Management of the Oral Infection: Part 1 · Earn 3 CE credits This course was written for dentists, dental hygienists, and assistants. Supplement to PennWell Publications Go Green,

Earn3 CE creditsThis course was

written for dentists, dental hygienists,

and assistants.

Supplement to PennWell Publications

Go Green, Go Online to take your course

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AbstractThis two-part course will review the management of the acute oral infection. Part one focuses on the essentials that must be considered when treating the dental infection including microbiology, triage, anatomy, and laboratory testing. It includes the surgical, antibiotic, and palliative actions needed in the treatment of the acute dental abscess. Part two will emphasize the treatment of oral infections due to fungal, viral, and bacterial organisms.

Educational ObjectivesAt the conclusion of this educational activity participants will be able to:1. Describe the features of oral

microbiology as they relate to oral infection.

2. Identify the clinical issues related to dental infection.

3. Describe the various strategies for treating the acute dental abscess.

Author ProfileIan Shuman DDS, MAGD, AFAAID maintains a full-time general, reconstructive, and aesthetic dental practice in Pasadena, Maryland. Since 1995 Dr. Shuman has lectured and published on advanced, minimally invasive techniques. He has taught these procedures to thousands of dentists and developed many of the methods. Dr. Shuman has published numerous articles on topics including adhesive resin den-tistry, minimally invasive restorative, cosmetic and implant dentistry. He is a Master of the Academy of General Dentistry, an Associate Fellow of the American Academy of Implant Dentistry, a Fellow of the Pierre Fauchard Academy. Dr. Shuman was named one of the Top Clinicians in Continuing Education since 2005, by Dentistry Today. Author DisclosureDr. Shuman has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Publication date: Feb. 2017 Expiration date: Jan. 2020

This educational activity was developed by PennWell’s Dental Group with no commercial support. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content.Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required fee, review the material, complete the course evaluation and obtain a score of at least 70%.CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products or services discussed in this educational activity. Heather can be reached at [email protected] Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.Image Authenticity Statement: The images in this educational activity have not been altered.Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents the most current information available from evidence based dentistry. Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the data and information contained in reference section. The research data is extensive and provides direct benefit to the patient and improvements in oral health. Registration: The cost of this CE course is $59.00 for 3 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

PennWell designates this activity for 3 continuing educational credits.

Dental Board of California: Provider 4527, course registration number CA# 03-4527-15152“This course meets the Dental Board of California’s requirements for 3 units of continuing education.”

The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to (10/31/2019) Provider ID# 320452.

INSTANT EXAM CODE 15152

Management of the Oral Infection: Part 1A Peer-Reviewed Publication Written by Ian Shuman, DDS, MAGD, AFAAID

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Educational ObjectivesAt the conclusion of this educational activity participants will be able to:1. Describe the features of oral microbiology as they relate to

oral infection.2. Identify the clinical issues related to dental infection.3. Describe the various strategies for treating the acute dental

abscess.

AbstractThis two-part course will review the management of the acute oral infection. Part one focuses on the essentials that must be considered when treating the dental infection including micro-biology, triage, anatomy, and laboratory testing. It includes the surgical, antibiotic, and palliative actions needed in the treat-ment of the acute dental abscess. Part two will emphasize the treatment of oral infections due to fungal, viral, and bacterial organisms.

IntroductionThe frequency of periapical abscess is supported by a volume of statistical proof. The results of a nine-year retrospective study (2000–2008) of hospital admissions showed that more than 61,000 hospitalizations in the United States were directly related to dental infection in the form of periapical abscess.1

Sixty-six patient deaths were attributed to these infections.2

Using the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, a 2007 study conducted by Allareddy et al,3 it was found that there were 7,886 hospitalizations for periapical abscess in the United States, amounting to total hos-pital costs of $105.8 million.

