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Orofacial Disease: Update for the Clinical Team: 9.

CRISPIAN SCULLY AND STEPHEN PORTER

acute sinusitis a cold is often followed by Abstract: Orofacial pain, the main reason why many patients seek dental advice, usually has local pain and tenderness (but not a local cause—primarily the sequelae of dental caries—but a wide range of diseases, particularly neurological, psychogenic and vascular disorders, can cause orofacial pain. This swelling) and radio-opacity of the article will discuss disorders that can present with pain and the neurological, psychogenic and affected sinuses, sometimes with an vascular causes of orofacial pain. obvious fluid level. Pain may be The first article in this series made several general observations on diagnosis and treatment aggravated by change of position of the which should be borne in mind in relation to the material presented here. head. With maxillary sinusitis, pain may be felt in related upper molars, which Dent Update 1999; 26: 410-417 may be tender to percussion. The pain of Clinical relevance: Orofacial pain is the main presenting complaint of many patients. ethmoidal or sphenoidal sinusitis is deep in the root of the nose. Tumours can also cause orofacial pain by infiltrating branches of the trigeminal nerve.

rofacial pain is the main reason palpation via the external auditory O why many patients seek dental meatus. When acutely inflamed, the Eyes advice. This usually has a local cause, joint may appear swollen and warm to Disorders of refraction, retrobulbar neuritis mainly the sequelae of dental caries. touch. A splinting protective mechanism or glaucoma can cause pain, which may However, a wide range of diseases, by the masticatory muscles may result in radiate to the orbit or frontal region. particularly neurological, psychogenic and muscle spasm, producing secondary vascular disorders, can cause orofacial pain and . pain (these are summarized in Table 1). Ears Middle-ear disease may cause Salivary Glands . LOCAL CAUSES Pain from the salivary glands is localized, may be quite severe and may be intensified by increased saliva production Local causes: such as occurs before and with meals. The Various orofacial lesions Pain from the temporomandibular joint affected gland may be swollen and tender Neurological disorders: Trigeminal may result from dysfunction, acute to palpation. In acute , mouth Malignant neoplasms involving the inflammation, trauma, and, rarely, opening causes severe pain and thus some trigeminal nerve primary or secondary malignant tumours trismus, and there may be fever and Glossopharyngeal neuralgia Herpes zoster (including post-herpetic or can be referred. It is usually malaise. Salivary flow from the affected neuralgia) intensified by movement of the gland is usually reduced. In children, the Psychogenic causes: ; the joint may be tender to most common cause of salivary pain is and other oral symptoms . In adults, pain from salivary Vascular disorders: glands results usually from blockage of a Migraine Crispian Scully, PhD, MD, MDS, FDS RCPS, salivary duct by calculus or a mucus plug. Migrainous neuralgia FFD RCSI, FDS RCS, FDS RCSE, FRCPath, Giant cell arteritis FMedSci, Professor, and Stephen Porter, PhD, Referred pain: MD, FDS RCSE, FDS RCS, Professor, Eastman Angina, nasopharyngeal, ocular and aural Dental Institute for Oral Health Care Sciences Sinuses and disease and International Centre for Excellence in Disease of the paranasal sinuses and Chest disease (rare) Dentistry, University of London. nasopharynx can cause orofacial pain. In Table 1. Causes of orofacial pain.

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trigeminal region; nor are other Dental surgeon Ancillary, Hygienist, Nurse neurological abnormalities present. Refer to specialist. Understand disease and Understand disease and management in or der to Neurological assessment is needed management in order to extend education extend education of, and reassure, patient because similar pain is secondary to of, and reassure, patient , tumours, Alert specialist to any possible adverse Oral health education of patient neurosyphilis, HIV and other effects of treatment lesions.

