How often does this happen post-op?

[TSDentSurg]

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Well, I've got some terrifying news to report about my patient. Just for the record, my patient is a 50 year old Czech female s/p GBR to repair a three-wall alveolar defect in the #29 site. PMH significant for adult-onset DM. PSH significant for RCT of #29 with PFM restoration. Current medications include metformin, Periostat, Periogard, and Vicodin.

http://forums.studentdoctor.net/showthread.php?t=1026108
http://forums.studentdoctor.net/showthread.php?t=1026623

She presented to the ER complaining of numbness of the right lip and fever. She was seen by one of our dental registrars, who saw dehiscence of the surgical site, which was inflammed and suppurative. He ordered an OPG, sent a sample of the pus to the lab for cultures, and paged my consultant. So I was dragged away from partying with some of my tranny friends after a long week in surgery and clinic.

When me and my consultant arrived, we reviewed the OPG, which showed nothing out of the ordinary save for the surgical hardware.

I suggested getting a CT scan, but my consultant said that the metal present would cause severe artifacts, so he told me to take the patient up to neuroradiology to get a MRI (neuroradiology covers for OMFR after hours; their MRI machine has software that can compensate for metal artifacts).

When we reviewed the MRI with the neuroradiologist, we found that the entire dentoalveolar process from 28-30 is severely inflammed, and there was a periapical abscess of #29, due to a small hairline root canal near the apex I apparently couldn't see with my loupes, thus missing it. We didn't see an abscess on the original PA radiographs, so it must've developed over these past days.

My consultant made a diagnosis of acute odontogenic osteomyelitis, and told me to page OMS immediately while he went to talk with the patient's son to explain what was going on.

When I paged the OMS team, I was told there was a major bus accident, and all of our OMSs were tied up fixing facial fractures. I went to go tell my consultant that OMS is unavailable, and I ran into a medicine registrar. I told him that we have a patient septic due to acute odontogenic osteomyelitis, and she needs admission for IV antibiotics.

He started saying "No, that's OMS, you should call them. I don't deal with post-surgical stuff." I screamed at him "She's ****ing septic, and she needs to be admitted. We tried OMS, and they're busy. You better admit my patient or you will be OMS's next case." Nothing scarier than a 6'5" punk rocker tranny screaming in your face.

He came down to eval our patient, and started her on IV fluids and IV clindamycin. I told my consultant that OMS is busy. He said that there's no time to wait for OMS, we have to remove the graft, and paged his dental anesthesiologist colleague (actually an MDA who decided to practice exclusively anesthesiology in dental cases for financial reasons).

So me, my consultant, and the dental registrar took the patient to a free OR. The DA induced GA and nasally-intubated her. I removed the sutures and the membranes, and irrigated the site. My consultant then removed the graft, and then we started debriding the bone. We decided to simply do a radical alveolectomy of the #29 site down to the basilar bone rather than do an apicoectomy in an attempt to save the tooth after debriding the infected bone (#28 and #30 sites were salvageable). We then packed the resection site with antibiotic beads (I made them!) to obliterate dead space, and closed the site.

The patient is currently in ICU, and my consultant has ordered an In-111 WBC scan for the morning, and OMS will be seeing her then.

That was a nightmare. I was SO hopeful she'd be able to keep the tooth! Now she's in ICU with a serious bone infection, and will now need another graft and placement of implant. I think I have a taste of just how hard OMS works, as they deal with this stuff on a daily basis. And I now know it is possible to run in 7" stiletto stripper boots.

 

[FlyingSky]

I'm a student going D2, I dont understand everything you wrote but I want to thank you for sharing with us, really really interesting.

 

[TSDentSurg]

I'm a student going D2, I dont understand everything you wrote but I want to thank you for sharing with us, really really interesting.

Basically, the root canal we did prior to bone grafting was incomplete unbeknownst to us, and an abscess formed. This lead to the graft and surrounding bone becoming infected. So we had to remove the infected graft and bone.

 

[TSDentSurg]

Anyone want to respond?

 

[theartofzahn]

only in prague

 

[TSDentSurg]

only in prague

I bet.

 

[DentinBond]

In these cases we have to remember that it all comes down to the virulence of bacteria and the intricacies of the host defenses.

I mean, the human immune system is the one, the only, the sui generis thing on the planet that's more complex than the United States Tax Code.

And one of the most important things to keep in mind about the bugs is how complex is the chemical milieu (soup? swamp?) that is their world. They hit each other with toxins and attractor molecules. They share DNA and RNA with plasmids and direct contact. A key question: is your infection due to bacteria in their planktonic form, or have they sent out quorum sensing proteins and formed a biofilm? A much more defensible structure, from their standpoint.

(Quorum sensing proteins are, as far as I'm concerned, the coolest discovery in biology of the last two decades. Those little buggers talk to each other!)

As for the host, doesn't it all depend on what the person's own individual "library" of immune responses is, and how rapidly the host can activate the proper antibodies and T-cells and all those other smart bombs and laser-guided missiles that reside in the human immune system's armamentarium? Plus we need to remember that antibiotics may be a highly useful adjunct, but in the end, they're only there to slow things down and buy time; the immune system is still the bit that does all the heavy lifting.

Hence, the heartache for us dentists. We can do the same procedure, essentially, for hundreds, maybe even thousands of patients, and the one that has the terrible complication relating to infection was, to our macroscopic eyes, just the same as all the rest.

Only they weren't.

Some nasty little prokaryote went like this:
1-2-4-8-16-32-64-128-256 and as you see if you do that just a few more times, at half an hour a shot, pretty soon we're into real money, as they say in Congress when they're talking billions-with-a-b not millions-with-an-m.

Years ago I saw a patient my own age who had almost every possible dental diagnosis: caries, endodontic infections, periodontitis, fractured teeth... I never extract impacted third molars, wisely leaving that for my oral surgeon colleagues, but she was in pain from a fully erupted thirdie and I confidently removed it in one of the most predictable, atraumatic extractions I can remember from my entire career. After all, her body was rejecting the literally bloody thing, and it was already loose. And then she got such a severe post-operative infection that she became seriously trismatic. Airway closure would be next so I referred her to my splendid oral surgeon colleague who loaded her with antibiotics and did an incision and drainage in the O.R. and monitored her overnight. She fully recovered with astonishing rapidity.

It was the germs and the host, not the specifics of the procedure. If only we could predict this sort of thing.

 

[Bitters]

How often does what happen? A patient developing a post op infection, or a complete overreaction and over management of the situation.