Article
FDS RCS parameters of care for patients undergoing third molar surgery
It is estimated that approximately half a million third molars are extracted every year in the UK (L McArdle, personal communication). In April 2020, Donnell and Clark in ‘Naughty or NICE?’1 highlighted a significant shortcoming of the 2000 NICE guidance on extraction of wisdom teeth: second molar caries.2 Previous papers report additional issues, including the impact of delayed surgery and resultant increased surgical morbidity.3
A health technology assessment was undertaken to review the NICE guidance published in 2020, concluding that ‘The evidence comparing the prophylactic removal of impacted mandibular third molars with retention and standard care is very limited. However, the results from an exploratory assessment group model, which uses available evidence on symptom development and extraction rates of retained impacted mandibular third molars, suggest that prophylactic removal may be the more cost-effective strategy’.4
On the 21st anniversary of NICE third molar guidance, the updated FDS RCS ‘Parameters of care for patients with third molar surgery’ was released.5 This work does not explicitly focus on the teeth, prophylaxis or cost implications, but rather on a holistic patient approach to risk assessment and optimal care. This multi-stakeholder work suggests strategy for not only interventional surgery (when needed), but therapeutic and prophylactic mandibular third molar extractions.
Guidance is provided for various interventions including the following:
It is hoped that these guidelines will promote optimal care for patients presenting with symptomatic or asymptomatic third molars and address the NICE guidance shortcomings.
Obesity: a problem getting bigger?
The obesity crisis within the UK has drawn large media coverage following the World Health Organization identifying the problem as a chronic disease.1 A range of comorbidities are often associated with the condition, including high blood pressure and diabetes. More recently, individuals with obesity have been shown to have poorer outcomes following COVID-19.2,3
Following the reduction in dental provision resulting from the lockdown period, many patients have required re-assessment for suitability for dental treatment, particularly conscious sedation. A recent departmental audit has highlighted a number of individuals with a BMI greater than 35 kg/m2, who prior to the lockdown period, were assessed as being suitable for dental-setting sedation. Assessment also highlighted other parameters of significance: hypertension or low oxygen saturations, along with anatomical complicating factors impacting airway management.3
Observation within the past year has highlighted an increased number of otherwise healthy and younger individuals who cannot be accommodated by a standard dental chair. The maximum weight for the vast majority of dental chairs is 140 kg (23 stones), therefore, consideration has been given to recording patient weight prior to undertaking dental work, especially for those exceeding safe chair limits. This, however, uncovers a further complicating factor: where can these patients receive care if they are unable to be safely accommodated in general practice? Referral of patients to secondary care services, whereby treatment can be undertaken safely in a bariatric chair or trolley is an option; however, this option is often limited and may add further pressure to hospital and community-based services.
Dental practitioners are accustomed to discussions offering healthy choices regarding sugar content, smoking cessation and alcohol advice, yet may feel less well versed in more sensitive discussions surrounding weight and implications for dental treatment. With a level of rapport often gained following higher-frequency visits, this poses the question of the dental team becoming gatekeepers to weight management services. Do we have a duty of care to liaise with our, often less well-visited, medical colleagues regarding our assessment findings? Training and policies based upon published guidance need to be put in place to support the dental team in such discussions.
Comment on the use of coronectomy to manage symptomatic mandibular third molars
The recent article on the use of coronectomy to manage symptomatic mandibular third molars1 provides a valuable addition to the limited literature on this procedure, which is gaining acceptance by clinicians. It is of particular interest to me because I use this technique when indicated, and have documented the follow-up of cases.
The article has provided a detailed review of indications, hazards and techniques with useful guidelines for decision making. I would like to add some experience with coronectomies in support of this paper.
The primary indication for coronectomy is to avoid inferior alveolar nerve injury; however, the procedure, which is technique sensitive, can introduce a risk of lingual nerve injury. As noted in the article, raising a lingual flap to protect the lingual nerve may itself introduce a risk. Using a careful technique, the known length of the bur serrations and the measured width of the tooth from the scans, can reduce the risk of lingual plate perforation and subsequent injury to the lingual nerve.2
Use of pre-operative antibiotics does not appear to improve the success rate of coronectomy.2,3
The remaining root fragment rarely becomes symptomatic. The fragment may migrate away from the inferior dental nerve so that the nerve becomes less vulnerable to injury should re-operation be required. Anatomical landmarks to remove the root fragment as mentioned are usually not significantly important because the fragment is, in most instances, mobile due to infection, which facilitates removal.4
Having prior consent for complete removal in case the coronectomy fails is essential.
