Teenager in Coma after Dental Infection at Montefiore Hospital

gryffindor · Apr 25, 2005

Does anyone have more info on this news story?

http://www.nydailynews.com/news/local/story/302734p-259173c.html

http://cbsnewyork.com/topstories/topstoriesny_story_115114629.html

How did the patient initially show up at the hospital? Why wasn't the infection treated? What kind of "dental infection" are they talking about anyways?

One of my patients mentioned this to me b/c she is now paranoid about her teeth ultimately killing her, so I decided to pay attention to the news on TV tonight. Now I'm left wondering about more details in this story, it sounds like something has been left out of it.

gryffindor · Apr 25, 2005

Actually, this article has some more details about the dental infection in it.

http://www.nypost.com/commentary/45054.htm

I'm still interested to know if anyone has any more info on this story. I don't know what to think b/c it's scary, it could happen to me or any of us working in the city clinics. I saw this situation myself today. A 19 year old (Medicaid pt) had a pulpectomy started on #30 two weeks ago, and his scheduled follow up root canal appt. was in early May, a month later. So he instead came in today in agony begging to have his tooth extracted. Even though it was totally restorable, I couldn't convince him otherwise. Fine, I was ready to extract #30 but I couldn't proceed b/c he had a liver transplant 7 years ago and there were no recent labs on him. I got on the phone to try and get him cleared today, but the liver clinic made it clear that it wouldn't happen till tomorrow at the earliest.

Sigh, I hope private practice is more time efficient in resolving dental pain/infection issues than these scenarios.

Doggie · Apr 25, 2005

I have a friend at Monti's GPR. I actually heard him mention something about this. Let me ask him for more details.

mvs04 · Apr 26, 2005

the dental clinic scheduled for 9 days after?!!?

I hope those ****s in that clinic each gets a bullet, in the knee caps.

lnn2 · Apr 26, 2005

griffin04 said:
Actually, this article has some more details about the dental infection in it.

http://www.nypost.com/commentary/45054.htm.

Man, sad story! Poor kid. He should at least have a pulpectomy tx at the Pedo clinic, unless he declined tx. The kid was in pain and the tx is covered by Medicaid, without requiring a pre-authorization for tx. I wonder whether they gave him antibiotic. Pain meds for 9 days? It doens't sound like a proper tx in this situation, imo. Had they done the pulpectomy the hospital could possibly identify/diagnose his problem before it's too late, or at least dental infection cause could be eliminated?!
Ummh, brain tumor, aneurysm? brain abscess from sinus infection? Infection spreading to cavernous sinus? scary!

DrJeff · Apr 26, 2005

Sad storry, but lets look at it from a different perspective before we lay all the blame on the medical/dental staff.

1st off, why hadn't the mother sought out dental care for this 13 year old before, afterall you just don't get an endodontic lesion overnight. I bet that if you were to look in their kitchen you'd see many, many sugary foods that MOM bought for her son

2ndly, if the pedo clinic rx's antibiotics and pain meds and referred out for the endo, thats perfectly within the standard of care. Sue they could have opened up the tooth and done the pulpotomy but I've seen many, many teeth that after opening up will have the symptoms get worse in the short term

3rd during the 9 days between the pedo clinic visit and the non-consentable visit(also done properly based on consent standards) if her son was feeling worse, then why didn't the mom atleast call the clinic 😕

While from a social standpoint this entire situation totally stinks, is it a case of malpractice? Based on the information given in the news report, no. Also, don't be too quick to rush to a judgement about what/how the residents/attending dentists acted, rememeber you weren't actually there to see the scenario/situation.

Also for those going into a GPR/AEGD, remember this situation because while you'll likely never be involved in one of the incredibly few cases where an infection of dental origin actually causes a death, the set up for this situation you'll likely encounter many parts of this

ItsGavinC · Apr 26, 2005

griffin04 said:
Actually, this article has some more details about the dental infection in it.

http://www.nypost.com/commentary/45054.htm

A bit off-topic, but this link reminded me of how poor the Post is. I can't believe that Ms. Peyser is "columnist of the year". That was a horribly written column.

toofache32 · Apr 26, 2005

DrJeff said:
Sad storry, but lets look at it from a different perspective before we lay all the blame on the medical/dental staff.

1st off, why hadn't the mother sought out dental care for this 13 year old before, afterall you just don't get an endodontic lesion overnight. I bet that if you were to look in their kitchen you'd see many, many sugary foods that MOM bought for her son

2ndly, if the pedo clinic rx's antibiotics and pain meds and referred out for the endo, thats perfectly within the standard of care. Sue they could have opened up the tooth and done the pulpotomy but I've seen many, many teeth that after opening up will have the symptoms get worse in the short term

3rd during the 9 days between the pedo clinic visit and the non-consentable visit(also done properly based on consent standards) if her son was feeling worse, then why didn't the mom atleast call the clinic 😕

While from a social standpoint this entire situation totally stinks, is it a case of malpractice? Based on the information given in the news report, no. Also, don't be too quick to rush to a judgement about what/how the residents/attending dentists acted, rememeber you weren't actually there to see the scenario/situation.

