Medical, Dental and Surgical Treatment of the Infected Patient

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Today we'll be discussing medical, dental, and surgical treatment of the infected patient. Our guest is Dr. Stuart Lieblich, a world-respected oral and maxillofacial surgeon. He is a contributor to over 19 textbooks and published over 45 peer -reviewed papers and abstracts related to oral surgery and oral medicine. He is a noted speaker nationwide and regularly presents webinars for vivalearning.com. He is currently in private practice in Avon, Connecticut, and is on the medical staff at a variety of hospitals in Connecticut. Before we get started, I would like to let our audience know that Dr. Lieblich’s webinar titled Urgent Dental, Medical, and Surgical Management of the Infected Patient is now available as an on-demand webinar on vivalearning.com. Simply type in the search field Lieblik and you'll see it. It's an excellent webinar for every dental team member to watch. Dr. Lieblich, it's a pleasure to have you on Dental Talk. Well, thank you very much, Dr. Klein, and great to be back. Yeah, so this is an important topic, the infected patient, because I actually recently had a discussion with a friend of mine who is a dentist, retired, who got very, very ill. He was in the hospital for months from a dental infection. Yeah, and almost did not make it. This podcast is certainly relevant to what happened to him. And he's a dentist and he almost lost his life over a dental infection. So what are some aspects of antibiotic prescribing that dentists may overlook? And of course, that's tied into the whole infected patient topic. Well, precisely. And I think we're always worried about your friend, and that's always in the back of our mind. And I think that leads us sometimes to potentially over-treatment with antibiotics. You know, there are a lot of different reasons to prescribe an antibiotic. From one, it's a way to end an appointment. You know, the patient's expecting something, and if you want to move on, write a prescription, and, you know, that's the end of the appointment. They can go from there. And sometimes we just don't know the source of the problem. And again, we'll... out an antibiotic and see. But, you know, antibiotics are not without risk. And, you know, we have to be good stewards of antibiotics for our society and the world so that we're not creating a lot of resistant bacteria. But the other side of the coin is that we want to use the right antibiotics at the right time. And I think, as you and I will discuss today, for the right duration. I think there's an issue with duration of approach. And we tend to prescribe them for too long of an outcome. So where are we on the spectrum of time related to the overprescribing of antibiotics? When I practiced 20 years ago, we were discussing the same topic where patients are coming in, they're not even... really taking x-rays the tooth hurts they're doing it on the phone they're not even really seeing the patient in person so antibiotics were being prescribed all over the place and what we talked about back then was that eventually these antibiotics aren't going to work as well and we're going to get these superbugs and when we're going to be in real trouble and it was very troubling to me to see how many general dentists especially and nothing against general dentists but more general dentists than specialists because as an endodontist i tried to stay away from prescribing antibiotics and I saw plenty of infected teeth. and you know it's not related to just one specialty or another but it's it's all of us in our practice and i think we understand the the issues involved as far as over prescribing uh you know there are about six things as we talked about in the webinar that occur once you give an antibiotic and only one of them is a positive thing which is that the host overwhelms the bacteria and recovers but we always have to remember as dentists we are doing procedures now we can say it's a surgical procedure say extracting the or it could be an endodontic procedure as in your practice to get drainage to start eliminating the infection and and once we do that you know antibiotics truly have a very secondary role so we really have to step back and and you know and it's our patients and they'll say I need a whole week and I've always been told I have to finish every last antibiotic for the week or ten days or else the infection is going to come back well We're not treating pneumonia. We're not treating urinary tract infections where you're using the antibiotics as the mainstay of management or therapy for the patient. Instead, we're tiding patients over. We're working with their host defenses to treat the patient by extracting the tooth, by performing the endodontic care to get definitive therapy. Once that's done, we can really take away the antibiotic. The antibiotic has really no role. Pushing patients out another six or seven days, we start to see more side effects. Not only resistant bacteria, but as we know, antibiotics are indiscriminate. They knock out our normal healthy bacteria. So we talk about our biome, which is the natural bacteria that we all have in our systems that make us who we are. They're homeostatic. We need it to absorb vitamins from our gut into our bloodstream and all the other aspects of digestion. And when we start giving antibiotics, we start taking away those healthy bacteria and