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News Bulletin : ADA News Bulletin December 2011
20 DECEMBER 20 11 Hopefully, members will have read the recent provocatively titled article in the Australian Prescriber on 'Mismanagement of dental infections'.1 This invited review was primarily aimed at medical practitioners who prescribe antibiotics to patients with dental infections without arranging concurrent appropriate dental treatment. The end result is the patients' condition deteriorates and they end up with potentially life threatening infections. Indeed, with the reported consecutive series of over 1,000 severe dental infections treated at the Royal Adelaide Hospital in the last 10 years, three have died, despite expert care. The first, a young, fit male who had an acute post-operative airway obstruction. This experience led to changes in airway management including a much lower threshold for keeping the patient intubated in intensive care until the swelling had settled. The second, a female who had misused antibiotics for most of her life, taking them for viral coughs and colds and any time she felt ill. This resulted in her becoming multiply resistant to most antibiotics including the penicillins, cephalosporin and somewhat unusually, metronidazole. Unfortunately, when she needed antibiotics nothing worked. Her simple periodontal infection spread and despite appropriate dental treatment and intensive in-hospital treatment via the full range of medical specialities, she died slowly over 10 days with multi-organ system septicaemia. The third, a young intravenous drug user who presented with a canine fossa abscess. He also had under recognised pan sinusitis. DENTAL INSIGHT Practical management of spreading odontogenic infection committee report He was experiencing severe pain and requesting large doses of narcotics which the hospital was unable to provide. Accordingly, he discharged himself against medical advice, presumably to obtain adequate street narcotics. A few days later, he was returned to hospital seriously ill and confused. He had a disseminated cerebral arterial infection and was found to have a community acquired methicillin-resistant staphylococcus aureus (MRSA). This is different to usual MRSA which is picked up secondary to medical and hospital treatment. Community acquired MRSA is increasing, particularly in the street drug culture. However, the end result is the same. The initial antibiotics he was prescribed didn't work due to his resistance. Again, despite intensive multi-specialist hospital care, he died after four days. All three of these cases had various long histories of antibiotic or general health abuse and had not received timely and simple dental treatment for their abscessed teeth. Importantly, is it only medical practitioners prescribing antibiotics to patients with swollen faces from dental infections who are sending them away until the infection has cleared? Sadly, the answer is a resounding NO. Many dental practitioners also do this, some even leaving a script with the receptionist without even examining the patient. PRACTICAL STEPS FOR MANAGING DENTAL INFECTIONS Hence, these practical steps are offered for appropriate management of dental infections: PREVENTION IS ALWAYS BETTER THAN CURE Most patients had not seen a dentist and ignored prolonged dental pain. If the swelling improved with antibiotics the first time they did not seek definitive dental care. The common excuses given were cost, fear and also a lack of understanding of the nature of dental disease. None of the 1,000 patients were on government dental waiting lists and most of these patients kept well away from dentists. Interestingly, about 5% were currently undergoing dental treatment and usually they and their dentist were trying too hard to save a particular tooth. If dental treatment is not working or if it is obvious that the tooth is split, or the periodontal disease is so advanced, then antibiotics will never fix it. You need to change the dental treatment, usually to extraction. MANAGEMENT OF SEVERE SPREADING DENTAL INFECTION -- AIRWAY ISSUES When a patient presents with a swollen face, they must be seen by the dentist that day. Many had either been sent away or misadvised on the telephone by the reception staff that the dentist was busy and didn't have another appointment for several days or even weeks. The first step is to teach your staff that a patient with face, jaw and/or neck swelling needs to be seen urgently within 24 hours. When the patient is seen, you need to fully evaluate them medically as well as dentally: • Generally, the extent of the swelling can be seen on the outside of the face and the jaw is at least of the same size internally. This is what is compressing the airway (Fig 1,2). Fig 1. The patient has a right submandibular abscess spreading into his face and neck. He is feverish and cannot open his mouth. Note the red swelling.
ADA News Bulletin November 2011
ADA News Bulletin February 2012