REFREC015
ORAL MAXILLO FACIAL SURGERY REFERRAL RECOMMENDATIONS
Diagnosis / Symptomatology
General problems include:



Soft tissue conditions of the face
and oral cavity
Teeth, gums and associated
conditions
Trauma facial bones
Last updated February 2006
Evaluation
Management Options
Referral Guidelines
Thorough history and physical
examination is required for determining
the diagnosis. All case histories
should include alcohol and tobacco
use, drug and allergy history.
Specific treatments depend on specific
problem identified as below.
Most OFM surgical diagnoses require
referral for specialist management.
However, these guidelines are
provided (below) to give greater clarity
in situations of the primary/secondary
interface of care. Clearly, telephone/
fax/e-mail communication would
enhance appropriate treatment.
Cross-reference to Hospital Dental
Surgery Referral Recommendations is
also advised.
A special needs benefit is available for
patients who have acute dental needs
and have a Community Services Card.
Access to dental services for holders of
Health Care Cards is through the
Suburban Dental Health Clinics or
O.H.C.W.A.,Monash Ave. Nedlands.
Page 1 of 9
REFREC015
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Soft tissue conditions of the face and oral cavity
Congenital
Infective
Salivary Gland Infection:
Sialadenitis/Sialoithiasis
Standard history and examination:

Radiographs.

Comment on bite, status of teeth
and gum disease.

Comment on jaw opening
(Trismus).

Presence of lymphadenopathy.

Associated neurological
abnormality.
Standard history and examination:

Radiographs.

Comment on bite, status of teeth
and gum disease.

Comment on jaw opening
(Trismus).

Presence of lymphadenopathy.

Associated neurological
abnormality.
1.
2.
3.
4.
5.
Last updated February 2006
Assess hydration of patient.
Palpate floor of mouth for stones.
Observe for purulent discharge
from salivary duct when palpating
gland.
Evaluate mass for swelling,
tenderness and inflammation.
Serum amylase.
Referral of suspected congenital
conditions should be made to dentists
or secondary service in the first
instance.
Tongue tie with reducing functional
impairment should be referred for
further treatment. Referral within the
first twelve months of life is preferable
to late referral – Category 3.
Refer to local dentist for consideration
for treatment.
(See Infective – Teeth and Associated
Conditions.) Developing dental
infections can very quickly become
serious and life threatening with airway
obstruction the main sequel. Early
referral to Dental services can prevent
major, expensive management.
1.
Otolaryngology – referral indicated for:
1. Poor antibiotic response within
one week of diagnosis.
2. Calculi suspected on examination,
x-ray or ultrasound.
3. Abscess formation.
4. Recurrent sialadenitis.
5. Hard mass present – neoplasm?
Culture of purulent discharge in
mouth.
2. Hydration.
3. Occlusal view x-ray of floor of
mouth for calculi.
4. Anti-staphylococcal antibiotics:
Augmentin, Ceclor.
5. Ultrasound or sialogram.
(Sialogram in absence of infection
or when cleared up with
antibiotics.)
Treat with antibiotics (penicillin and
flucloxacillin) for four days.
If no response, refer to OMF or
General Surgery Service – Category 2.
Limited eye opening, facial swelling,
increasing pain, trismus, dysphagia,
Page 2 of 9
REFREC015
should be referred urgently to the OMF
Service for surgical management, IV
antibiotics etc – Category 2.
Facial Trauma, eg Lacerations
Lumps and Suspected Neoplasms
Standard plus radiology.
Oral cavity: small lacerations leave.
Contaminated lacerations, suggest
broad spectrum antibiotics.
-0.2% Chlorhexidine mouthwash.
Minor: managed by GP, eg
debridement and suture. Consider
Tetanus prophylaxis and antibiotics.
Consider biopsy if skilled.
Significant injury should be referred to
Secondary Hospital Service –
Category 1.
Refer suspected malignancy to
Hospital ENT/OMF/ Plastics/General
Surgery, depending on local practice –
Category 2.
Refer to pathology lab for FNA.
Ulcers.
Refer to patient’s dentist in the first
instance for assessment for local
causes and treatment.

Topical anaesthetic paste and 0.2%
Chlorhexidine mouthwash may assist
comfort and healing – leave out
dentures.
Traumatic Ulcers.
Larger and contaminated lacerations,
refer to Hospital Service – Category 2.
Refer to OMF service or Oral Medicine
specialist if no improvement after 2
weeks.
These should heal within 10 days. If
not, biopsy.

