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Treatment
- Periapical abscesses involve the presence of osteomyelitis and
necrotic tissue (soft tissue, tooth and/or bone) as well as the
presence of a thick capsule; these features make purely medical
treatment ineffective. (J29.17.w3)
Remove the offending object, if still present (including
tooth spikes causing soft tissue abscesses or teeth associated with
periapical abscesses). (B600.8.w,
B601.18.w18)
- If associated with a tooth or teeth, the tooth (or teeth) have to be
removed. (B601.18.w18)
- If a penetrating foreign body has reached an alveolus, removal
of the affected tooth is also required. (B600.8.w8)
Local and systemic antibiotic treatment. (B600.8.w8,
B601.18.w18)
- Systemic antibiotics: e.g. cephalexin,
enrofloxacin. (B600.8.w8,
J513.3.w1,
J513.6.w4)
- Choice of antibiotic should be based on bacterial culture and
sensitivity testing. (B601.18.w18)
This is particularly important for fast-growing abscesses since
unusual organisms may be involved. (B600.8.w8)
- A study published in 2002 found that the bacteria involved in
rabbit tooth-associated mandibular and maxillary abscesses
included anaerobic gram-negative rods (particularly Fusobacterium
nucleatum), anaerobic gram-positive spore-forming rods
(especially Actinomyces spp.) and aerobic cocci,
particularly from the Streptococcus milleri group. Pasteurella
multocida was not isolated. All of the isolates tested
were susceptible to chloramphenicol and to clindamycin, and most
(96%) to penicillin, ceftriaxone and cefazolin, with 86%
susceptible to azithromycin and tetracycline. However only 54%
were susceptible to metronidazole and ciprofloxacin and only 7% to
trimethoprim-sulfamethoxole. Clinically, 97 of 104 such abscesses
(97%) had not recurred following treatment involving AIPMMA
(antibiotic-impregnated polymethyl methacrolate) beads
of clindamycin and/or ceftiofur. (J93.40.w5)
PLUS
- Remove the abscess: complete removal if possible, otherwise
(e.g. with bone involvement) use thorough debridement followed by
appropriate treatment to remove infection and allow healing. (B600.8.w8,
B601.18.w18,
J513.2.w1,
J513.6.w4)
- For superficial abscesses:
- Excision followed by systemic antibiotics. (B600.8.w8)
- For deeper subcutaneous abscesses (e.g. following fight
wounds or tooth spurs):
- Excision. (B600.8.w8)
OR
- Lancing and expression of pus (B600.8.w8)
followed by aggressive/thorough debridement and
- Placing of
antibiotic-impregnated beads (B600.8.w8,
B601.18.w18)
OR
- Marsupialisation and topical treatment with e.g. honey,
gentamicin drops. (B600.8.w8)
- For large, fast growing abscesses with associated skin
necrosis:
- Use systemic antibiotics with good penetration (e.g.
cephalexin, enrofloxacin). (B600.8.w8)
- Provide analgesia (NSAID such as carprofen or meloxicam, and
an opioid e.g. buprenorphine). (B600.8.w8)
- Surgical drainage as above. (B600.8.w8)
- For mandibular abscessation with bone/tooth involvement:
- Removal of the whole abscess, including the abscess capsule,
together with removal of any teeth involved and curettage of
infected/necrotic bone is required for successful treatment. (J513.6.w4)
- These abscesses are usually associated with acquired dental
disease (Acquired Molar Abnormalities in Rabbits)
but occasionally may be due to impacted food or splinters
entering the periodontal space. (B600.8.w8)
- Description of surgical procedure:
- Place the anaesthetised rabbit in dorsal or lateral
recumbency (depending on the site of the abscess). (J513.6.w4)
- Drape over the area - a transparent adhesive drape
allows visibility of the head position. (J513.6.w4)
- Incise the skin over the swelling, taking care not to
cut through into the abscess.(J513.6.w4)
- Carefully dissect through subcutaneous tissue and muscle
to free the abscess capsule. (J513.6.w4)
- A Lone Star retractor system allows optimal access
to the site. (J513.6.w4)
- Use a No. 11 scalpel blade or the tip of a Crossley's
luxator to incise between the capsule and mandibular bone.
