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So for those of you who weren't here last week, my name is Jan B. I'm a Maxx specialty doctor, uh having done dentistry and medicine. Um and this is just an introductory introductory series on max FX conditions aimed at doctors who are working either in or primary care or just generally those who don't have a dental degree. Um So the last session was on facial injuries. Today, we're gonna talk about the next most common presentation that I think you'll see which is infections and we're gonna do kind of a tour on all the different kinds of orofacial infections that you can see and kind of how you can deal with them and when to refer appropriately. So we'll go through some basic dental and facial anatomy first, go through how to take a more focused history, um how to do a proper examination, any investigations that we may need management and then we'll go through different causes of orofacial infections and just say what the specific management for all of them are and um how you can know when you need to refer and when you don't need to refer. Ok, perfect. So, orofacial infections frequently present to the ed and to the GP practices. And as I mentioned in my last lecture, this is getting more common because it's really difficult as everyone probably knows to find an NHS dentist. Um And therefore people are accessing what they can more frequently, which is GP practices than A&E unfortunately, because people are not going to the dentist as often. It means that also teeth are not as good as they once were. And unfortunately, we are seeing this more and more especially after COVID and everything. The reason it's really important is to make sure that people get prompt treatment. Obviously, things that are treated earlier with all infections, less likely to lead to severe complications and specifically with the head and neck region. It's really important that we diagnose and treat these promptly because the proximity to the airway, kind of the swallowing difficulties, the eye, there are loads of different important structures on the face. Um and infection can spread really quickly and we'll come on to why that is as well. So this is a cross section of someone's mouth. So you can see the top teeth and the bottom teeth here. And really what this was meant to show you is that the head and neck have so many multiple communicating spaces and pathways. So infection can spread really rapidly. Um So if you look, this is the top tooth, this is the maxilla, bottom tooth and mandible. And as you can see if you had an infection in the bottom tooth. For example, there are so many places that it can spread and all of these spaces are also interconnected. So it's very easy. Even if infection gets to one place, it doesn't stay there, it can really rapidly progress. Most often we see infections that spread to either the buccal space, which is kind of this area here. So just on the outside of the cheek. So they'd present with a fat cheek, the buccal sulcus. So that's before the buccinator muscle over here. So what happens is they present with the swelling inside their mouth and worryingly for bottom teeth, they can also spread to the sublingual and submandibular spaces, which is this bit with the floor of mouth and this area. These are quite worrying because they can lead to airway issues as you can appreciate. If you to, if you get swollen at the bottom of your mouth, your tongue rises up and you can't breathe, you can't swallow, it can have really severe consequences. So just briefly, some dental anatomy, I assume most of you in medical school don't get taught much about anything dental, which is in a way that the dentists are for. But I think it's good to have a basic understanding. So dental decay initially starts out in the outside layer of the tooth, which is the enamel. Normally, no one gets any symptoms at this point. That's why we say everyone should go to the dentist regularly to stop it from spreading. Um, but it can be a little dark mark or a brown spot. Once the uh decay spreads, it goes to the denti into the inside. That's when people start getting some sensitivity, a little bit of um sensitivity to cold or sweat, things like that again, it's not that obvious. So by the time it spreads far enough to the pulp, which is the bit inside the tooth and that's the bit with the blood vessels and the nerves. And that's when people start getting really bad pain. And I'm sure you've all understood, all heard of the dental pain is the worst pain you'll ever have. And the reason is once infection spreads to the pulp of the tooth where the nerves are, the tooth is a very enclosed space. There's nowhere for that pressure to go. So all that pressure builds up and it's incredibly, incredibly painful. Once that infection goes down the tooth, it gets to the bottom of the tooth. And that's when you get an abscess because there's nowhere else for the pus to go. So it goes all the way to the bottom and it starts spreading at the roots of the teeth. Now, this shows up on an X ray or something as a kind of a dark area because it's where it's eating away at the bone and it's all like a pus filled area. And that's the point where most people, the pain becomes so unbearable that they have to seek help. But we in theory want to stop it before we even get to that stage. But I'm thinking probably most of you won't see people until they get an abscess. So just