A man with three days of toothache now has swelling under the jaw, cannot swallow his saliva and has a muffled voice. What is the priority? ANSWER: this is an AIRWAY EMERGENCY, not a dental complaint. MECHANISM: infection from a lower tooth has spread into the tissue spaces of the floor of the mouth and neck. As they swell, the TONGUE is pushed upwards and backwards, narrowing the airway from a direction that is hard to see and hard to instrument. THE RED FLAGS PRESENT HERE: swelling under the jaw · inability to swallow saliva · muffled voice Also: raised tongue, trismus, any difficulty breathing. ACTION: call SENIOR and ANAESTHETIC help EARLY. Do not wait for stridor — stridor means the airway is already substantially narrowed and deterioration can be rapid.

A previously well 45-year-old has oral candidiasis. What does this finding require? ANSWER: a search for an underlying cause. Candida is uncommon in a healthy adult, so it is a FINDING rather than a diagnosis. CONSIDER: DIABETES (may be undiagnosed) HIV or other immunosuppression Malignancy Recent broad-spectrum ANTIBIOTICS INHALED STEROIDS used without rinsing the mouth CONTRAST: oral candida in a BABY is ordinary and needs no such workup. LEARNING POINT: the mouth is a window onto systemic disease, and looking in it costs nothing. Other examples — bleeding gums (gingivitis, but consider vitamin C deficiency, clotting disorders, leukaemia); a sore smooth tongue (iron, B12 or folate deficiency); dry mouth (very often drugs).

A 60-year-old who chews betel quid has a PAINLESS ulcer on the side of the tongue, present for six weeks. What is the concern and what do you do? ANSWER: ORAL CANCER until proven otherwise. Refer for assessment and biopsy. TWO TRAPS IN THIS PRESENTATION: 1. PAINLESS does not mean harmless — early oral cancer is frequently not painful, so the patient may not complain and the clinician may be falsely reassured. 2. BETEL QUID and areca nut are often NOT volunteered, because they are not thought of as a drug. Ask specifically. RULE: any oral ulcer persisting beyond a few weeks needs assessment. RISK FACTORS TO ASK ABOUT: tobacco in ANY form (smoked or chewed), betel quid and areca nut, alcohol — and combinations multiply the risk. WHY IT MATTERS: oral cancer is VISIBLE with a torch and curable when small, yet is commonly diagnosed late because nobody looked.

A child arrives with a permanent front tooth knocked out 20 minutes ago. The tooth is in a tissue in the parent's pocket. What is the correct management? ANSWER: 1. Hold the tooth by the CROWN, never the root — the delicate cells on the root surface are what allow reattachment, and handling destroys them. 2. If dirty, RINSE GENTLY. Do not scrub. 3. REPLANT IMMEDIATELY into the correct socket, right way round; have the child bite gently on a cloth to hold it. 4. If replanting is not possible, transport in MILK or the patient's own SALIVA. NOT water (damages the cells) and NOT dry (kills them). 5. Urgent dental care — survival falls with every minute out of the socket. THE ERROR HERE: the tooth has been kept DRY in a tissue, which is the worst option. TWO EXCEPTIONS: Do NOT replant a BABY tooth — it risks damaging the developing permanent tooth above it. ACCOUNT for any missing tooth: it may have been INHALED, which needs a chest X-ray.

A parent asks whether it is better to give a child sweets once a day or spread through the day. What is the correct advice, and why? ANSWER: ONCE, preferably with a meal. FREQUENCY matters more than total quantity. MECHANISM: 1. Plaque bacteria metabolise sugar into ACID. 2. Acid dissolves enamel. 3. After each exposure the mouth needs TIME to neutralise the acid and allow remineralisation. 4. Each new exposure RESTARTS the attack before recovery is complete. So the same amount of sugar spread over an afternoon does far more damage than the same amount eaten at once. PRACTICAL ADVICE: reduce the NUMBER OF TIMES sugar enters the mouth. AND THE RELATED RULE: never put a baby to bed with a sweetened bottle. Saliva flow falls during sleep, so sugar sits against the teeth for hours with nothing to wash it away — causing severe early childhood caries that is entirely preventable by advice.

Why does a persistently dry mouth matter beyond discomfort? ANSWER: because SALIVA PROTECTS TEETH. Saliva washes away food debris, buffers acid produced by plaque bacteria, and supplies minerals that allow early enamel damage to remineralise. Without it, decay proceeds rapidly and extensively. COMMON CAUSES: DRUGS — a great many cause dry mouth, and this is the commonest cause Dehydration Poorly controlled diabetes Autoimmune disease affecting salivary glands CLINICAL POINT: a patient complaining of dry mouth deserves a MEDICATION REVIEW before anything else — it is frequently iatrogenic and frequently correctable.