MDS 622

Q1:

WEEK (5)

A). Provisional diagnosis for this Pt.

Pt complain from Odontogenic infection
related to badly decayed tooth #47.
The infection spread in buccal space &
cause Large buccal abscess .
Necrosis of the dental pulp as a result of deep caries allows a pathway for bacteria
to enter the periapical tissues. Once this tissue has become inoculated with bacteria
and an active infection is established, the infection will spread equally in all
directions but preferentially along the lines of least resistance. The infection will
spread through the cancellous bone until it encounters a cortical plate. If this cortical
plate is thin, the infection erodes through the bone and enters the soft tissues.

As infection erodes through bone, it

can express itself in a variety of
places, depending on thickness of
overlying bone and relationship of
muscle attachments to site of
perforation. This illus-tration notes
six possible locations: vesttbular
abscess (1), buccal space (2), palatal
abscess (3), sublingual space (4),
submandibular space (5), and
.)maxillary sinus (6

B). Management of this case:

MDS 622

Exra & intraoral examination .

(1) medical support of the patient including analgesics, fluid requirements, and nutrition.
(2) administration of proper antibiotics in appropriate doses.

WEEK (5)

(3) surgical removal of the source of infection as early as possible.

(4) surgical drainage of the infection, with placement of proper drains.
(5) constant reevaluation of the resolution of the infection.

The primary principle of management of odontogenic infections is to perform

surgical drainage and removal of the cause of the infection. Extraction provides
both removal of the cause of the infection and drainage of the accumulated pus
and debris.
Surgical treatment may range from something as simple as the opening of a tooth
and extirpation of the necrotic tooth pulp to treatment as complex as the wide
incision of soft tissue .
With this the dentist has the three options for surgical management of endodontic
treatment, extraction, or I&D.
After drainage of abscess ( by extraction in this case) give Pt medical support of the
patient including analgesics & bactericidal antibiotics.
After infection gone remove the impacted tooth #48 but after re-evolution the area of
infection of #47.

B). Complications avoid:

Misdiagnosed between Abscess & Cellulitis:
Early-stage infections that initially appear as a cellulitis with soft, doughy, diffuse
swelling do not typically respond to I&D procedures. Surgical management of
infections of this type is limited to removal of the necrotic pulp or removal of the
involved tooth.

Mechanical spread of infection to adjacent spaces.

MDS 622

Q2:Pt had been heavy steroid supplements , need to extract

tooth #26..

WEEK (5)

A).Primary concern with this Pt & Complications:

Patients on steroids who present for surgery may be at increased risk of complications because of:
The adrenal suppression caused by steroid therapy. This often poses the greatest risk and deserves
particular attention. It is important for patients to be educated about the risk. Steroid cards should be
carried by patients taking steroids.
The disease or condition which required them to take steroids. Corticosteroids are used in a
wide variety of conditions. Some of these may also have attached risks for anaesthesia (those for
example affecting lungs, neck joints or drug metabolism).
Long term and other side effects of steroid therapy. These include:
o Hypertension
o Diabetes mellitus
o Fatty liver
o Susceptibility to infection
o Osteoporosis
o Avascular necrosis of bone
o Skin sepsis
o Electrolyte disturbance: hypokalaemia, metabolic alkalosis
There is a wide range of diseases for which corticosteroid treatment is commonly used. It is
important to remember that these conditions may also carry risk for both anaesthesia and surgery.
Examples of conditions likely to have a consequence for surgery and anaesthesia include:
* Asthma
* Rheumatoid arthritis
* Glomerulonephritis
* Idiopathic thrombocytopenic purpura
* Cerebral oedema
* Malignancies and chemotherapy
These conditions should be fully assessed pre-operatively.

B). Complications:
This Pt use Steroid so will complain from a lot things like:
1.
2.
3.
4.

Inability to tolerate the stress.

Delayed healing.
Susceptibility to infection.
Hypertension with steroid use.

MDS 622

C). Management of this case:

WEEK (5)

Peri-operative management
It is useful to summarise who should receive steroid cover for surgery (and during major illness):

Patients on corticosteroids at a dose of 10 mg or more of prednisolone (or equivalent) daily

(equivalent to Betamethasone 750 micrograms, Fluticasone 375 micrograms, Dexamethasone 6 mg,
Hydrocortisone 20 mg, Methylprednisolone 4 mg daily).
Patients who have received corticosteroids 10 mg daily within the three months preceding surgery.
Patients on high dose inhaled corticosteroids (for example beclomethasone 1.5 mg a day).
Patients who stopped their steroids more than 3 months ago or who are taking 5 mg or less require
no steroid cover.

Peri-operative steroid cover

Note that infusion is now preferred to bolus (this avoids excessive doses of steroid with possible
complications). Historically doses were even higher, further revision of doses may be recommended with
further research, but for the moment empirical recommendations are:

Minor surgery - 25 mg hydrocortisone at induction of anaesthesia and then resume normal

medication postoperatively.
Moderate surgery - Usual dose of steroids pre-operatively and then 25 mg of hydrocortisone
intravenously at induction followed by 25 mg IV every 8 hours for 24 hrs. Usual pre-operative dose
then continued.
Major surgery - Usual dose of steroids pre-operatively, then a bigger 50 mg of hydrocortisone
intravenously at induction followed by 50 mg Intravenously every 8 hours for 48-72 hrs. Continue
this infusion until the patient has started light eating, then restart normal pre-operative dose.
Remember that patients receiving <10 mg of prednisolone or equivalent do not need steroid cover
but should continue with their usual maintenance steroid dosage. Patients on long term steroids do
not require supplementary steroid cover for routine dentistry or minor surgical procedures under
local anaesthesia.

Summary