cranial nerve. Involvement of the lower jaw is unusual but can occur. It presents with burning and tingling pain in the skin with eruptions on the lower lip. Post-herpetic neuralgia is chronic pain with skin changes following acute herpes zoster. There may be a burning sensation or itching and crawling dysaesthesias in skin. In the acute phase, stellate ganglion blocks using local anaesthetic such as bupivacaine, may help for severe pain. Transcutaneous nerve stimulation (TENS), capsaicin cream, and tricyclic antidepressants are also useful.
Trigeminal neuralgia (‘tic douloureux’)
Trigeminal neuralgia is most commonly a disorder seen in middle-aged and elderly patients. It is more common in women with a peak incidence between 50 and 60 years of age. In young patients it may be an early feature of MS, HIV disease, or as a consequence of a lesion irritating the trigeminal nerve. Patients complain of a sharp, intense, lancing/‘electric-type’ pain induced by a specific trigger point that radiates across the distribution of a branch of the trigeminal nerve. The pain is almost always unilateral, with over 30–40% of patients showing a distribution affecting both the maxillary and mandibular divisions. In approximately 20% of patients, the pain is confined to the mandibular division, and the ophthalmic division in 3%. Episodes may last up to several hours. The aetiology of trigeminal neuralgia is presumed to be multifactorial, with local nerve microcompression within the skull base and possible demyelination.
• Always consider skull base pathology and intracranial disease/demyelination. Imaging may be required.
• The mainstay of treatment remains medical, typically with anticonvulsant agents. Usually, trigeminal neuralgia responds well to carbamazepine and/or amitriptyline, and a muscle relaxant such as baclofen. Carbamazepine remains the drug of choice with an initial regime of 100 mg three times daily being gradually increased to a maximum of 1200 mg daily titrated against effect. 20% of patients may develop side effects such as tremor, dizziness, double vision, and vomiting, which will obviously limit its use. They should have regular monitoring of FBC, electrolytes, and LFTs. Approximately 20% can develop folic acid deficiency with megaloblastic anaemia, and hyponatraemia in the elderly. Withdraw therapy slowly.
• Alternative agents include phenytoin, sodium valproate, lamotrigine, and baclofen.
• Local surgical procedures may be considered in trigeminal neuralgia not responsive to medical management. This can include cryotherapy to the nerve, alcohol/glycerol injections.
• Neurosurgical decompression in severe cases following imaging confirming there is nerve compression.
• Gamma Knife® (stereotactic radiosurgery). High-resolution imaging provides excellent definition and allows a focus beam of ionizing radiation to irradiate the proximal trigeminal nerve at its entry into the pons. Results are very promising (see http://www.gammaknife.org.uk).
Atypical facial pain
Atypical facial pain has many distinguishing features that make it a clinical entity in its own right and not just a ‘catch all’ diagnosis for seemingly unexplained facial pains. It is, however, essentially a diagnosis of exclusion that should only be made after all other possible organic causes have been excluded. These patients therefore often undergo extensive investigation.
Patients often have a ‘flat affect’ and the more they are questioned about the pain, the more vague their answers become. The pain is typically described as being a deep, dull ache, sometimes fluctuating, sometimes continuous, with intermittent severe episodes that the patient can find no causative factor for. Often the pain has been present for several years and analgesics rarely affect its nature. It is most commonly bilateral, but ill defined, and its distribution cannot be explained on an anatomical basis. The patient may say they are kept from sleeping by the pain but usually look well rested. When they do admit to sleeping, the pain does not wake them. A proportion of these patients may show symptoms of depressive illness or anxiety states, and patients often complain of other symptoms such as back and neck pain and irritable bowel syndrome. The patient’s mood often does not correlate to the description of their symptoms and they may show exaggerated responses to examination and report stressful life events.
Often the ill-defined nature of the patient’s pain results in unnecessary dental work being carried out. In light of the association of atypical facial pain with the neuroses (particularly depression), and the belief that it essentially has a psychogenic basis, emphasis has been placed on the use of antidepressant agents as the main treatment option:
• Dothiepin, a tricyclic antidepressant, has been shown to be effective in reducing the painful symptoms (as it has in TMJDS).
• Selective serotonin re-uptake inhibitors (SSRIs).
Salivary gland pathology can either be obstructive, infective, or neoplastic in origin. Regardless of the origin of the pathology salivary gland disease can present with swelling and pain around the lower jaw. This pain can mimic jaw pain because of the intimate relationship of the major salivary glands to the mandible.
Cystic lesions of the mandible
(See Chapter 11.) Cystic jaw lesions comprise an extremely varied group of conditions and to consider each individually is beyond the scope of this book. Slow-growing cysts can present with painless firm swellings of the jaw. But they can present acutely following infection. Oral bacteria gain access to the cavity and a superimposed infection arises. Larger cysts may also present with a pathological fracture. Malignant or invasive lesions can present with paraesthesia of the inferior alveolar nerve. Consequently the most likely presentation of cystic lesions in the emergency department will be pain and swelling.
Tumours of the mandible
Tumours of the mandible can be:
• Invasive tumours from oral mucosa squamous cell carcinomas
• Primary bone tumours
• Metastatic tumour.
Presentation can be varied. Swelling of the lower jaw and associated cervical lymphadenopathy will usually be present as these tend to be advanced by the time patients seek help. Pain, although not an initial feature, will become more significant as the disease progresses regardless of the type of tumour. Bony involvement may result in paraesthesia of the inferior alveolar nerve or pathological fracture. There is often some degree of trismus. Larger tumours will present with fistulae to the skin, bleeding and occasionally airway compromise. Urgent referral is then required for management of acute symptoms and further investigation (see http://bahno.org.uk/docs/head_and_neck_cancer.pdf).
In the emergency setting always be aware of the common causes of referred pain in the lower jaw. These include:
• Neoplasms of pharynx, nasopharynx, base of tongue
• Lesions of the ear and Eustachian tube
• Major salivary glands
• Intracranial lesions.
Giant cell arteritis
Patients can present with lower jaw pain and claudication of the muscles of mastication. This results from involvement of the maxillary artery. Diagnosis is histologically (biopsy of the superficial temporal artery) but this should not delay commencement of treatment with glucocorticoid steroids. Suspect in any elderly patient with a high ESR.
These are rare, accounting for <2% of all fractures of the mandible. They are defined as fractures that occur in regions where the bone has been weakened by an underlying pathological process. These include:
• Surgical interventions (third molar removal and implant placement)
• Large cystic lesions
• Benign, malignant, or metastatic tumours.
Treatment of pathological fractures can be challenging and complex. Diagnosis radiologically in the emergency setting then urgent referral is required.
Acute sickle cell
The most important pathological event of sickle cell anaemia is vascular occlusion resulting in ischaemia. Pain is typically disproportionately severe. Other sites may be affected. Patients presenting with a sickle cell crisis need IV fluids, analgesics, and oxygen to prevent further sickling of the cells. Although the pain may be in the mandible, this is a medical emergency, not a maxillofacial one.
Altered sensation of the lower lip
Patients who present acutely with a non-trauma-associated altered sensation of the lower lip need to be assessed carefully. Many of the serious conditions outlined previously in this chapter can be associated with numbness. These include:
• Cystic lesions
• Pathological fractures
• Paget’s disease
• Central haemangiomas/intraosseous AVM
• Iatrogenic injury.
All patients who present acutely with altered sensation of the lip following jaw surgery should have plain radiography to exclude a pathological fracture. Rarely, the ‘numb chin’ presentation can be a presentation of a paraneoplastic neurological disorder and can be associated with breast, ovarian, and lung cancer.