Will a good GPR train you to do I&D in the emergency room for odontogenic infections?

[Jumpman26]

Recently had this thought when a friend of mine had to go to the ED because of a buccal space infection. There was no OMFS on call to come drain the abscess. Just had me thinking about if a dentist with solid GPR experience managing fascial space infections could get privileges in a local hospital ED to come do I&Ds

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[Racquetball3r]

It should. Although I’ll say GPR residents who work at my hospital don’t get called for any of the odontogenic abscesses. If trained well, I think they could get comfortable draining superficial abscesses that are lateral to the mandible, and drainable intraorally. Any deep infections, infections medial to the mandible, threatening the airway, or needing percutaneous drainage should be managed by a surgeon.

It would be hard for an ED doc to be able to wade through when it’s appropriate for a dentist and when an OMFS is needed. So they’d just call the surgeon

 

[Screwtape]

It should. Although I’ll say GPR residents who work at my hospital don’t get called for any of the odontogenic abscesses. If trained well, I think they could get comfortable draining superficial abscesses that are lateral to the mandible, and drainable intraorally. Any deep infections, infections medial to the mandible, threatening the airway, or needing percutaneous drainage should be managed by a surgeon.

It would be hard for an ED doc to be able to wade through when it’s appropriate for a dentist and when an OMFS is needed. So they’d just call the surgeon

As a former GPR, this is a great answer. Although in my VA GPR we took all tooth call in the ED, anything beyond our comfort we’d call in the affiliated program’s OS resident on call. However, I have no idea why a general dentist would want to put themselves on any hospital ED call list for I&Ds… that’s crazy talk. For so many reasons.

 

[HungrilyCandid]

I did I&Ds at my GPR as well as my other classmates at their respective GPRs.

However, in private practice, I can't imagine that you'll be coming across this type of emergency that often. Once it's advanced, the patients are better off in the hands of OMFS/ENT than a general dentist. Even at a GPR, you most likely will not be treating these infections when they become an airway issue.

 

[DrJeff]

Getting on staff at one's local hospital for dental emergencies is likely to open one up to a plethora of calls from the ED at all hours of the day, 7 days a week, for things that there is no way you'd likely want to do in the ED, for among other little to no re-imbursement for your time and expertise, way too many "nuissance" calls for things like denture sores and re-cement crowns (etc), and the fact that you're more than likely to be the only dentist on staff, and as such will be the primary call from the ED 24/7/365.

The nobiltity of wanting to do good in select situations like you described in your OP is great, however the reality of what the system in place in a hospital ED with respect to dental issues, are often makes the reality completely polar opposite to what you wish it would be, and since dental is such a small billing aspect of any hospital, the reality is that trying to change it you what you would like isn't going to get past what the CFO of the hospital administration looks at much more than a short cursory glance at the proposal

 

[gryffindor]

If it was financially worthwhile for the OMS to show up, someone would have been there. The fact that none came to see your friend should be a major clue that a GP will get paid beans or less to show up as well.

 

[UncleJoesVeneers]

Recently had this thought when a friend of mine had to go to the ED because of a buccal space infection. There was no OMFS on call to come drain the abscess. Just had me thinking about if a dentist with solid GPR experience managing fascial space infections could get privileges in a local hospital ED to come do I&Ds

It's not beyond the scope of practice for an ER physician or PA to do I&D for an intraoral abscess. Anyone can make a 2mm vertical incision in an abscess. Anything more severe than that likely isn't going to be drained anyway, but managed with antibiotics first.

 

[Racquetball3r]

It's not beyond the scope of practice for an ER physician or PA to do I&D for an intraoral abscess. Anyone can make a 2mm vertical incision in an abscess. Anything more severe than that likely isn't going to be drained anyway, but managed with antibiotics first.

What is your training? I haven’t found any of what you said to be true.
-I have never seen an ED physician even attempt I&D for odontogenic abscess.
-Making a 2mm incision would never be adequate to drain an abscess. It also likely would not be dependent drainage, and many would need drain placement anyways.
- It is (almost) never appropriate to treat an infection that has progressed to abscess with antibiotics alone.

 

[DrJeff]

What is your training? I haven’t found any of what you said to be true.
-I have never seen an ED physician even attempt I&D for odontogenic abscess.
-Making a 2mm incision would never be adequate to drain an abscess. It also likely would not be dependent drainage, and many would need drain placement anyways.
- It is (almost) never appropriate to treat an infection that has progressed to abscess with antibiotics alone.

