January 1, 2005
by Ross D. Anderson, DDS, MSc, FRCD(C)
In this issue of Oral Health, Dr. Keith Titley has published a case report regarding a child who was admitted with a facial cellulitis to hospital, placed on IV antibiotics for 17 days and discharged. The child never saw a dentist. Bizarre as this might seem, it can still happen.
As I sat down to write this editorial and reflected on my work day, I marveled at how well cases are managed at our hospital.
A two and a half year old came into the emergency room at 0330 hours this morning with a swollen face. A dentist in the community had diagnosed the child with an abscessed maxillary primary incisor 4 days previously. The dentist placed the child on Amoxicillin with the intent of seeing the patient one week later to extract the tooth. The child now had a notable labial cellulitis. This space infection had crossed into the caninus space that is continuous with the periorbital space. The nasolabial fold was obliterated on the affected side and the cellulitis was rapidly extending to the infraorbital area. The child was irritable and had not slept well. The emergency room physician (ERP) ordered IV Clindamycin for the child and maintenance intravenous (IV) fluids. Wisely, the ERP kept the child NPO and kindly waited until 0700 hours to page the paediatric dentist on call. I saw the patient at 0800 and noted a labial/caninus cellulitis with fluctuance in the labial mucobuccal fold. Our staff took appropriate radiographs. I quickly called up to the operating room (OR) and put the child on the wait list for the end of the day. The child went from the emergency room up to the day surgery area.
We then did rounds with the dental students and staff. As part of our daily rounds process we triage any new consults or out patient referrals. A consult note had been faxed down from haematology/oncology regarding a five-year-old that had been diagnosed the previous day with acute lymphocytic leukemia. The patient was inserted into the consult spot held open during the elective clinic that was running that morning.
The clinic began with the staff directing me from patient to patient reviewing histories with the dental students. The oncology patient came down from the inpatient unit, had a history taken, an examination and appropriate radiographs. Caries that were not invading the pulp were noted and I paged the oncologist. The oncologist answered within 30 seconds and we agreed that given the child’s neutropenic state and an understanding of the progress of dental disease in the primary dentition, we would treat the caries at day 28 when the next round of chemotherapy was to be given.
Our work would be combined with a bone marrow aspiration and lumbar puncture for the intrathecal chemotherapeutic medications. I spoke with the family and obtained informed consent. I discussed our mouth care protocol for oncology patients and gave them a handout that we had developed with the haematology/oncology service’s input.
The staff completed all the paper work and I spoke with our nurse so that everything could be put in motion to ensure that the case could be done within the specified window of time.
The rest of the day was routine. An elective clinic in the morning and to the OR in the afternoon for the elective treatment of a three-year-old developmentally delayed child with severe early childhood caries.
At about 1600 hours, after all the elective rooms in the OR had finished, there were enough nurses available to do our wait list case. Under general anaesthesia I removed the abscessed 61 and the three other grossly decayed primary incisors. I did an incision and drainage in the mucobuccal fold that resulted in an immediate gush of approximately 1.0 cc of purulent exudate. I cultured the pus aerobically and anaerobically. I inserted a penrose drain and the child went off to the recovery room.
As I was pulling into my driveway at 1900 hours the day surgery nurse paged me to ask if the child could have his IV Clindamycin 30 minutes ahead of schedule so that the child could be discharged home through day surgery as opposed to going back down to the very busy emergency room for the next dose of IV Clindamycin. I thanked the nurse for her thoughts on behalf of the little one and the IV Clindamycin was given, the IV heplocked and the child sent home.
I saw the little one the next morning in the paediatric dental unit and removed the drain. The nurse in our unit gave him another dose of IV Clindamycin and then discontinued the IV. I gave the family a prescription for oral Clindamycin. The parents were delighted that his facial swelling had gone down and he was back to himself. Our nurse called the family 24 hours later and the child was continuing to improve.
In review, a well-oiled machine. Multiple sequential tasks by many individuals to care for the patients. Incredible interdisciplinary teamwork. An extensive collective mind with the child and the family at the centre of focus–and just for teeth! Necessary– absolutely–shining examples of the importance of oral health as it relates to general health.
But how did it get this way? Across the country similar stories unfold daily in tertiary care teaching hospitals that have dental services.