Also for those going into a GPR/AEGD, remember this situation because while you'll likely never be involved in one of the incredibly few cases where an infection of dental origin actually causes a death, the set up for this situation you'll likely encounter many parts of this

Great post. I agree. I have seen this scenario several times in my OMFS residency. A couple of months ago we had a rare case of necrotizing fasciitis (google it if you want to know more) from on odontogenic source. She had a lower molar pulled at a local dentist and went back 3 days later with continued pain and swelling. He (appropriately) put her on antibiotics with an ER warning to the patient & patient's daughter for fever, airway difficulty, or increased swelling. The swelling continued and she developed fever, but she would not go to the ER because she was scared that 2 of her sisters had already "died in the hospital". Her daughter finally forced her to come to the ER. By that time her entire neck was swollen, she had airway problems, and the skin erythema had spread across her face and all the way down to her mid-chest. She was septic and her coags were already out of whack. We took her to the OR for a trach and to debride the wound, and got General Surgery to hack away at the area below her clavicles. She lasted about 10 days in the ICU with several return trips to the OR for further debridement (including part of her mandible). She finally died.

My point is that the media likes to point fingers and the doctors are the easiest target for the lay public, despite appropriate care and self-neglect on the patient's part.

Brush your teeth. Go to the dentist.

zdaddy08 · Apr 27, 2005

ItsGavinC said:
A bit off-topic, but this link reminded me of how poor the Post is. I can't believe that Ms. Peyser is "columnist of the year". That was a horribly written column.

i agree...she SUX!

sdog · Apr 28, 2005

DrJeff said:
Sad storry, but lets look at it from a different perspective before we lay all the blame on the medical/dental staff.

Totally agree with DrJeff, you will see this general scenario in a GPR all the time. All of the treatment rendered, or not rendered, to the child were within the standard of care. We all do our best to treat the amazing number of patients in a timely manner while doing the best possible dentistry, however, sometimes we have to script them, tell them what signs and symptoms to be on the lookout for, and come back immediately if the situation worsens. We have a dentist available in the Emergency Room 24/7. I have found that countless times, the medical staff harbors patients with complaint of "chest pain" or "trouble breathing" and ignores the chief complaint of toothache. Several days or weeks later, the patient shows up in a terrible state of swelling, airway obstruction, etc. So... it is necessary to realize that this can happen to a person (brain death, etc.) and that all parties involved need to be aware of the possibility of this situation, including the patient and patient's family

tx oms · Apr 28, 2005

Good posts, even from DrJeff! I will add that if the patient is swollen (either intra or extraorally) they need the tooth pulled or opened that day. Nothing else will reliably fight the infection. I see dentists and even oral surgeons place patients on antibiotics to "wait for the swelling to go down". That's not a good plan and I would testify against it in court. There is an urban myth that infected teeth can't be treated until the infection goes away. I don't think any dentist really believes that, I think it's just a matter of convenience to tell the patient that and schedule another appointment.

Leaving an infected tooth unopened/unextracted is like leaving an infected splinter in someone's hand and wondering why the antibiotics aren't working.

omfsres · Apr 28, 2005

USC2003 · Apr 28, 2005

I believe there are situations where an I & D does not have to be done that same day. When I get called in to the ED if the patient has a small vestibular selling in the anterior maxilla or anterior mandible I feel comfortable placing the patient on ABX and having them return the next day to clinic to have the tooth taken out. Good judgement on a case by case basis is what can be done. It all depends on the facial space the infection is in, and how large the swelling is. Why have the patient go through an I & D and then return for an extraction if it is not necessary. Again I will state that location, size and clinical exam can determine whether or not you can start the patient on ABX and have them f/u in clinic without performing an I & D.

tx oms · Apr 28, 2005

With my patient populuation I will not I&D without pulling the tooth simultaneously.

toofache32 · Apr 28, 2005

tx oms said:
With my patient populuation I will not I&D without pulling the tooth simultaneously.

I agree. I'm actually one of the few residents in my program who will go to the ER with a forceps (when clinic is closed). I have done several I&D's at night with instructions to F/U in the morning in OMFS clinic for extraction and they never show up because I fixed the acute pain. I always think to myself, "they'll be back tomorrow or the next day" but I never see them again. Either they died somewhere or Baylor decided to bite the bullet and pulled one for free.

LSR1979 · Apr 29, 2005

toofache32 said:
I agree. I'm actually one of the few residents in my program who will go to the ER with a forceps (when clinic is closed). I have done several I&D's at night with instructions to F/U in the morning in OMFS clinic for extraction and they never show up because I fixed the acute pain. I always think to myself, "they'll be back tomorrow or the next day" but I never see them again. Either they died somewhere or Baylor decided to bite the bullet and pulled one for free.

Sorry I'm borderline ******ed, but what is I&D, and what is F/U. Thanks.

45540 · Apr 29, 2005

I&D = Incision and Drainage - It's used to treat abcesses for the most part. Cut it open with a scalpel and let the pus drain. Sometimes it's packed with gauze to keep it from healing shut allowing it to continue to drain while healing basically from the inside out. That's a pretty basic explanation.

F/U is the Follow Up by the next care professional

45540 · Apr 29, 2005

mvs04 said:
the dental clinic scheduled for 9 days after?!!?

I hope those ****s in that clinic each gets a bullet, in the knee caps.

