OS Sheet #3 By Ibrahim Al-Omari

http://www.4shared.com/file/Mke6ybne/drziad_malkawe__3rd_oral_suger.html

The doctor started the lecture with a story about a patient who have diabetes, prosthetic heart valve , liver cirrhosis ,and hepatitis C .
referred to the ER from other hospital, because of diffuse submandibular bilateral swelling of 2 days duration(it means it is progressive ) and pain .
Patient was doing well until 5 days prior to admission when he started to complain of simple pain next to lower right first molar ,patient take simple analgesia and didn’t seek dental treatment , 2 days later pain increased in severity and started to notice a swelling on his right side of his lower jaw went to al basher hospital and admitted for management ,1 day prior to admission the swelling increase in size and extended to left side with dysphasia( difficulty in swallowing) and change in voice .
On admission the patient was exhausted and dehydrated and despnening (shortness in the breath), with hoarseness in voice
On examination : bilateral submandibular swelling ,tender and firm to palpation with hotness and redness of the overlying skin
it was small swelling and no fluctuation
Tender neck along the plan anterior to sternocydomastoied muscle
intra orally :halitosis and multiple decayed teeth, decayed and tender lower left second premolar and first molar teeth, sinus track with pus discharge next to first molar from the lingual side(although there is a sinus ,it is not enough to discharge all the pus because it is progressive ) , no tongue elevation , decreased mouth opening (trismus) , dysphagia , hoarseness of voice (those are sings to admit the patient).
He had Minimal wheeze, dyspnea in supine position ,productive cough with Wight sputum , cardiomegaly(heart enlargement) and diffuse infiltration on chest X-RAY , tracheal shift to the right , bacteremia and septicemia ( all of this because of dental infection and having a low immunity)
Abdomen : central obesity , soft lax , no palpable masses no ascites (related to liver, means an accumulation of fluid in the peritoneal cavity ) , normal bowel sound .
lower left and bilateral limp angel pitting edema , 2 small spot of ecchymosis on right chin most probable due recent trauma
MANEGMENT :
in ER >> blood sample for CBC , kidney function test CBC, electrolyte , LFD ,PT INR , PTT , and air blood gasses .
Requested mandible and chest CT scan
intravenous fluids and IV antibiotics augmentin 1200 mg, flagyl(metronidazole) 500 mg
Patient sent to CT-SCAN , while patient was waiting for CT became more distress ,confused and gasping for air and resuming sniffing position
Immediately he had been given O2 under pressure applied with a facemask and taken to surgery
Left submandibular stab incision 2 finger inferior to left mandibular inferior margin on the midway between the sternoclydomastoid and the mid line
You have to do three incisions (bilateral and sub mental) , only the left one there was pus (it' not necessary to have pus coming out but you have to do the three incisions )
Extraction of first molar and second premolar teeth
5-7 pieces of vacuum drain was inserted and fixed to all incisions ( you have incise and drain too for day)
Post operative patient was transferred to ICU and intubated for 24 hours, swelling decreased and he came back to normal.

Now we start the lecture
evaluate state of patient
Evaluate state of patient’s host defense mechanisms :
medical condition that compromise host defense :
either medical condition that allow more bacteria to enter the tissue or to be more active like uncontrolled metabolic disease ( such as sever diabetes )
medical condition that prevent cellular or humeral defense from existing their full effect (such as leukemia ,lymphoma and many types of cancer)
because of that when a patient come with lymphoma we extract without fear but we must give him prophylactic antibiotic ( and must be one dose preoperative(1 hour if orally, 15 min if suppository , at induction if IV "if the patient is sedated") before the surgery … more than that it is not prophylactic )
now the idea of prophylactic is the blood level of antibiotics is high at the time the patient exposed to bacteria …. Not after the patient exposed to bacteria … so if you give the patient antibiotic after surgery it is not prophylactic, it is treatment.
Patient that we give them prophylactic antibiotics
 Uncontrolled metabolic diseases:
 Uremia.
 Alcoholism.
 Malnutrition.
 Severe diabetes.
 Suppressing diseases:
 Leukemia.
 Lymphomas.
 Malignant tumors.
 Suppressing drugs:
 Cancer chemotherapeutic agents.
 Immunosuppressive agents.

