Expanding horizons
We look at Specialist Level Oral Surgery in Primary Care, in association with Edinburgh Dental Specialists
In the realm of modern dentistry, collaboration and synergy between specialised expertise and general practitioners play a pivotal role in delivering comprehensive patient care.
The landscape of dentistry is evolving at a remarkable pace, driven by the pursuit of excellence and the desire to provide comprehensive care under one roof. Historically, certain dental procedures were seen as the exclusive domain of specialists due to their intricate nature and demanding skill sets.
However, we find ourselves in a transformative era where the boundaries between specialties are blurring, and increasingly dentists who would once have considered themselves general practitioners are acquiring and honing skills that were historically deemed to be exclusively specialist-level.
The complex landscape of advanced oral surgery is one that often demands a specialised touch.
Despite this, the spirit of collaboration and the symbiotic relationship between general practitioners and specialists remains as vibrant as ever and enriches the dental ecosystem, ensuring that patients benefit from a wide spectrum of expertise and experience.
The complex landscape of advanced oral surgery is one however that often demands a specialised touch. The route to this level of care for patients has traditionally been through referral to consultant-led secondary care centres, but here at Edinburgh Dental Specialists we are tackling intricate surgical cases with our specialist skillset in primary care, providing patients with an alternative often more timely option.
Wisdom teeth
Wisdom teeth come in all shapes and sizes, and there are certainly some wisdom teeth which are more than ably taken out by general practitioner colleagues on a daily basis, according to their personal skill set, comfort and experience.
If not already aware, there are some excellent Faculty of Dental Surgery guidelines published in 2020 which provide general practitioners and specialists alike with sensible advice regarding when to remove wisdom teeth and when to monitor them.1
Wisdom teeth that are probably best tackled by a specialist include those that sit close to the inferior dental alveolar nerve. There are seven or eight signs to look for on plain film radiographs that suggest the nerve may be in contact with the tooth root.2,3
Cysts
Sometimes high-risk wisdom teeth are associated with pathological lesions such as cysts. In this case a 46-year-old female was referred with a swelling arising from around her unerupted lower right wisdom tooth. She remembered that she had previously had a CBCT in 2007 and recalled being told that the tooth was a “nightmare” case for the nerve.
Clinical examination revealed a fluctuant swelling distal to the second molar, and a new CBCT confirmed a complex and high-risk relationship of the tooth and nerve, with the nerve running directly between three curved roots, along with a large radiolucency arising from the CEJ of the tooth.
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- Figure 1: 3D reconstruction of CBCT showing the nerve running through the LR8 roots.
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- Figure 3: Sagittal slice of CBCT showing position of nerve next to LR8 roots and yellow arrow showing extent of cystic lesion.
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- Figure 3: Sagittal slice of CBCT showing position of nerve next to LR8 roots and yellow arrow showing extent of cystic lesion.
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- Figure 2: Axial slice of CBCT showing position of nerve between three LR8 roots and yellow arrow showing the cystic lesion.
The lower right wisdom tooth was surgically divided under 5.0x magnification, and all three roots successfully removed. The nerve was visible in the socket running in between the mesiobuccal and lingual root sockets; exposed but intact.
All surgical patients at EDS are contacted by telephone the day after surgery, and this established that she had no lingering altered sensation to her lower lip or chin. The histopathological diagnosis was confirmed as a dentigerous cyst. The patient was reviewed 6 months later to ensure there was evidence of bony healing.
Sedation
Often more complex oral surgery patients require an extra level of anxiety management in the form of intravenous sedation with midazolam. Our well-established protocol allows us to comfortably undertake procedures such as removal of all four wisdom teeth, or complex surgery such as that already described, on those patients who require this extra level of care.
Of course, any anxious patient no matter how straightforward the extraction or procedure is offered intravenous sedation as an option for their treatment. Our sedation-trained oral surgeons also regularly work as a team with their other surgical colleagues to provide longer sedations for more complex work such as full arch implant cases.
Multi-disciplinary team
At Edinburgh Dental Specialists, our strength is in our team of specialists and the collaboration and collective wisdom that our team brings to your patients. They are of course supported by our wonderful patient care co-ordinators, dental nurses, LDU practitioners, typists, practice management team and highly experienced and skilled onsite dental laboratory.
Working together and with the wider team, our specialists navigate complex and challenging cases, striving to find comprehensive treatment strategies that are as predictable, long-lasting and cost-effective as possible. In this environment, the boundaries of innovation are pushed, and patients emerge as the ultimate beneficiaries.
We endeavour to extend this multi-disciplinary team to our dental colleagues in general practice through our tele-dentist service and our regular study evenings.
If you have a patient and you are not sure how best to manage them, then please send your questions or queries in to us via tele-dentist@edinburghdentist.com and it will be forwarded to the most appropriate specialist for their opinion.
Our regular study evenings also offer you high-quality CPD, and a chance to pick the brains of our specialists in person. Both our tele-dentist service and our study evenings are free of charge.
Upcoming development opportunity
Should you wish to learn more about how to successfully manage the basics of oral surgery in primary care, then our next ‘Oral Surgery for the GDP’ course is running and available to book for the 1 and 2 December 2023.
This is a small course with limited spaces, providing hands-on practice on models and pig‘s heads alongside comprehensive theory on common oral surgery presentations and complications you might see in general practice.
Please contact Gemma Grant (email) for more information, oral surgery mentoring in your own practice can also be arranged.
References
- Renton, T, Coulthard P et al. (2020). Parameters of care for patients undergoing mandibular third molar surgery. Produced by Faculty of Dental Surgery.
- Rood JP, Shehab BA. (1990) The radiological prediction of inferior alveolar nerve injury during third molar surgery. Br J Oral Maxillofac Surg. 28(1):20-5.
- Renton, Tara. (2009). Prevention of Iatrogenic Inferior Alveolar Nerve Injuries in Relation to Dental Procedures. Dental Update. 37. 350-2, 354.
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