I'm not going to say too much since i'm usually amused by your posts ... But, it's people with mindsets like yours that further the frivolous lawsuits that plague the healthcare industry. I feel that people should be held responsible for iatrogenic care, but why is it automatically the health system that's at fault. Having decay on a 13 year root would be pretty extreme and for the mother to wait that long with an infection and then until the tooth pain turned into seeing double and vomiting seems grounds for child neglect more than anything else. And sending your sick child with "relatives" that are not even adults themselves isn't an excuse to blame the system. He made it to his appointment 9 days later on a Friday but irresponsibility on the parent's part caused the boy to be turned away. What was her plan after his appointment was missed? Wait it out?

Obviously I'm generalizing, but people from lower income families don't seek dental care. They have a higher prevalence of most every time of dental disease and by the time they do show up, there's not many options to save teeth or infected tissue or much else. It's more of damage control.

Granted you're not in school, which is fine, but typically 9 days isn't terribly bad to wait for endodontic treatment. If your GP doesn't do endodontic work you'll have to be referred out and if the GP doesn't pull some springs, endodontists are generally backed up a week if not more.

I'm sure the child's abcess/infection was pretty noticeable on the radiograph, but many people use the ABX and referral method.

Maybe it's just me, but I'm more appalled that the mother waited as long as she did to seek care for her son than at the dental clinic for scheduling treatment 9 days later.

TaliaTN · Apr 29, 2005

People like this are nuts. I have some kids who come in every 3 months to get their teeth cleaned because Mom can't take care of her own teeth, much less spend 10 minutes brushing her kids teeth each day, despite our continued effort to educate. How do they afford this? The kids have new cavities every single time. We don't even take Medicare!!

How long did the tooth hurt? Did a dentist tell her he needed a RCT 3 years ago and she "didn't have the money" or time to take care of it? Did he tell her again 2 weeks ago and again those "greedy doctors" were just trying to get her money? Did she think every doctor is as worthless as ALL the ones she's seen? Does she have a history of neglect with her kids? For all we know, they could have offered her same day treatment and she may have declined because she was again too busy. Did they offer her a referral to a dentist who could do it sooner but she refused because it wasn't free?

I hate to say it, but this is no one's fault BUT the mothers IMHO. Poor kid.

gryffindor · Apr 29, 2005

TaliaTN said:
People like this are nuts. I have some kids who come in every 3 months to get their teeth cleaned because Mom can't take care of her own teeth, much less spend 10 minutes brushing her kids teeth each day, despite our continued effort to educate. How do they afford this? The kids have new cavities every single time. We don't even take Medicare!!

How long did the tooth hurt? Did a dentist tell her he needed a RCT 3 years ago and she "didn't have the money" or time to take care of it? Did he tell her again 2 weeks ago and again those "greedy doctors" were just trying to get her money? Did she think every doctor is as worthless as ALL the ones she's seen? Does she have a history of neglect with her kids? For all we know, they could have offered her same day treatment and she may have declined because she was again too busy. Did they offer her a referral to a dentist who could do it sooner but she refused because it wasn't free?

I hate to say it, but this is no one's fault BUT the mothers IMHO. Poor kid.

The patient had New York State Medicaid and showed up in a Medicaid clinic. I'm sure the root canal would have been free - the pulpotomy/pulpectomy is definitely covered and so is the extraction. The patient started at the dental dept. at Bronx Lebanon which has a HUGE dental department. This is my best guess on the scenario after reading the news articles & my experience in our clinic - they didn't treat the kid b/c he didn't come with a proper guardian, so they gave him an Rx and a referral for endo 9 days later. When they finally did return to the hospital due to new symptoms, it was too late. I'd be willing to bet that if the mother had shown up with the kid the NEXT DAY or even later the same day in the emergency dental clinic, some sort of treatment would have been rendered.

We will be discussing this case at our grand rounds meeting in 2 weeks, I'll keep you updated if I learn anything new.

omfresident · Apr 30, 2005

tx oms said:
Good posts, even from DrJeff! I will add that if the patient is swollen (either intra or extraorally) they need the tooth pulled or opened that day. Nothing else will reliably fight the infection. I see dentists and even oral surgeons place patients on antibiotics to "wait for the swelling to go down". That's not a good plan and I would testify against it in court. There is an urban myth that infected teeth can't be treated until the infection goes away. I don't think any dentist really believes that, I think it's just a matter of convenience to tell the patient that and schedule another appointment.

Leaving an infected tooth unopened/unextracted is like leaving an infected splinter in someone's hand and wondering why the antibiotics aren't working.

I feel it is neccesary to corrected a few points in this point. First off, their are instances and good reasons to put a pt on abx and wait for the infection to resolve before txn. First, you will be able to get better anesthesia once the infection resolves. I don't think I need to review the pharm behind this. Second, some feel that extracting 17/32 while infected risks spreading the infec. to the lateral pterygoid space. I think this is all pt dependant.

As far as extracting/opening teeth. The first pnt, is that extracting a tooth in any ed I have been in, does not meet standard of care. You have no dental imaging available, and are not properly equiped to handle any complications which might arise. I believe it is best to avoid extractions in the ed setting.