Oral healthcare; in particular to avoid Avoid any trigger zones causes of pain Diagnosis and Management Patients with trigeminal neuralgia are Oral health education of patient Alert dental surgeon to any changes, or possible adverse effects of treatment ideally seen at an early stage by a specialist in order to confirm the Avoid any trigger zones diagnosis and initiate treatment (Tables

Avoid drug interactions with carbamazepine 2 and 3). or other agents Medical treatment, typically using , is successful for most Table 2. Roles of the dental clinical team in the management of a patient with trigeminal neuralgia. patients. Carbamazepine (Tegretol) is still the main agent used. It must be given continuously prophylactically for Neck atherosclerotic blood vessel pressing on long periods. However, it is not an Neck pain, usually from cervical the roots of the trigeminal nerve. and, if given when an attack spondylosis, occasionally causes pain to starts, will not relieve the pain. be referred to the face. Clinical Features Carbamazepine must be used carefully Trigeminal neuralgia has the following and under strict medical surveillance main characteristics. because it can have a range of adverse NEUROLOGICAL CAUSES Pain which is: effects, particularly affecting balance, Sensory innervation of the mouth, face blood cells, blood pressure and liver and scalp depends on the trigeminal ● severe; function. Typically, the dose is increased nerve, and disease affecting this nerve ● of abrupt onset and termination; to try to control the pain while at the can cause orofacial pain or sensory ● electric shock-like, brief, stabbing same time trying to avoid ataxia and loss—or, indeed, both. (lancinating); other adverse effects. If carbamazepine Severe orofacial pain suggestive of ● unilateral; fails, phenytoin or baclofen or other trigeminal neuralgia but with physical ● restricted to the trigeminal nerve drugs are occasionally useful. signs such as facial sensory or motor distribution. If medical treatment fails or the impairment can result from: adverse drug effects are too pronounced, The pain usually involves the surgery may be required. Injections of ● cerebrovascular disease; mandibular and, rarely, the other local analgesic will temporarily block ● multiple sclerosis; divisions of the trigeminal nerve. the pain. Local cryosurgery to the ● such as HIV; or In some patients the pain is triggered. ● neoplasms. The trigger site may bear no relation to the painful area, but is always ipsilateral to the pain. Patients do not necessarily Neuralgia with no ● This is an uncommon disorder recognize the trigger for what it is, and ● The cause is unknown but involves Apparent Organic Cause may find that pain is brought on by spontaneous activity of pain ner ves Such conditions have many names: chewing, talking, swallowing, smiling or ● It is not inherited ● It is not known to be infectious idiopathic trigeminal neuralgia, temperature change—usually exposure ● Similar symptoms may be seen in some trigeminal neuralgia, benign paroxysmal to cold air. neurological conditions (which we will trigeminal neuralgia, tic doloureux. Pain-free Intervals Between Attacks exclude) ● There are usually no long-term Trigeminal neuralgia is the most This is often an intermittent disease, consequences common neurological cause of orofacial with apparent remissions for months or ● X-rays and blood tests may be required pain. It is, however, rare and seen years. However, recurrence is common. ● Symptoms may be controlled but not cured by drugs with an mainly in middle-aged or older patients. Very often the pain spreads to involve a action wider area over time and the intervals ● Uncontrolled pain may be treated by Aetiology between episodes tend to shorten. freezing the nerve, or by surgery The cause is unclear, but trigeminal Lack of Neurological Abnormality Table 3. Patient information sheet: trigeminal neuralgia may be due to an There is no sensory loss in the neuralgia.

