Sir, having completed a resident post in oral and maxillofacial surgery, and being a non-resident on-call for a maxillofacial team at a Children's Hospital, it became apparent the number of doctors in the Accident and Emergency Department who were unable to correctly read facial radiographic views and diagnose maxillofacial injuries. This was especially noticeable during the months of August and February. This period of time is notorious for mistakes occurring, as Senior House Officers (SHOs) change their rotations, and those that have been in the A&E department for six months and have become adept at diagnosing trauma patients, then rotate onto another department.

This meant that maxillofacial SHOs were unnecessarily called out for injuries that did not require specialist treatment, but, even more worryingly, some patients who had facial injuries were not referred at the appropriate time.

Examples of such misdiagnoses included a case of periorbital ecchymosis and subconjunctival haemorrhage with no radiographs taken at the time. These patients would usually then be referred to the outpatients department, where a correct diagnosis would be made some days later.

There were inevitably some patients who would be incorrectly diagnosed with no follow-up appointment in place, and could simply then get 'lost in the system'. In one of the worst cases, an orbital blow-out fracture came to be diagnosed 10 days post-injury, with signs of diplopia due to the entrapment of the inferior rectus muscle of the affected eye. It has been reported in the literature that one of the commonest fractures missed on radiographs in a one year study of an A&E department included those involving the zygoma.1

Incorrect terminology was also frequently applied; I once received a telephone referral from an A&E SHO stating with conviction that the 'top part of the lower maxilla was fractured on the right side'. Radiographs revealed a fracture of the right condylar head of the mandible, with a second fracture of the left body of the mandible, which had been missed completely.

Another difficulty faced by A&E doctors appears to be distinguishing between trauma to the primary and permanent dentitions. I appreciate that oral and maxillofacial surgery is its own speciality, and that we as BDS graduates undergo five years of training to be of a sufficient standard to practise in our chosen field. However, a simple one or two day intensive course may suffice for all new A&E doctors, which could be delivered in a similar way as the 'Dentist on the Ward Course' that is offered to us when we embark upon our role as maxillofacial SHOs in a general hospital.

As well as improvements in the teaching of junior doctors, especially in the interpretation of facial radiographic views, increased supervision by senior medical staff may be appropriate, especially in the first few weeks of the new A&E rotations. In the interests of patient safety, and in the increasing climate of medico-legal claims, it is imperative that such mistakes are avoided wherever possible.