allow sites now for other things to grow. So a classic example is yeast infections, thrush candidiasis. Now, normally the oral cavity has receptor sites all bound up with bacteria, which are healthy and living well in our bodies, and we're all plussing together. And you take away those bacteria, now the yeast, which are out in our environment, have a site to latch onto, and then they take over and create a secondary infection. Again, a lot of secondary issues that occur with an antibiotic prescription that we can sometimes overlook. So before we get into the allergic aspect of penicillin, what is the de facto antibiotic to give to a patient who has been diagnosed with a dental infection? Maybe drainage was done, maybe drainage was not fully done, depending on where the infection is and so forth. What would be the de facto antibiotic at this point? So our best antibiotics with the least amount of side effects will be in the penicillin class. So whether you choose amoxicillin or penvk, both of those drugs are very well absorbed. They're not affected by foods that people eat, so you don't have to worry about taking an hour before dinner or two hours after. maintaining the blood levels are very good and they are bactericidal antibiotics where they actually will break the the bonds of the bacteria themselves and cause them to break down. So those would be are certainly a first line of agents. There is a tendency to jump ahead and and go to Augmentin or Amoxicillin with clavulanic acid and that does give you a little bit broader spectrum coverage but again what we have to understand is that our infections, odontogenic tooth source infections, have multiple bacteria. That's not one or two, but it's five or six or eight different bacteria. And we don't have to knock out each one of those eight bacteria for the patient to get better. And again, primarily, we should be thinking, what can I do dentally to get that patient out of their infected state and allow the body then to recover? So we showed in the webinar some descending infections the cellulitis that spreads and obviously those are more concerning and require perhaps intravenous antibiotics but most of the times we can treat our patients with oral antibiotics in conjunction with dental care now the patient shows up five o'clock on friday that ever happened to you in your practice dr klein never never happened yep from that from that guy down the street who never sends you anybody else that's right that's right yeah oh i have a great patient for you well no there's nothing wrong with tidying that patient over assuming we've eliminated that they have a serious infection where they should go to a hospital but if it's been painful and maybe a little bit of swelling in the area that's not affecting swallowing or speech or breathing, then certainly an antibiotic over the weekend, getting the patient in Monday, Tuesday, Wednesday, and opening the tooth, extracting the tooth, whatever you may need to do. Now, as we talk about antibiotics options, if they're allergic to penicillin, I think that's where we get into some discussion, and we're trying to get clindamycin out of our practices. I don't know if that was part when you were still practicing, but there has been sort of a black box put on clindamycin, and even with a low dose and a single dose in young, healthy people, you can get the secondary clostridium infections, the C. difficile, and the pseudomembrous colitis that persists afterwards. And I just recently saw a patient that had been prescribed clindamycin, a healthy 18-year-old, just for routine. They gave it to him for third molar surgery and he wasn't really infected ahead of time. prophylactic and had to have a bowel resection, had to go through six months of a colostomy bag. They were able to reconnect him, but his bowels will never be back to normal. And this is a lifelong situation for an individual that was previously young and healthy. And there's no evidence, for example, for antibiotic usage for, say, third molar impacted teeth. And unfortunately, when we give an antibiotic for that, a lot of times we take out the teeth and hand the patient a prescription or electronically send it in now for their pain reliever. And that's a whole separate conversation as well as the antibiotic. Well, if you take it after the procedure, there's no prophylactic benefit. It has to be in the system one or two hours ahead of time. So handing a patient an antibiotic afterwards, you're going to get all the secondary risk factors, secondary side effects, but you'll have the same risk of infection. So if you are going to give an antibiotic prophylactically, it has to be in the system prior to the procedure. What are we doing for patients that are allergic to penicillin? And also, Dr. Lieblich, address the real broad spectrum antibiotics like cefalexin or something like that, Keflex. Sure. First of all, 90% of people who say they're penicillin allergic are not allergic. Now, we don't want to be allergists. I don't want to be one of my practice. But we do need maybe to ask a little bit more questions to that patient. what type of reaction did you have? So if the patient had a very minor rash and they're younger, it's interesting, but people grow out of penicillin allergies because penicillin is a little bit in our environment. So again, it is a little bit of a factor. Do we want to take that risk? The risk, of course, in the back of our minds is