Autoimmune.
Tend to be on unattached mucosa,
occur singularly or as a couple and are
larger than herpes (up to 10mm). May
take 14 days to heal. Often on soft
palate, ventral surface of tongue/floor
of mouth and lips.
Corticosteroid spray or paste (Kenalog
in Orabase).

Infectious/viral.
Herpes appear in clusters and on
attached gingiva, have small white
centre and with erythematous halo.
Usually on palate and gums.
Acyclovir ointment at first sign of
vesicles.

Malignant.
Often painless, unhealing ulcer, rolled
margins, firm. Usually occur on lateral
margin of tongue. Cervical
History of tobacco and alcohol abuse,
sharp teeth or dentures. Non healing
tooth extraction socket.
Last updated February 2006
Refer to OMF – Category 2.
Page 3 of 9
REFREC015
lymphadenopathy??

Dermatological disorders (eg
Lichen Planus).
(See Hospital Dental Surgery
Referral Recommendations for
“white patches”.)
Last updated February 2006
Treat painful ulcerations within these
white patches with Kenalog in
Orabase. Persistent ulcerations are
suspicious as malignant transformation
can occur in any white, red or blue
patch.
Seek advice from Dermatologist/OMF
or Hospital Dental Service.
Page 4 of 9
REFREC015
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Teeth, gums and associated conditions
Congenital
Standard history and examination:
 Radiographs.
 Vitality tests if done.
 Comment on bite, status of teeth
and gum disease.
 Comment on jaw opening
(Trismus).
 Presence of lymphadenopathy.
 Associated neurological
abnormality.
Refer to local dentist for consideration
for treatment or possible referral.
Children over 12 months who have not
developed teeth should be referred to
a dentist.
Presence of additional teeth preventing
eruption, cysts and other pathologies
should be referred to the OMF service
if local skills are not available.
Infective
Standard history and examination:
 Radiographs.
 Vitality tests if done.
 Comment on bite, status of teeth
and gum disease.
 Comment on jaw opening
(Trismus).
 Presence of lymphadenopathy.
 Associated neurological
abnormality.
Refer to local dentist for consideration
for treatment. This may include:
No improvement after 48 hours’ dental
management, refer to OMF.
Patients with limited eye opening,
facial swelling, increasing pain,
trismus, dysphagia, should be referred
urgently to the OMF Service for
surgical management, IV antibiotics
etc. Signs of severe infection, refer
immediately to OMF Service (or local
General Surgery Service, if available).
Standard history and examination:
 Radiographs.
 Vitality tests if done.
 Comment on bite, status of teeth
and gum disease.
 Comment on jaw opening
(Trismus).
 Presence of lymphadenopathy.
 Associated neurological
abnormality.
Retrieve and save lost tooth and
replace in socket if possible or place in
milk. Significant dental fragments
should be retained.
Traumatic
Last updated February 2006

Drainage – through tooth or soft
tissue or extraction.
 Antibiotics (Penicillin/
Erythromycin) for two days and
referral to local dentist.
Note: If a GP prescribes antibiotics
for an infective dental condition,
he/she must refer to dentist, or in
the case of children, refer to a
dental therapist or school dental
service.

Traumatic teeth injuries should be
referred to the dentist.