basically the, the teeth, I'm sure most of, you know, you have incisors, canines, premolars and then molars, um the teeth are divided into four quadrants. Um You have your upper right, upper left, lower, left and lower right, and then they're numbered from the middle backwards, 1234, all the way to eight, which is your wisdom tooth. Um And then you the normal, normal way to say it is you say upper right, two upper right seven and then that locates the tooth for you. It's not that important for you guys, but it's just interesting to know if you ever see any documentation and it's also a lot easier to communicate with dentists, which is the problem too. So in terms of history, the most important thing as you guys, I'm sure all know is to take a proper pain history. Um You can use obviously Socrates as we're all taught. So if we think about the site, most dental pain is kind of well localized, but it's very hard to tell exactly which tooth, it is. All the nerves in the head and neck are really closely linked. So sometimes they can't tell the difference between top and bottom or if it's their first molar or second molar, but the dental pain should never cross the midline because the nerves obviously come from different sides. So if this pain ever crosses the midline, then you know that it's something maybe to be a bit more worried about or just think that something's not quite right onset. So normally most patients, if you ask them, they'll say, oh, I've had some dental pain on and off for the last few months. It's very unlikely if it's dental related that they'll say suddenly it just hurt me. They will have had some sort of history of something going on beforehand and then suddenly it blows up character. So knowing whether it's sharp, dull, persistent, um, is it, does it come and go, um, how we, how does it feel for the patient? Radiations? Often these things are so painful, it causes headaches, things like that associated symptoms. So, this is really important for uh, any infections in the facial area. So, do they have any, um, history of swelling? Do they feel generally unwell or feverish? Do they have any difficulties or pain, breathing or swallowing? And that's really key. Have they had any changes to their voice again, that can show spread to the throat? And, um, have they had also any recent dental treatment? So, have they been to the dentist recently? Had a filling? And unfortunately it hasn't worked time again. Similar. We need to have a proper uh uh history exacerbating or relieving factors. So often with people who have an abscess, they'll say the pain is a lot worse when they bite and that's really common or when they're eating or they'll say it's with hot, cold, sweet foods. And that's really key because if it's something else, for example, a salivary gland swelling, then often it's worse when they eat, but not when they bite. So it's really important that we differentiate between the, what's causing the pain. I mean, lastly severity, I'm sure most people with dental pain will say it's incredibly painful. The last thing is of course to have full medical larking. But it's also really important to take a thorough medical history and check other any signs of immunocompromise. So this includes diabetics, people on chemotherapy, just generally immunocompromised people mainly because um this can lead to really uncontrolled infections. And often we see a lot of patients who come with dental abscesses and the first time they're diagnosed with diabetes is actually because of that. It's also interesting to ask, have they had abscesses in their mouth before it just shows you maybe poorly kept uh teeth, maybe a fear of the dentist. Sometimes it's the same abscess, they've burst it, they've left it alone and then it comes back obviously, because we haven't got rid of the source of the pain. So in terms of examination, the best thing to do is start from extraorally and then go inside the mouth. So, extraorally, it's important to check the actual swelling, obviously. Where is it the size of it? And the fluctuant, if the swelling is incredibly hard, it shows it's more likely that there is a collection there of pus that needs to be drained. And antibiotics may not work if it's incredibly soft and not that severe in size, then often just some oral antibiotics will get rid of it. Is there any sign of erythema or spreading cellulitis? Can the patient swallow their own saliva or is there any drooling? And I think we've all seen that picture of a patient leaning forwards because they can't breathe lying back. That's obviously an incredibly concerning sign. Another thing to check is the patient's mouth opening and we should record that in millimeters. So normally normal mouth opening is between say 30 to 50 millimeters. But sometimes like with the talk we gave last week with the facial injuries, it can be limited by either structural things. So if they have an abscess that's pressing on a muscle, or it could just be due to severe pain check for any cervical lymphadenopathy. And the most important question to ask, especially with lower swellings is can you palpate the lower border of the mandible? If you can't palpate the lower border of the mandible? Then it shows that basically that the infection is submandibular or sublingual. And that's more concerning than say, a buccal infection because it can't, it it doesn't tend to affect your breathing because if you can't palpate this