Cone beam computed tomography (CBCT) is a popular and often indispensable imaging modality used for the dento-alveolar tissues and immediate surrounding structures. It can be used across several dental disciplines including endodontics, implant planning, oral surgery and orthodontics. Furthermore, it is commonly used in the medical specialties of oral and maxillofacial surgery (OMFS) and ear, nose and throat (ENT) surgery. In part 1 of this series, we described some of the common incidental findings found in the dento-alveolar complex and immediate neighbouring structures. Part 2 looks further afield and depicts some common and important incidental findings and anatomical variants that can be found on larger fields of view. CPD/Clinical Relevance: Many incidental findings are innocuous, yet their recognition and documentation are essential because some will warrant medical or surgical intervention.
The consent process remains a pillar of excellent clinical care. The changes in the law after the Montgomery ruling in 2015 has changed the shape of consent, and now, taking adequate consent can be extensive and sometimes confusing for clinicians and patients. Dentists are sometimes faced with the unenvious task of weighing up what patients should know versus what they want to know. This paper aims to describe the consent process for more common oral surgical procedures, helping clinicians to allow their patients to make informed decisions. CPD/Clinical Relevance: To assist primary and secondary care clinicians in taking adequate consent for oral surgical procedures.
Cone beam computed tomography (CBCT) is a popular and often indispensable imaging modality used for the dento-alveolar tissues and immediate surrounding structures. It can be used across several dental disciplines including endodontics, implant planning, oral surgery and orthodontics. Furthermore, it is also commonly used in the medical specialities of oral and maxillofacial surgery (OMFS) and ear, nose and throat (ENT) surgery. In many of the images taken, there will often be findings/presentations that may not be expected, or familiar, to the reporting clinician. CPD/Clinical Relevance: Many incidental findings are innocuous, yet their recognition and documentation are essential because some will warrant medical or surgical intervention.
Oral disease poses significant health, social and economic burden globally, often causing pain, infection, hospital admission and mortality. Dental caries (tooth decay) is amongst the most common health conditions despite being non-communicable and entirely preventable. The Global Burden of Disease Study estimated that greater than 530 million children suffer from caries in their primary dentition (WHO, 2020). Within the NHS, is it estimated that 25-30% of the overall paediatric waiting list consists of cases that require removal of grossly decayed teeth under general anaesthesia (GA) (figure 1). Between 2015 and 2016, the financial cost to the NHS of extractions amounted to £50.5M. Before the COVID-19 pandemic, there was an existing burden within London NHS trusts of children on waiting lists for exodontia under GA. This issue has been further compounded by the cessation of elective dental activity in primary and secondary care settings due to the pandemic. Project Tooth Fairy was thus conceived to manage the growing paediatric GA waiting list.
Methods
Project Tooth Fairy is a collaborative, pan-London initiative designed to address London's growing paediatric GA waiting list. The new facility will employ clinical and non-clinical staff in a passport-type scheme allowing clinicians from different units to deliver care centrally in a purpose-built unit. The initiative started in November 2021. The project will deliver paediatric extractions, comprehensive care and complex oral surgery under GA. It will also serve as a source of training for dental trainees and anaesthetic trainees.
Results
Early results demonstrate that Project Tooth Fairy has treated over 250 children over two months, working with staff from over six NHS trusts, most cases comprising paediatric dental extractions. In March 2021, the total number of children waiting for paediatric GA across 19 London hospitals was around 14,400. To tackle the existing (and future) paediatric GA waiting lists in London, Project Tooth Fairy aims to increase capacity to treat 290 children over six days each week across three procedure rooms. Demand and capacity analysis suggests that approximately 212 procedures would be required each week (not including the backlog resulting from the pandemic). The backlog has seen a 61% increase from approximately 2,500 children waiting in March 2020 to an estimated 4,000 today, with projections of 7,000 by the time capacity is restored for P4 category work across London. It is estimated that 72% of these children have waited longer than 30 weeks, with greater than 1000 children waiting more than 52 weeks – a 96% increase in 52 week-waits compared to pre-COVID figures. The initiative also provides a more cost-effective solution due to the collaborative approach between trusts and staffing with an estimated saving of approximately £850,000 over 17 months compared to a more traditional system using two modular theatres.
Conclusion
Project Tooth Fairy is a more cost-effective and collaborative approach to tackling spiralling waiting lists within individual trusts. Nonetheless, a conceptual shift is needed away from 'downstream' strategies and those addressing the 'upstream' underlying inequalities in oral health across the population to achieve a more sustainable healthcare system.
Solitary fibrous tumour is a soft tissue tumour of mesenchymal origin. It was first described in the pleura and has since been reported in many anatomical locations. Thirteen cases in the tongue have hitherto been reported. A positive CD34 result has traditionally been used to confirm the diagnosis, although this is often non-specific to solitary fibrous tumour. To date, nuclear STAT6 expression has not been reported in solitary fibrous tumour of the tongue.This paper presents a further four cases of solitary fibrous tumour of the tongue, the largest series to date. Clinical, histopathological and immunohistochemical findings are detailed, including nuclear STAT6 expression.All four cases were positive for CD34; two cases showed nuclear expression of STAT6. The tumours were excised completely and there have been no recurrences in at least one year.Solitary fibrous tumour should be considered as a differential diagnosis for tongue swellings, with the potential to recur.
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