Sarah Haslam, a mouth care specialist nurse from Kent, explains what her trust is doing to raise awareness of sepsis in dentistry.
The first I became aware of the possibility of sepsis in relation to dentistry was when I was still working in general practice. A patient rang up complaining of “a sore tooth” and asked for an appointment. As a result of further probing by my dentist, the patient reported that his face had gradually been swelling up over a few days. On learning this, my dentist advised the patient to go straight to our local hospital. Meanwhile, the dentist contacted the on-call Maxfacs SHO (maxillofacial house officer) to alert him to the imminent arrival of the patient. My employer explained how quickly sepsis can develop and in some cases may be fatal. The patient was admitted and operated on that same afternoon. The swelling was drained and the patient was put onto IV antibiotics. He was kept in hospital for a few days and only discharged once he was fully recovered. There is no doubt that without my dentist's prompt referral and the immediate intervention in hospital, this patient could have been at risk of developing sepsis. Who knows what would have happened next?
What is sepsis?
Sepsis has been defined as “life-threatening organ dysfunction due to a dysregulated host response to infection”1. The body's immune system responds abnormally to infection by attacking its own tissues and organs, leading to eventual organ failure. Any infection can trigger sepsis but the most common occur as a result of bacterial infection of the lungs, urinary or abdominal systems or skin infections.
The number of sepsis cases that occur in the UK is difficult to assess but it is thought to be between 200,000 and 1.7 million cases each year. The number of deaths from sepsis in the UK is also difficult to quantify due to inadequate reporting, but it is thought there are upwards of 40,000 deaths from sepsis every year in the UK.
If a patient or anyone you know has any or several of the following signs or symptoms, they may need referral to hospital for IV antibiotics:
a high temperature (fever) or low body temperature
chills and shivering
a fast heartbeat
feeling dizzy or faint
a change in mental state – such as confusion or disorientation
nausea and vomiting
severe muscle pain
less urine production than normal – for example, not urinating for a day
cold, clammy and pale or mottled skin
loss of consciousness.
NICE requires all health care professionals, including dental care professionals to be trained in identifying people who may have sepsis. NICE guidelines state, “all healthcare staff involved in assessing people's clinical condition are given appropriate training in identifying people who may have sepsis”2.
Sepsis is rare in dentistry, but there have been case which are odontogenic in origin3 and the British Dental Journal has published a recent letter of concern highlighting the warning clinical signs of sepsis4. Recently, a trainee midwife told me about a young pregnant woman who had to be induced because she was at risk of developing sepsis from an ongoing untreated dental infection.
Tom Ray is a quadruple amputee with additional facial amputations from gangrene as a consequence of sepsis. The infection that led to his life-changing situation is thought to have originated after a dental visit whilst he had a chest infection and when his gingivae were nicked. Tom, from Rutland, became seriously ill and went into a coma for several months. He had several limbs amputated and his face was seriously disfigured by additional facial amputations to remove gangrene caused by sepsis. A film has been made – Starfish - which tells the story of his recovery and how he and his wife rebuilt their lives together.
In my role as the mouth care specialist nurse, I have linked up with the trust's sepsis specialist nurse. We are looking at delivering joint training and how we can raise awareness of sepsis. Just recently a sepsis awareness day was organised to get information out to the public and healthcare professionals. We had a stand and our sepsis nurse and ITU team ran a quiz and took the opportunity to talk about the signs and symptoms of sepsis.
When I deliver my mouth care awareness training I ensure that I highlight the importance of good oral health and how that can help reduce the risk of sepsis and other infections such as hospital acquired pneumonia.
Hand hygiene is a very important part of preventing and spreading infection. When raising awareness of hand hygiene, we talk about the 5 moments. This approach advocates hand-washing at the following points:
before touching a patient,
before clean/aseptic procedures,
after body fluid exposure/risk,
after touching a patient, and
after touching patient surroundings.
We can all take the opportunity to stress the importance of oral hygiene as a way to help prevent dental infections. Social media is a great educational tool when used correctly, as you can interact and learn with other healthcare and dental professionals as well as patients. This is how I met Melissa Mead, the campaigner who lost her son William to sepsis, and who has done so much good work as project manager for the Sepsis Trust. The trust website https://sepsistrust.org is a fantastic resource and I urge anyone who wants to know more to go to it.
I would like to see sepsis awareness incorporated into medical emergency training as it's a core part of CPD for all dental professionals. It would be good to have NEBDN and other training and examination bodies on board as we know patients are more likely to chat to their dental nurse. Collaboration is key. Meanwhile, I am delighted to work in a trust where highlighting the risk of sepsis is a priority.
Sarah Haslam is a mouthcare specialist nurse for Dartford and Gravesham NHS Trust. She has been a qualified dental nurse for 13 years and worked in general practice, community and hospital. She is a qualified Oral Health Educator and Dental Nurse Assessor. Her special interest in dental nursing is supporting adults and children with learning disabilities and mental health issues.
Shankar-Hari M, Phillips GS, Levy ML, Seymour CW, Liu VX, Deutschman CS, Angus DC, Rubenfeld GD, Singer M . Developing a New Definition and Assessing New Clinical Criteria for Septic Shock For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), 2016; 775–787.
National Institute for Health and Clinical Excellence Sepsis: recognition, diagnosis and early management. 2016; NICE guideline 51.
Carter L, Lowis E . Death from overwhelming odontogenic sepsis: a case report. Br Dent J 2007; 203: 241–242.
Gilway D, Brown SJ . Medical emergencies: Sepsis in primary dental care). Br Dent J 2016; 220: 278.