The best way to manage a fascial space infection is an I+D. If I get called to the ed, the pt is getting a drain. Even when frank pus has not yet collected, the pt will benifit from this procedure. At a min. 02 is introduce to change the local flora. Not to mention decrease pressure in the area to increase abx penetration and copious nl saline. These are basic surgical principals. For more detail, review oral and maxillofacial infections by Dr. Tobazian. When this is procedure is performed, the pt can get a few mg of morphine wiht the local, put on abx (or changed) and the tooth extracted in a few days. (wait for inef. to clear, and then able to get good anesthesia) Lastly, the drain should be placed with chromic, incase the pt doesn't return. With this txn plan, the infec. will clear, granted it will return unless the tooth is treated, but you can only do so much. Puling a tooth in the ed is not good pt management.

lnn2 · Apr 30, 2005

Man, I have absolutely not a clue what you just said!!! :scared:

toofache32 · Apr 30, 2005

I think you bring up some good points here, but I think some of this is more preference of the oral surgeon rather than dogma.

omfresident said:
The best way to manage a fascial space infection is an I+D. If I get called to the ed, the pt is getting a drain. Even when frank pus has not yet collected, the pt will benifit from this procedure.

I agree and this is what I do. If I have to go to the ED, someone is getting cut with a blade. Also, a shot of Bicillin in the a$$ on the way out (burns like hell!) gives them something to think about next time they want to wake me up for a toothache that could be treated during the day just as easily. Some people make a distinction between abscess vs. cellulitis, but there is good evidence that opening a cellulitis will hasten the healing, as you said. But, in theory, you could also run some IV antibiotics for a cellulitis without airway issues and watch for a response.

omfresident said:
As far as extracting/opening teeth. The first pnt, is that extracting a tooth in any ed I have been in, does not meet standard of care. You have no dental imaging available, and are not properly equiped to handle any complications which might arise. I believe it is best to avoid extractions in the ed setting.

We have a Panorex machine in our ED. I'm not sure what kind of complications you're talking about, but we have a tackle-box in which we carry every instrument and material we have in clinic. Except a Stryker...but I can usually tell which ones need a handpiece.

omfresident said:
their are instances and good reasons to put a pt on abx and wait for the infection to resolve before txn. First, you will be able to get better anesthesia once the infection resolves. I don't think I need to review the pharm behind this. Second, some feel that extracting 17/32 while infected risks spreading the infec. to the lateral pterygoid space. I think this is all pt dependant.

If anesthesia is going to be a problem, I just hit them hard with 4-8mg morphine and 25 of phenergan (for morphine-related nausea and added sedation). This is like a poor-man's sedation.

omfresident said:
Lastly, the drain should be placed with chromic, incase the pt doesn't return.

I only use silk sutures for drains to give them a reason to come back. This is for the same reason we leave arch bars on for 6 weeks even though they were treated open and are usually not in elastics. This is to keep a "handle" on the patient so you can get them back. If you're worried about them not coming back, that's a reason to extract in the ED. But I guess everyone has their own reasons.

drPheta · Apr 30, 2005

It's like I know what you guys are talking about, but I still feel dumb.

toofache32 · Apr 30, 2005

drPheta said:
It's like I know what you guys are talking about, but I still feel dumb.

Dont worry....I've been in touch with that feeling before.

tx oms · May 2, 2005

omfresident said:
I feel it is neccesary to corrected a few points in this point.

I'm going to contain all my sarcasm and respond kindly. I'm glad you felt the need to "correct" me. At our hospital the ER is directly below the OMFS clinic with a elevator that opens at the door to each. If I get a call for a toothache in the middle of the night I ask if the patient's swollen. If no swelling and they're only in pain they get a clinic appointment. If they are swollen/infected I take them from the ER to my clinic, take a pano, and go back to the ER where I am able to extract the tooth. I do have dental imaging and I can handle any complications that occur. I'm not sure which complications you had in mind that can't be handled in an ER (EMERGENCY room!?).

Sure, you can get better anesthesia when they're not infected and if my aunt were a man she'd be my uncle or a cross-dressing tranny named north2southoms. In other words, the patient got themselves infected, now they have to deal with the consequences. The situation is out of our control. As for spreading the infection via an extraction, there are others out there that would disagree. I have never seen an infection spread from an extraction. I have seen infections spread when a patient was placed on antibiotics rather than having the tooth extracted and the tissue opened if warranted.

Why are you willing to cut open the tissue, spread the tissue, and place a drain but not pull the tooth? You're not getting any better anesthesia for those procedures than I am for pulling the tooth.

omfresident · May 2, 2005

tx oms said:
I'm going to contain all my sarcasm and respond kindly. I'm glad you felt the need to "correct" me.

Thank you so much for sparing me from your sad sarcasm.

"At our hospital the ER is directly below the OMFS clinic with a elevator that opens at the door to each. If I get a call for a toothache in the middle of the night I ask if the patient's swollen. If no swelling and they're only in pain they get a clinic appointment. If they are swollen/infected I take them from the ER to my clinic, take a pano, and go back to the ER where I am able to extract the tooth. I do have dental imaging and I can handle any complications that occur. I'm not sure which complications you had in mind that can't be handled in an ER (EMERGENCY room!?)."

