Advice to the general practitioner

ANZAOS Letter_30.03

Oral Surgery in Unprecedented Times for the General Practitioner
The management of dento-alveolar infection is now complicated by the presence of the highly
infective COVID-19 virus. It is reasonable now to assume that all our patients can be carriers of
the virus. This put extra demands on personal protection for all the staff involved.

The patients who present with pain and an infection, must be treated. There will be
increased usage of antibiotics in lieu of active surgery. In many ways this goes against the
primary method of treatment being that the removal of the source of infection. We know that
antibiotics can stall the progress of odontogenic infection. The use of antibiotics is usually
associated with surgical intervention, but this now has to be reconsidered.

The question is, when can you delay the relief of acute infection by antibiotic usage alone and
when is it necessary to forward the patient to specialist and/or hospital care? We recognise that
the latter option incurs increasing difficulty as the hospitals are engaged in more pressing
procedures. In addition, general hospitals will only do oral/maxilla-facial patients in full infectious
disease personal protection cover. This includes of negative air pressure surgical sites. It is only
reasonable when reading the above that we will have to stall as much as possible.

The danger signs that we all recognise for the spreading of infection which can become life
threatening are now more important than ever to be recognised. The combination of trismus and
dysphagia, with or without, elevated temperature is a paramount sign of progress towards airway
obstruction. Such a patient will normally have swelling (which is indicative of infection spreading
from its dental source). These patients must be sent to a hospital.

n the absence of trismus or dysphagia, aggressive antibiotic therapy can be utilised.
Radiographic examination is mandatory so that one can confirm that the infection is of dental
origin. Augmentin is the preferred antibiotic because Penicillin alone is unlikely to provide clinical
improvement. Should the patient be allergic to Penicillin based drugs, Clindamycin is the
alternative.

Ibuprofen coupled with Paracetamol (400mg/1gm, 8-hourly, 3 days) is recommended for
immediate interim analgesia. The patient ought to be assessed within 24 hours. Telephone
communication may not be sufficient and any deterioration of a patient by malaise is best
determined by face to face consultation. It is not considered adequate patient care to issue
antibiotics and to review at the patient’s discretion.