anaphylaxis, but the chance of that occurring with an oral dose is almost nil. It's always associated with an IV dose, unless the patient had anaphylaxis in the past. So all that said, you really have to ask the patient, what was your allergy like? Many times they'll say, my stomach got really upset or I had diarrhea. Well, if you ask them further, more likely than not, they were on Augmentin, which is the amoxicillin clavulanic acid. And that's fairly irritating to the stomach. of patients will develop gastrointestinal side effects, which they may call it allergy or someone told them they're allergic, but it just means they should not have augmentin, but they can certainly have amoxicillin or penicillin. So I'm fairly comfortable giving those patients a dose. I've had a patient today that had multiple allergies listed and I asked, well, don't tell me what you're allergic to. Tell me what you've taken. been successful. So if we do have a true allergy, we're concerned, then I would go with azithromycin. I think that's going to be our next choice, or clarithromycin. And again, these are nice in the sense they have a little bit longer duration of action, so patients have to take them once a day. You do get a little bit of gastrointestinal side effects, but not as bad as the augmentin or the amoxic clavulanic acid. So I keep that in the back of my mind for my pen allergic patients. And that's now our protocols with prosthetic heart valves and things like that to go to azithromycin. So before we get off the topic of clindamycin, is that off the table now in the dental practice? Yeah, I would be very, very reticent to prescribe clindamycin anymore. It's got a black box warning on it. And again, you know, it's not common, but someone who develops a pseudomembrous colitis, a C. difficile super infection. You know, their treatments are bowel resections, fecal transplants from other members of the family. And, you know, it's very, very, has a significant morbidity to it. That's for sure. So talking about infected patients, there is a component of pain to that. Now, not all infected patients have pain. You could have an infection and have no pain. So when a dentist does face a patient that is very uncomfortable with pain and has an infection. What's the best way to go there? Well, and those are many times new patients to our practice. They've maybe neglected their dental care for a while, and it's our chance to shine and convert this patient to a regular patient in our practice. So if you get someone out of pain and they're very appreciative, they can become a lifelong patient. First off, if there's a significant swelling in the area, again, a treatment with antibiotics for, you know, three to five days before coming back for definitive care, whether it's extraction or endodontics or periodontal curetage, certainly will improve our ability to get pain control at the time of the procedure. So in general practice, specifically, local anesthetics we know are not always effective and we kind of use the terminology and discussion with our patients that the infection makes the area more acidic and that counteracts the local anesthetic that we're giving you and it's not quite that simple because we know you have infection next to number 30 but you give a block. posteriorly and superiorly and way out of that range, but yet the patient has lip numbness, but yet they're still feeling pain when you're luxating their tooth or drilling into it. So the nerve receptors are really changed by inflammation and the mediators of infection, and we don't need to get into all those details, but it's not as simple as the acid-base changes, you know, on the site. But what can we do? Well, again, we can probably treat pre-treat with an antibiotic to get the infection under control, to get those mediators of inflammation out of there, pre-treating them with anti-inflammatories. And then as we pick and choose our local anesthetics, you know, we have a few options that are out there. But in these situations, arcticane, for example, I think is the ideal agent to use as your first-line drug. And reason being is two. First off, it's a 4% solution versus our 2% lidocaine. So for every... ml of injection you're getting twice as many local anesthetic molecules and that's certainly a benefit to increase the concentration. And then the other aspect is its pKa or dissociation is a little bit lower and closer to normal tissue pH than is lidocaine, so it's going to have a faster duration of action. So we do need to give it more time. As you can see by my frenetic pace of speaking, I tend to want to move quickly and get my patients treated and move on. But, you know, these are patients that will give local anesthetic injections to, step out of the room, come back, give a second injection, and step out again and give them a good 15 or 20 minutes and explain to the patient that you're infected, it's a hot tooth, you're going to take a little bit longer to get anesthetized than someone who comes in that's not infected. And it's not that I'm ignoring you, although I might be. seeing other patients or browsing the web in between. But indeed, it's actually beneficial giving that patient more time. Right. Now, where does IND come in with this? Yeah, IND is a great adjunct. If there's some localized swelling adjacent to the tooth, we can get a little wheel of local anesthetic just submucosally. Just put a blade in it. We can get drainage, and that's