W2 Case 2_integrated

Case 2: Dental Infection and Extraction

Patient Presentation¹

5.5-year-old boy
Presented to surgery this afternoon
Lower right-hand-side submandibular swelling started this morning
Lecturer noted: Parents report the child has never seen a dentist before.

Medical and Dental History²

Medically fit and well, immunised
History of chronic nocturnal pain
- Worsened over past few days
- Managing with analgesia
No previous swellings or history of trauma
No prior dental treatment

Clinical Considerations

Questions for parents?
Initial investigations before looking in mouth?
==Facial Swelling Dynamics: Swellings can occur very quickly if an infection is not draining and tracks into the soft tissue. A child may be fine or have minor pain the night before, and the face may “blow up” by the following morning.==
==Systemic Involvement: It is critical to determine if the infection is localized or showing systemic signs.==
- ==Fever: The most common systemic sign.==
- ==General Malaise: The patient may appear miserable, tired, withdrawn, or “off.”==

Initial Investigation and Findings

==Vaccination Status: Necessary to rule out conditions like Mumps, which usually presents as bilateral swelling but can be unilateral.==
==Pain History Details:==
- Type of pain (lingering vs. non-lingering).
- Location (swelling on one side does not rule out a painful tooth on the contralateral side).
- Aggravating/Relieving factors.
==Analgesia Use: Determine if the parents have already been administering pain relief.==

Clinical Findings

Temperature: 38.5 degrees C
Firm tender swelling localised to lower RHS
Weight: 18kg
==Extraoral Examination:==
- ==Palpation: Firm, tender swelling localized to the lower right-hand side (submandibular).==
- ==Location: Submandibular swelling around the angle of the mandible or underneath is typically associated with lower teeth (as opposed to buccal swelling, which is often maxillary).==
- ==Visual: Overlying redness from inflammation may be present.==
==Temperature: Vital to check for fever to assess systemic spread.==

Intraoral Examination³

Early mixed dentition
46, 85, 84 visible
Large cavity with debris present at 85DO
Loss of Q4 buccal sulcular depth
==Soft Tissue: The sulcus may look swollen or feel full upon palpation due to underlying inflammation or localized infection.==

Diagnostic and Management Planning

Possible causes of 85 cavity?
What will you see on an x-ray?
Plan for today’s management
Calculate dosages of any medications used (18kg)

Differential Diagnosis for 85 Cavity⁴

HSPM (Hypomineralised Second Primary Molar)
- Note: If a child has HSPM, they have a 2.4 to 10 times higher chance of having similar defects in the permanent dentition.
Dental caries
- Likely an occlusal lesion that has spread.
- Note: Contact point caries is less likely as the 46s have not been erupted long enough for significant progression.
Failed existing restoration
- A previous filling that has fallen out.
Trauma (fracture)
Consideration of MIH (Molar Incisor Hypomineralisation) if HSPM is present
==Secondary Caries: Caries secondary to an enamel defect or breakdown.==

Radiographic Examination

Radiographic Modalities⁵

Size 0 bitewing: Preferred if the child can tolerate it.
OPG: An option if the child is uncooperative due to pain, though it provides less detail.
Vertical bitewing
PA with parent holding film: A PA can be taken with the parent holding the film (using a "carrot" technique) so the child does not have to bite down on a sore area.

Radiographic Findings

Cavity extending to pulp
Furcation radiolucency
- In primary molars, signs of infection are most likely seen in the furcation region rather than the apex due to numerous accessory canals.
Accessory canals in furcation area
==Comparison: To confirm a lucency, compare the area to the contralateral side or the opposing arch to observe differences in bony trabecular patterns and the PDL space.==

Pharmacological Management

Penicillin V Dosage

Dosage Calculation (18kg Patient)

Recommended Dose: 12.5mg/kg (up to 500mg) orally every 6 hours for 5 days
- Standard range: 12.5 mg/kg to 17.5 mg/kg.
Calculation: 12.5mg x 18kg = 225mg
Preparation: Oral suspension 150mg/5ml
Administration: 7.5ml every 6 hours for 5 days