(J513.6.w4)
- Elevate the lateral wall of the abscess and incise it. (J513.6.w4)
- Remove the thick pus with cotton-tipped applicators. (J513.6.w4)
- Debride the bony cavity with a bone curette, removing
all pus and infected bone down to bleeding bone. (J513.6.w4)
- Debride infected/necrotic bone using a small rongeur or
needle holders. (J513.6.w4)
- Remove any teeth or tooth fragments - use a Crossley's
luxator or needle to free the tooth from any attachment to
bone. (J513.6.w4)
See: Extraction of Cheek Teeth in Rabbits
- Extraoral approach
- Debride the bony cavity again. (J513.6.w4)
- Flush with saline and dilute povidone iodine. (J513.6.w4)
- EITHER Suture the soft tissues of the cavity to
the skin (marsupialization) using 3-0 nonabsorbable suture
material. (B601.18.w18,
J513.6.w4)
- Fill the bone cavity with povidone iodine/antibiotic
ointment at the end of the surgery. (J513.6.w4)
- Marsupialization allows postoperative flushing and drainage. (B601.18.w18,
J513.6.w4)
- The cavity can heal by second intention, reducing
the risk of recurrent infection. (B601.18.w18,
J513.6.w4)
- Flush the site
often with saline and povidone iodine, and apply
antibiotic ointment. (J513.6.w4)
- OR implant antibiotic-impregnated
methylmethacrylate (PMMA) beads into the cavity. (B600.8.w8,
B601.18.w18)
- Use several small beads rather than a few large
beads, to improve local concentrations of antibiotic.
(J513.2.w1)
- Use as few sutures as possible to close the wound
(particularly deeper in the wound), and use fine
monofilament and small knots, to reduce the chance
that suture material will act as a nidus for
infection. (B600.8.w8)
- Leave these for at least four weeks. (B600.8.w8)
- The beads can be left in place permanently. (B600.8.w8,
B601.18.w18)
- Alternative treatments:
- Calcium hydroxide paste made up by mixing dry
calcium hydroxide powder with 2% lidocaine has been
used for filling tooth-related facial abscess cavities
(after debridement and removal of teeth), and left for
one week (by which time it is hard and dry) before
removal. This produces a pH
of 12.0, which is bactericidal, and good results have
been reported. (J432.12.w1,
J513.1.w1)
- However the high pH can also damage soft
tissues of the animal, causing necrosis. (B600.8.w8,
B602.34.w34b)
- Current opinion is that this should not
be used. (B602.34.w34b,
V.w125)
- A wound packing technique has been described
for use where the size and anatomical location of the
abscess makes complete removal of the abscess capsule
difficult and risks damage to nerves and blood
vessels.
- After incision into the abscess, the purulent
contents are removed using suitable instruments
(e.g. sterile cotton-tipped applicators) and
capsular margins are reduced. Thin strips of gauze
cut from a sterile synthetic gauze square are
moistened with an appropriate amount of antibiotic
(penicillin or ampicillin if culture and
sensitivity results are not yet available). The
strips are carefully packed into the abscess
cavity using forceps. Once the dead space of the
cavity has been filled, the packing material is
saturated with the remaining antibiotic solution
(total amount is pre-calculated). The skin is
closed in a simple interrupted pattern using 3-0
or 4-0 monofilament suture material.
Post-operatively, a complementary systemic
antibiotic is given, plus NSIAD (meloxicam, 0.3
mg/kg once daily). At intervals of seven days,
packing is removed, the cavity inspected, and
further packing introduced. If necessary the
anitibiotic used is changed based on culture and
sensitivity, and on clinical response. (J513.5.w1)
Supportive treatment:
- Analgesia: NSAID such as carprofen or meloxicam, and
an opioid e.g. buprenorphine. (B600.8.w8,
J29.17.w3,
J513.3.w1,
J513.6.w4)
- Melxoicam at doses as high as 0.7 mg/kg three times
daily provides improved analgesia compared with the
more conservative doses (e.g. 0.3 mg/kg once daily)
seen in the literature. (V.w125)
- Fluids as required. (J29.17.w3)
- Supportive feeding as required. (J29.17.w3)
Note: facial abscesses that do not receive surgical treatment:
- Many facial abscesses are slow growing.
- Antibiotic therapy should be continued long term.
- Many rabbits will live for several months in comfort even with a
relatively large abscess.
(B609.2.w2)
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