Antibiotic cover

BACKGROUND: Ms G attends her dental surgery for an emergency appointment, complaining of intense pain in her lower jaw. Clinical assessment and radiographic investigation reveals a wisdom tooth that has a soft tissue impaction, is extensively decayed, but not intimately involved with the inferior dental nerve canal. The dentist – Dr K – advises extraction and Ms G consents to the procedure.

It is noted in Ms G’s medical history form and in the notes that she suffers from hypothyroidism.

Local anaesthetic is administered, a small incision made in the overlying soft tissue and the tooth extracted with forceps and elevators. Haemostasis is achieved and Dr K provides post-operative instructions. Ms G is advised to return if she experiences any fresh bleeding, pain not controlled with painkillers, or abnormal swelling.

The next evening Ms G is brought to A&E by her partner. She complains of excruciating pain in her jaw. Her face and neck are swollen and she has trouble breathing. Ms G undergoes an emergency procedure under general anaesthetic to drain a buccal space infection. She is admitted to a hospital ward and discharged two days later.

A solicitors letter is later received by the practice claiming damages for clinical negligence in failing to take heed of Ms G’s concerns over her autoimmune condition and to offer post-extraction antibiotics as a precaution against infection.

It is alleged that had her concerns been properly heeded and antibiotic cover provided, Ms G would have avoided unnecessary surgery and a hospital stay – as well as enduring distressing pain and difficulty breathing due to the swelling adjacent to her airway.

ANALYSIS/OUTCOME: MDDUS reviews the case and commissions an expert report from an oral surgeon who examines the case documents and radiographs. She concludes that extraction of the tooth was clearly indicated and the notes indicate Ms G was appraised of the risks and potential complications.

The notes also indicate that Dr K was made aware of Ms G’s hypothyroidism . The expert acknowledges that the use of prophylactic antibiotics was common in the past but that this pattern of clinical care has changed considerably in the last 15-20 years with the heightened awareness of antibiotic resistance. Recently the Faculty of General Dental Practice (now College of General Dentistry) released guidance in which it cites systematic reviews which have concluded that there is no evidence to support the routine use of prophylactic antimicrobials in reducing the risk of postoperative complications after extraction of wisdom teeth, or teeth requiring surgical extraction.

The guidance does recognise that prompt, aggressive management of dental infections in immunocompromised patients is imperative and should be carried out in conjunction with the patient’s specialist, but there is no evidence to support the increased risk of surgical site infections (SSIs) arising as a result of dental procedures in these patients.

The expert reviewer concludes that postoperative antibiotics would not have been indicated in this case and there is no evidence to support that such a prescription would have influenced the clinical outcome. Despite careful surgery in a clean environment, post-operative infections will still occur and cannot be predicted or avoided through routine prescription of antibiotics.

A letter of response citing the expert evidence is drafted by MDDUS with approval by Dr K and the case is subsequently dropped.

KEY POINTS

• Ensure patients understand risks and potential complications.
• Address any patient concerns regarding real or perceived risks.
• Ensure notes clearly record these discussions.