i really think this is something i dont update enough. inertia and ennui get in the way of me sitting down to type out things, reflect on actions and improve my approaches.
today i saw the results of questionable management. it was a situation which, when presented to me, was something that i found myself unable to cope with and had to urgently refer. and it is because that situation may have been preventable that i want to blog this out, to settle mind and emotions.
the patient first presented to us on 070109, c/o pain q3. NRMH, NKDA. in addition to the poor oral hygiene status, assorted caries and a root stump, #37 was deemed to be non-vital with an acute suppurative apical periodontitis. due to the buccal swelling, the practitioner who saw the case decided to prescribe antibiotics and painkillers and gave a 2/52 return visit.
the patient returned the next day, with the pain unrelieved and the swelling even bigger despite the prescribed medication having been eaten.
o/e: L buccal swelling, of a doughy consistency and extremely tender to palpation. there was trismus, preventing insertion of 2 finger-breadths. intraorally, the sulcus adjacent to #37 appeared raised and hyperaemic. #37 was impressively carious, the entire buccal aspect was missing to a subgingival level.
my approach was to attempt an extraction kiv i&d. the patient was progressively wedged open with a rubber mouth prop (no gag-prop available to crank him open unfortunately) and periodontal infiltration was delivered to the tooth, followed by an attempt at an IDN block, which was not successful. anaesthesia was however sufficient to attempt extraction, and despite the remaining lingual coronal structure shearing off the tooth was elevated and delivered in pieces, completely.
this is where things didnt run the way i wanted them to. there was no drainage from the socket, even after curettage. there was no obvious fluctuant point in the sulcus despite the apparent raising, and so for a shot in the dark i went for an incision at the buccal of #37. no pus, no joy. the patient was then referred to a nearby hospital with oral surgical facilities for immediate management of the abscess.
what is the surgical lesson to be gained here? our professors and texts left us with 2 excellent principles. firstly, the surgeon's best antibiotic is his scalpel. secondly, do not let the sun go down on undrained pus! i believe that both these principles were breached in giving antibiotics and a 2/52 return date. extractions can and should be carried out in the presence of swellings. these prevent a dento-alveolar abscess from turning into a facial abscess and a dental emergency from turning into a possible medical emergency. while it is not entirely clear that, given that i could not achieve drainage today, drainage may have been achieved yesterday, it sure as heck would not be raising questions in my mind if the tooth had been removed yesterday while the swelling was still small. it may well have saved the patient a trip to the hospital...