Careful removal of additional root structure, below crestal level, following the initial oblique cut, is required to sufficiently submerge the root and allow primary closure. The benefits of guided bone regeneration will require further studies to establish.
The importance of good primary closure for the success of coronectomy should not be underestimated. This may require some modification in the form of sectioning of tooth below the CEJ and, in some cases, advancement of a buccal flap.2,4
My case studies have indicated that coronectomy can give excellent outcomes even for teeth with caries without pulpal involvement, teeth with pathological lesions, such as cysts, and also for patients with comorbidities, although more research in this area is required.4
The use of Alveogyl, or similar medications, should be avoided. Packing the socket to reduce post-operative pain may result in an unwanted reaction to the foreign body. The use of a mouthwash and analgesics are important in the post-operative phase. Rarely, oral antibiotics may be required.2
It will be valuable to see further research and publications in this area.
Comment on the check record
I would like to comment Patel and Walmsley's ‘The Check Record’.1 I believe that this technique is much underused when correcting an ICP/RCP discrepancy in complete dentures.
Articulating paper is not ideal when used intraorally in an edentulous patient. The dentures are often unstable and when the patient taps together a plethora of confusing and inaccurate ink marks are recorded on the occlusal surfaces. Articulating paper is far more accurate when the dentures are firmly secured after remounting on an articulator post check record.
The one issue I would like to draw to the attention of the authors and your readership is that if the check record inaccurately records centric relation, any adjustments will potentially further worsen the RCP/ICP relationship.
Figure 3 shows how this problem can occur. Unless the lower denture is firmly stabilized on the lower ridge, it will move, thus giving an inaccurate record. The image shows that the lower denture has not been securely located against the lower ridge as a clear gap can be seen between the denture and the underlying ridge. This is often caused because the clinician places excess force in a posterior direction, thus pushing the denture off the ridge.
Any force applied to the lower denture should be placed in the premolar region to optimize stability, and the thumbs should be placed beneath the chin to support the mandible
If clinicians are to incorporate this technique into their armamentarium, they must always check that the lower denture has no gap beneath it prior to sending the dentures to the lab.
Traumatic ulcerative granuloma with stromal eosinophilia
We would like to share some of the cases of traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) that have presented to our unit.
Literature review revealed that TUGSE is commonly seen on the tongue, gingivae and buccal mucosa, with a male: female ratio of 1:1. Patients are generally aged between 30 and 50 years. Trauma has been found to be the contributing factor in many cases.
TUGSE presents as an isolated ulcer with a firm indurated white or yellow base (Figure 1). Ulcers have a well-defined raised margin and history will reveal a rapid onset. The following differential diagnoses should be considered.
A biopsy is required for a definitive histopathological diagnosis.
Management includes extraction of the teeth causing the trauma and intralesional steroid injections for slow-healing ulcers. Rapid healing may be noticed following excisional or incisional biopsy (Figure 2). Aggressive surgical intervention is not usually required.
TUGSE is a chronic, benign, self-limiting lesion of the oral cavity. Its clinical appearance often resembles SCC of the mouth. Investigations in the form of incisional biopsy should be carried out to eliminate the possibility of malignancy.
Swallowed removable partial denture: a rare dental emergency
We report a dental emergency caused by the accidental ingestion of a foreign body – a rare event in general dental practice. A fit and healthy 52-year-old Indian woman was referred to us after she inadvertently swallowed her 10-year-old loose single-tooth lower removable partial denture (RPD) while drinking water by reclining her head backwards. She was able to swallow her saliva, but had a feeling of choking in the throat.
A lateral neck radiograph revealed a well-defined radiopacity in the tracheal lumen abutting the superior surface of thyroid cartilage at the C4 vertebral body impinging on the posterior wall of trachea, and confirmed the presence of a swallowed RPD (Figure 3). The patient was referred to the emergency unit where the tooth was retrieved following endoscopy. The patient's post-operative recovery was uneventful.
