Patient centered care.
Below is an interesting article from the AAE’s Paper Point, May 2016 edition. It’s a great example of the importance of a multidisciplinary approach for the treatment of our patients. At Southwest Endodontics, we work closely with all dental specialties in patient care.
As an Endodontist, When Should I Refer?
Multidisciplinary Approach to Treating Odontogenic Infection
Chase Wicker, Kimberly A. Morio and Nick Morio
University of Iowa
A 31-year-old male was referred to the Department of Endodontics resident clinic for emergency treatment. The patent’s chief complaint was, “I have been having severe pain since I had a root canal started.” The patient’s health history was significant for previous cancer therapy, asthma and an allergy to prochlorperazine. Current medications included albuterol sulfate, tramadol and amoxicillin.
Initial Endodontic Treatment
The patient was seen in the student clinic four days prior (02/26/16). At that time, initial exam revealed no lymphadenopathy, swelling or sinus tract. Extensive decay was noted on #19 MOB. Periapical radiograph revealed a large coronal carious lesion encroaching the pulp chamber space. Also, radiolucencies were noted in the furcation area as well as the mesial and distal roots of #19. Initial diagnosis was #19: pulp necrosis with asymptomatic apical periodontitis. Root canal therapy was initiated and working length was obtained at the first appointment. The following day (02/27/16), the patient called the clinic reporting slight swelling and discomfort associated with the left mandibular posterior quadrant. Prescriptions for tramadol and amoxicillin were phoned into the patient’s pharmacy.
Emergency Endodontic Examination
Extraoral examination the day of the emergency visit (03/01/16) revealed submandibular space swelling associated with the patient’s left side. Induration and pain on palpation was noted. The inferior boarder of the mandible was not palpable. Intraoral examination revealed vestibular swelling buccal to #19 with purulent discharge through the sulcus of #19 upon palpation. The patient was also very symptomatic to palpation of the area. Trismus was present with a maximal incisal opening of 20 mm. #19 temporary restoration was intact and no carious lesions were noted in the left mandibular quadrant. The patient reported an alleviation of pain following the prescription of Amoxicillin and Tramadol. However, the patient did report a progressive nature of the swelling. Digital thermometer gave a reading of 98.2 °F. The patient did not report any dyspnea or dysphagia.
Diagnostic evaluation revealed:
Emergency Endodontic Diagnosis and Treatment
Diagnosis #19: previously initiated therapy with acute apical abscess. Local anesthesia of 3.4 cc 2% Lidocaine with 1:100k epi via IANB and 3.4 cc 4% Articaine with 1:100k epi buccal infiltration. Rubber dam isolation. Upon access, three orifices were located and a white material consistent with Ca(OH)2 was found. Working lengths were established and the canals prepared up to a 40/.04 instrument. Copious irrigation with 3% NaOCl was done throughout the procedure and a final rinse following 17% EDTA. Canals dried with paper points. Ca(OH)2 dressing was placed and #19 temporized with cotton pellet and IRM. An incision was made in the buccal vestibule adjacent to #19 and irrigation was performed with copious saline. The patient was advised to continue antibiotic regimen.
The patient was contacted 24 hours after the procedure and reported no resolution of symptoms. In addition, the patient stated the swelling had progressed over the past 12 hours: “the swelling is getting worse and I am starting to feel it in my throat.” A referral was made to the Oral Surgery Clinic at the local hospital for evaluation and treatment.
Oral Surgery Referral and Hospital Course
Upon presentation to the hospital, a maxillofacial CT scan with contrast was done. Fluid collection was noted in the L submandibular region that appeared to have originated from tooth #19. Blood work done on presentation revealed a slightly elevated WBC count of 12,500 and the patient was afebrile. The patient was taken to the operating room that evening for removal of tooth #19 and an extraoral incision and drainage of the L submandibular space. The patient was placed under general anesthesia. The skin was prepped and a 10 cc syringe with an 18 Ga. needle was utilized to attempt aspiration of the fluid collection for aerobic and anaerobic cultures. Due to the relatively small fluid collection, a sample was not obtained. A 1 cm skin incision was made 2 cm below the inferior boarder of the mandible on the L over the peak of the swelling to enter, drain and irrigate the submandibular space. A one-fourth inch penrose drain was placed (lingual to #19 through the sublingual and submandibular spaces exiting the skin) to allow for dependent drainage. He was admitted post-operatively for observation and IV antibiotics (3 g IV q6hr). On post-operative day #3 his WBC count had normalized and the facial swelling and associated trismus had resolved to the point he could be discharged to home on PO Augmentin. Prior to discharge, the penrose drain was removed bedside. He was placed on a 10-day course of Augmentin (3 g IV q6hr) 875 mg PO BID. He was followed as an outpatient and his post-operative course was uncomplicated. The patient was contacted one week following admission to the hospital by the treating endodontist and reported complete resolution of infection and symptoms.
Patient-centered care is crucial for patient success. This case highlights the importance of multidisciplinary care from the perspective of not only understanding but recognizing endodontic clinical limits and when to refer for surgical management. Sometimes as endodontists we may become focused on the anatomy of teeth, but continual review of the anatomy of fascial spaces, the pathways infections may take and clinical presentations of these infections will create confidence in your abilities as a clinician.
Endodontics is amazing! We have numerous tools in our tool box to manage tooth-related infections, but, as in this case, true submandibular infections cannot be managed endodontically. These infections require extraoral incision and drainage and, most often, removal of the source of the infection, which was tooth #19 in this case. If not treated in a timely fashion, these fascial space infections can escalate quickly into airway compromise, tracheostomy and ICU admission. The extraoral incision and drainage of the submandibular space infection allows for dependent drainage and disrupts the environment the bacteria need to survive. Removal of the source of infection (the tooth) helps to ensure this infection does not progress or recur. In cases like these, reaching out to experts outside of endodontics allows us to provide the best care for our patients.
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