Acute Dental Problems Clinical Case #1

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Question 1 of 3

1. Question
Susie is a healthy 4 year old who recently began attending pre-school. Her father received a call asking him to pick her up early one day. Susie had lost her appetite, was not playing with the other kids, and was quite cranky. He then brought her to your office for evaluation.

On exam, Susie shows little interest in interacting with either you or her father. Neither she nor Dad could add any additional historical details. They deny fever, cough, runny nose, ear pain, abdominal pain, urinary symptoms, and diarrhea. She has no new skin rashes, medications, or travel exposures. Her vital signs were completely normal. On physical exam no abnormalities are noted except the following finding on oral exam:

ICOHP

The correct diagnosis based on the photo is:
- Missing dental filling While it is possible that there was once a dental restoration on the first molar that has since been lost, the larger issue is the presence of the fistula indicating decay that has extended through the enamel and dentin to the pulp, resulting in inflammation, pulp necrosis and subsequent infection that has extended through the apex to form an abscess that subsequently drained through the fistula.
- Periapical abscess with fistula
- Granuloma A granuloma typically appears as a smooth or lobulated mass that grows rapidly and bleeds easily. They are not usually associated with an infected tooth, and are more common in adults with a source of local tissue trauma or in pregnancy. In this patient the raised area above the first molar represents a fistula through which pus from the abscess cavity drains. Lower photo depicts a pyogenic granuloma in a pregnant woman.
- Petechiae secondary to ITP In this child, although the gingival are irritated appearing, petechiae are not present. If thrombocytopenia were present, bleeding would typically be at the gingival margin.
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Question 2 of 3

2. Question
You correctly diagnose a fistulized periapical abscess. Dad tells you that Susie has never been to a dentist.

The most appropriate next step in management is:
- Immediate referral to a dentist for extraction of the tooth
- Observation in the hopes that the abscess will resolve on its own now that it is draining Observation will not result in resolution of this problem. To definitively treat this problem and prevent further complications such as invasive infection, Susie needs extraction of the tooth. Primary teeth that are necrotic and have periapical abscesses typically are extracted as root canal treatment is difficult in primary teeth and results unpredictable. If this was a permanent tooth, root canal treatment would also have been an option.
  
  Further, Susie has advanced Early Childhood Caries (photo) involving many teeth and needs to become established in a dental home to receive comprehensive care of her extensive disease.
- Start oral amoxicillin and see Susie back in a week for follow-up Oral antibiotics are not required for uncomplicated periapical abscesses. Antibiotics are only indicated if cellulitis is also present.
- Incise and drain the abscess Incision and drainage of an extensive fluctuant, painful abscess by an appropriately trained and experienced primary care clinician is reasonable if there is no access to a dentist for definitive treatment within a reasonable period of time. However, incision and drainage is only a palliative measure and does not address the underlying process. In this case Susie’s abscess is fistulized and therefore already draining, so incision and drainage is not necessary.
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Question 3 of 3

3. Question
Three weeks later Susie returns to your office with fever and facial swelling. You examine her mouth and see that the original problem tooth has been extracted, but gross decay remains in the molars in the mandible. You diagnose facial cellulitis which appears associated with one of the lower right molars.

Donald Greiner, DDS

The most appropriate choice for initial oral antibiotic therapy would be:
- Amoxicillin + clavulanate
- Ciprofloxacin Ciprofloxacin is not indicated as it has relatively poor gram positive and anaerobic coverage. Further, due to its higher potential for side effects in children than other first line antibiotics its use is usually reserved for when first line agents are contraindicated.
- Cephalexin The first generation cephalosporins have poor anaerobic coverage, so would not be good coverage for a facial cellulitis of dental origin.
- Trimethoprim/sulfamethoxazole Trimethoprim/sulfamethoxazole is useful for a number of common childhood infections, but is not a first line agent for oral infections. If a child is allergic to penicillins, clindamycin is a more appropriate substitute.
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Acute Dental Problems

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