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trigeminal nerve branches involved PSYCHOGENIC CAUSES OF OROFACIAL PAIN ● This is fairly common (cryoanalgesia) can produce analgesia ● The cause is not completely known without permanent anaesthesia, but the ● It is not inherited ● benefit can usually be measured only in It may be caused by increased nerve Tension Headaches sensitivity months rather than years. ● There may be a background of stress For intractable cases neurosurgery, Tension headaches are not uncommon ● There are usually no serious long-term such as destruction of the trigeminal stress-related pains in the forehead, temple consequences ● X-rays and blood tests may be required ganglion (radiofrequency ganglionolysis) and/or neck, seen mainly in young adults. ● Treatment takes time and patience; some or decompression of the trigeminal nerve, nerve-calming drugs can help Aetiology may be required. Unfortunately, pain is Table 5. Patient information sheet: atypical exchanged for anaesthesia and risk of Tension headaches are caused by or facial pain. damage to the cornea and, occasionally, stress-induced muscle tension, presumably continuous anaesthesia but with pain because the accumulation of metabolites in (anaesthesia dolorosa). the tense muscles produces pain. individual, and disorders of structures such as the , teeth, and oral Clinical Features mucosa can hold enormous emotional Glossopharyngeal The pain affects the upper face (frontal or significance. It may be for these reasons, Neuralgia temporal muscles) or neck (occipital therefore, that there are a range of types Glossopharyngeal neuralgia affecting the muscles), and not the mouth. Typically it of orofacial pain for which an organic throat and ear is much less common than is felt as a constant ache or band-like cause cannot be identified even with trigeminal neuralgia but the pain is pressure, often worsening towards the sophisticated modern techniques, and similar, and typically triggered by evening. However, tension headaches do which are thought to have a psychogenic swallowing or coughing. Occasionally it not waken the patient in the night. basis. It must be stressed that such a is secondary to a tumour. Carbamazepine diagnosis should be made only where is used but adequate relief of pain can be Management there has been very careful exclusion of difficult to obtain. Reassurance may be effective, but the pain organic disease. may be helped by relaxation or Psychogenic orofacial pain can be seen such as a little alcohol or benzodiazepines. in: Herpetic and Post-herpetic A change to a more relaxed lifestyle may Neuralgia be indicated. ● normal persons under stress; Herpes zoster () is often ● people with a personality trait, such preceded and accompanied by as hypochrondriasis; neuralgia, and post-herpetic neuralgia Psychogenic Orofacial Pains ● neurotic, often depressed persons; can cause a continuous burning pain ● psychotic patients. that may be so intolerable that the Aetiology patient contemplates suicide. Specialist The mouth is concerned intimately with Clinical Features advice is required. the psychological development of the The following features are common to patients suffering psychogenic oral pains: Dental surgeon Ancillary, Hygienist, Nurse ● the pain is chronic; Understand disease and management in Understand disease and management in ● the pain is often of a constant dull order to extend education of, and reassure, order to extend education of, and reassure, patient patient boring or burning type; ● there may be ill-defined localization; Exclude organic causes of pain. Oral health education of patient ● the symptoms do not waken the Initiate treatment with or Alert dental surgeon to any changes, or possible patient from sleep; refer to specialist adverse effects of treatment ● objective signs and all investigations are negative; Be alert to any possible adverse effects of ● treatment the patient often appears otherwise quite well; Oral healthcare; in particular to avoid causes ● adverse life-events, such as of pain and unnecessar y operative intervention bereavement or family illness, may precede the onset of pain; Oral health education of patient ● multiple oral complaints, such as dry Avoid drug interactions with tricyclic or other mouth or bad taste, are common; agents ● other psychogenic related complaints, such as headaches, chronic back Table 4. Roles of the dental clinical team in the management of a patient with atypical orofacial pain.

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● Denture problems exodontia have been attempted, in ● Deficiencies of vitamins B, folic acid or vain. iron ● Mucosal disorders: Management migrans () Attempts at relieving pain by restorative treatment, endodontia or exodontia are Infections (candidosis) ● Diabetes mellitus usually unsuccessful but the patient may ● blame the dental surgeon for the problem. ● Psychogenic: The dental team can help in several ways, Cancerophobia particularly by offering reassurance Anxiety states (Table 4), but many patients need to see a specialist for psychiatric assessment. ● Drugs Patients must be kept informed about the Table 6. Causes of burning mouth. condition (Table 5). Some patients respond to antidepressants such as Figure 1. Oral dysaesthesia: the tongue often looks normal. dothiepin, but others refuse psychiatric help or . pains, or dysmenorrhoea, are common; Aetiology ● few of those affected seem to try or Burning Mouth The condition may result from restricted persist in using ; This condition is also known as tongue space from poor denture ● many patients are middle-aged, glossopyrosis, glossodynia, oral construction, or parafunction such as often older women; dysaesthesia. It is a common chronic tongue-thrusting, in about 50% of cases. ● cure is unlikely; complaint, seen especially in middle- A psychogenic cause such as anxiety, ● multiple consultations are common. aged or elderly women, who typically depression or cancerophobia is present in complain of a burning sensation in the about 20%. Systemic problems such as a Management tongue. haematological deficiency state are found Many patients need to see a specialist because psychiatric assessment may be helpful. Some patients respond to antidepressants such as dothiepin, but Type Symptom pattern Other features others refuse psychiatric help or 1 No BMS on waking, but increases during the day Unremitting medication. 2 BMS on waking and through the day Unremitting

