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W2 Case 2

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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

Clinical Considerations

  • Questions for parents?
  • Initial investigations before looking in mouth?

Initial Investigation and Findings

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 Findings

  • Temperature: 38.5 degrees C
  • Firm tender swelling localised to lower RHS
  • Weight: 18kg

Intraoral Examination3

  • Early mixed dentition
  • 46, 85, 84 visible
  • Large cavity with debris present at 85DO
  • Loss of Q4 buccal sulcular depth

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)
  • Dental caries
  • Failed existing restoration
  • Trauma (fracture)
  • Consideration of MIH (Molar Incisor Hypomineralisation) if HSPM is present

Radiographic Examination

Radiographic Modalities5

  • Size 0 bitewing
  • OPG
  • Vertical bitewing
  • PA with parent holding film

Radiographic Findings

  • Cavity extending to pulp
  • Furcation radiolucency
  • Accessory canals in furcation area

Pharmacological Management

Penicillin V Dosage

Dosage Calculation (18kg Patient)

  • Recommended Dose: 12.5mg/kg (up to 500mg) orally every 6 hours for 5 days
  • 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)

Medications Prescribed

  1. Penicillin V oral suspension
    • Concentration: 150mg/5ml (200ml bottle)
    • Instructions: Take 7.5ml orally every 6 hours for 5 days.
  2. Metronidazole oral suspension
    • Concentration: 40mg/ml (200ml bottle)
    • Instructions: Take 4.5ml every 12 hours for 5 days.
    • Note: For dental treatment only.

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

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.

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)

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.

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 Records

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

Footnotes

  1. Original PDF page 7: W2 Case Based Discussion 2, p.7 ↩

  2. Original PDF page 8: W2 Case Based Discussion 2, p.8 ↩

  3. Original PDF page 9: W2 Case Based Discussion 2, p.9 ↩

  4. Original PDF page 10: W2 Case Based Discussion 2, p.10 ↩

  5. Original PDF page 11: W2 Case Based Discussion 2, p.11 ↩

  6. Original PDF page 14: W2 Case Based Discussion 2, p.14 ↩

  7. Original PDF page 16: W2 Case Based Discussion 2, p.16 ↩

  8. Original PDF page 22: W2 Case Based Discussion 2, p.22 ↩

  9. Original PDF page 23: W2 Case Based Discussion 2, p.23 ↩

  10. Original PDF page 21: W2 Case Based Discussion 2, p.21 ↩

  11. Original PDF page 24: W2 Case Based Discussion 2, p.24 ↩

  12. Original PDF page 25: W2 Case Based Discussion 2, p.25 ↩

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