Not sure which complications? Granted it is nice to get dental imaging, but I question wether you have a hall/stryker available? If not, why get the word out people can have extractions in the ED. Not worth the hassle. Let them wait a few days (not admitable of course)

"Sure, you can get better anesthesia when they're not infected and if my aunt were a man she'd be my uncle or a cross-dressing tranny named north2southoms. In other words, the patient got themselves infected, now they have to deal with the consequences."

Your compasion is scarry. This is a nice practice builder. Granted My procedure is a lot quicker, at least in my hands. Nothing a few mg of morphine won't cover.

"The situation is out of our control. As for spreading the infection via an extraction, there are others out there that would disagree. I have never seen an infection spread from an extraction. I have seen infections spread when a patient was placed on antibiotics rather than having the tooth extracted and the tissue opened if warranted."

Never seen an infection spread via an extraction, even with your vast experience, must not be able to happen. Granted not every one holds this view, and it is tooth/space dependanet. If your do a proper I+D and use the appropriate abx, the pt will get better. Though the infec. will return until the tooth is txn.

let me know if you cowboy tooth pulling hicks need any more clarification before tonight

toofache32 · May 2, 2005

omfresident said:
let me know if you cowboy tooth pulling hicks need any more clarification before tonight

Nuh uh! Oh no you di'int!

<with hands on hips, snaps, & head rocking back and forth>

omfsres · May 3, 2005

toofache32 said:
Nuh uh! Oh no you di'int!

<with hands on hips, snaps, & head rocking back and forth>

omfsresident, please stop replying. You are coming off like an ameture. It makes us real residents laugh. Please reveal your program so I can tell everyone not to go there.

On what planet is an extraction such a major production for any competant resident. Unless it is full bony, 99% of all teeth can be removed without a handpiece. And I assure you it is not conventional thought that an extraction will lead to spread into deeper spaces. Please explain to us all how this happens. Yes, it was believe back in the 60's that an extraction in the presence of cellulitis could cause hematogenous spread. That has since been disproven with about 5 studies. Fortunately for you I don't have the specific references in front of me, I believe its in the 3rd edition knowledge updates. All recent texts, including the new peterson's refutes this claim. If we're talking abcesses, the chances are even less. Another point, cellulitis is the only instance in head and neck infections where abx have a chance to have some effect on the infection. In a frank collection of pus, as in an abcess abx will not touch it. This is not to be confused with situations of peritoneal or pelvic abcess where abx is/was the treatment of choice. And then you're talking weeks of parenteral abx. This is even in flux with new IR capabilities and percutaneous image guided aspiration.

omfsresident said:
The best way to manage a fascial space infection is an I+D. If I get called to the ed, the pt is getting a drain. Even when frank pus has not yet collected, the pt will benifit from this procedure. At a min. 02 is introduce to change the local flora. Not to mention decrease pressure in the area to increase abx penetration and copious nl saline

I don't think anyone disagrees with this statement, but the tooth needs to come out as well. It is your feeling of the need to correct us and saying that the standard of care hasn't been met that gets the tex riled up. It is condesending at the very least, especially from someone with a rather poor knowledge base. There are many different ways to treat these things and obviously going to the OR of I and D and extractions is the easiest. I have drained many a submandibular space and extracted the teeth in the ER simply under local with complete resolution of the infection. It is important for you not to doubt what you have not seen or heard. These things are done in many programs. It is obvious to me and other residents on this forum that either you have not done many of these or you are poorly read on the subject. Either way you have a lot to experience/learn.

toothie · May 3, 2005

omfresident said:
I feel it is neccesary to corrected a few points in this point. First off, their are instances and good reasons to put a pt on abx and wait for the infection to resolve before txn. First, you will be able to get better anesthesia once the infection resolves. I don't think I need to review the pharm behind this. Second, some feel that extracting 17/32 while infected risks spreading the infec. to the lateral pterygoid space. I think this is all pt dependant.

As far as extracting/opening teeth. The first pnt, is that extracting a tooth in any ed I have been in, does not meet standard of care. You have no dental imaging available, and are not properly equiped to handle any complications which might arise. I believe it is best to avoid extractions in the ed setting.

The best way to manage a fascial space infection is an I+D. If I get called to the ed, the pt is getting a drain. Even when frank pus has not yet collected, the pt will benifit from this procedure. At a min. 02 is introduce to change the local flora. Not to mention decrease pressure in the area to increase abx penetration and copious nl saline. These are basic surgical principals. For more detail, review oral and maxillofacial infections by Dr. Tobazian. When this is procedure is performed, the pt can get a few mg of morphine wiht the local, put on abx (or changed) and the tooth extracted in a few days. (wait for inef. to clear, and then able to get good anesthesia) Lastly, the drain should be placed with chromic, incase the pt doesn't return. With this txn plan, the infec. will clear, granted it will return unless the tooth is treated, but you can only do so much. Puling a tooth in the ed is not good pt management.

just wondering why local anesthesia would not work .... esp when giving a nerve block.
i agree that local infiltration will not work.. but what about nerve blocks..!!!
please qoute sources when answering .

in case of acute pulpitits , it is an emergency condition and only treatment that will immediately relief is doing a root canal opening, no where does it say that giving antibiotics is first line treatment...

another thing , treatment for a badly carious tooth which is indicated for extraction is doing extraction under antibiotic cover , which can be done the following day just to prevent spread of infection.
any thoughts....

omfresident · May 3, 2005

omfsres said:
omfsresident, please stop replying. You are coming off like an ameture. It makes us real residents laugh. Please reveal your program so I can tell everyone not to go there.