going to definitely improve the blood flow to the area. get the mediators of infection and inflammation out of there and then therefore allow us to get much more profound local anesthetic when we get the patient back two or three days later. And one of the questions often comes up as well as the use of drains and I think a lot of general dentists are not comfortable placing a drain and it's not really necessary. If it's pointing, it looks like it's ready to burst. Again, by getting some drainage, as you mentioned, patients are infected and not in pain so the infection is still there. However, from that aspect, by draining it, it's going to resolve the area much more rapidly. And again, our goal is to get profound local anesthetic so we can provide definitive care to that area. So I think the knee jerk is to prescribe an antibiotic. But as practitioners, I think draining infections, taking out teeth, doing endo is really going to be the main key for our patient. Right. With soft tissue incision and drainage as an oral surgeon, as we're on the topic, do you make the decision to use a blade to do an ind only when you see it localized like if you can't really feel confident that that soft tissue exudate is local right there ready to be drained do you stay away from that and wait for to localize later once the antibiotics take hold what's the process yeah that's that and that's a great question actually we studied that when i was on faculty at uconn does say early incision and drainage help improve outcomes versus waiting for it to point or develop and you know the old thought process we do the eye the incision where we can get the d the drainage and that was always the thought but if there's an area of cellulitis of redness there's a thought that opening it up may help change the aerobic anaerobic environment to allow better circulation i think In general practice though, unless it's if it's pointing, and you're going to be very safe at just hitting it with a blade and letting it drain and maybe irrigating with a little bit of saline. The actual use of drains are when the infections are descending, involving multiple spaces, and we want to have each space communicating with each other to allow the infection to continue to come out. So I would not be as concerned. I think in general practice, once you have multiple space involvement or considering drainage placement, then maybe you want to refer to someone who does those. more regularly because you start to enter into other anatomical sites. But a superficial infection that's pointing, it looks like a pimple that's going to break open any minute. Again, that's going to really help the patient get rid of that pressure in there. They're going to feel a lot better very quickly. And that's really all you need to do on day one when you see that patient. So what is the tipping point regarding hospitalization? What does a patient have to show up with in the office, whether it's a GP or specialist, where you go, okay, we're a little bit further down the line here. we need to admit this patient and many times it's a phone call like the patient calls you at night and you have to make that decision should you tell the patient to go to the emergency department or wait till tomorrow morning and i'll see you or what have you or make a referral so the key symptoms we look at are difficulty in swallowing inability to open the mouth trismus infections that are spreading around vital areas particularly around the eye so if they say they can't open their eye or they have any signs of double vision, those are very concerning to us. But the ones that we see a lot, especially in oral surgery, are perichoronitis. Infections around the wisdom teeth are spreading back into the throat area and again the main problem will be difficulty in swallowing that they are not controlling their secretions, they rather drool out their mouth and as unpleasant as that is versus the pain of swallowing, it's very painful. And then also voice changes because as an infection descends and creates inflammation, it'll start to affect the vocal cords and that is a sign of, we call it a hot potato voice. and I was like a sore throat kind of feeling. What about fever? Ah, fever. Thank you very much. Yes. So fever, and we're all taking temperatures nowadays, right? So we're always worried about fevers and inappropriately so. Fever is actually a fairly good physiologic response. So if someone's a healthy individual, they mounting a little bit of a fever to the infection. and they don't have any other signs, you know, you may be able to treat them and start them with antibiotics and follow them closely. However, fever and dehydration with a rapid heart rate would indicate it's time to go to the hospital to get fluids and IV antibiotics and probably a trip to the operating room and getting these opened up and drained. So before we go on to the last question, Dr. Lieblik, and this has been very, very helpful what you've been talking about, what kind of arcticane do you recommend? Any particular one that you use? Yeah, the Articane has different formulations, but the Perel Pharma, who sponsored our talk, produces OuroBlock. And what's interesting about OuroBlock is the way they formulate it. Most local anesthetics are combined, all the chemicals, and then they're sterilized, which creates a lot of heat. And that creates some byproducts of breakdown, as well as degradation of the epinephrine. In