The Global Burden of Disease Study in 2010 showed that cleft lip/palate, edentulism, oral cancer, caries, and periodontal disease accounted for over 18 million disability-adjusted life years.4 Evaluation of the global burden of oral diseases such as caries, periodontal disease, and cancer showed a marked increase of 45.6% from 1990 to 2010, on par with major non-communicable diseases such as diabetes.3 Dentists are usu-ally the first to see patients with early odontogenic infections. Therefore, it is vital that they be prepared to evaluate and treat problems before they become severe enough to demand hospi-talization.5

The complexities of oral infection Enormous numbers of pathogenic bacteria, nonpathogenic bacteria, and fungal organisms naturally colonize the oral mu-cous membranes. Numerous transient and potentially infective organisms (e.g., viruses) can be present as well. Opportunistic microorganisms such as Escherichia coli, Streptococcus pneu-moniae, Staphylococcus aureus, and Klebsiella pneumoniae can cause systemic versus oral disease.6

With respect to oral hard tissue, multiple bacterial interac-tions exist within the diverse dental microenvironments and

within each biofilm substrate. Biofilm is a combination of bacteria, extracellular DNA, protein, and polysaccharides that rapidly accumulate intraorally. If left undisturbed for several days, a biofilm may contain up to 1011 microorganisms/mL.7 In relation to this fact, oral hard tissue disease in the form of apical periodontal infection and marginal periodontitis has been as-sociated with 200 to 500 bacterial species.8,9,10

Bacterial interaction within a biofilm may either boost or suppress metabolic activity that leads to dental infection. Many factors regulate the number and types of oral bacteria within biofilm including the complexity of the flora, bacterial reten-tion and interaction, native resistance, saliva, hygiene, and diet. For example, a carbohydrate-rich diet favors bacteria such as Streptococcus mutans, an organism that causes dental caries. Diet consistency is also important because coarser foods can help to eliminate lodged food particles and disrupt the biofilm that can support microorganisms. In addition, oral bacteria have regional preferences vis-à-vis tissue adherence; Streptococcus salivarius is found primarily on the tongue while S. mutans and Streptococcus sanguis typically adhere to hard surfaces.11

The presence of systemic disease also influences the oral microbial population. Host defense mechanisms can be com-promised by conditions such as diabetes, heart failure, chronic lung disease, lymphoproliferative disorders, renal failure, malnutrition and alcoholism, among others. This compromise of the immune function can lead to a reduction in phagocytic activity, pulmonary clearance and circulation, among others. Immunosuppressant medications that are cytotoxic also reduce host defense mechanisms and increase the risk of infection. Prolonged systemic antibiotic therapy reduces normal bacte-rial flora, resulting in the selection of resistant flora and/or the emergence of competing fungal organisms. Other factors associated with oral infection include age, behavioral consid-erations, drug abuse, the social environment, and the patient’s psychological status.

A further consideration is the concept of virulence. Virulence is a harmful quality possessed by microorganisms that can cause disease. It involves the invasive nature of the organism and the detrimental toxins and/or metabolic and enzymatic byproducts produced in the course of the infectious process. Infection involves the interactions of microbial popu-lations, microbial virulence, and host defenses. Intraorally, host defenses are part of the mucosal immune system, an important factor in the prevention of oral and systemic infection. This sys-tem includes advantageous elements to protect the host against invading pathogens that include the resistance to tear and com-pression forces provided by the lamina propria.12 Colonization is minimized by cell shedding from the surface layer and by salivary secretion. Beside mechanical protection,chemical pro-tection is present in the form of an elaborate immune system. One example is the production of lymphoid cells producing immunoglobulins. In addition, serum proteins such as hista-mine, prostaglandins and lymphokines are released as a result

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of inflammation. There are also cellular defenses dependent on receptors, phagocytes, and lymphocytes (e.g., B and T cells).13,14,15

Triage The majority of acute oral infections are self-limiting and can be managed with minimal intervention. However, some types of oral infection can be associated with significant morbidity and mortality. The treating clinician must recognize the sig-nificance of the history and clinical signs. This information is vital in the diagnosis of the disease process and providing appropriate triage for the patient. For example, consider a pa-tient who presents with pallor, reporting a rapidly increasing swelling under the jaw into the neck or superiorly into the eye (suggesting spread beyond the oral cavity). This coupled with other local and systemic symptoms such as difficulty breath-ing or swallowing, fever (with chills or cold sweats), a thready pulse with lethargy and/or altered consciousness, trismus, a changing pain quality (i.e., change of pain from a mild ache to a severe throb), and dehydration should be considered for urgent oral surgical or medical referral as these clinical signs and symptoms indicate systemic toxicity.