 Criteria for referral to a specialist(y3ne el 7alat elly fog be9er n3alejhom bas etha kan 3endhom el 7alat el jay lazem n7awelhom 3al e5te9a9e ):
 Rapid progressive infection.
 Difficulty in breathing.
 Difficulty in swallowing.
 Facial space involvement.
 Elevated temperature (Greater than 101 F or 38.3 C)
 Severe jaw trismus (less than 10 mm)
 Toxic appearance.(he looks dehydrated and can't speak)
 Compromised host defenses
4. Treat infection surgically.
 Surgical drainage.
 Removal of the cause
You have to do both or it will reoccur

Now doctor changed the subject and started to talk about incisions … he said we can do intraoral incision but we have to try not to do it sublingual because it is a vascular area and there is a space... so if you injured an artery or a vein it will bleed and it will collect interstitial and suffocate the patient ( if we do it anywhere else it will bleed out and it will not collect )
Now the stab incision : 1 cm just with the blade in depth and width , then we insert the artery forceps closed and open it inside then we turn it to open the incision wide … and let the pus go out .
Then we put drain (a tube made of soft plastic) and stitch it to the skin and we put dressing >>> the pus will go out through a the drain … if you don’t put it, the incision will close .

Support the patient medecaly (pain killers , IV flueds .. etc )


In this picture the patient don’t have an infection … she had a mass originated from the deep lob of the parotid gland the doctor's idea is to open our mind … and not every swelling it is a infection

#now the antibiotics:
Determination of the need for the antibiotics :
Like if we had a patient with a partially erupted wisdom and he is fit and healthy … we font need to give him antibiotics , and if we want to give him(like if had a bad oral hygiene , I work in a non-sterile conditions or area ) , we don’t give him vancomycin (it will cause problems in the liver and the stomach , and the regular antibiotics will not work after using vancomycin , and expensive ) but we give him narrow spectrum like penicillin or amoxicillin .

So if we want to use an antibiotics it has to be :
 empiric therapy routinely( but if you know the cause by culture you can give a specific antibiotic) .
 Narrowest spectrum antibiotic.
 Antibiotic with lowest incidence of toxicity and side effects.
 Use bacteriocidal antibiotic if possible.
 Be aware of the cost of antibiotics.
Indications for use of antibiotics:
 Rapidly progressive swelling.
 Diffuse swelling.
 Compromised host defenses.
 Involvement of facial spaces.
 Severe pericronitis.
 Osteomyelitis
Situations in which use of antibiotic is not necessary:
 Chronic well – localized abscess.
 Minor vestibular abscess.
 Dry socket.
 Mild Pericoronitis( the treatment for it good oral hygiene , good irrigation, and mouth wash ).
 Effective orally administered antibiotic useful for odontogenic infections:
 Penecillin.
 Erythromycin.
 Clyndamycin (very efficient in bone infections ).
 Cefadroxil (we do not use it as a first line therapy )
 Metronidazole (if the case was very serious we give metronidazole and something else ).
 Tetracycline.

 Indications for culture and sensitivity testing:
 Rapidly spreading infection.
 Postoperative infection.
 Non responsive infection.
 Recurrent infection.
 Compromised host defenses.

7. Administer antibiotic properly.
 8. Evaluate patient frequently:
 Reason for treatment failure:
 Inadequate surgery.
 Depressed host defenses.
 Foreign body.
 Antibiotic problems.
 Patient noncompliance.
 Drug not reaching site.
 Drug dose too low.
 Wrong bacterial diagnosis.
 Wrong antibiotic.
 consider it a first choice )
The doctor ended the lecture here and said the rest is self reading and he will ask about it in the exam (it is about antibiotics and how it works "from slide 22-40(41 not included)")

Correction are more than welcomed
dr.ziad malkawe / 3rd lecture / oral surgery