Dentistry — Facial Swelling, Jaw Injury and Oral Pain, NMC MBBS licence examination syllabus (Nepal Medical Council).
The dental problems that reach a doctor rather than a dentist are the ones where the mouth has stopped being the point — the airway, the jaw, or a pain that was never dental at all.
NMCDN01 covered dental infection spreading to the airway, the mouth in systemic disease, and the ulcer that must not be dismissed. This chapter covers the four presentations that arrive in a general clinic or an emergency department.
Most facial swelling from a dental cause is uncomfortable rather than dangerous. Three features change that, and each of them is found by looking and asking rather than by any test.
Swelling under the jaw and in the floor of the mouth, particularly when both sides are involved and the tongue is being pushed upwards. That is infection in the spaces that surround the airway rather than in the tissues of the face.
Trouble swallowing saliva, or a change in the voice. A patient who is drooling because swallowing hurts too much, or whose voice has become muffled, is describing a narrowing airway.
Difficulty opening the mouth. Infection has reached the muscles of chewing — and it carries a second implication, because the same restriction makes intubation harder for whoever has to secure the airway.
These patients need urgent senior and surgical help rather than antibiotics and review. NMCAS01 covers the airway; the point here is that the swelling is not the emergency — the airway is, and it can close over hours.Three non-dental causes of facial pain are worth carrying, because each is missed in a predictable way.
Cardiac pain radiates to the jaw, and can occasionally be felt there alone. Jaw or tooth pain brought on by exertion and relieved by rest is a cardiac history until proven otherwise, and NMCMD01 covers what follows.
Sinus disease makes several upper teeth ache together, typically worse on bending forward and accompanied by nasal symptoms. The giveaway is that it is not one tooth — dental pain is usually localised to a single tooth that is tender to percussion.
Trigeminal neuralgia gives brief, severe, shock-like pain triggered by touching the face, chewing or cold air. It is worth naming here because it is a recognised reason teeth are extracted unnecessarily — the pain continues afterwards, because it was never in the tooth.
Assessment of a suspected mandibular fracture begins with a question rather than an image.
"Do your teeth meet normally?" A patient notices a changed bite immediately and reliably, often before any imaging demonstrates the fracture. A bite that feels wrong after facial injury is a significant finding.Numbness of the lower lip and chin is the second finding. The nerve supplying that skin runs inside the mandible, so altered sensation there suggests a fracture through its canal.
The mandible is a ring, and a ring rarely breaks in only one place. Finding one fracture is a reason to keep looking for a second, often on the opposite side or at the condyle. NMCSU02 covers facial trauma more broadly, including the assessment of the rest of the patient — a blow hard enough to break a jaw is a blow to the head.
Bleeding from a socket is common, and most of it stops with sustained, firm pressure — a rolled gauze bitten continuously rather than removed every minute to check. The checking is what prevents the clot forming.
When it does not stop, the useful question becomes why. Anticoagulant or antiplatelet treatment, liver disease, and a previously unrecognised bleeding disorder all present this way.
A man with a week of toothache now has swelling under both sides of his jaw, is drooling, and sounds muffled. This is an airway emergency, not a dental one. Urgent senior and surgical involvement; do not send him home on antibiotics.
A 58-year-old describes jaw ache that comes on when he walks uphill and settles when he stops. That is exertional pain with a cardiac pattern. An ECG comes before a dental referral.
A young man is punched and says his teeth do not meet properly. Suspect a mandibular fracture, examine for lip numbness, and look for a second fracture — and assess the head injury.
A patient returns four hours after an extraction still bleeding. Apply sustained pressure first, then ask about anticoagulants, liver disease and any personal or family bleeding history.
Facial swelling and airway compromise. Size is not the danger; involvement of the floor of the mouth, voice change and difficulty swallowing are.
Dental pain and sinus pain. One tooth tender to percussion, against several upper teeth aching together with nasal symptoms.
Dental pain and cardiac pain. Separated by the relationship to exertion.
A socket that keeps bleeding and a technical problem. After pressure has been applied properly, consider a systemic cause.
Floor-of-mouth swelling, drooling, voice change or trismus — airway emergency, urgent help.
Jaw pain on exertion — think heart, get an ECG.
Several upper teeth aching, worse bending forward — think sinus.
"Do your teeth meet normally?" — the single best question after facial injury.
Numb lower lip — fracture through the nerve canal. The mandible is a ring — look for a second break.
Sustained pressure first, then ask why the bleeding did not stop.
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