Swallowing a small one-tooth unilateral removable partial denture without cross-arch stabilization is hazardous,1,2 and in this case resulted in a potentially life-threatening emergency. Hence, the fabrication of such prostheses should be avoided.2 Whenever fabrication of an RPD is required, it should be designed to render it retentive and stable. A patient should be instructed on the importance of adherence to instructions for its use, life span and recall visits for denture maintenance to assess the retention of denture. Patients should be advised not to wear the denture at night.1
In cases of acrylic resin dental prostheses, it is advisable to use 40% poly-2,3-dibromopropylmethacrylate, added to the poly-methyl-methacrylate to render the denture base radiopaque.3
The aim of this letter was to report an avoidable dental emergency of a swallowed RPD in private dental practice as a result of drinking water by reclining her head backwards, a very common habit among Asians, especially Indians.
The Christian Dental Fellowship
These are, and have been, difficult times for the dental profession as a whole. Thankfully our mental health and wellbeing has been recognized as being equally important as our physical health and we are all encouraged to talk more.
So how is our physical, emotional, spiritual, mental health and wellbeing? Do we need to talk to someone about how we are feeling, about our concerns and worries? Would it help to talk to another dentist or DCP? In matters of faith and work, would it help to talk to a Christian Dental colleague?
There are many good listening and counselling services out there specifically for dentists and the dental profession to be recommended. In addition, the Christian Dental Fellowship has a pastoral care scheme, provided by dentists and DCPs, and while we are not a professional counselling and listening service, we are happy to listen to and talk with any member of the dental profession about any matter, and signpost, where appropriate, to other services. Prayer is optional, but we believe a problem or situation shared and prayed for is a powerful thing.
Enquirers don't need to be a member to access the scheme, and all enquiries are welcomed, dealt with in confidence and it is free to all.
The Christian Dental Fellowship is recognized as a faith group in the recently published Wellbeing Support for the Dental Team document. Any enquiries can be made to: cdfadmin@cdf-uk.org.
Todos Juntos: a paediatric dental charity
Todos Juntos is a small paediatric charity that provides free dental care and oral hygiene education to thousands of disadvantaged children living in the slums of Argentina's capital city, Buenos Aires. It is a non-profit organization with the principal aim of improving the daily living conditions and oral health of some of the most impoverished children. Usually, the charity would see 6000 children and provide 30,000 restorative dental treatments over two clinics each year, at no cost to patients. As a result of the coronavirus pandemic in 2020, all treatment stopped. The charity adapted to address the immediate needs of the most vulnerable families in their community, which would inevitably be affected by the pandemic. They supplied food for soup kitchens, blankets and other household essentials, as well as toothbrushes and toothpaste for families. Families are struggling in overcrowded homes where dental items are a cost most families cannot afford.
Children are the unseen victims of the pandemic. School closures, isolation and unsafe living environments are the secondary consequences affecting vulnerable children. These neglectful situations will negatively impact children's dental health, education and development.1 The pandemic has caused an increase in child poverty,2 which risks deepening previously existing inequalities.
There are no charities like Todos Juntos in the UK that provide free routine dental care exclusively to children. In comparison with Argentina, UK dentistry has a higher emphasis on prevention, for example published prevention guidance for dentists in the form of ‘Delivering Better Oral Health’.3 Like the UK, Argentina also offers free dental care; however, there are long waiting times, few health centres to access care and limited resources for children. Commonly, kids only visit the dentist when it is too late for restorative care, leaving only the solution of extractions. This is easily preventable with regular check-ups, good diet and oral hygiene.4,5
Todos Juntos combats this by providing not only free dental care to children, but the charity also works very hard with local families to instil the importance of oral hygiene. Children with poor oral hygiene leads to untreated decay and missing teeth, which decreases their quality of life.6,7 Now outdoor, educational diet and hygiene classes run alongside treatment at the clinics and in local schools in a new initiative called the ‘Brush behind the mask’ programme (Figure 4). Evidence also suggests that oral hygiene education in developing countries can substantially improve oral health to help prevent future health issues.8,9 At a time when access to dental care is even more difficult, and poverty levels are increasing, the importance of dental health prevention during this unusual time is of the utmost importance.