Atypical Facial Pain 3 No regular pattern May remit This term is given to the chronic Table 7. Types of (BMS). orofacial pain seen mainly in older women, for which no organic cause can Dental surgeon Ancillary, Hygienist, Nurse be found. Understand condition and management in Understand condition and management in order to extend education of, and reassure, order to extend education of, and reassure, Aetiology patient patient

Over 50% of such patients are Exclude organic disease Oral health education of patient depressed or hypochondriacal, and some have lost or been separated from parents Initiate treatment or refer to specialist Alert dental surgeon to any changes, or possible adverse effects of treatment in childhood. Many lack insight and will persist in blaming organic diseases for Be alert to any possible adverse effects of their pain. treatment Oral healthcare; in particular to avoid causes of Clinical Features pain. Treat any candidosis. Features in addition to those mentioned Oral health education of patient above include the following: Avoid drug interactions with tricyclic or other ● a dull, continuous ache; agents ● pain is usually in the upper jaw; Table 8. Roles of the dental clinical team in the management of a patient with burning mouth ● often restorative procedures and/or syndrome.

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migrans (geographic tongue), candidosis ● ● This is a common condition This is a common condition ● ● The cause is not usually known but it or lichen planus (these conditions were It seems to be related to stress, damage may be a nerve hypersensitivity described fully in article 6 of this series: or habits involving the teeth and joints ● ● It is not inherited It is not inherited Dent Update 1999; 26: 254-259). ● ● It is not infectious There are no serious long-term ● It may occasionally be caused by some Laboratory screening for anaemia, a consequences: does not result ● mouth conditions, deficiencies, diabetes vitamin or iron deficiency ( blood tests), The symptoms usually clear or drugs spontaneously after some months diabetes (blood and urine analyses), ● ● It has no long-term consequences Various treatments such as rest, ● Blood tests or biopsy may be required xerostomia (salivary flow rates) or exercises, drugs, splints, or adjustments ● Burning mouth syndrome may be candidosis (oral rinse) may be indicated, to the teeth may help controlled by some nerve-calming drugs as may psychogenic assessment, and thus Table 11. Patient information sheet: TMPD. Table 9. Patient information sheet: burning specialist referral may be warranted. mouth syndrome. Reassurance, and occasionally psychiatric care, are indicated (Tables 8 and 9). ● habits; or in about 30% of patients. Denture allergy ● stress. is remarkably rare (Table 6). Temporomandibular Pain- In any event, the underlying cause of Clinical Features Dysfunction Syndrome discomfort appears to be muscle tension The burning sensation is usually bilateral Temporomandibular pain-dysfunction and an ischaemic type of pain. and often relieved by eating and drinking, syndrome (TMPD; also called in contrast to pain caused by organic myofascial pain-dysfunction or facial Clinical Features lesions which is typically made worse by arthromyalgia) is the term given to TMPD refers to any or all of the triad of: food. Burning mouth ‘syndrome’ most symptoms such as discomfort, limited frequently affects the tongue. It may also opening and/or click related to the ● pain (typically mild and dull and affect the and, less commonly, the temporomandibular joint. It is seen over one side of the face or joint but lips or lower alveolus. There are no mainly in young adult women in whom can radiate elsewhere); clinically detectable signs of mucosal no organic cause can be reliably ● limitation of jaw opening (jaw disease (Figure 1). Three types have been identified. opening is not always limited but in described (see Table 7): type 2 is most some there may even be locking); and common, type 3 least common. Aetiology ● clicking from the temporomandibular The cause is not clear and has been joint (clicking or crepitus may be Diagnosis and Management variously attributed to: heard on opening or closing the Oral examination is important to exclude mouth). organic causes of discomfort such as ● trauma; deficiency states, , erythema ● occlusal abnormalities; There appear to be no long-term sequelae to TMPD such as arthritis.