Metronidazole Dosage⁶

Dosage Calculation (18kg Patient)

Recommended Dose: 10mg/kg (up to 400mg) orally every 12 hours for 5 days
Calculation: 10mg x 18kg = 180mg
Preparation: Oral suspension 40mg/ml (equivalent to 200mg/5ml)
Administration: 4.5ml every 12 hours for 5 days
Recommended Dose: 10mg/kg (up to 400mg) orally every 12 hours for 5 days
Calculation: 10mg x 18kg = 180mg
Preparation: Oral suspension 40mg/ml (equivalent to 200mg/5ml)
Administration: 4.5ml every 12 hours for 5 days

Prescription Documentation

Prescription Details

Patient: Riley Child (DOB: 2/1/2020, Weight: 18kg)
Address: 12 Macarena Place, Claremont WA 6010
Date: 1/1/2025
Prescriber: Dr Senior Student DMD (Prescriber no. 11094567)
Instructions must include the specific milligram dose, volume (ml), frequency, and duration.

Medications Prescribed

Penicillin V oral suspension
- Concentration: 150mg/5ml (200ml bottle)
- Instructions: Take 7.5ml orally every 6 hours for 5 days.
Metronidazole oral suspension
- Concentration: 40mg/ml (200ml bottle)
- Instructions: Take 4.5ml every 12 hours for 5 days.
- Note: For dental treatment only.
==Antibiotics: Combination of Penicillin V and Metronidazole per current guidelines.==
==Analgesia: Paracetamol and Ibuprofen can be used together for better pain relief; Ibuprofen provides anti-inflammatory effects.==

Extraction Appointment Preparation

Immediate Symptom Management⁷

Analgesia:
- Paracetamol: 15mg/kg, 4-6 hourly (max 4000mg/day)
- Ibuprofen: 10mg/kg, 6-8 hourly (max 2500mg/day)
Dietary Advice: Soft diet
==Antibiotic Delay: If the environment is too acidic due to infection, local anesthetic (LA) will be less effective. In non-systemic cases, antibiotics can be started first, with the extraction booked for 5 days later at “peak effectiveness.”==

Emergency and Follow-up Protocols

If symptoms worsen:
- Contact clinic immediately.
- Provide referral letter to PCH Dental. Call PCH Dental before the patient leaves the surgery.
- After hours: Attend PCH Emergency Department (ED).
Scheduled Treatment: Book for extraction of 85 in approximately 1 week.
==Hospital Referral (PCH/Local Hospital): Justified if there is significant swelling, fever, or systemic signs.==
==Regional Management: In rural areas, patients may be sent to a local hospital for IV antibiotics or flown to PCH via the Royal Flying Doctor Service.==
==Referral Protocol: Always call the hospital dental team first. Advise the patient on fasting status if surgery is imminent. Calling ahead allows the patient to be listed as “expected,” reducing wait times in the Emergency Department.==

Local Anesthetic Techniques

Topical Anesthesia Protocol

Agent: Topical lignocaine gel 2-5%
Procedure:
1. Dry surface
2. Apply with cotton bud
3. Leave in situ for 2 minutes
4. Wipe away with damp gauze

Injection Technique

Buccal and lingual infiltration (access lingual via interpapillary route)
==Effectiveness: LA is less effective in the presence of infection due to the acidic environment.==

Anatomical Considerations for Nerve Blocks

Pediatric vs. Adult Mandibular Anatomy

Ramus is shorter vertically in children.
Ramus is narrower anterio-posteriorly in children.

Local Anesthetic Agent Selection

Primary Choice: 4% Articaine with adrenaline 1:100,000
- Rationale: More effective mandibular infiltration and short acting time.
Alternative Choice: 2% Lignocaine with adrenaline 1:80,000
- Considerations: Acidic environment from infection may result in shorter acting time and require longer onset time.