Anatomic considerationsA basic understanding of head and neck anatomy including the location of lymph nodes and fascial spaces is useful in determin-ing the relative risk associated with infection. Lymph nodes that

are tender, enlarged, indurated, or fixed suggest the presence of infection. Infection and swelling of the pterygomandibular, para-pharyngeal (lateral pharyngeal and retropharyngeal), peritonsil-lar and cervical spaces, and the infratemporal or parotid space is considered high risk and necessitates urgent intervention.

Another potentially life threatening ailment is cellulitis. Cellulitis is a spreading bacterial infection just below the skin surface (i.e., the fascial planes) most commonly caused by Streptococcus pyogenes or S. aureus.16 Ludwig’s angina, a cellulitis-causing condition, arises from the oral cavity. This infection most commonly originates from an infected second or third mandibular molar tooth invading the submandibular space. This space consists of two compartments in the floor of the mouth, the sublingual space and the submylohyoid (fig-ure 1). It is an aggressive, rapidly spreading cellulitis without lymphadenopathy and with the potential for airway obstruc-tion. It requires careful monitoring and rapid intervention for prevention of asphyxia and aspiration pneumonia. Clinical signs include upward and backward displacement of the tongue and bilateral submandibular swelling extending inferiorly into the anterior neck to the clavicles and dysphagia.

Another example of an anatomic area of great importance in life-threatening infection is the infratemporal space (figure 2). Infection of the maxillary molars can invade the infratemporal space with a possible risk of spread to the orbit and ascension to the cavernous sinus via the venous plexus in the ovale and spinosum foramen.17

Tongue

Supramylohyoidportion of submandibularspace

Mylohyoid muscle

Inframylohyoid portionof submandibular space

Sublingual gland

Geniohyoidmuscle

Mylohyoid muscle

Super�cial fascial layerDigastric muscle (anterior belly)

Submandibulargland

Submandibularspace

Sublingual space

Submaxillary space

Figure 1: Ludwig’s Angina


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Laboratory considerationsMinor oral infections can be well managed empirically without culture if attention is paid to three important considerations: infection origin, involved anatomy and bacterium most likely involved. Most oral infections are odontogenic, superficial in nature, and in the majority of patients caused by Streptococcus bacteria. Infection by anaerobic bacteria such as Staphylococ-cus, Neisseria, and others can also occur, though with much less frequency.18,19

Infections that do not respond to routine antibiotic therapy require identification of the culprit microorganism(s) by way of laboratory evaluation. This provides the greatest precision in selecting appropriate antibiotic coverage. As a rule, a culture must be taken if (1) the infection has spread to one or more fascial planes of the head and neck, (2) initial antibiotic treatment has failed to contain the infection, (3) the patient’s underlying health is compromised by other conditions that affect immune response, and (4) the patient shows evidence of systemic toxicity.20

Of the various in-office examination techniques that should be considered in assessing infectious microorganisms, the Gram stain may be the most useful procedure as it provides immedi-ate results and allows determination of the type and numbers of species involved.21 Techniques for assessing infected (purulent) oral material include pulp chamber access of an infected tooth with collection of the emerging pus, transmucosal aspiration, and tissue biopsy. Unless the treating clinician is competent with these in-office techniques, it is best to refer to a specialist for collection, further lab evaluation, and subsequent dental or medical treatment.

Managing the dental abscessThe dental abscess develops as a result of bacterial invasion of the pulp and ultimately, the alveolar bone. Therefore, the pre-vention of caries is still the best first line of defense against the development of the dental abscess. The other effective preven-tive measure against dental caries and dentoalveolar abscess is proper dental hygiene. This includes brushing teeth after meals and regular dental check-ups. ADA Dental Practice Param-eters suggest that the dentist should utilize treatments designed to “reduce pulpal symptoms and/or protect the pulpal tissue of the tooth with pulpitis.”22 The document recommends that management of the dental abscess should be considered as fol-lows: nonsurgical approaches (e.g., antibiotics), chemothera-peutic modalities, dental restorations, endodontic therapy, tooth extraction and surgery.16 However, with any acute infec-tion, prior to the initiation of an antibiotic, purulence must be eliminated via surgical drainage.