In our case, the service that the dental department provides is highly valued within the hospital. Our facility is accredited with the Canadian Commission on Dental Accreditation and our Administration and Board of Governors is encouraged by the standards that we have met. In addition, we have worked hard to teach physicians and nurses about the value in oral health care for patients.
When I arrived at the hospital in 1991, the case of cellulitis that I treated today would have involved a three-day admission. Management is now accomplished within an efficient 24-hour period. Only those with dehydration, trismus, dysphagia, dysphonia or who are “glassy eyed” sick are admitted. This has occurred through a desire for better patient care and respect for families. We have spent time doing rounds with our ERPs, local paediatricians and nurses.
The Emergency room staff have been most helpful in making the observation unit available and in providing follow-up IV antibiotics so that patients can be treated on an out patient basis. This has been done through hard work and letting the physicians know what our service is capable of offering. The anaesthetists and OR staff have been equally helpful in appreciating our needs. We have been honest in utilizing after-hours wait list time for emergent care only.
In the case of the oncology patient, we have spent time with the oncologists/haematologists and nurses offering discipline-specific rounds. They know our service places a high importance on their severely immuno-compromised population and we see all new oncology patients within 24 hours of admission.
We not only train undergraduate dental students but train medical clerks and interact with residents from all paediatric and surgical disciplines. We keep an open mind and learn from our colleagues as well. We respond promptly to consults, pages and telephone calls from our physician colleagues.
As well, we ensure that we are full members of the hospital structure. We sit on Medical Advisory Committee, Operating room committee as well as other hospital and Medical Staff committees and are committed to attending and participating actively in Medical Staff meetings. We have had departmental members be presidents of their medical staffs in their respective hospitals.
As presidents of medical staff they have sat on the board of the hospital. Many of the committee meetings occur at seven in the morning and at five or six at night and run into the evening…a significant time commitment!
We communicate effectively so that the administration understands the importance of oral health in relationship to general health, in the hope that the budget reflects our patient’s needs. If there are budgetary issues we have allies in our medical colleagues that will ask the questions of administration on our behalf as they recognize the value of our service.
WE ARE VISIBLE
So what’s t
he point? Many of you, if you are still reading, may have a visual image of the length of my arms required to pat myself on the back in this way. How does this reflect back to a 17-day admission for a cellulitis that is never seen by a dentist?
While the Romano Commission on the Future of Health Care in Canada spoke little about Dentistry specifically, it did note the need to change the scopes and patterns of practice of health care providers to reflect changes in how health care services are delivered, particularly through new approaches to primary health care. Romano noted that “changes in the way health care services are delivered, especially with the growing emphasis on collaborative teams and networks of health providers, means that traditional scopes of practice also need to change”.
The challenge for dentists is to integrate themselves into the collaborative (primary) health care team. How can we do this? Through much of dental school we are trained to work on our own and make independent decisions. Besides phoning a physician to ask, “if the heart murmur requires antibiotic coverage” we often have little interaction with them.
To have an efficient, well running dental service is important but it does not take place just by showing up to the OR to treat your patient and leaving. We need to integrate ourselves with the hospital and show a presence. We need to profile what we do. We need to do rounds for our emergency room physician colleagues.
We need to educate ourselves on how hospitals function. What is the hospital organizational structure and where does dentistry fit? Can it be profiled more? Can we add value for our patients? Do we make proper chart entries that acknowledge our presence as part of health care team? Do we participate after hours on committees? Consider looking at the standards for the Commission on Dental Accreditation and having your service evaluated and accredited. As individual practitioners, many of whom are good at the business of dentistry, we have much to offer.
It is our job to continue to emphasize the value that oral health plays on general health. I am truly amazed at the collective human mind and the incredible discoveries and accomplishments that have been made through the sharing of knowledge. However, in order for the collective mind to work, the mind must be aware of all the parts to make it function on behalf of patients. In terms of hospital dentistry there are many contacts to make and educate. Just like a neurological pathway, the more we utilize the pathway and make it known to the brain, the more efficient it becomes.
Dr Anderson is Dentist-in Chief, IWK Health Centre, Halifax NS, and Contributing Consultant, Oral Health.
1.Building on values. The Future of Health Care in Canada – Final Report. R.J. Romanow. www.hc-sc. gc.ca/english/pdf/care/romanow_e.pdf
2.Dental Service and Health Facilities. www.cda-adc.ca/english/dentistry_in_canada/cdac/accreditation_requirements.asp