Infection Postoperative dental infection is either acute or chronic. The dental practitioner should take the patient’s baseline body temperature before surgery to avoid confusing swelling from an infection postsurgery with iatrogenic traumatic swelling from the surgery itself. Postsurgical patient complaints that include malaise, a bad taste in the mouth, swelling, trismus, or pus drainage may indicate an infection. Odontogenic infections often can be treated effectively with either penicillin VK or amoxicillin. For moderate infections in an adult patient with no history of antibiotic allergy, penicillin VK can be given at a dosage of 250 to 500 mg three times daily (Ahmadi et al., 2021; Gilbert et al., 2016). However, in actual dental practice, the typical dosage for a moderate oral infection is 500 mg of penicillin VK taken four times a day for an adult patient and 250 mg for a pediatric patient for seven days. Amoxicillin is a broad-spectrum antibiotic that is often used as the first-line choice to treat patients who aren’t allergic to penicillins (Ahmadi et al., 2021). Recommended dosage is 500 mg four times per day. There is conflicting evidence as to whether antibiotics interfere with the effectiveness of oral contraceptives, but a recent review suggests there is a low level of concern when taking nonrifamycin antibiotics (et al., 2015; Simmons et al., 2018). Still, it is standard practice to warn female patients taking oral contraceptives of possible drug interactions that may occur and to advise the practice of alternate methods of birth control while taking a prescribed antibiotic regimen. A macrolide or lincosamide is preferred if the patient has penicillin sensitivity. Of the macrolides, azithromycin 500 mg on day one and then 250 mg daily for the following four days (e.g., Z-Pak) would be the drug of choice. Erythromycin should be avoided. Of the lincosamides, clindamycin 150 to 300 mg three times a day would be the drug of choice (Ahmadi et al., 2021; Gilbert et al., 2016). In actual dental practice, the typical dosage for a moderate oral infection is clindamycin 150 mg taken three times a day for seven days. If the infection is fluctuant, the preferred treatment is incision and drainage followed by antibiotic therapy (Ahmadi et al., 2021). When incision and drainage are required, the incision should be made through the mucosa and submucosa, and the wound should be undermined with a closed, curved hemostat to open loculations of pus in the abscess. A drain, as simple as a piece of dental dam, should then be placed. It should be sutured to the margin of the wound to keep the wound from closing until drainage has occurred. The dentist should obtain a Gram stain, aerobic and anaerobic cultures, and a sensitivity test. Sensitivity testing may indicate the need for clindamycin, penicillin plus metronidazole, or Ecchymosis Extravasation of blood in the tissue planes, if sufficiently superficial, presents as ecchymosis. In the patient’s face, ecchymotic areas drop into the tissue planes and become dispersed in the cervical areas, and sometimes they are drawn down onto the anterior chest wall. This sequence occurs occasionally as a complication of extractions when postoperative hemorrhage is inadequately controlled. Hemorrhage Often, hemorrhage can be averted by accurate and thorough medical history taking, evaluation, and questioning of the surgical patient before the procedure. Patients with a history of uncontrolled high blood pressure, bleeding complications, or genetic bleeding disorders, or those on anticoagulant therapy for conditions such as past stroke, atrial fibrillation, or blood clots in the legs, are at risk of hemorrhage. The dentist should consult the patient’s physician before scheduling surgery if there are concerns. If necessary, the patient’s physician can order appropriate blood tests, including a prothrombin time, partial thromboplastic time,
cephalosporin. Even though clindamycin therapy has been associated with severe colitis, with sometimes fatal results (Wu et al., 2015), it is still routinely used in dental practice as the antibiotic of choice for patients who have an allergy to penicillin (Ahmadi et al., 2021). Nevertheless, clindamycin should be reserved for serious infections for which less toxic antimicrobial agents are ineffective. Metronidazole has been demonstrated to be effective in treating mild to moderate Clostridium difficile infection (Banawas, 2018). While metronidazole has been the antibiotic of choice for the treatment of C. difficile infection, recent clinical trials have highlighted the use of a 10-day course of vancomycin or fidaxomicin as the first line of therapy for C. difficile infections (Kociolek, 2018). This type of infection can be asymptomatic or can be characterized by symptoms ranging from mild diarrhea to pseudomembranous colitis. Colitis is usually characterized by severe, persistent diarrhea and severe abdominal cramps. It may also be associated with the passage of blood and mucus. The practitioner must take care when prescribing a cephalosporin derivative for patients allergic to penicillin because of the possibility of allergic cross-sensitivity (Aiyaka & Techakehakij, 2019; Picard et al., 2019). Among patients who report penicillin allergies, an average of 2% will react if given a cephalosporin (Shenoy et al., 2019). However, medical history should be taken into consideration when assessing risk if a skin test has not been conducted. “In practice, only 5% to 10% of persons who have hypersensitivity reactions to penicillins have them with cephalosporins. In general, if a patient has had only a non-urticarial rash as the manifestation of penicillin hypersensitivity, then using cephalosporins is safe. For patients who have had urticaria or an anaphylactic reaction in response to penicillins, cephalosporins should be used with great caution” (Wynn et al., 2016). If the patient returns three to six weeks following the surgery with a postoperative infection, the diagnosis is typically a chronic or subperiosteal abscess. It is often a lingering, slow, chronic infection that develops below the periosteum, usually at the base of the surgical flap. This condition develops if small bone chips and/or debris were not removed by thorough debridement at surgery or because the patient’s postoperative oral hygiene was poor. Thus, proper irrigation and good oral hygiene are essential to help prevent chronic infection. A chronic or subperiosteal abscess requires the same type of treatment as acute infection. Thorough irrigation requires the retractor to be moved back and forth as irrigation progresses so that no debris is left at the base of the flap. Ecchymosis is typically seen in older patients, given their ease of bruising. The ecchymotic discoloration changes from black and blue to greenish yellow. Within one week, the sequela usually resolves. The practitioner should take steps to reassure the patient that the situation will resolve itself. If the slow bleed persists, however, it must be located and addressed. bleeding time, clotting time, and platelet count. If the patient’s blood pressure is uncontrolled, their physician may need to treat the patient with appropriate hypertension medication before the oral surgery takes place. Diastolic pressure is of concern because the patient will tend to have more postoperative oozing than normal. Hemorrhagic activity can be divided into two main types: Soft tissue or bony, which can be arterial, venous, or capillary in origin. Regardless of whether the bleeding is soft tissue or bony, it is crucial to locate the area, debride it of any excessive clots, and apply appropriate pressure.
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