On what planet is an extraction such a major production for any competant resident. Unless it is full bony, 99% of all teeth can be removed without a handpiece. And I assure you it is not conventional thought that an extraction will lead to spread into deeper spaces. Please explain to us all how this happens. Yes, it was believe back in the 60's that an extraction in the presence of cellulitis could cause hematogenous spread. That has since been disproven with about 5 studies. Fortunately for you I don't have the specific references in front of me, I believe its in the 3rd edition knowledge updates. All recent texts, including the new peterson's refutes this claim. If we're talking abcesses, the chances are even less. Another point, cellulitis is the only instance in head and neck infections where abx have a chance to have some effect on the infection. In a frank collection of pus, as in an abcess abx will not touch it. This is not to be confused with situations of peritoneal or pelvic abcess where abx is/was the treatment of choice. And then you're talking weeks of parenteral abx. This is even in flux with new IR capabilities and percutaneous image guided aspiration.

I don't think anyone disagrees with this statement, but the tooth needs to come out as well. It is your feeling of the need to correct us and saying that the standard of care hasn't been met that gets the tex riled up. It is condesending at the very least, especially from someone with a rather poor knowledge base. There are many different ways to treat these things and obviously going to the OR of I and D and extractions is the easiest. I have drained many a submandibular space and extracted the teeth in the ER simply under local with complete resolution of the infection. It is important for you not to doubt what you have not seen or heard. These things are done in many programs. It is obvious to me and other residents on this forum that either you have not done many of these or you are poorly read on the subject. Either way you have a lot to experience/learn.

Granted the majority of teeth can be extracted in the ed w/o complication. What I am saying is This is not the best/ideal management. Splinting teeth?, are you using chisels? And, what program are you in, were you have enough time to exo teeth, no floor pt to manage, any real trauma? Do they not let you do mid-face? With all this time you can do some reading.

Wow star, not talking about hem spead, but fascial space-to- space spreed. I agree, this is only a small concern in certain cases. I refer you to Topazain's book ('02) For a full review of this topic. It does happen.

Draining sunmand. spaces in the ed?

omfresident · May 3, 2005

toothie said:
just wondering why local anesthesia would not work .... esp when giving a nerve block.
i agree that local infiltration will not work.. but what about nerve blocks..!!!
please qoute sources when answering .

in case of acute pulpitits , it is an emergency condition and only treatment that will immediately relief is doing a root canal opening, no where does it say that giving antibiotics is first line treatment...

another thing , treatment for a badly carious tooth which is indicated for extraction is doing extraction under antibiotic cover , which can be done the following day just to prevent spread of infection.
any thoughts....

They don't even bother calling us for pulpitis, I don't care how you want to manage this.

I tell pts at lease two days with abx, to calm down infection for better anesthesia. If I saw a pt in the ed, they get an I+D this actually has more to do with decreasing spread of infection than abx. These are basics in any text book.

lnn2 · May 3, 2005

omfresident said:
They don't even bother calling us for pulpitis, I don't care how you want to manage this.

Of course not, Reversible/Irreversible Pulpitis should be treated by a GP in a hospital setting.

omfresident said:
I tell pts at lease two days with abx, to calm down infection for better anesthesia. If I saw a pt in the ed, they get an I+D this actually has more to do with decreasing spread of infection than abx. These are basics in any text book.

Wouldn't it be better just to address pulpitis instead of prescribing abx (also pain med)? I thought that abx is recommended to be used 7-10days? I'm getting the impression from your posts that you're handing out abx left and right! what about the chances for superinfection?

omfresident · May 3, 2005

lnn2 said:
Of course not, Reversible/Irreversible Pulpitis should be treated by a GP in a hospital setting.

Wouldn't it be better just to address pulpitis instead of prescribing abx (also pain med)? I thought that abx is recommended to be used 7-10days? I'm getting the impression from your posts that you're handing out abx left and right! what about the chances for superinfection?

Sorry, I am talking about fascial space infec., not pulpitis. I am not aware of any one rx abx for a pulpitis.

The length of abx txn depenfs on many different factors. With the typical mild buccal space infec., I+D, abx, exo in 2 days with cont. of abx for 5 days or longer depending on infec. I would also see them on follow-up for re-eval.

DrJeff · May 3, 2005

😀

omfresident said:
I refer you to Topazain's book ('02) For a full review of this topic.

That name sends shivers down my spine 😱 He was the one faculty member during my UCONN years that you did everything humanly possible to avoid going into the OMFS clinic during his precepting times! Basically it would go as follows. Scenario, you're bringing a perfectly healthy patient in for the simpliest exo you can imagine. Lets say for arguement sake a 20 Y.O. for elective ortho bicuspid exos. You'd literally spend well over an hour in the conference room of the OMFS clinic getting "pimped" about everything from who invented the ASH forcep to who invented the dental napkin that the patient was wearing(he actually asked me about the napkin and I dumbfounded him by knowing the answer since it was my Grandfather's company that made the 1st dental napkin 😀 )

Then after he'd asked you every conceivable question he could think of, he'd be watching over you like a hawk in the clinic, if your wrist angle on the forcep was off by 1 degree, you'd hear about it after 😱 Heaven forbid you actually had a patient with anything that resembles a significant medical history or anything other than a simple extraction or else you'd need a calender to measure how long you'd be in the conference room. He even once "pimped" one of my classmates for so long that they didn't even get to exo the tooth(one of the OMFS residents finally did it after seeing the patient sitting in the operatory for 3 hours with no dental student in sight :scared:

)

While he may very well be one of the world's foremost experts on facial space infections, man was he a pain in the a$$ as a preceptor

toofache32 · May 3, 2005

omfresident said:
Draining sunmand. spaces in the ed?

