Dr Akinlade Akinwaleola
Mr Saleh (not his real name) presented to the accident and emergency unit, late, one evening in an altered state of consciousness and a blocked airway. He had received preliminary emergency care to optimize him, while my team did an extensive clinical assessment. Our findings revealed that there was a large swelling below the chin blocking his airway hence his breathing difficulty. The swelling discharged a substance, which was foul smelling and could be encountered at a distance from the patient. A diagnosis of septicemia on background descending odontogenic infection was made; simply put – a blood infection, caused by a bad tooth- that tooth which can kill.
My training as a doctor entails that I follow a set of principles when I see such cases; chief of which, is to restore and maintain the airway and breathing of the patient. This necessitates preparing an emergency surgical airway in the patient’s neck, which can only be done in an operating suite. Failure to do this within the first hour of his presentation-the golden hour, will cause his ability to survive to be reduced by half.
Within the hour of his presentation, we were in the operating suite giving Mr Saleh an arificial surgical airway called a tracheostomy. It entails placing a tube at a specific area of the neck and circumventing the obstructed area in the airway, an arduous task, made more difficult by the swelling in the neck caused by the infection.
After a successful but grueling procedure, he was admitted in the high dependency unit with medical and nursing care, on heavy doses of high end antibiotics, with infusions and nutritional supplementation through a tube passed through his nose. In all, Mr Saleh spent 20 days in hospital, before he was safely discharged to his family but had incurred hospital bills in hundreds of thousands of naira.
The cause of Mr Saleh’s condition was an untreated molar tooth (commonly called wisdom teeth) with a big hole which had been there for ten years and which had been intermittently painful. He had taken care of his symptoms using over-the-counter pain killers and by patronizing traditional herbalists. Gradually, over time, the cavity in his tooth had become infected and generated pus which had spread to the spaces in his neck, causing a blockage of his airway (windpipe) and his ability to breathe.
I’ve been practicing oral and maxillofacial surgery, the branch of dentistry that treats diseases of the face and mouth, for over ten years. Every time, I encounter patients who have had these close calls with death from an infected tooth, their medical history is somewhat like Mr. Saleh’s and their presentations are typically late. As you may imagine, it is psychologically and mentally taxing for the physician to treat such conditions. This is further complicated by the point that the patient’s life hangs in the balance and isn’t always determined by your intervention, but rather, the patient’s innate ability to ward off these infections. This ‘’ability’’ is conditioned by underlying comorbidities (as we call it in our parlance) which include diabetes, cardiac disease, and other non-communicable diseases which are usually first diagnosed when they present with the tooth symptom. Arguably, many Nigerians lack good health seeking behaviors and for the most part are ignorant of their easily diagnosable conditions, hence their morbid presentation at late disease sequelae.
It is sufficient to mention that tooth infections are the primary cause of death in my practice and are also the most expensive to treat due to the elaborate, non-negotiable but then again unquestionably expensive protocols of care. It’s fascinating how a tooth, despite being one of the smallest parts of the body, has the potential to harm someone seriously or even kill them if left untreated. Albeit, the speed with which a dental infection spreads and can enter other body parts, such as the neck (obstructing the windpipe), the chest (compressing the lungs), and even the blood (causing sepsis) is significant to this discovery.
Understandably, the ministry of health in its national oral health policy document, describes the burden of care to be emergent requiring urgent intervention, as over sixty percent of Nigerians have one untreated oral health problem or the other. To worsen matters, untreated dental problems are related to a propensity for cardiac illness, infertility and preterm birth. In proffering solutions to this problem, proper government policy should be enacted which aids oral health education to be incorporated in basic health education during primary school as well as during antenatal care programs. Oral healthcare should also be democratized such that anyone who needs it can get it at an affordable cost. Hence, incorporation of basic oral health interventions into primary health care facilities, especially in rural Nigeria should be a front burner issue in government health policy. To ensure these oral interventions are strong, capacity needs to be built hence the need for an incentivized health care system which encourages dentists and allied dental professionals to remain in the Nigerian workforce and not seek to “japa”—flee—to greener pastures abroad.
Additionally, the government has a responsibility to implement favorable policies that encourage preventive dental care for all citizens, improve health insurance coverage to include preventive dental care, and stem the tide of dental quackery. I further urge the government to make it simpler to register health-related activities with charitable intentions and to form alliances with such efforts. The enormous impact of this strategy is demonstrated by my personal experience in starting an organization that encourages oral health awareness and education among marginalized groups in rural Kano. Our flagship activity,” the toothbrush and toothpaste drive” has helped more than a thousand people, providing them with oral hygiene competences. Additionally, free routine screenings for non-communicable diseases, especially dental disease, must be made available to the general public.
Mr Saleh lives today, but not so many have been as lucky as he was. Presently, many of us are just another Mr. Saleh before his ordeal, walking around with a tooth that can kill.
Akinlade Consultant Oral and Maxillofacial; Surgeon Wellness Smiles Health Initiative