From Volume 47, Issue 11, December 2020 | Pages 924-926
Challenges arose in ascertaining accurate diagnoses for patients via remote phone triage during the COVID-19 crisis in 2020. We report on a case that highlights possible pitfalls in remote consultation versus chairside contact in making clinical diagnoses and illustrates a complication that may arise in orthodontic patients who have not been seen for an extended period of time.
A myriad of factors make accurate diagnosis of dental pain challenging. The practitioner is reliant on a thorough history and clinical examination, supplemented by appropriate special tests, including radiographic investigations, to establish the correct diagnosis and treatment plan.
The ability to differentiate between pain from odontogenic and non-odontogenic origins can be complicated in situations where patients present with non-specific symptoms and unclear clinical findings. This is further complicated when remote consultation is required instead of contemporaneous clinical examination.
The SARS-CoV-2 (‘COVID-19’) pandemic led to a ‘lockdown’ in the United Kingdom from 23rd March 2020. An aspect of lockdown was that practice of dentistry was limited due to a multitude of factors including the requirement for social distancing, the aerosol-generating procedure (AGP) nature of most dental procedures and lack of appropriate PPE, to name but a few reasons. Remote consultations were arranged for emergency patients over the phone by the patient's dental practice or by an urgent treatment centre, such as a dental hospital, where patients could be assessed if advice, analgesia and remote antibiotic prescription had been previously ineffective.1
Patients may be unable to voice their dental issue during remote telephone consultations if the cause is not obvious. A statement such as a ‘broken tooth with a gumboil above it, painful especially on biting’ is sufficiently descriptive for the practitioner to make a diagnosis with a degree of certainty, and confidently determine appropriate management compared to a vaguer statement. Remote consultation is further complicated if the triaging practitioner has no prior records or information about the patient to hand as the patient may be registered elsewhere for their routine dental care.
The following case was managed in accordance with COVID-19 management protocol (Standard Operating Procedure) established at Birmingham Dental Hospital at the start of the pandemic; however, the final diagnosis was made only when the patient was physically seen. The reason for the patient's pain was unexpected. This case highlights the importance of thorough clinical examination and appropriate special investigations to arrive at an accurate diagnosis and subsequent management of dental pain.
The patient was a 60 year old woman who initially had a phone consultation with a triaging clinician at Birmingham Dental Hospital (BDH) (her nearest UDC) owing to persistent pain present around the upper left quadrant. Symptoms had been ongoing for around 2 months and had not changed in nature. The patient was originally managed by her general dental practitioner (GDP) who, in accordance with national and local policy at the time, had prescribed two courses of oral antibiotics for suspected apical pathology of an associated tooth.1 The antibiotics had been ineffective and the pain had remained following completion of the course. The patient was subsequently referred and presented to BDH's phone triage via the Urgent Hub pathway, which involved the GDP sending an email referral to the Urgent Hub email account, which was then assessed and booked in for a callback by a triaging clinician at BDH.
Further discussion with the patient over the phone revealed a vague pain history for which there was no report of sleep disturbance from the pain, or pain specifically being elicited on biting or with hot, cold or sweet stimuli. This suggested the cause of her symptoms to be of non-odontogenic origin. The patient specifically mentioned that she had been unable to open her mouth as normal due to discomfort felt around her left cheek over the previous 2 months, but had still been able to function otherwise. Over-the-counter topical anaesthetic preparations had provided some relief. She also did not report any swelling or other such features associated with the area and she mentioned that she was currently undergoing fixed orthodontic appliance therapy under private contract.
The patient's medical history was unremarkable, with no reported medical conditions, no allergies, and a statin for cholesterol management reported as the only regular medication taken. The patient was a non-smoker and drank alcohol socially. She was a regular attender with her GDP.
The patient was accepted for assessment at the Primary Care (Emergency) Department at Birmingham Dental Hospital. Local protocol involved the patient coming in alone, having confirmed no COVID-19 symptoms. Only panoramic views were available; PA views were not available at that time given their aerosol-generating risk and the higher risk of salivary transmission. Once the radiograph was completed, the patient was then consulted over a webcam system by the emergency department practitioner.
The sectional dental pantomograph (Figure 1) revealed that the maxillary orthodontic archwire was displaced by 3 cm past the anterior margin of the left ramus, which indicated it was buried into the soft tissues, accounting for the given history. It was clear at this point, that the current pain diagnosis was of non-odontogenic origin, namely wire dislodgement and penetration into the infra-temporal tissues. This corresponded with the symptoms already described by the patient.
Extra-oral examination revealed that there was no trismus and no obvious swelling visible. Poorly localised discomfort on mouth opening was reported. Intra-oral examination revealed the patient's maxillary orthodontic archwire to have slipped three units to the left and was buried within soft tissue as seen in Figure 2. The upper right molar brackets were unsupported as a result.
Arrangements were made for an orthodontist colleague to reposition the archwire back to the original position and ensure it was secured by cinching the ends of the wire. The patient reported relief of her discomfort almost immediately.
Orthodontic wire-induced trauma is often limited to superficial soft tissue abrasion and ulceration.2 This degree of wire displacement can be considered a rare occurrence, especially considering the lack of previously reported cases in the literature.
There were no signs of infection, which may have been managed by the antibiotics prescribed (albeit for an entirely different suspected reason) and no significant haematoma. Had the wire fractured within this region, removal may have been complex, often mandating removal via an intra-oral approach,3 which poses significant surgical challenges and risks.4
This case is a rare presentation of a dental emergency of orthodontic origin, whose diagnosis and management was complicated by restrictions of dental practice at the time. Thorough history taking is clearly paramount in all cases, in conjunction with an analytical diagnostic process. Above all, this report highlights the importance of thinking laterally and considering all possibilities of diagnosis, including suspecting the very unlikely, and the importance of the clinical examination.