That's how we do it in my program. As long as their is no airway encroachment, obviously. I give a V3 block, lingual block, and also block "Erb's point" down on the SCM to knock out the great auricular nerve supplying the region around the angle of the mandible. Just know how to avoid the obvious hazards (marginal mandibular branch of VII, etc).

tx oms · May 3, 2005

omfresident said:
And, what program are you in, were you have enough time to exo teeth, no floor pt to manage, any real trauma? Do they not let you do mid-face? With all this time you can do some reading.

I can tell from the level of excitement in your posts an infected tooth is one of the largest cases of your year.

lnn2 · May 4, 2005

tx oms said:
We do things at our program you only read about in a book. . .

Just out of curiosity, what edition is that book?! out of published or latest edition?! 😀

gryffindor · May 4, 2005

toothie said:
in case of acute pulpitits , it is an emergency condition and only treatment that will immediately relief is doing a root canal opening, no where does it say that giving antibiotics is first line treatment...

Heck no, I'm not doing any root canal openings in the ER. If the only complaint is "toothache" (from the acute pulpitis) and there isn't any swelling, difficulty breathing, talking, or swallowing or fever, then it's not an emergency. The patient can get some nice, strong, pain meds and come back to the dental clinic at 9 am the next day.

toothie · May 4, 2005

omfresident said:
They don't even bother calling us for pulpitis, I don't care how you want to manage this.

I tell pts at lease two days with abx, to calm down infection for better anesthesia. If I saw a pt in the ed, they get an I+D this actually has more to do with decreasing spread of infection than abx. These are basics in any text book.

I and D in case the person has a swelling is definately first line treatment and not giving antibiotics..

toothie · May 4, 2005

griffin04 said:
Heck no, I'm not doing any root canal openings in the ER. If the only complaint is "toothache" (from the acute pulpitis) and there isn't any swelling, difficulty breathing, talking, or swallowing or fever, then it's not an emergency. The patient can get some nice, strong, pain meds and come back to the dental clinic at 9 am the next day.

i was mentioning about emergency condition in he dental office. even i know its not possible to do a RC opening in an ER.
in case a person comes complaining of sereve pain .. due to acute pulpitis and the treatment plan is to do a Root canal. in that case doing an RCO in the dental clinic is first line treatment and not giving antibiotics , sending the patient home and rescheduling him for treament for 9 days.

north2southOMFS · May 5, 2005

omfresident said:
And, what program are you in, were you have enough time to exo teeth, no floor pt to manage, any real trauma? Do they not let you do mid-face? With all this time you can do some reading.

Oh, if you only knew the scope of practice of our program. If I were you I'd ask around before making the above statement.

stinkycheese · May 5, 2005

DrJeff said:
1st off, why hadn't the mother sought out dental care for this 13 year old before, afterall you just don't get an endodontic lesion overnight. I bet that if you were to look in their kitchen you'd see many, many sugary foods that MOM bought for her son

How is this relevant? If a kid eats sugar, then damn it, he better expect to end up in a coma from a stupid DENTAL problem?

stinkycheese · May 5, 2005

toofache32 said:
My point is that the media likes to point fingers and the doctors are the easiest target for the lay public, despite appropriate care and self-neglect on the patient's part.

Necrotizing fasciitis has nothing to do with patient neglect. It is an extremely deadly, opportunistic infection that even if treated immediately, stands little chance of being cured.

stinkycheese · May 5, 2005

TaliaTN said:
How long did the tooth hurt? Did a dentist tell her he needed a RCT 3 years ago and she "didn't have the money" or time to take care of it?

I wonder why this is in quotes. Dental care IS ridiculously, prohibitively expensive. It even makes ME want to never go to the dentist and I am not in poverty. It is a shame that it is so difficult to find affordable dental care. It is a real issue, whether you want to acknowledge it or not.

aphistis · May 5, 2005

stinkycheese said:
Necrotizing fasciitis has nothing to do with patient neglect. It is an extremely deadly, opportunistic infection that even if treated immediately, stands little chance of being cured.

Gee, thanks, Gomer. Is there anything else the surgery residents here need to know before you start school this summer?

stinkycheese said:
Dental care IS ridiculously, prohibitively expensive. It even makes ME want to never go to the dentist and I am not in poverty.

Then don't go. Just like any other area of medicine, if it's not worth the cost to you nobody's going to force you to take care of it.

TaliaTN · May 5, 2005

stinkycheese said:
I wonder why this is in quotes. Dental care IS ridiculously, prohibitively expensive. It even makes ME want to never go to the dentist and I am not in poverty. It is a shame that it is so difficult to find affordable dental care. It is a real issue, whether you want to acknowledge it or not.

