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Managing facial dog bites
J Oral Maxillofac Surg 53:1368-1369, 1995
MANAGING
serts that come with human and equine rabies immune globulin products in Asia still carry a recommendation that only half of the dose be given into or around bite wounds. This disregard of the 1991 WHO Rabies Expert Committee recommendation could have been one contributing factor to the treatment failures previously mentioned. It is also noteworthy that in three of the five failures, wounds were surgically closed before infiltrating them with immune globulin. We therefore try to avoid primary closures of potentially rabies-infected bite wounds, cleaning them thoroughly and scheduling secondary closures where necessary after the patient can be expected to have an adequate circulating neutralizing rabies antibody titer. If primary closure cannot be avoided, it is performed after infiltration of the wounds with the immune globulin.
FACIAL DOG BITES
To the Editor:--Morgan et al’s article dealing with dog bite injuries of the face represents a useful review of this not uncommon problem.’ It is, however, focused on injuries occurring in developed countries where rabies is a lesser problem than bacterial infection and potential disfigurement. The situation can, however, be quite different in a canine rabies endemic region where up to 30% of severe facial dog bites are due to very likely or proven rabid animals’ and where postexposure rabies treatment failures are not unknown.*~’ They can occur even when treatment rendered is “state of the art,” with tissue culture vaccine and immune globulin.‘,’ Our group has recently collected five cases from South and Southeast Asia where deaths from rabies occurred despite treatment with World Health Organization (WHO)approved tissue or avmn culture vaccine and rabies immune globulin (RIG) (Wilde H, submitted for publication, June 19951. These cases were all small children weighing 22 lbs or less who had multiple, severe facial bites. Furthermore, the calculated volume (from the weight of the child) of the RIG was insufficient for infiltration of all wounds, particularly since only half of the dose was given into wounds and the rest intramuscularly into the gluteal region. Incubation periods were as short as 8 days in one Thai child aged 2 years; a period inadequate for endogenous antibody production from vaccine. Baer et al had shown in prospective animal experiments that injecting the rabies infection site can be life saving.4 The 1991 WHO rabies expert committee conference at Bangkok therefore decided to amend the previous WHO recommendations,5 which had stated that half of the calculated dose of RIG be injected into the wounds and the rest intramuscularly. This statement is still found in many textbooks and manuals, and was repeated by Morgan et al.’ The new edition of the WHO Technical Report on Rabies, therefore, now states that as much as possible, and all if necessary, of the human or equine rabies immune globulin be injected in and around the wounds.’ Soon after this, however, our staff became aware of a treatment failure in Thailand where the total calculated volume of RIG was insufficient to infiltrate all the facial wounds. They decided arbitrarily to dilute the calculated dose with normal saline, a practice that is now routine for such cases at this institution. One or two such patients are seen monthly at the Queen Saovabha Memorial Institute; dilutions range from one to threefold in severely bitten children and we have not had a treatment failure during the past 3 years. Approximately 30% of animal bites seen at emergency rooms and rabies prevention clinics in Thailand are in children under 10 years’ and proper use of vaccine and immune globulin are therefore not insignificant issues. Package in-
HENRY WILDE, MD Bangkok, Thailand
References 1. Morgan JP, Hang RH, Murphy MT: Management of facial dog bite injuries. J Oral Maxillofac Surg 53:435, 1995 2. Wilde H, Chutivongse S, Tepsumethanon W, et al: Rabies in Thailand-1990. Rev Infect Dis 13:644, 1991 3. Wilde H, Choomkasien P, Hemachuidha T, et al: Failure of rabies postexposure treatment in Thailand. Vaccine 7:49, 1989 4. Cabasso VJ: Local wound treatment and passive immunization, in Baer GM (ed): The Natural History of Rabies. Boston, MA, CRC Press, 1991, pp 551-570 5. WHO Expert Committee in Rabies. 7th Report. Geneva, Switzerland, WHO, 1984 6. WHO Expert Committee in Rabies. Technical Report Series (824). Geneva, Switzerland, WHO, 1992 7. Bhanganada K, Wilde H, Sakolsataydom P, et al: Dog-bite injuries at a Bangkok teaching hospital. Acta Tropica 55:249, 1993 SATISFACTION
FROM PERFORMING DENTOALVEOLAR SURGERY
To the Editor:-1 was reading my most recent edition of the Journal of Oral and Maxillofacial Surgery and was pleasantly surprised to read the editorial on dentoalveolar surgery. I think the time has come for all oral and maxillofacial surgeons to remember the roots of their profession. I have been a practicing oral and maxillofacial surgeon for 23 years. In that time I have exposed myself to all the “new techniques and surgeries” that have been researched and presented to our profession. The one area that has not been expounded on in the last several years has been dentoalveolar surgery. The trend has been so much diversification that we have almost forgotten what we do better than anyone else in the health professions. Several years ago I made a major decision to limit my practice to dentoalveolar surgery, dental implants and treatment of TMJ, both conservative and surgical. I have never regretted my decision because it made me look for a better way to do what I do best. After several years I found a better technique to remove third molars. I do not mind boasting that approximately 90% of my third molar patients, including adults, have no swelling and do not take any prescription medication after surgery. They are most
1368
MANAGING
serts that come with human and equine rabies immune globulin products in Asia still carry a recommendation that only half of the dose be given into or around bite wounds. This disregard of the 1991 WHO Rabies Expert Committee recommendation could have been one contributing factor to the treatment failures previously mentioned. It is also noteworthy that in three of the five failures, wounds were surgically closed before infiltrating them with immune globulin. We therefore try to avoid primary closures of potentially rabies-infected bite wounds, cleaning them thoroughly and scheduling secondary closures where necessary after the patient can be expected to have an adequate circulating neutralizing rabies antibody titer. If primary closure cannot be avoided, it is performed after infiltration of the wounds with the immune globulin.
