Prlnciplell: Evaluate State of Patient’s Host Defense Mechanisms
Part of the evaluation of the patient’s medical history is designed to establish the patient’s ability to defend • against infection. Several disease states and several types of .drug use may compromise this ability. Compromised
patients are more likely to have infections, and these infections. often become serious more rapidly. Therefore to manage their infections more effectively, it is important to be able to discern those patients who may have a compromised host defense mechanism. .\]edical conditions that compromise host defenses. It is important to delineate those medical conditions that ay result in decreased host defenses. These compromises
allow, more bac teria to enter the tissues or to be mote active, or they prevent the humoral or cellular defenses from exerting their full effect. Several specificconditions may compromise patients’ defenses (Box IS-I).
Severe, uncontrolled meta bolic diseases, such as severe diabetes, end-stage renal disease that leads to uremia, and severe alcoholism with malnutrition: result in decreased function of leukocytes, including decreased chemotaxis, phagocytosis, and bacterial killing, The’ second major group of host compromisers is diseases that interfere with host. defense mechanisms, such as leukemias, lymphomas, and many types of cancer. These result in decreased w ite cell function and decreased antibody synthesis and production. Patients taking certain drugs are also ompromised.Cancer chemotherapeutic agents decrease circulating
white cell counts to extremely low levels, commonlybelow 1000 cells per milliliter. When this occurs patientswill be unable to defend themselves effectively againstbacterial invasion. Patients on immunosuppressive therapy,usually for organ transplantation or autoimmune diseases,are compromised. The common drugs in these categoriesare cyclosporin, corticosteroids, and azathioprine(Imuran). These drugs decrease T- and B-Iymphocytefunction and immunoglobultn productlon.Thus patient taking these medications are more likely to. have severe
Compromised Host Defenses
Uncontrolled metabolic diseases:
• Severe diabetes
• Malignant tumors
Suppressing drugs: .
It . Cancer chemotherapeutic agents
D Immunosuppressive agents .
In summary, when evaluating a patient whose chief complaint may be an infection, the patient’s medical history should be carefully examined for the presence of diabetes-evere renal disease, alcoholism with malnutrition,
I~ukemias and lymphomas, cancer chemotherapy, andimmunosuppressive therapy of any kind. When the patient’s history includes any of these, the patient with an infection must be treated much more vigorously, as
the infection may spread more rapidly. Early and aggressive surgery to remove’ the cause and more intense par- enteral antibiotic therapy must be considered. Additionally, when a patient with a history of one of
these problems is seen for routine oral surgical procedures, it may be necessary to provide the patient with prophylactic antibiotics to. attempt to prevent an infection from occurring .
Criteria for Referral to a Specialist
• Rapid progressive infection
• Difficulty in breathing
• Difficulty in swallowing
• Fascial space involvement .•
• Elevated temperature (greater than 1010 F)’
• Severe jaw trismus (less than 10 mm)
• Toxic appearance
• Compromised host defenses
Principle III: Determine Whether Patient Should Be Treated by General Dentist or Spectaist
Most odontogenic infections seen by the dentist can be managed with the expectation of normal rapid resolution. Odontogenic infections, when treated with minor surgical procedures and commonly used antibiotics, almost always respond rapidly. However, some. odontogenic Infections
are potentially life threatening and require aggressive medical and surgical management. In these special situations, early recognition of the potential severity is essential and these patients should be-referred to a specialist,
usually an oral-rnaxllofactal surgeon, for definitive management. For some patients, hospitalization will be – required, whereas others will be managed as outpatients. When a patient with an odontogenic Infection comes
for treatment, the dentist must have a set of criteria by which to judge the seriousness of the infection (Box 15-2). If some or all of these criteria are met, immediatereferral must be considered.Three main criteria suggest immediate referral to a specialist.The first· is a history of a ,’apidl), progressing intecn I. This means that the lnfectton began 1 or 2 days
before the interview and is growing rapidly worse, withincreasing swelling, pain, and associated signs and symptoms. This type of odontogenic infection may spread toareas in which it is potentially llfethreatenmg and therefore-must be treated aggressively. The second criterion is
difficllity ill breathillg.·Patients whohave severe swelling btthe soft tissue of the upper airway as the result of infectionmay have difficulty maintaining a patent airway. lnthese situations the patient often cannot lie down, has
_difficulty with speech, and is obviously distressed withthe breathing difficulties. This patient should be referreddirectly to an emergency room, because immediate surglcalattention may be necessary to maintain an intact airway:The third urgent criterion Is difficult}’ III swallowing.
Patients who have s’..r•elltng and trismus rnav have dlfflculty
swallowing their saliva. This is an ominous sign,because difficulty in swallowing frequently indicates anarrowing of the oral pharynx and potential for acute airwayembarrassment. This patient should also be referred to the hospital emergency room, because surgical intervention
may be required for airway maintenance.Several other criteria should indicate referral to the