DomsAntibiotics in a Nutshell: Part I

We are often faced with a patient situation in which we must deal with an infection or the prevention of an infection. Several factors must be considered before we decide whether to prescribe antibiotic medication or not. The choice of antibiotic, quantity, dose, and for how long must also be considered.

The use of antibiotic therapy for prevention or prophylaxis is controversial in some situations, and unclear in others. Often the decision is made with the comfort level of the practitioner in mind. Several questions must be asked:

-is the procedure going to cause an infection?
-is the region already infected?
-can the patient manage the treatment insult by themselves?
-is the material that I am using potentially infectious?
-would an infection interfere with the healing or
-would the lack of an infection enhance the healing
-would prescribing antibiotics expose the patient unnecessarily to the drug

Also, ask:
-what would be the best antibiotic to prescribe for prophylaxis?
-what infection (bacteria) are we ‘probably’ treating?
-what strength and for how long if no infection occurs?
-how do you feel about performing the procedure without antibiotics?
-what is the science behind prescribing or not prescribing antibiotics?

The list can go on with specific questions but we can deal with the above and allow the practitioner to extrapolate to reach the solution.

The science is somewhat vague in the area of prescribing antibiotics when we are treating an area with a minor infection and we treat the source (extract an abscessed tooth) directed at correcting the pain and sensitivity. The thought is that once the source is removed the region will heal uneventfully. The variables to the situation include the ability of the patient (immunocompromised, medically compromised, physically compromised) to manage the risk of an infection occurring.

There are many procedures in our offices which could cause an infection based on the number and variety of bacteria, viruses, and fungi in our patient’s mouths. For the most part our patients have an environment in which the flora and fauna live in harmony of checks and balances.

We have all extracted teeth without prescribing antibiotics and the patient has done well. Should the surgery take place in a region of the mouth (floor of the mouth, retromolar region, and maxillary sinus) where infection could take place and spread or the bacteria do not normally live in that region, then antibiotics can be considered. Also, when large areas of soft tissue or bone are exposed as with large flaps, or in the case of implants, grafts, membranes, or other foreign bodies, antibiotics should be considered as ‘protection’ for a wound or environment that needs to heal without infection.

Prophylactic antibiotics are directed at preventing an infection from bacteria that normally exist is the surgical region. Most viruses and fungi in the mouth will not cause an infection in the wound, but there are several bacteria which could cause a disruption to the healing wound.

The better protection for our wounds is with PenVK 500mg q.i.d. Patients who are allergic to penicillin can be prescribed clindamycin 300mg t.i.d. Amoxicillin is prescribed very often and is also beneficial for prophylaxis in our surgical procedures when no infection exists. Penicillin is more specific for the bacteria in the mouth and is my preference, but amoxicillin would be acceptable. Amoxicillin has a broader spectrum than penicillin, and is prescribed for 500mg at t.i.d dosage.

That said, the question of when and for how long leads to several issues. Ideally, the medication would be in the system at the time of surgery and should be taken for as long as the wound or the surgical region is at risk. When prescribing antibiotics for protection (prophylaxis) the numbers and directions should be spelled out: take three or four times a day until gone. That way we can be sure the antibiotics is in the system for the time period we desire. To simplify the directions, for example, tell the patient to take the penicillin ‘one hour before meals and at bedtime.’ Medication compliance is one of the foremost problems in treatment success.

The length of time to take the medication should be from three days to five days after the surgery. This allows the wound to seal and local swelling to no longer be a medium for bacterial growth.

Top Eleven Health Reasons to Remove Wisdom Teeth

Not all third molar teeth need to be removed, but listed below are eleven good reasons to consider their extraction:

