A bleeding socket after tooth extraction
BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1217 (Published 03 April 2017) Cite this as: BMJ 2017;357:j1217
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Dear Editors
I am writing in response to Dr Thomas' rapid response, where he is lamenting the soon-to-be-passing generation of "simpletons" (his phrasing) who were used to manage gum bleeding from teeth extraction, pulled elbow of tots, ingrown toenail (you may call it onychocryptosis or unguis incarnates but it will only be helpful in scrabbles or trivia pursuit - medical edition).
During the course of my orthopaedic training in Australia, I have been asked to see all the conditions Dr Thomas listed: sports injuries, bleeding noses, ingrowing toe nails, boils on bums, and childrens’ ‘pulled elbows, bleeding gums*
* no, not from tooth extraction, but mandible fracture. Why, you may ask? I don't know how the referring doctor seemed to think a fractured jaw should be managed by an orthopod, but then I was also once asked to see a patient with a fractured penis (not a joke): such is the state of medicine in current times.
The reflex "referring on" behaviour is particularly sad considering Prof John Murtagh's (relatively recent) classic text described the practical management of all these conditions. Entitled "General Practice" now in its 6th Edition, it is one of the more helpful and practical books GP trainees in Australia can use to learn and manage what used to be bread and butter primary care conditions.
It is even more distressing if you know that until recently Sports Physicians in Australia are mostly fellows of Royal Australian College of General Practitioners (for purposes of billing with Medicare) with special interests and training in sports conditions; now there is a separate direct pathway to Fellowship of the Australasian College of Sport and Exercise Physicians which allows Medicare billing.
I cannot speak on behalf of my orthopaedic colleagues in Mother England or Down Under, but for myself I am very happy for the competent GP (and even the competent emergency physician) to manage uncomplicated sports injuries, bleeding noses, ingrowing toe nails, boils on bums, and childrens’ ‘pulled elbows, bleeding gums without my involvement.
And on the subject of sports injury, for the record, I consider most acute isolated ATFL ruptures (often found on ultrasound for unknown indication) part of the spectrum of a common condition known as "a bad ankle sprain"; many of which can be appropriately managed non-operatively with RICE therapy with or without physiotherapy over 2-3 months.
(I apologise for misusing this platform for my soapbox stance)
Competing interests: No competing interests
In the bad old days, before portfolio GPs were born, when sports injuries, bleeding noses, ingrowing toe nails, boils on bums, and childrens’ ‘pulled elbows’ made life interesting and satisfying for we (now ageing) simpletons, the occasional bleeding tooth socket would usually respond magically and quickly to a homeopathic remedy like arnica or phosphorus. Nowadays all must all be redirected to ENT, A&E, podiatry, surgery or orthopaedics. Even back to the dentist.
Little wonder that GPs wish to retire from the creaking NHS in early middle age.
Competing interests: No competing interests
Unless it is an emergency situation such as the patient actively haemorrhaging post-dental extraction, medical professionals should not manage dental problems. Patients often present to their GP in order to avoid their dentist because of dental anxiety or perceived risk of cost; however, this does not mean that GPs are trained or indemnified to provide dental care and care of this kind is not within the sphere of GPs competence. Suggesting otherwise in a '10 minute consultation' is unsafe and risks giving the false impression that GPs ought to be managing this dental problem, and can do so within ten minutes. Any post-operative dental problems should be managed by a dentist, ideally the dental surgeon responsible for the operation.
Competing interests: No competing interests
In English-language handbooks, a gentle socket curettage after the tooth extraction is recommended;[1] while in Russia[ 2] it is usually performed more intensely, with the goal of complete removal of granulation tissue.[3] In case of gingival atrophy and retraction, excessive curettage of the socket may contribute to a root denudation of neighboring teeth, which can result in increased sensitivity. More details and images: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3768195/
1. Waite DE. 3rd ed. Philadelphia: Lea and Febiger; 1987. Textbok of practical oral and maxillofacial surgery; pp. 92–117.
2. 3. Jargin SV. Some aspects of dental caries prevention and treatment in children: A view from Russia. Pesq Bras Odontoped Clin Integr. 2010;10:297–300.
3. Robustova TG. Large Medical Encyclopedia. Vol. 26. Moscow: Soviet Encyclopedia; 1985. Extraction of teeth; pp. 14–5.
Competing interests: No competing interests
Re: A bleeding socket after tooth extraction - what a 'bloody' shame....
Sarah EE Mills, your comment allows us to highlight several important points regarding management of a bleeding socket:
1. The article does not state that a patient should be visiting a GP following a problem with a tooth socket, however as you have even explained in your comment, unfortunately ‘patients often present to their GP in order to avoid the dentist.’ Of course the best health care professional for a patient to return to would be the dentist or surgeon who performed the procedure. However, as you are aware this does not always happen, so the article was aimed to provide useful advice to doctors if such a patient presented to them. Not only would this aid in the efficiency of management, but also reduce referrals in to secondary care and most importantly optimize the care delivered to the patient.
2. A large proportion of these procedures are undertaken in secondary care, which can be a significant distance away from where patients live. Thus, having a local reliable primary care service is crucial.
3. Management of haemorrhage is a basic skill of any trained doctor and refusal to provide primary care to a patient would be considered a breach of duty of care to the patient and thus severe negligence by the GMC. The article is not suggesting you should work beyond your competency, but be able to provide basic primary care which patients should be able to expect.
4. The BMJ suggested that this article was put under the title of ’10 Minute Consultation.’ If you refer to any of the 10 Minute Consultation subjects such as ‘A suspected viral rash in pregnancy’ and ‘Pelvic pain’ to name just a couple, 10 minutes is not likely to allow you to achieve the best clinical outcome, but using the information all of these short articles provide should help improve care quality and efficiency.
5. The key to the NHS delivering the world-class service that it offers is ‘working together for patients.’ As the link below will show you, this is subsequently, considered as a core NHS value, highlighting that ‘the value of “working together for patients” is a central tenet guiding service provision in the NHS and other organizations providing health services. All parts of the NHS system should act and collaborate in the interests of patients’ (http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples.aspx). In addition in the GMC standards, point 35 states ‘you must work collaboratively with colleagues.’ Thus, to ensure that our patients are put first and the best possible care is delivered, we must work as a TEAM and help each other to manage situations. If the attitude of ‘not my problem’ was adopted by all health care professionals our patients would be the ones at loss and this is a great pity.
Competing interests: No competing interests