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In pediatric dental pain, think: cavity, eruption infection and referred pain unrelated to the tooth
I really appreciate the many excellent teaching points and clinical pearls included in this segment, but what is up with this repeated universal recommendation for getting these patients "seen by a dentist the next morning"? I don't know about how things are with access to dental/oral surgery care where you guys practice, but in my practice environment this is not going to be possible for at least 90% of the patients that I see. Making this kind of unachievable recommendation sound as if it is some sort of "standard of care" just adds to my angst when dealing with these cases. How about adapting these recommendations to the real world of practice? How about saying something to the effect "ideal care is follow up the next morning, but if that is not possible, do x,y,z"?
I have to take issue with Dr. Tehrani's recommendation of sending patient's to the ED for IV antibiotics for any facial swelling. I understand if the patient's is ill appearing, febrile, having respiratory symptoms, unable to take PO, etc... but just because there is a little redness and swelling? I have heard previous segments on EMRAP telling us that PO antibiotics are often just as good as IV antibiotics, so why the need to go the ED, why the need for admission? The emotion-based response, that that is what she would want for her child, does not sit well with me. I don't work in, or live any where close to, a pediatric hospital. I don't want my kid in the ED, surrounded by cursing drunks and ESBL-infected nursing home patients, poked and prodded for an IV, and then given antibiotic associated diarrhea. Rob, you touched on the fact that some of this is practice patterns, is this a pretty common practice? I send most of my odontogenic cellulitis patient's home with PO antibiotics and dental follow up. Granted most of the patients are older (ie not young babies). Am I doing this wrong?
I don't know that there is enough info out there to say if you are right or wrong. Across the board, it seems like about half of kids with any dental-associated facial cellulitis get admitted, and that aggressive treatment with antibiotics does seem to shorten duration/ LOS. I get what you are saying, but the cursing drunks with no where to go really don't belong in an ED and shouldn't preclude the patients who do. Please remember that 1) most of these kids have little to no realistic hope of dental care in a timely fashion, as is underscored by Lars' comment and 2) this isn't just cellulitis, it's a large area of cellulitis emanating from an abscess that we are not treating (unless you are routinely pulling teeth, and 3) it's an area more prone to serious complications than an abscess/cellultitis of the arm or thigh. Personally, I have always been taught to admit if the cellulitis reaches the eye because it can quickly become orbital cellulitis, but I think the patient's access to a dentist who can provide definitive management of the abscess needs to be taken into consideration when making a dispo decision
What you do matters.