contrast, when they manufacture OuroBlock, which is what made me enthusiastic about this product, is that their pre-sterilizing all the individual ingredients so that when it's packaged together in our dental cartridges that they don't have to re-sterilize it, there's no terminal heat sterilization. And so the stability of it, the longevity of it is a little bit greater, there's less breakdown products of the epinephrine that are in there. And the vasoconstrictors are very important for our local anesthetic effect. Again, particularly in the infected patient, we have inflammation, increases blood flow. So as we place a local anesthetic solution, the body's going to be removing it and breaking it down and taking away from the nerves. So again, I'd recommend individuals and dentists who have not used OroBlock before to consider that there are a cane of choice. So final question, Dr. Lieblich. And again, as I said, it's been very insightful. How long should antibiotics be continued for once definitive dental treatment like endodontic treatment or extraction has been completed? And that's the key thing. Once we've treated the patient, the patient's going to get better. So if I... talk to you on Friday night because you had an infection. I got you in Saturday, Monday morning and remove your tooth. I would tell you take your antibiotics till Monday night and then you don't need to take them anymore on Tuesday. So the complete them on the day of the definitive procedure and then it's time to stop the antibiotic. Again it's conversation, it's an education that we need to provide to the patient, because again there's this overlay of, no I have to take all the antibiotics until they're done, otherwise resistant bugs are going to pop up and I'll have issues. So that's a key point there, and we touched earlier on antibiotic prophylaxis, I would say the other area is implant prophylaxis, and so again if you are going to prescribe antibiotics with your implant surgeries. then again, they should be in the patient's system or they need to be in their system prior to us making the incision or drilling into the bone. And one interesting article that came up recently from NYU that was published was on failure rates of implants. And they found in their patients who were allergic to penicillin and therefore did not receive penicillin preoperatively for an implant, had a 17.2% failure rate, where those that were not allergic to penicillin and received that before surgery had half the failure rate of 8.4%. So those are still fairly large numbers of failure rates. So it's hard to... accept the article, but, you know, they're treating, this is from dental students and residents, so perhaps their failure rates may be a little bit higher than yours and mine, Dr. Klein. So, again, if we can get patients off the clindamycin, I think that's a key take-home, and use the azithromycin, and again, really ask your patients about their penicillin allergies, and if there's no reason or secondary side effects in their stomach, then go with the penicillin. whether it's amoxicillin or pen VK, there's no differences there. Yeah, fantastic. Do you think we're at a stage now where superbugs are a threat to us with all the oversubscribing of the last 20 to 30 years, or are we still in the safe zone? No, there are. I mean, working in the hospital, you know, we all hear about MRSA and things like that, and that's still out there and doesn't get quite as much. I think a lot of it is knocking out our own biome. So our best protection is our cells. And we want to maintain the bacteria that live within us and on us. And so every time we give a patient an antibiotic, we are definitely affecting them homeostatically, that their whole system will change over a little bit. And again, most people will adapt very quickly to that, but not everyone does. It might be worth looking into taking probiotics of some kind. Oh, yes. Thank you for mentioning that. Yeah. Go ahead and comment on that. No, you're 100%. Thank you for mentioning that. And, you know, we always, that's an automatic prescription at our hospital. Whenever we do prescribe clindamycin, it comes up to prescribe probiotic as well, too. So we don't have a lot of those measures in our... uh office prescribing systems even if they're electronic but again i agree with you and encouraging that to patients and and warning them about side effects and that if they have two episodes of loose stools in a row to stop the antibiotic and call us because again any antibiotic can cause the c difficile infection it's much much more likely with clindamycin but it could occur with anything so yeah and when it comes to probiotics not all probiotics are the same and there are some companies that have very strict type quality control guidelines like Clare Labs is one. I think Clare is spelled with a K. There's other ones and they're not sponsoring this and there's no endorsement here. It's a fairly unregulated industry, probiotics. So if you go to the grocery store and pick up probiotics, doesn't mean it's really active and it's going to help you. So one should look into the quality ones that are out there. Dr. Lieblich, I love talking to you. You've done some amazing stuff for Viva Learning. I hope you continue to work with us. You just bring so much knowledge to the table and our audience really enjoys listening to you. Thank you so much. Real pleasure on my part. Thank you very much, Dr. Klein.