1. Tooth decay can occur on erupted, partially erupted, and even impacted 3rd molar teeth. Also, the adjacent second molar tooth can become decayed from food impaction between the two teeth
2. Once it has been determined that a 3rd molar tooth will not successfully erupt into the mouth and be maintained in a healthy state, early removal of wisdom teeth is associated with faster and easier recovery
3. Even 3rd molar teeth that seem to be asymptomatic remain a breeding ground for oral infection and inflammation. Research supports the concept that such inflammation may enter the bloodstream and contribute to the development and/or progression of a variety of diseases, including diabetes, cardiovascular disease and stroke
4. Third molar teeth may contribute to crowding of nearby teeth
5. Periodontal disease and inflammation associated with 3rd molar teeth may lead to receding tissues, deterioration of the alveolar bone and tooth loss
6. With age, the chance for complications related to the removal of 3rd molar teeth increases
7. In some cases, impacted 3rd molar teeth develop associated cysts and/or tumors. Removal of such lesions may require extensive procedures to repair and restore jaw function and appearance
8. Even when 3rd molar teeth erupt through the soft tissues, they rarely provide any meaningful function and are always difficult to keep clean
9. Research suggests that oral inflammation associated with 3rd molar teeth may contribute to preterm or low birth weight infants
10. Because there is limited space for wisdom teeth to erupt and because the surrounding soft tissue is difficult to keep clean, infection and inflammation are common even when there is no apparent symptoms. Research shows that once inflammation takes hold, it is almost impossible to eliminate and may involve other teeth
11. Poorly positioned third molar teeth can cause resorption on the distal of the second molar tooth which could result in the loss of the third molar and second molar tooth

Bone Sequestra: Ideopathic or Iatrogenic

It happens to our patients now and again and we can be frustrated as to the etiology. Whatever the cause, we must deal with it. I am talking about the pesky, and irritating segment of bone that is or has been poking through the mucosa that has caused our patients varying levels of grief.

Most often the bone is found projecting though the mucosa on the lingual shelf of the mandible in the molar region, although it can appear in the maxillary molar and cuspid regions. When you consider the anatomy of the regions, the clinical signs can be understood. The bone on the lingual shelf of the mandible and maxillary buccal and labial plates is dense, much like pure cortical bone. In many patients, especially those with mandibular tori and maxillary exostosis, that is the case. In addition to having dense bone, the overlying mucosa is thin, and in the case of the mandibular lingual area, the circulation is fair to poor.

Injury to the area can be the result of mechanical trauma or irritation (such as poorly fitting prosthesis), tooth removal, or for no known reason. A break in the thin mucosa will expose the cortex. The wound heals uneventfully for the most part, but a series of events can occur which leads to a nonhealing or poorly healing ulcer. The bone in the region looses its blood supply and begins to separate from the viable alveolar bone.

Teeth are removed by expanding the alveolar bone, and in the process of extraction the bone (especially the unforgiving bone) may fracture or segments may separate from the alveolus. If left attached to the soft tissue the bone likely will remain viable, but not infrequently, the segments may loose their blood supply and begin working their way through the gingiva.

Loose sequestra may be removed most often without anesthesia by lifting them off much to the relief of the patient. Simple massage of the soft tissue will promote healing, and the tissue will return to normal in 1-2days.

The sharp bony shelf on the lingual of the mandible and buccal of the maxilla can be more problematic. Often the bone is sharp and the soft tissue is thin accentuating the bony prominence and making the region very tender. Treatment can consist of watchful waiting and wound massage or surgical reduction to relieve the sharpness. If left long enough the bone will remodel, but the area can be painful and the patient may not want to delayt. Removal of the bony prominences is usually a simple surgical procedure that may be performed with local and usually takes 10-15 minutes.

A simple incision is made over the area and the bone is removed with ronguers or small bone file. The soft tissue is repositioned with sutures, and the wound will heal with less pain or tenderness.

The idiopathic exposed bone usually on the lingual of the mandible can be managed locally. Exposed bone and healthy surrounding soft tissue is managed with irrigation, massage, and watchful waiting. If the region remains healthy the soft tissue will (should) cover the bone. (See Bisphosphonate in this section) In time the wound will heal or the body will try to lift the foreign body, in this case necrotic bone, by the advancement of granulation tissue beneath the bone. The process may be aided by removing the bone, which may be loose at this time, under local anesthesia. Rinses with saline and gentle massage can enhance the healing process.

Bone is supposed to be covered with soft tissue, but when it is exposed, the better treatment consists of local therapy, health to the soft tissue in the region, and antibiotics and debridement as needed to reestablish the continuity of the oral mucosa and hard tissues.