bit, the lower border of your mandible and it's submandibular, it can quite easily cause problems with breathing and of swallowing. Next, we move on to inside the mouth. So, intraoral, so the most important thing to check again with the breathing and swallowing is to look under the tongue at the floor of the mouth. Is it raised? Is it firm? Is there any way that the tongue is kind of gone upwards? And these are all obviously concerning features are the teeth tender to percussion. If you remember from, if I go back, if there's an abscess at the bottom, if you touch the tooth, it will be acutely painful. So that's really interesting to see which tooth it is actually that's hurting them. Are there any intraoral swellings next to any of the teeth? And that can obviously be an abscess. Is there any obvious decay or gum disease? So if you see a massive hole in the tooth really red or inflamed gums, anything like that, any loose teeth? Which could again, if your abscess got bad enough, then the bone supporting the tooth goes become very wobbly. And finally, the last thing to check is sometimes these um infections can spread to the pharyngeal area. It's rare but it can happen and often this is missed because it's all the way at the back and it's something to be really careful of So if you just use a tongue depressor, put the tongue down, just get them to say, ah, just check that there's symmetry in that area. Again, this is just to show you that the mouth has loads of different areas. And it's worth looking at all of them to check. Most commonly infections cause swelling in kind of the buccal sulcus. So, here at number 10, but it's important to check the whole floor of mouth to check. There's no swelling, check that they have free movement of their tongue. And this was where I was saying the pharyngeal area here just check that there is symmetry. If it get, if it gets really swollen, it can obstruct your airway again as well. So investigations, I think you've obviously all seen loads of different infections. Um but it's important to do bedside observations. So uh check for tachycardia or fever. Basically, we wanna check if the patient isn't septic, then this can happen really easily with these infections. It's also worth sometimes checking a blood glucose. Like I said, sometimes patients who are non, not known diabetics are actually diabetic in terms of blood tests. It's important to do a VBG to check for lactate, then FBC CRP S using these normal things, blood cultures, if they're hemodynamically unstable and if you do see any pus draining from it anyway, if it's inside the mouth, outside the mouth or wherever, it's worth just taking a swab of it and sending it for microbiology testing. So in terms of imaging, the most common thing we would do is do an OP G and orthopantogram, which is a machine that goes around your head and it creates a, I'll show you a picture in a second two D picture of your teeth. If there's any concern about airway compromise, not knowing exactly where the infection is or, you know, they're going for surgery and they need it for surgical planning because they're so significantly swollen, it's worth doing a ct neck or facial bones to check exactly which space the swelling is in. That means if they go for surgery, they can know exactly which space to access. If it's a salivary gland swelling, you can get act, but they're not often not as sensitive, it's better to sometimes get an ultrasound. But of course, this is a little bit more difficult in hours. So this is an OP G of a patient. I don't know if anyone can let message on the chat if they can see where there is any problems or um, any abscess or decay. Um, the thing to remember is uh in these kind of things. So metal fillings come up incredibly white. So all the really white areas are all metal fillings. So if anyone can message where they can see maybe an abscess or something that doesn't look quite right. Um That would be great. It's like any normal x-ray, the left side of the image is the right side of the patient. Um And yeah, if you can just generally see where something is happening, I'll give you guys a minute. I know it's tricky because you're not often taught how to read these kind of x rays. I'll give you guys another few seconds to have a good look. Although if someone just puts it in the message box, if not, I'll just let you know where it is. So there's obviously a big hole in that teeth. You can see it's not as radioopaque as the rest of the teeth. Um And also you can see at the bottom at the roots, this darkening, that means that there's an abscess that so pus has built up. Yeah, exactly. So it would be the s uh six. So the right upper six, so well done. Uh nausea. That's really good. So it's 123456. So this is the central incisor. It's a bit, I think it's hard to tell because it's the center is really off place. So I understand why you say five. But uh yeah, it's 123456. And you can see this darkening here shows that there's an abscess forming and it's eating away at the bone and that's gonna be really acutely painful. And here's another one, there's a few different things going on here. But if you could see where the really obvious abscess is and pop it on the chat. That would be great. And this is really helpful, especially if you have swellings in the mouth and you're not sure. Are they dental? Do they need to go to Max Vax? Do they need to go to Ent, where do they need to go? If you