Maximum Local Anesthetic Dose Calculation

Dosage Calculation for 4% Articaine (1:100,000)

Patient Weight: 18kg
Maximum safe dose calculation: 7mg/kg x 18kg = 126mg (Note: text indicates 146mg, but calculation 7x18 equals 126mg)
Concentration: 4% Articaine = 40mg/ml
Volume Limit: 126mg / 40mg/ml = 3.15ml
Cartridge Limit: 3.15ml / 2.2ml = 1.4 carpules

Surgical Procedure and Instrumentation⁸⁹

Surgical Instruments¹⁰

Forceps: Lower baby hawks
Luxators: 3S or 3C luxator
Forceps: Lower baby hawks
Luxators: 3S or 3C luxator

Extraction Technique¹¹

Luxator Use: Wedge around the tooth to separate PDL fibres; drive gently in an apical direction.
Forceps Technique:
1. Engage molar beaks at the furcation area.
2. Apply apical pressure (primary drive).
3. Move lingually.
4. Apply continuous buccal movement.
5. Remove tooth towards the buccal aspect.
The tooth (85) requires extraction once the infection is managed or if emergency intervention is required.

Post-Extraction Care

Immediate Post-Operative Steps¹²

Irrigate with saline to rinse out pus.
Apply digital pressure to compress socket walls.
Have patient bite on sterile gauze to achieve haemostasis.
Suture soft tissues if required.

Follow-up and Records¹³¹⁴¹⁵¹⁶¹⁷¹⁸¹²³⁴⁵¹⁹²⁰⁶²¹⁷²²²³²⁴²⁵¹⁰⁸⁹¹¹¹²²⁶²⁷²⁸²⁹³⁰³¹³²³³³⁴³⁵³⁶³⁷³⁸³⁹

Provide verbal and written post-operative instructions.
Complete clinical documentation.

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Quartz 4

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W2 Case 2_integrated

Case 2: Dental Infection and Extraction

Patient Presentation1

Medical and Dental History2

Clinical Considerations

Initial Investigation and Findings

Clinical Findings

Intraoral Examination3

Diagnostic and Management Planning

Differential Diagnosis for 85 Cavity4

Radiographic Examination

Radiographic Modalities5

Radiographic Findings

Pharmacological Management

Penicillin V Dosage

Dosage Calculation (18kg Patient)

Metronidazole Dosage6

Dosage Calculation (18kg Patient)

Prescription Documentation

Prescription Details

Medications Prescribed

Extraction Appointment Preparation

Immediate Symptom Management7

Emergency and Follow-up Protocols

Local Anesthetic Techniques

Topical Anesthesia Protocol

Injection Technique

Anatomical Considerations for Nerve Blocks

Pediatric vs. Adult Mandibular Anatomy

Local Anesthetic Agent Selection

Maximum Local Anesthetic Dose Calculation

Dosage Calculation for 4% Articaine (1:100,000)

Surgical Procedure and Instrumentation89

Surgical Instruments10

Extraction Technique11

Post-Extraction Care

Immediate Post-Operative Steps12

Follow-up and Records131415161718123451920621722232425108911122627282930313233343536373839

Footnotes

Graph View

Table of Contents

Patient Presentation¹

Medical and Dental History²

Intraoral Examination³

Differential Diagnosis for 85 Cavity⁴

Radiographic Modalities⁵

Metronidazole Dosage⁶

Immediate Symptom Management⁷

Surgical Procedure and Instrumentation⁸⁹

Surgical Instruments¹⁰

Extraction Technique¹¹

Immediate Post-Operative Steps¹²

Follow-up and Records¹³¹⁴¹⁵¹⁶¹⁷¹⁸¹²³⁴⁵¹⁹²⁰⁶²¹⁷²²²³²⁴²⁵¹⁰⁸⁹¹¹¹²²⁶²⁷²⁸²⁹³⁰³¹³²³³³⁴³⁵³⁶³⁷³⁸³⁹