lower jaw abscess

Question
QUESTION: I have an 8 year old female netherland dwarf, who the last two years have had quite a time with her teeth. Basically I have taken her to my vet (who specializes in rabbits) for molar grinding about every 4 months, as she always would start with signs of malocclusion (drooling, decrease in appetite, especially avoiding hay) about every 4 months. Things would always normalize hereafter. At one point, a year ago, she had to have a loose molar removed, which resulted in a rough recoup for a few days, where I had to syringe feed her. This last year her left lower teeth have stopped growing, according to the vet. Around November 10th, she started having a palpable small hard lump below the left lower jaw, about pea size, so I took her to the vet again. She took an Xray, and told me it looked rather bad, as infection had started to spread of the whole lower left jaw, with roots looking rather fuzzy, and a pea size abscess forming. She felt that bunny would do poorly taking several teeth out, and cleaning out the jawbone, so we decided a more conservative approach, in lieu of her age. I have been injecting her every day sq with 0.4 cc Penicillin G with Benthazine, as well as .3 cc Metcam (she is about 3 pounds), and a drop of probiotic. I have done this now for over a month, she is still eating well, including hay, poops are fine, and she still moves around enough for a geriatric bunny, HOWEVER, the abscess is much bigger, I'm thinking at least like a gumball size, still hard, going from lower jaw down.
My question to you is whether we should/ could do anything to reduce the abscess without extensive surgery, she probably would not survive. Can you lance and drain this abscess under anesthesia. Would steroids help?
At this point, my only choice is to have her enjoy her favorite foods, her favorite places in the house, and bring her to the vet for euthanasia if she shows signs of suffering. I am actually OK with that, cause she has had a great bunny life, I just wanted a second opinion from you, whether anything else could be done at all. Thank you so much for your time, Nora

ANSWER: Dear Nora,

While many jaw abscesses respond well to long-acting Penicillin injections (you don't say what your bunny weighs, so I can't tell what dose of bicillin she's getting, in mg/kg), some don't. It depends on what the resident bacteria are, and what their antibiotic sensitivities are.  Some really nasty strains of Pseudomonas or Staph are pretty much resistant to Pen, and other antibiotics (e.g., a fluoroquinolone [e.g., ciprofloxacin, Baytril, marbofloxacin] combined with an aminoglycoside [e.g., amikacin], depending on what a culture and sensitivity test reveals) might be more effective.  Please read:

www.bio.miami.edu/hare/jawabscess.html

and

www.bio.miami.edu/hare/culture.html

It should be possible to at least sample the abscess from below, to minimize the chances of false-positive growth of mouth bacteria (which might well be in the abscess, but better not to get the sample from the mouth, which would likely cloud the results), and have a culture and sensitivity test done.  This will tell you if a different type of antibiotic might be best to try at this point.
It might also be possible to simply *add* another antibiotic, rather than stopping the Pen.  In jaw abscesses, there can be a real "stew" of bacteria, each species and strain sensitive to a different antibiotic.  So if the choices are "too many" antibiotics versus death...well...I guess I, personally, would try the antibiotics.

Steroids are not recommended when infection is present, as they suppress the immune response (that's why they reduce inflammation, which is due to the immune system's reaction to a stimulus).  So I'd explore other antibiotic options before throwing in the towel.

I hope this helps.

Dana


---------- FOLLOW-UP ----------

QUESTION: Thank you for your very quick response.....the rabbit is 3 lb 1oz and gets 0.4 cc of penicillin G with Benthazine.

So I guess they can culture the abscess by an aspiration of pus right from the outside into the lump?? Why couldn't they just aspirate as much out as possible, to take the pressure off a bit?
Those Clindamycin beads are you familiar with those, supposedly better tolerated for the gut, and works inside the abscess...
I will definitely contact the vet tomorrow, since I hate to "throw in the towel", unless absolutely necessary (she just gives me the impression that bunny is quite geriatric being 8 years old).  

Answer
Dear Nora,

The Pen-G dosage he's on is about right, I think.  

In answer to your other questions:

"So I guess they can culture the abscess by an aspiration of pus right from the outside into the lump?"

Yes, but a better sample would be from the abscess capsule itself, where there are more live bacteria. In the center, it's mostly dead white blood cells, if the immune system is doing its job.

"Why couldn't they just aspirate as much out as possible, to take the pressure off a bit?"

If this were a dog or cat, they could.  But rabbit pus is often so thick it's like cheese, and it simply doesn't aspirate or express easily.  The only way to get it out, in many cases, is to open the abscess with a large incision and physically cut out the pus.  And if the infection is in the bone, this can get grisly.  Debridement of a severe, hard abscess is a good way to relieve the pain, though, so you might want to ask about that.  If the vets are reluctant, then maybe try to find another vet here:

www.rabbit.org/vets

who is more willing to be aggressive.

I'm not a big fan of beads, actually.  In my own experience, they've been nothing but a nidus for infection, and they just don't seem to work well.  Maybe the vets who have implanted them in my rabbits just weren't using good technique.  But I never consider them any more.

And don't let the vet tell you that the bunny is old at eight. What that suggests to me is that she just may not be very current in rabbit medicine and potential longevity.  :(  (We have a bunny now who's more than 15, and have had two others live to be 14.  In the household now, we have three more who are over 10 years old.  So don't let anyone tell you your bunny is doomed because she's "old".)

Hang in there!  
Dana