FACIAL DOG BITES
To the Editor:--Morgan et al’s article dealing with dog bite injuries of the face represents a useful review of this not uncommon problem.’ It is, however, focused on injuries occurring in developed countries where rabies is a lesser problem than bacterial infection and potential disfigurement. The situation can, however, be quite different in a canine rabies endemic region where up to 30% of severe facial dog bites are due to very likely or proven rabid animals’ and where postexposure rabies treatment failures are not unknown.*~’ They can occur even when treatment rendered is “state of the art,” with tissue culture vaccine and immune globulin.‘,’ Our group has recently collected five cases from South and Southeast Asia where deaths from rabies occurred despite treatment with World Health Organization (WHO)approved tissue or avmn culture vaccine and rabies immune globulin (RIG) (Wilde H, submitted for publication, June 19951. These cases were all small children weighing 22 lbs or less who had multiple, severe facial bites. Furthermore, the calculated volume (from the weight of the child) of the RIG was insufficient for infiltration of all wounds, particularly since only half of the dose was given into wounds and the rest intramuscularly into the gluteal region. Incubation periods were as short as 8 days in one Thai child aged 2 years; a period inadequate for endogenous antibody production from vaccine. Baer et al had shown in prospective animal experiments that injecting the rabies infection site can be life saving.4 The 1991 WHO rabies expert committee conference at Bangkok therefore decided to amend the previous WHO recommendations,5 which had stated that half of the calculated dose of RIG be injected into the wounds and the rest intramuscularly. This statement is still found in many textbooks and manuals, and was repeated by Morgan et al.’ The new edition of the WHO Technical Report on Rabies, therefore, now states that as much as possible, and all if necessary, of the human or equine rabies immune globulin be injected in and around the wounds.’ Soon after this, however, our staff became aware of a treatment failure in Thailand where the total calculated volume of RIG was insufficient to infiltrate all the facial wounds. They decided arbitrarily to dilute the calculated dose with normal saline, a practice that is now routine for such cases at this institution. One or two such patients are seen monthly at the Queen Saovabha Memorial Institute; dilutions range from one to threefold in severely bitten children and we have not had a treatment failure during the past 3 years. Approximately 30% of animal bites seen at emergency rooms and rabies prevention clinics in Thailand are in children under 10 years’ and proper use of vaccine and immune globulin are therefore not insignificant issues. Package in-
HENRY WILDE, MD Bangkok, Thailand
References 1. Morgan JP, Hang RH, Murphy MT: Management of facial dog bite injuries. J Oral Maxillofac Surg 53:435, 1995 2. Wilde H, Chutivongse S, Tepsumethanon W, et al: Rabies in Thailand-1990. Rev Infect Dis 13:644, 1991 3. Wilde H, Choomkasien P, Hemachuidha T, et al: Failure of rabies postexposure treatment in Thailand. Vaccine 7:49, 1989 4. Cabasso VJ: Local wound treatment and passive immunization, in Baer GM (ed): The Natural History of Rabies. Boston, MA, CRC Press, 1991, pp 551-570 5. WHO Expert Committee in Rabies. 7th Report. Geneva, Switzerland, WHO, 1984 6. WHO Expert Committee in Rabies. Technical Report Series (824). Geneva, Switzerland, WHO, 1992 7. Bhanganada K, Wilde H, Sakolsataydom P, et al: Dog-bite injuries at a Bangkok teaching hospital. Acta Tropica 55:249, 1993 SATISFACTION
FROM PERFORMING DENTOALVEOLAR SURGERY
To the Editor:-1 was reading my most recent edition of the Journal of Oral and Maxillofacial Surgery and was pleasantly surprised to read the editorial on dentoalveolar surgery. I think the time has come for all oral and maxillofacial surgeons to remember the roots of their profession. I have been a practicing oral and maxillofacial surgeon for 23 years. In that time I have exposed myself to all the “new techniques and surgeries” that have been researched and presented to our profession. The one area that has not been expounded on in the last several years has been dentoalveolar surgery. The trend has been so much diversification that we have almost forgotten what we do better than anyone else in the health professions. Several years ago I made a major decision to limit my practice to dentoalveolar surgery, dental implants and treatment of TMJ, both conservative and surgical. I have never regretted my decision because it made me look for a better way to do what I do best. After several years I found a better technique to remove third molars. I do not mind boasting that approximately 90% of my third molar patients, including adults, have no swelling and do not take any prescription medication after surgery. They are most
1368