With respect to the skill set of the ED physicians, I think (anecdotally) that some of it will be based on the location of the hospital. Such as in a more rural location, where less specilaists are readily available, you will tend to see an ED staff doing a few extra things compared to an ED staff in a more urban setting where specialists are more readily available. So location can play a role in things, depending on the comfort level of the ED doc

 

[HungrilyCandid]

It's not beyond the scope of practice for an ER physician or PA to do I&D for an intraoral abscess. Anyone can make a 2mm vertical incision in an abscess. Anything more severe than that likely isn't going to be drained anyway, but managed with antibiotics first.

Removing the source of infection or flushing out the anaerobic bacteria is the ideal approach vs simply just RXing abx. Recommending that antibiotics will take care of an abscess that requires I&D is borderline irresponsible advice IMHO. It is not a magic cure.

This approach is what has led to the antibiotic resistance crisis we are experiencing in medicine. In dental school, an endodontist I loved working with would rarely RX abx. He was adamant about us just finishing the RCTs. The abscesses would go away. Yes, I realize this is anecdotal but he was trained at a renowned Endo program which is evidence-based.

Literature:

"The main conclusion is that, unfortunately, the prescribing practices of dentists are inadequate and this is manifested by over-prescribing."

Antibiotic prescribing practices by dentists: a review

Antibiotics are prescribed by dentists for treatment as well as prevention of infection. Indications for the use of systemic antibiotics in dentistry are limited, since most dental and periodontal diseases are best managed by operative intervention and ...

www.ncbi.nlm.nih.gov

"When given in addition to incision and drainage, systemic antibiotics do not significantly improve the percentage of patients with complete resolution of their abscesses"

Systemic antibiotics after incision and drainage of simple abscesses: a meta-analysis - PubMed

When given in addition to incision and drainage, systemic antibiotics do not significantly improve the percentage of patients with complete resolution of their abscesses.

pubmed.ncbi.nlm.nih.gov

"In immunocompetent patients with no confounding risk factors, incision and drainage under local anesthetic is generally sufficient for abscess management. There is no compelling evidence for routine cultures or empiric treatment with antibiotics."

Evidence-based approach to abscess management

To provide family physicians with an overview of the evidence for managing superficial cutaneous abscesses.PubMed (from 1950), EMBASE (from 1974), The Cochrane Library (from 1966), and Google (from 1998) were searched as were reference lists of identified ...

www.ncbi.nlm.nih.gov

I'm not necessarily saying that antibiotic therapy after incision and drainage for simple abscesses cannot be associated with improved cure rate and decreased recurrence, but it is not always even necessary.

 

[PerioDont]

just because you can do something does not mean you should and it definitely does not mean it will be profitable

 

[UncleJoesVeneers]

What is your training? I haven’t found any of what you said to be true.
-I have never seen an ED physician even attempt I&D for odontogenic abscess.
-Making a 2mm incision would never be adequate to drain an abscess. It also likely would not be dependent drainage, and many would need drain placement anyways.
- It is (almost) never appropriate to treat an infection that has progressed to abscess with antibiotics alone.

I did a GPR. Did a rotation in emergency medicine. Then did NHSC dentistry for several years where I dealt with a lot more than your typical private practice dentist. And now I am in endodontics residency where we do I&D all the time ... My point was clearly regarding routine intraoral abscesses. I don't think there are many GPRs training general dentists to manage fascial space infections. We learned to intubuate (how useful).

 

[UncleJoesVeneers]

Recommending that antibiotics will take care of an abscess that requires I&D is borderline irresponsible advice

That's not what I said. I said "anything more severe than that" is likely not going to be drained. You can't drain every cellulitis. This discussion is regarding dentists being on call for an ER. I'm simply providing a point that it's not really necessary.

 

[SilkyJ]

To answer the question being asked, it depends on the GPR program and the attitudes of everyone involved. At my hospital, the GPRs damn well better learn to do I&Ds, because OMFS is not coming in the middle of the night to drain a vestibular or buccal abscess, and it better not still be sitting there in the morning. However, I don’t believe any GPR will train you to manage sublingual, submandibular, or any parapharyngeal infections. Most GPRs can’t even spell platysma, let alone manage a legitimate multi-space infection.

 

[Screwtape]

To answer the question being asked, it depends on the GPR program and the attitudes of everyone involved. At my hospital, the GPRs damn well better learn to do I&Ds, because OMFS is not coming in the middle of the night to drain a vestibular or buccal abscess, and it better not still be sitting there in the morning. However, I don’t believe any GPR will train you to manage sublingual, submandibular, or any parapharyngeal infections. Most GPRs can’t even spell platysma, let alone manage a legitimate multi-space infection.

“Tell me that you’re an OMFS without telling me you’re an OMFS.”