Principle VIII: Evaluate Patient Frequently

Once the patient has been treated by surgeiy and.antiblotic therapy has been prescribed, the patient” should be 0  followed up carefully to monitor response to treatmentand complications. In most situations the patient should 0be asked to return to the dentist 2 days after the origihal therapy. Typically the patient is much improved. If therapy is successful, swelling and pain decreases dramatically. The dentist should check the I&D site to determine whether the drain should be removed at this time. Other
parameter  s, such as temperature, trismus, swelling, andthe” patient’s subjective feelings of improvement, should also be investigated. ”
“If there is not an adequate response to treatment, the patient should be examined carefully for clues to the reasonfor failure (BOX 15-7). The most common cause of treatment failure is inadequate surgery. A tooth may have
to be reevaluated for extraction, or a fluctuant area not “obvious at the first treatment may have to be incised

BOX 15-7

Reasons for Treatment Failure

• Inadequate surgery
• Depressed host defenses
• Foreign body
• Antibiotic problems
• “p~tient noncompliance
• Drug not reaching site
• Drug dose too low
• Wrong bacterial diagnosis
• Wrong antibiotic •

A second reason for failure is depressed host defense mechanisms. A review of the patient’s medi,cal history should be performed and more careful probing questions asked. Local defense mechanism depression by things
such as dehydration and pain should also be considered and corrected if necessary. A third reason for treatment failure is the presence of a foreign body. Although this is unlikely in an odontogenic infection, the dentist may consider taking a periapical radiograph of the area to help ensure that a foreign .body is not present. . Finally, there may be problems with th. antibiotic that was given to the patient. The dentist firs, ascertains if the
patient has bee n compliant. The patient must have the prescription filled and take the antibiotic according to directions. Many patients fail to follow the orders of their . dentists as carefully as they should. Another problem to
consider is whether the antibiotic reached the infected area. Failure to reach the area may be related to inadequate surgery, inadequate blood supply to the local area, or it dose that is too low to be effective against the bacteria. Another antibiotic-related problem is an incorrect bacterial
diagnosis . If a culture Was not performed ‘at the initial surgical treatment or if no surgical treatment was done at the initial therapy, the dentist should obtain a pus spec. Imen for culture and antibiotic sensitivity testing. Finally, it is possible that the wrong antibiotic was prescribed for
the infection, which’ may be because of an inaccurate bacterial diagnosis or an unusual antibiotic resistance of typical bacteria. For example, Prevotella organisms are usually resistant to penicillin, but rarely cause persistent infection if penicillin 15given and surgery is done. However, if the
patient has a persistent, low-grade infection that does not resolve, prescribing an antianerobic antibiotic such as ctindamycin would be appropriate. • The clinician must also examine the patient to look
specifically for  toxicity reactions and untoward side effects.Patients may report complaints ‘such as nausea and abdominal cramping but may fail to associate watery diarrhea with the drug administration. Specific questioning about the expected toxicities is important to their early recognition. The dentist should also be aware of the possibility of
secondary or superinfections. The most common secondaryinfection encountered by denttsts is oral or vaginal candidiasis. This is the result of an overgrowth of Candida organisms, because the normal oral flora has been altere : by the -antlblotic therapy. Other secoridary infections
may arise as normal host flora is altered, but they are not seen with any degree of frequency in the management of odontogenic infections.
Finally, the dentist should follow the patient carefully once the infection has resolved, to check for recurrent infection. This would be-‘seen in a patient who had incomplete therapy for the infection. A variety of reasons
may acc ount for this. For-example, the patientmay have stopped taking the antibiotics. too early. The drain- may’ have been removed too early and the drainage site sealed too early, which reestablished the infectious process. If
infection does recur , surgical intervention and reinstitutionof antibiotic therapy should be considered.

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