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News Bulletin : ADA News Bulletin December 2011
21 DECEMBER 20 11 committee report • Can they open their mouth? If it is less than 2 cm interincisal it is possibly the commencement of an airway problem. • Are they having difficulty breathing, i.e., can they lie flat without choking? • Are they having difficulty swallowing? If they try anything more solid than liquids and they start to choke they have a swallowing problem. • Do they feel ill and do they have an elevated temperature? You need to record their temperature. • Do they have a history of previous antibiotic misuse or abuse? If the patient is experiencing some of the above symptoms, they are at risk of airway obstruction. This is a Category A Medical Emergency. Dentists sometimes complain that the ambulance service won't come for the patient. This is because they have told the ambulance service that the patient has a dental abscess. This is a mistake. Advise the signs and symptoms but conclude the patient has a threatened airway. This will ensure the ambulance service will definitely come. The patient needs to be seen in an appropriate major hospital with experienced anaesthetic and oral and maxillofacial surgery staff on site. If the patient is assessed as being at airway risk and has the above listed signs emergency staff will control the airway and once stabilised, send the patient via ambulance or by air evacuation if they are in the country. The patient should be sent to a major metropolitan hospital with an Oral and Maxillofacial Surgery Department and usually there is an on call registrar who will be available and be of invaluable assistance. Fig 2. The CT Scan shows the external swelling but also the internal swelling. There is a large pus collection to the medial side of the right ramus and the tongue and airway are being pushed to the left. Immediately following the CT Scan the patient was intubated and the pus drained. FACIAL SWELLING -- NO AIRWAY ISSUES If on assessment the patient has no airway issues, i.e., they feel well, can lie down, breathe and swallow and have a jaw opening of greater than 2 cm they can be treated at your clinic. Remember that Hippocrates described the management of infection several millennia ago, namely remove the cause, drain the pus and support the host. This works well but we have tended to become lazy since antibiotics became available. Day 1 -- Attempt to treat the cause and drain the pus. Sufficient anaesthesia can either be obtained by a closed mouth mandibular block or by direct infiltration. Remove the pulp or the tooth. If there is a soft tissue fluctuant swelling incise and drain. It is always advisable to obtain a microbiological swab when draining pus to send to the laboratory for culture and sensitivity. As an adjunct give adequate antibiotics. High and appropriate doses are indicated (Table 1). If at the first appointment the cause cannot be treated and the pus drained prescribe antibiotics. However, do not advise the patient to return when the swelling has gone. The patient must return or at least contact you by phone daily until dental treatment can be provided. Ensure the patient is not forgotten -- the dentist should follow them up, if they have not been in daily contact. Warn the patient they may feel worse with only antibiotic treatment. Advise the signs and symptoms to be aware of and provide your contact number so the patient can seek advice. Everyone has a mobile phone; it is a common complaint from both medical practitioners and patients that the dentist "could not be contacted". It is your ethical responsibility to be contactable. If the patient's condition deteriorates they need to know how to contact you for advice or contact the Emergency Department of your local large metropolitan hospital. It is unlikely that a repeat course of antibiotics will work, if the first course has been unsuccessful in treating the condition. Check that all the necessary dental treatment has been completed. Recheck the patient antibiotic history to determine whether they are likely to be resistant. This is where the initial pus sample will help guide therapy. If you are unsure as to what course of action should be undertaken, seek advice from your usual oral and maxillofacial surgeon. This includes patients with current Enhance Primary Care (EPC) forms. The good news is this simple advice will assist you to improve the management of spreading dental infections. The bad news is the problem of spreading dental infections will continue to get worse as bacterial resistance; secondary to antibiotic misuse and abuse is on the rise. Alastair Goss Professor of Oral and Maxillofacial Surgery Emeritus Consultant Surgeon Royal Adelaide Hospital Paul Sambrook Senior lecturer in Oral and Maxillofacial Surgery Director, Oral and Maxillofacial Surgery The Royal Adelaide Hospital and Adelaide Dental Hospital On behalf of the ADA Inc. Dental Therapeutics Committee Members who are not currently on the mailing list to receive a free copy of the monthly Australian Prescriber should contact www.australianprescriber.com to receive this valuable independent advice. This covers the full range of medical issues and other helpful dental notes which you should read. There have also recently been a series of specific dental articles. REFERENCES 1. Kumar R, Sambrook P, Goss AN. Mismanagement of dental infections. Australian Prescriber April 2011:40-41. Table 1 Antibiotics for spreading dental infection Pen V 500mg 6 hourly Or Amoxycillin 500mg 6 hourly • If allergic to penicillin Clindamycin 400mg 8 hourly • If severe and spreading add Metronidazole 400mg 8 or 12 hourly • Previously non-responsive to the penicillins Amoxycillin plus Clavulanate 875 + 125mg 12 hourly • Total 5 days If not working don't repeat but reassess diagnosis and check you have removed the cause and drained the pus.
ADA News Bulletin November 2011
ADA News Bulletin February 2012