Yeah, dental care is expensive. So is medical care. So are cigarrettes, chewing tobacco, new cars, big homes. Getting your oil changed is expensive. So is an education. I could go on and on. Everything is expensive to somebody. EVERYONE has to prioritize. I have patients that say 4 cleanings a year is just "too much" and these people really NEED it. A lot of them are physicians. Many have insurance. That works out to be about $100 a yr extra in my area. The same forks are somtimes spending $1200 a year plus on cigarettes and hundreds on video games and sneakers for their kids. I'm not saying this mother did all these things, but It would suprise me if she didn't! Expensive doesn't give you an excuse to neglect your children... you find a way and work it out. Or you put forth *some effort* and try to make sure they never get in the situation in the first place... you know, prevention?!

TaliaTN · May 5, 2005

stinkycheese said:
How is this relevant? If a kid eats sugar, then damn it, he better expect to end up in a coma from a stupid DENTAL problem?

No but its an issue of responsibility. The mother contibuted to the diease in her child, hypothetically, since we don't know all the facts in the case. She was maybe neglectful by not seeking preventive care and not making his health a major priority ( sending an underage kid to be with her son for a coplex procedure??).

People like to minimize dental disease and this goes to show how dramatic it can really be if you look at it that way. Lets say the kid had a broken arm. The mom thought it might be broken, but she hadn't taken him to a doctor, so really she didn't know how bad it was. Sometimes he complained that it hurt, but not too much so she thought it was okay. She kept taking him to school and making him do chores with the broken arm. She never offered him advil or anyting. How could she possibly know how serious this was?? It grets worse and worse so she takes him to the hospital. They schedule him for surgery, but she can't take him... his 16 year old sister will have to do it. Well, now the doctors wont operate because no one old is there to sign his consent form or listen to post-op instructions. By the time the doctors get to work on it, the patient is dead.

Now do you think the mom contributed to his disease? Try to look at things from another perpective. Because medical care is expensive does that exclude her from seeking treatment for her son?

This is all hypothetical and the public will never know all the facts to the case. Its just sad things turned out like they did.

stinkycheese · May 5, 2005

aphistis said:
Gee, thanks, Gomer. Is there anything else the surgery residents here need to know before you start school this summer?

Hahahaha, I love how you put your two cents in all over the medicine forums, but lord forbid someone puts their two cents in on your precious dental forum. Anyone who knows anything about necrotizing fasciitis (which includes me) knows what I posted. Just because I haven't started medical school doesn't change the fact that what I posted is accurate, factual, and correct.

Then don't go. Just like any other area of medicine, if it's not worth the cost to you nobody's going to force you to take care of it.

Medical care is generally better covered by insurance plans than dental care. And I have never heard of someone being turned away from an ER because they couldn't pay, but I have heard of people with cavities who don't have insurance (which in many places, is only available through work), can't afford the treatment, and don't get treated. Dentists have a lot more freedom to refuse care based on ability to pay than do physicians, which may be why you're all rolling in it with the master lifestyle while the physician's lifestyle is getting worse and worse. I'll still take the latter, though.

aphistis · May 6, 2005

stinkycheese said:
Hahahaha, I love how you put your two cents in all over the medicine forums, but lord forbid someone puts their two cents in on your precious dental forum. Anyone who knows anything about necrotizing fasciitis (which includes me) knows what I posted. Just because I haven't started medical school doesn't change the fact that what I posted is accurate, factual, and correct.

And you haven't answered my question. Also, I'd challenge you to find the last time I flatly contradicted a medical resident on a topic in their area of expertise.

Medical care is generally better covered by insurance plans than dental care.

This is our fault?

And I have never heard of someone being turned away from an ER because they couldn't pay, but I have heard of people with cavities who don't have insurance (which in many places, is only available through work), can't afford the treatment, and don't get treated.

I'm no physician, but my understanding is that there's a lot more to medicine than the ED.

Also--hold the phone here. Are you proposing that the economically underprivileged have poorer access to health care than the wealthy? What a revolutionary concept!

Dentists have a lot more freedom to refuse care based on ability to pay than do physicians, which may be why you're all rolling in it with the master lifestyle while the physician's lifestyle is getting worse and worse. I'll still take the latter, though.

I'll take one lifestyle specialty--hold the sour grapes, please. 😀

Teenager in Coma after Dental Infection at Montefiore Hospital

Full Member

Full Member

Professional Jackass

Membership Revoked

Oral Fixation

Senior Member

Full Member

Full Member

Membership Revoked

Member

Welcome to Thunderdome

Full Member

Member

Welcome to Thunderdome

Full Member

LSR1979

45540

45540

Member

Full Member

Junior Member

Oral Fixation

Full Member

Some random guy

Full Member

Welcome to Thunderdome

Junior Member

Full Member

Full Member

Senior Member

Junior Member

Junior Member

Oral Fixation

Junior Member

Senior Member

Full Member

Welcome to Thunderdome

Oral Fixation

Full Member

Senior Member

Senior Member

Yummy.

Stinky and Cheesy

Stinky and Cheesy

Stinky and Cheesy

Full Member

Member

Member

Stinky and Cheesy

Full Member

Similar threads