just do one of these x rays you can easily see. Oh, there's an abscess that you know, that it's probably for the dentist to have a look at, I'll give you guys a few seconds to look at this. There are a few things going on here, but there should be some obvious abscess. So we can see there are a few retained roots. So basically, that means the decay is so bad that it's eaten the crown of the root away and it's only the bottom bit remaining. And you can see here this dark area and this dark area under this tooth as well shows that there's abscesses forming in these areas. So sometimes you can see this like for example, this retained root doesn't have a dark area. So it might be painful, but it probably doesn't have an abscess. Whereas these dark areas show that the infection has spread to the bone. And as I said before, lower teeth are more worrying because they can spread the infection really easily. So the immediate management is similar to any sort of infection that we see any kind of pneumonia, anything like that. So if the patient is septic and dehydrated fluid resuscitation. Um, obviously gives some good analgesia. Um IV paracetamol if they need it some Oramorph and if they can have it, um some ibuprofen is normally best because if it's a nonsteroidal um anti-inflammatory, it really works well on in tooth pain because it's inflammation that's causing the pain often works even better than morphine stat dose of some IV antibiotics if they're really unwell. So normally we go for Coamoxiclav, but if they're pen allergic, then Clarithromycin, it's worth checking micro guide obviously. But this is normally what most trusts recommend if there are any signs of airway compromise or you think there's impending airway compromise. If they're really swollen, like under the neck or um at the bottom of the jaw or their floor of mouth is a little bit firm or raised, then give some stat IV dexamethasone as well. So you can either give 6.6 or 8 mg if you think that they might need surgery worth keeping them nil by mouth. So we can go to theaters as soon as possible. And then if needed, obviously refer to Maxx or to a local dentist. If the swelling is not bad enough, we'll come on to it. But you can refer to dentists out of hours in emergency dentists. They normally work during day hours weekdays and some weekends and they can get through to a dentist by just calling 111 and getting, hopefully getting an appointment. But as you all know, the state of dentistry is pretty poor right now. So we'll go on to the different types of infection now. Um and just stop me if you have any questions at this point or later on because it's obviously a lot of new information. So, dentoalveolar infections are anything that affects the teeth and the gums, they're often caused by either tooth decay or gum disease. Now, you'll see that most patients have such horrendous teeth, they have decay everywhere, but you can see like dark areas, holes in the teeth, the gums are really inflamed, they're bleeding, anything like that shows that there's some signs of infection there. As I said before, painful teeth on gentle pressing and the patient will often be able to say this is that is the truth that's hurting me when you press it. They might have fullness in the sulcus like here. For example, that shows that the infection has spread to just the inside of the mouth. They might have restriction of mouth opening. And like I said, that's normally either because of severe pain or because the infection is pressing on a muscle or it's near a muscle. The swelling is normally either submandibular. So under the neck, submental under the chin buckle and that's when people get a fat cheek canine space is just here. So it's above your upper canine and that can cause um impingement of your eye. So if it's spreading and it's closing the eye that's also really important to keep in mind. And like I said before, it can track parapharyngeal as well and that can cause some real issues with the airway. So what's the management in the emergency department or in primary care? And I'll try, there's obviously no set rules about what you do for patients and it's very patient dependent. It's very um kind of hospital driven services driven, things like that. But this is kind of how I could do it basically for you. So if the patient is systemically, well, no signs of any sepsis, their blood, the inflammatory markers are probably likely to be raised but not so badly raised and they have no or mild swelling. Um even if they have really mild extra or swelling, but it's really soft, doesn't look too bad. Then normally they can have some oral antibiotics or either some amoxicillin or Coamoxiclav or a Clarithromycin, a pen allergic and then referral to an emergency dentist. So they can get that through one on one or if they have a dentist themselves. If there is swelling inside the mouth in the sulcus next to the causing tooth, then you can either send them to a dentist or to refer to max bags for incision and drainage under local anesthetic. And this can normally be done just in the A&E department. It just gets rid of that pressure and you get immediate relief. They then need either IV or oral antibiotics, depending on how unwell they are. Normally just some oral antibiotics and they all need to go to a dentist. So even after you deal with the abscess itself, we can't take out teeth in emergent in an emergency department in hospitals. So the tooth