CDA Essentials 2018 • Volume 5 • Issue 4

36 | 2018 | Issue 4 S upporting Y our P ractice  Day 19: The patient was starting to feel better and tried going back to work. At the end of his first day at work the pain and swelling had returned.  Day 20: The man now had limited opening of his mouth and couldn’t eat. He went to the hospital, where they started him on IV clindamycin and 2 Toradol injections per day. He had ultrasonic and CT scans of the head and neck area and saw a number of physicians over the next few days. The hospital physician recommended another general dentist for the extraction of 36. But this new dentist would not do the extraction when he saw the patient’s condition. Wisely, he deemed it unsafe to perform the extraction. However, this dentist did mention to the patient that, based on the panoramic X-ray, it appeared that his jaw was at risk for fracture because pronounced loss of bone at the angle of the ramus on both sides. In fact, his jaw was fine but the dentist had misread the washout on the panoramic X-ray. This dentist referred the patient to an oral surgeon. Slow recovery in hospital  Day 21: The oral surgeon extracted tooth 36 in the hospital under general anaesthetic. He performed extraoral drainage and for three days, post-op, the patient was intubated and unconscious. Once the man started regaining consciousness, he exhibited bizarre behaviour. Fearing the infection had spread to the brain, the oral surgeon made a second incision and drainage under general anaesthetic. The soft tissue and fluid was sampled and Eikenella corrodens was identified as the primary bacterial species. E. corrodens is found in the mouth and upper respiratory tract and is often called the “fight bite” infection, because infection can happen to a person who has punched someone in the face and cuts their knuckles on the teeth of the person they punched. It’s likely that the incision and drainage created the opportunity for the E. corrodens infection because the incisions were so large. The extraction of 37 was the right thing to do, but the extraction site was another avenue for the opportunistic E. corrodens to invade the area, further complicating an existing problem. The oral surgeon noted there was little to no destruction of the mandible, increasing the suspicion of an infection of non- odontogenic origin. After two weeks in the hospital, the patient was discharged. Four weeks of daily IV antibiotics followed. The numbness, earache and swelling eventually resolved and the man has since returned to work. a What Can We Learn from This Case? Guide treatment with definitive testing and diagnosis. The dentist who first saw the patient said he measured pocket depths and cold tested some teeth in quadrant three. However, the test results were not written in the chart and no diagnosis was recorded. The second dentist merely followed the proposed treatment plan: RCT 36. Without evidence of pulp and periradicular testing and a resultant endodontic diagnosis, the proposed treatment plan is unsubstantiated. This is a precarious position for either dentist to be in and not in the best interest of the patient. Don’t overlookmedical and dental history. The history of a motor vehicle accident causing trauma that warranted the removal of teeth in quadrant four is relevant to all future care for this patient. He is at a heightened risk of cracks on all remaining teeth for the rest of his life. The amalgams in quadrant three are over 20 years old and shallow. With time, it is possible for the tooth structure encompassing a filling to fatigue and develop cracks. This is especially true for shallow amalgams that rest on hard enamel rather than soft and forgiving dentine, which results in more force being transferred laterally towards the cusps. Although counter-intuitive, be wary of old, shallow amalgams as they produce more lateral stress than deeper fillings. To watch Dr. Fransen discuss the case, visit oasisdiscussions.ca/2018/02/16/dx and use password 5*67