Diagnosis and Management Dental surgeon Ancillary, Hygienist, Nurse (Tables 10 and 11)

Understand condition and management in Understand condition and management in In all cases, organic disease must first order to extend education of, and reassure, order to extend education of, and reassure, be carefully excluded: similar patient patient manifestations have been seen in Exclude organic disease Oral health education of patient, in particular malignant disease, for example. There to avoid parafunctional habits is no defined treatment, and therapies range from rest through to the use of Initiate treatment. Construct occlusal splints, Alert dental surgeon to any changes, or and undertake occlusal rehabilitation as indicated. possible adverse effects of treatment anxiolytics, antidepressants, analgesics, exercises, short-wave Be alert to any possible adverse effects of diathermy and even , treatment lasers or surgery. Oral healthcare; in particular to avoid causes of In the absence of any evidence that pain or occlusal disharmony intervention is indicated or Oral health education of patient significantly effective, it seems prudent to counsel rest, and possibly use an Avoid drug interactions with tricyclic or other occlusal splint at night in the first agents instance. Certainly most patients Table 10. Roles of the dental clinical team in the management of a patient with TMPD. respond well to this regimen.

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Dental Periodontal Mucosal Salivary Neuralgic Vascular TMPD Psychogenic glands

Site Mouth, ear, Tooth Mucosa Area of gland Nerve Orbit or Temple, ear, Diffuse, deep, jaws, cheek distribution upper face jaws, teeth sometimes across midline

Localization Poor, diffuse, Good Usually Usually Good Usually Poor, but Poor radiating, good good good usually does not unilateral cross midline

Duration Seconds to Hours to Hours to Hours to Seconds Minutes Weeks to Weeks to days days days days to hours years years

Character Intermittent, Steady, boring Burning or Drawing, Lancinating, Throbbing, Dull, Dull, boring, of pain sharp, sharp pulling paroxysmal deep continuous continuous paroxysmal

Precipitating Heat and Chewing Sour and Eating Touch, wind Alcohol Yawning, Stress, fatigue factors cold spicy foods chewing

Associated Caries, exposed Abscess Erosions None Lacrimation, Click in TMJ, None signs dentine or ulcers swelling usually injected eye, trismus nasal discharge

Aetiological Caries, trauma, Acute Varied Saliva, Idiopathic, Vasomotor Stress, Depression factors cracked tooth, periodontitis retention, multiple parafunction gingival infection sclerosis recession

Treatment Restoration, Periodontics According Drainage, Carbamazepine, According Antidepressants, Antidepressants endodontics or extraction to cause antibiotics nerve block, to cause other cryoanalgesia, (Table 13) treatments neurosurgery

Table 12. Differential diagnosis of orofacial pain.

Atypical Odontalgia facial pain, it should be treated including: Pain and hypersensitivity in teeth, similarly. indistinguishable from or ● alcohol; periodontitis but occurring in the absence ● various tyramine-containing foods of detectable pathology, and aggravated VASCULAR CAUSES such as ripe bananas, some red by dental intervention, characterize this Orofacial pain is occasionally caused by wines or chocolate; disorder. It is probably a variant of disorders in which the most obvious ● the contraceptive pill; atypical facial pain, and should be treated organic feature is vascular dilatation or ● stress. similarly. constriction. However, the pain is usually more obviously in the face or Clinical Features head than in the mouth (see Tables 12 Classical migraine has the following The Syndrome of Oral and 13). features: Complaints Multiple pains and other complaints ● preceding warning symptoms (an such as dry mouth or bad taste may Migraine ‘aura’) of visual, sensory, motor or occur simultaneously or sequentially in Migraine is an uncommon severe speech disturbances. Visual this condition, and patients may bring associated with nausea and phenomena are often of zig-zag diaries of their symptoms to emphasize sometimes photophobia, seen mainly in coloured lights (fortification spectra) their problem. This has been termed the adult women. or transient visual defects. ‘maladie du petite papier’, and though ● recurrent headache which is usually there is not always a psychogenic basis, Aetiology severe, unilateral (hemicrania) and such notes characterize patients with Migraine headache is probably related to lasts for hours or days; non-organic complaints. Relief is rarely arterial dilatation. Attacks may be ● photophobia; admitted. Probably a variant of atypical precipitated by a number of factors, ● nausea or vomiting.