either needs to be taken out or they need to have a root canal. So they need to go to a dentist to get that done. If they have a really large firm, extra oral swelling, they're septic, they're immunocompromised in some way. Then it needs urgent Maxx review for IV antibiotics. Then either incision and drainage under local anesthetic or often if they're that large, then it needs to be done under general anesthetic. If they have a very large swelling on the outside of their face, then often they need to have a cut done on the outside of their face to allow all the pus to drain out. If there is any difficulty in breathing significant submandibular or submental swelling, especially if it's crossing the midline or causing a raised floor of mouth, then you need both an urgent max fax review or if you don't have max fax in your hospital, then ent and an urgent anesthetic review because these people, their airway can go like that. So as long as they're reviewed, um and people are aware also, they need to be kept in a kind of monitored environment in A&E they can't be kept kind of in minors or in the waiting room, someone needs to be watching them or they need to have someone with them because they can kick off really, really rapidly. And these people often need are the ones that need to have urgent, urgent surgery. So this is what we're most worried about. Something called Ludwig's Angina. So this is when there's acute floor of mouth cellulitis, which leads to a bilateral infection of the submandibular submental spaces. And it's a significant airway risk. You can see on this patient, he's got significant submandibular swelling. His tongue is raised, looks like he can't really close his mouth very well because of the swelling. Um And these ones need urgent urgent anesthetic review. If you can imagine if your tongue gets too high, you can't get oral tube in even. And these patients sometimes require tracheostomies to get it in. And it's very hard tracheostomies because they've got such significant neck swelling, signs of impending airway obstruction, uh a raised floor of mouth drooling, difficulty swallowing and a hoarse voice. And these are the people you need to be really worried about. Next, we're gonna go on to another source of infection. This is more common in kind of people in their late teens, early twenties and it's due to the, it's called something called pericoronitis. It's related to your normally your lower wisdom teeth. And I'm sure you've all seen or heard of people where your wisdom teeth only comes half out. It takes ages to come out. It's really painful. Often you can get infection of the gum tissue around the wisdom teeth. So these people don't normally have any swelling. They have no swelling, but they have s significant pain and it's often due to food trapping there. These people because it's a more anaerobic environment are given oral metroNIDAZOLE and are told that they need to frequently clean and clean and wash the area to prevent food trapping and they need to go to a dentist to maybe have the wisdom tooth taken out. So, next, we'll go on to salivary gland infections, um or sialadenitis, these are usually caused by a stone that obstructs the salivary gland and we'll talk more about stones in the next presentation. Um It's more common in the parotid gland than the submandibular and then quite, quite rare in the sublingual clinical features of salivary gland infection. So they have a painful swelling over the gland. So either over the parotid or submandibular and this is where the history is really important because if you have a swelling, obviously in the cheek over the parotid, it's hard to tell. Is it from tooth or is it from salivary gland? They often have overlying erythema and they have something called mealtime syndrome. So it's when the pain is a lot worse when you're eating or drinking. And basically, the reason is normally if you have a blockage or you have inflammation of your salivary gland, then when you eat or drink, they trigger saliva production and that saliva has nowhere to go. So you suddenly get excruciating pain that then relieves itself. Often you can get pus that's draining from the salivary gland duct. And I'll show you a picture of that in a sec and check for sle lymphadenopathy. These people obviously don't have any dental pain and that's a really easy way to differentiate the cause of it. And these, the infections are either dealt with by ent or by max. So management is again, analgesia a pus swab if they're expressing any, the best thing to do is actually to massage the gland, try to get the saliva out. Um You can also tell them to have kind of sour foods and that encourages so much saliva production if they have a stone that's blocking their duct, that will flush it out antibiotics. And if systemically unwell, they'll need admission for an incision and drainage. Long term, these patients either need to have the stone removed and maybe the gland as well. So as you can see here, that's the opening of your parotid duct and it's just in your cheek, near your upper teeth and you can see there's some pus coming out of there. So that's obvious um parotid gland infection. This again is a swelling of the parotid gland. You can see it's a little bit more posterior than a dental swelling would be, which would be here and it goes all the way behind the ear because the parotid spreads over there. And this is just showing a sub uh mandibular