Refer to Hospital OMFS Services
with other suspected associated
injuries:
– Large lacerations.
– Associated jaw fractures.
– Significant behavioural
problems.
All Category 1.
Page 5 of 9
REFREC015
Lumps and Suspected Neoplasms
Standard history and examination:
 Radiographs.
 Vitality tests if done.
 Comment on bite, status of teeth
and gum disease.
 Comment on jaw opening
(Trismus).
 Presence of lymphadenopathy.
 Associated neurological
abnormality.
Lumps and suspected neoplasms
should be referred to the OMFS
Service.
See CPAC.
NB: Long term unhealing extraction
socket, suspect malignancy.
Gum Disease
Last updated February 2006
Standard history and examination:
 Radiographs.
 Vitality tests if done.
 Comment on bite, status of teeth
and gum disease.
 Comment on jaw opening
(Trismus).
 Presence of lymphadenopathy.
 Associated neurological
abnormality.
Teeth to be cleansed, chlorhexidine
mouthwash (Savacol) and consider
antibiotic.
Patients with Gum Disease: Refer
Dentist or Dental Hospital Clinic.
Page 6 of 9
REFREC015
Diagnosis / Symptomatology
Evaluation
Management Options
Referral Guidelines
Trauma Facial Bones
Mandible
Standard history and examination.
Radiographs including OPG.
Comment on:
 Mal-occlusion.
 Swelling.
 Trismus – ability to open mouth.
 Sensory loss.
 Lacerations soft tissue and gums.
Refer to specialist Oral and
Maxillofacial surgeon or Hospital
Dental Service.
Displaced fractures with mobility.
Refer immediately – Category 1.
Undisplaced, non-mobile fractures.
Refer within 24 hours – Category 1.
Zygoma
Standard history and examination:
Radiographs – Occipito-mental 15,
30, 45 views,C.T. Comment on:
 Swelling around eye.
 Numbness over cheek.
 Bony steps around orbit.
 Bony protrusion intra-orally.
 Trismus.
 Limited eye movements.
 Bleeding in conjunctiva and sclera.
Refer to Specialist Oral and
Maxillofacial Surgeon.
History and examination.
Assess airway patency and maintain.
Check for cervical spine injury.
Check for any lost teeth.
Assess neurological status
Radiographs including Occipitomental
15, 30, 45 views.
CT scans if available.
Comment on:
 Malocclusion.
 Movement of upper jaw.
 Movement at bridge of nose.
 Bony steps around orbits.
 Diplopia.
History and examination.
Refer to base hospital immediately –
Category 1.
Midface, ie Le Fort, I, II, III
Cysts, lumps and suspected
Last updated February 2006
Displaced fractures – Refer 12-24
hours. Eye closed – refer immediately.
Undisplaced fractures – refer within 72
hours – all Category 1.
Attempt aspiration if fluctuant.
Urgent referral within 24 hours –
Page 7 of 9
REFREC015
neoplasms affecting jaws
Radiographs including local teeth
periapicals and O.P.G..
Comment on:
 Swelling of jaw buccal and/or
lingual.
 Hard bony expansion.
 Loss of lip sensation.
 Tooth mobility.
 Fluctuation.
 Unhealing ulceration.
 Change of bony density on
radiographs.
Diagnostic, FNAB.
Category 2.
Infective processes of the jaws
History and examination.
Radiographs including .O.P.G.
Comment on:
 Acute/chronic pain.
 Tender to palpation.
 Red, hot, swollen.
 Trismus.
 Malaise.
 Degree of dysphagia.
 Tongue swelling and decreasing
mobility.Hard swelling floor of
mouth.
Airway threatened – establish and refer
immediately.

Urgent referral to Oral and
Maxillofacial Surgeon or General
Surgeon – Category 2.
Commence IV antibiotics.
 Penicillin Q6h 1g IV.
 Flucloxicillin Q6h 1g IV.
 Analgesia – avoid NSAIDs.
 Metronidazole 500mg IV tds.

Acute and chronic infections –
refer within 24 hours.
Degenerative conditions affecting the
jaws.
a. Degenerative joint disease, ie
TMJ Arthritides.
History and examination.
Radiographs including O.P.G.,C.T.
Comment on:
 Trismus.
 Joint pain with radiographic
evidence of bone destruction.
 Hot, tender swelling over joint.
 Clicking or grating of jaw joint.
 Pain on chewing or opening wide
NSAIDs for analgesia, soft diet.
Limit mouth opening.
Moist heat for joint and associated
musculature.
Refer to Oral and Maxillofacial
Surgeon within 7-10 days – Category
2.
b.
History and examination.
Radiographs including O.P.G.
Comment on:
 Loose dentures.
 Painful ulcers under dentures.
 Large mucosal growths under

Leave dentures out as much as
possible.
Refer to General Dental Practitioner –
Category 4.

Soft diet.

Topical analgesics.

Treat oral thrush if present.
Alveolar Ridge Resorption.
Atrophy of jaws.
Last updated February 2006
Page 8 of 9
REFREC015

denture.
Oral thrush.
Chronic Osteomyelitis
History and examination.
Radiographs including OPG.
Comment on:
 Pain.
 Constant discharge despite
antibiotics.Skin sinus.
 Radiographic lucency, pathological
#.
 PH radiotherapy (ORN)





Degenerative – Xerostomia (Dry
Mouth)
Patient complains of dry,
uncomfortable mouth with difficulty with
speech and swallowing.
Consider role of existing medication in
producing xerostomia.
Sugar free chewing gum.
Artificial saliva.
Trial with pilocarpine – it is important to
measure salivary flow prior to trial.
Condition may be isolated or
associated with rheumatic disease, eg
Sjogrens or PH radiotherapy to
jaws/neck. Medicines,dry mouth more
common in older age group.
Last updated February 2006
Culture pus.?Actinomycosis.
Antibiotics.
Chlorhexidine Mouthwash.
Analgesia.
Soft diet.
Refer to Specialist Oral Maxillofacial
Surgeon – Category 3.
Refer to OMF or Hospital Dental
Service – Category 4.
Page 9 of 9