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TMJ pain Psychogenic Idiopathic trigeminal Migraine Migrainous dysfunction neuralgia neuralgia

Age (years) 20-30 35-60 50 Any 30-50

Sex F>M F>M F>M F>M M>F

Site Temple, ear, jaws, Diffuse, deep, Unilateral, mandible Any Retro-orbital teeth. Usually sometimes across or maxilla unilateral midline

Associated Click in TMJ, Life-events, back Photophobia, nausea, Conjunctival , features trismus pain etc. vomiting lacrimation, nasal congestion

Character Dull, continuous Dull, boring Lancinating Throbbing Boring continuous: stress, fatigue

Duration of Weeks to years Weeks to years Brief (seconds) Hours Few hours episode (usually day) (usually night)

Precipitating Yawning, stress, Depression Trigger areas Foods Alcohol factors parafunction

Relieving factors Antidepressants, Antidepressants Carbamazepine Sumatriptine Sumatriptine other treatments (see text) (see text)

Table 13. Differentiation of important types of facial pain.

Management ● is unilateral; to be fragmented, with giant cells In acute attacks or paracetamol ● occurs in attacks, which last less numerous in the region of the deranged may give some relief and ergotamine or than 1 hour, commence and often internal elastic lamina. It appears to be an sumatriptine given early may abort an terminate suddenly; immunological type of disease. attack. However, these should be ● is often precipitated by alcohol prescribed by a physician, because they consumption; Clinical Features can produce serious adverse reactions. ● often awakens the patient at night or Cranial arteritis is characterized by: There is no reliable evidence that in the early hours of the morning (2- occlusal problems underlie most 3 a.m.); ● deep and aching, throbbing and migraine and thus splints etc. are rarely ● is burning and ‘boring’ in character; persistent pain, often over the temple; indicated. ● is localized around the eye; ● pain that is made worse when the Often patients prefer to lie in a quiet, ● is associated with profuse watering patient lies flat (it may be dark room. Fortunately, the number, of the eye on the affected side, exacerbated or reduced by pressure frequency and intensity of attacks congestion of the conjunctiva, nasal on the artery involved); usually diminish with increasing age discharge and obstruction. ● tenderness of the affected superficial and spontaneous remissions are not temporal and other cranial arteries; uncommon. Management ● malaise, weakness, weight loss, Migrainous neuralgia should be managed anorexia, fever, sweating; by a physician, with oxygen inhalations, ● a raised erythrocyte sedimentation Migrainous Neuralgia non-steroidal anti-inflammatory agents, rate (or plasma viscosity). (Cluster Headache) ergotamine or sumatriptine. Migrainous neuralgia is a rare type of Management retro-orbital pain occurring mainly at Patients with cranial arteritis may be night, in young men. Cranial Arteritis threatened with loss of vision, and Cranial arteritis (temporal arteritis; giant therefore urgent treatment with systemic Aetiology cell arteritis) is a rare condition seen corticosteroids (prednisolone) is indicated. Migrainous neuralgia is less common mainly in elderly people; the pain is than migraine, and is related to vascular associated with dilated, throbbing changes. superficial temporal arteries. OTHER ORGANIC CAUSES These include: Clinical Features Aetiology The pain typically: Biopsy shows the arterial elastic tissues ● raised intracranial pressure;