duct with an obvious stone in it. And then obviously, you can say straight away, that's the source of the infection. So next will come on to skin cysts. So it's normally due to an infected sebaceous cyst that someone comes. Obviously, there are skin cysts that we don't worry about because they're not infected. And that's just if someone has some swelling, they need to be removed at some point, but they're not an emergency, but often these can get infected. Um And that's when they become really, really painful because again, it's similar to teeth when you have pus that builds up in your face anywhere on the skin, there's nowhere for that to go and the pressure just becomes unbearable. They can be found in any hair bearing region of the body. But often we see these in kind of men with beards who shave and things like that. So, again, history is really important. So is there a spot that they might have squeezed or was there an ingrown hair? Was there a previously painless lump or just a cyst? But it's now acutely painful when you see these, they're quite obvious they're warm, tender erythematous and they're normally very fluctuant because there's a lot of pus underneath. They can sometimes have a punctum visible as well. And that's where the pus is trying to escape. So it's like just like a big spot really. So management. So if it's fluctuant and amenable, then we try to drain this under local anesthetic in A&E um which is normally done by either max fax or depending on where it is obviously, uh can be done by any surgeon. They're then given either oral or IV antibiotics and normally flu cloxacillin because it's a skin infection, then sometimes the this because the cyst is still there. It might need to be excised in 4 to 6 weeks after, especially if people keep getting recurrent abscesses in the area, the way we drain it under local anesthetic and Ed is the same as any abscess. If we give some local anesthetic, a little nick on the face wherever it is just near the punctum and you just flush and squeeze all the pus out. And I'm sure we've all seen videos of that being done and that's a really obvious spa cyst. You can see it's got a punctum where the pus is coming out. Uh But you can see by this location as well, it's very difficult to sometimes tell what the cause of the infection is. Is it dental? Is it salivary gland, is it skin? But the history is really key in differentiating that. So, in conclusion, when seeing patients in the emergency department with facial swelling, it's really important to keep out the signs of imminent airway compromise. So that any swellings that cross the midline hoarse voice, inability to swallow your own saliva or drooling. A raised floor of mouth, a protruding tongue or dysphagia or pain or difficulty in swallowing. Um And then there's just some references and if I would be very grateful if people could uh give some feedback and hopefully meal will send you an email anyway. Um And then if anyone has any questions, so it's a very quick presentation this one. So I don't want it, it's really difficult to know until you've seen loads of swellings what to do. Majority of swellings you see, especially in GP practices are things that just need oral antibiotics and they just need to go see a dentist and then you can just direct them call NHS 111, try to get an emergency dental appointment. Um The ones that are really concerning, obviously, they're really obvious when you see them. It's really scary when you see it the first time. Um But hopefully most of these people either come blue lighted to A&E or they're already there or something. So it's, and you've got all the support there. Um Yeah, so if anyone has any questions, if you just write in the messages and I'll try to answer them as best as I can. Um But yeah, the important thing is just to really know how to take a proper history for these patients, knowing who to refer to how to refer. I think if you're ever in doubt, just either ask a senior or just call Max Vax, they're really helpful just to give them a little bit of history and if you know exactly what you're looking at, obviously it's a lot easier. Um, so yeah, if you have any questions at all, just pop it in the chat. Um, and I'll try to answer them as best as I can. I'll give you guys a few minutes. Um But in the meantime, I would say thank you for watching. We've got our last session for our mini Max Vax series on Wednesday. Um and that's just covering everything we haven't covered. So we've covered the main things last week which were facial trauma infections today, but everything else is on Wednesday. Um And it's really important because I think people are seeing more and more of these um in hospitals and GP practices. Like I said, last time, if anyone's interested in getting learning more about Max as a career or just a specialty, then feel free to just email me um the mind of your email address or ask any questions and hopefully you'll be happy to answer them. I'll give you guys a few minutes if you have any questions, try to share my screen. Ok? I think there's no questions. So I think we'll end it there. I'll hang around for a few minutes just in case someone thinks of anything but otherwise hope to see you all on Wednesday for the last session and if you could please fill out some feedback just so we know how to improve these sessions, that would be really helpful. Ok, perfect. Have a good evening. Everyone. Take care. Bye.