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● meningeal irritation; of ageing: facial and oral pain. In: Barnes IE, Scully , Welbury . Colour Atlas of Oral Disease in ● diseases of the skull; Walls A, eds. Gerodontology. Oxford: Children and Adolescents. London: Mosby- ● medical diseases; Butterworth-Heinemann, 1994; pp.7-16. Wolfe, 1994. ● Burton J, Scully C. The lips. In: Champion RH, Scully, C, Flint, S, Porter, SR. In: Oral Diseases, 2nd chronic post-traumatic headache. Burton J, Burns DA, Breathnach SM, eds. ed. London: Martin Dunitz, 1996; pp.1-371. Textbook of Dermatology, 6th ed. Oxford: Scully C, Porter SR, Greenman J. What to do Blackwells, 1998; pp.3125-3148. about halitosis. BMJ 1994; 308: 217-218. REFERRED CAUSES Eveson JW, Scully C. Colour Atlas of Oral Pathology. Scully C. Diagnosis and diagnostic procedures: Pain may occasionally be referred to the London: Mosby-Wolfe, 1995. general and soft tissue diagnosis. In: Pathways Jones JH, Mason DK. Oral Manifestations of in Practice. London: Faculty of General Dental face or jaws from the neck (see above), Systemic Disease, 2nd ed. London: Baillière- Practice, Royal College of Surgeons of lungs or heart. Tindall, 1980. England, 1993; pp.25-33. Anginal pain usually affects the Millard HD, Mason DK, eds. Perspectives on 1993 Scully C. The oral cavity. In: Champion RH, mandible, is initiated by exercise World Workshop on Oral Medicine. Chicago: Burton J, Burns DA, Breathnach SM, eds. (especially in the cold) and abates quickly University of Michigan, 1995. Textbook of Dermatology, 6th ed. Oxford: Scully C. Handbook of Oral Diseases. London: Blackwells, 1998; pp.3047-3124. on resting. Martin Dunitz, 1999. Scully C. The pathology of orofacial disease. In: Barnes Scully C, Cawson RA. Medical Problems in IE, Walls AWG, eds. Gerodontology. Oxford: Dentistry, 4th ed. Oxford: Butterworth- Butterworth-Heinemann, 1994; pp.29-41. Heinemann, 1998. Wray D, Lowe GDO, Dagg JH, Felix DH, Scully C. F URTHER READING Scully C, Flint S, Porter S. Oral Diseases. London: Textbook of General and Oral Medicine. Baillie S, Woodhouse K. Scully C. Medical aspects Martin Dunitz, 1996. Edinburgh: Churchill-Livingstone, 1999.

that it is now on its 3rd edition shows children to is BOOK REVIEW how popular it has been. covered. The authors intend that students The book has been updated with will use the book as an aide memoire and Oxford Handbook of Clinical some new chapters and contributions, in support of this there are spaces on Dentistry, 3rd edn. By Mitchell. Oxford particularly from Brian Nattress in the pages on which additional notes can be University Press, Oxford, 1999 Restorative chapters, which have been made. (£17.95). ISBN 0-19-262963-8. revised for the better. New sections have Dipping into the book for information been included on evidence-based is easy and useful and I think that this This is a difficult book to review, there practice, the new NHS complaints edition like the others will become very is so much in it! The book was initially procedure, OSCEs and the 1997 ALS popular. I think its place as a white coat written to be a white coat pocket book guidelines. book is safe! providing easy reference not only for the The text is set out in chapters Madeleine C. Murray dental student but also practitioners who according to specialty or topic of interest. Senior Lecturer Dental Primary Care wanted a quick reference guide. The fact Everything from local anaesthesia for Glasgow Dental School BELLE MAUDSLEY LECTURE APPLICATIONS FOR THE BELLE MAUDSLEY LECTURER 2000

This award of £500 is intended for those who have Orthodontic Society at the 1999 British Orthodontic completed their specialty training in orthodontics within Conference in Brighton, and the paper will be submitted to the past five years and are in hospital, university, community Dental Update.* Where a paper received from an or specialist practice. Submissions should be of clinical unsuccessful applicant is considered to be of suitable interest within the field of orthodontics and should be in merit, this will also be submitted to Dental Update for the form of a paper suitable for publication in Dental possible publication in a later edition of the journal.* Update. Applications, which should conform to the Guidelines Prospective applicants are advised to consult past issues for Authors (available from the publishers), should be sent to discern the particular style and nature, especially for to: The Chairman, Scholarship & Awards Committee, orthodontic articles, as published in Dental Update. British Orthodontic Society, Eastman Dental Hospital, The successful applicant will be required to deliver the Gray’s Inn Road, London WC1X 8LD. The deadline for Belle Maudsley Lecture at the invitation of the British applications is 1 February 2000.

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