Incision and drainageDrainage of odontogenic purulence can be accomplished through pulpal access, surgical incision, or tooth extraction. Surgical incision requires that the tissue is incised and spread with a hemostat followed by placement of a Penrose drain.23 A Penrose drain is a surgical device, typically a strip of latex or soft rubber tubing, placed inside a wound to drain fluid (figure 3). The drain is sutured into place with a patent opening, al-lowing fluids to drain from the infection site. In addition, the infected site can be decontaminated by irrigation with a saline solution (typically 60–100 ml) or chlorhexidine mixed with sa-line if necessary. The patient should be advised to: avoid touch-ing the area after surgery, apply firm direct pressure for 30–60 minutes, use a moistened tea bag to control bleeding, avoid the application of ice, and not apply heat until three days have passed to avoid spread of the infection. The drain is removed as soon as drainage output is minimal or has ceased.

Figure 3:

A. B.

C. D.

Temporalfascia

Zygomaticarch

Massetericspace

Masselermuscle

Mandible

Pterygomandibularspace

Medialpterygoidmuscle

Hamular process

Lateralpterygoid muscle

Infratemporalspace

Sphenoid bone

Deep temporal space

Super�cial temporal space

Temporalis muscle

Figure 2: Temporal Spaces

• Infra temporal space• Lies posterior to maxilla• Bottom portion of the deep temporal space• Source of infection- Maxillary third molars


AntibioticsIn most instances, antibiotics should only be prescribed for the dental abscess when the infection has spread beyond the radicular area, causing local involvement and/or systemic symp-toms.24 Once the infection spreads beyond the radicular area, the involved bacteria typically include a combination of anaerobic and aerobic organisms. This change in bacterial composition is a complication that can significantly alter the relative virulence of the infection and complicate antibiotic selection. An important consideration when using antibiotics is microbial resistance.25

The best approach for curtailing resistance is to prescribe a high dose of antibiotic for as short a course as possible.

The choice of antibiotic is largely empirical because the science supporting the efficacy of one antibiotic or treatment regimen over another is presently not definitive. This is due to the confusion posed by a number of methodological problems associated with the published research. These include issues related to study design and choice of outcome measures.26 In general, penicillin is often the first drug of choice for dental infections. An article by Olsen and Winkelhoff describes acute oral infections that can spread extraorally, recommending peni-cillin (when suspicion of methicillin-resistant S. aureus is low).27

Historically, antibiotic use has included the use of the penicillins, including penicillin V (table 1).28,29 Amoxicillin is favored as the drug of first choice due to its broad spectrum of action against many gram positive and negative bacteria.30 If there is a history of antimicrobial resistance, metronida-zole31 (although the drug itself has also been associated with increased resistance32) or amoxicillin combined with clavu-lanic acid should be considered.33 For individuals allergic to the penicillin-based antibiotics, clindamycin can be prescribed.34 Clindamycin is effective against both aerobic and anaerobic bacteria and penetrates bone readily.

Table 1: Empiric Antibiotics of Choice for Odontogenic Infections38 Type of Infection Antibiotic of ChoiceEarly (first 3 days of infection) Penicillin VK, amoxicillin

ClindamycinCephalexin (or other first-generation cephalosporin)1

No improvement in 24-36 hours

Beta-lactamase-stable antibiotic:Clindamycin or amoxicillin/clavu-lanic acid (Augmentin®)

Penicillin allergy ClindamycinCephalexin (if penicillin allergy is not anaphylactiod type)Clarithromycin (Biaxin®)2

Late (>3 days) ClindamycinPenicillin VK-metronidazole, amoxicillin-metronidazole

Penicillin allergy Clindamycin1 For better patient compliance, second-generation cephalosporins (cefctor: cefuroxime) at twice

daily dosing has been used.2 A. macrolide useful in patients allergic to penicillin, given as twice daily dosing for better patient

compliance.Adapted from Drug Information handbook for Dentistry; Richard Wynn, Timothy Meiller, Harold Crossley, 12th Edition

Azithromycin, a structural derivate of erythromycin, has also been recommended as an option for the treatment of mild to mod-erate bacterial infection.35 It has a broader spectrum of activity, increased bioavailability, and fewer gastrointestinal (GI) effects. For the patient with identified cephalosporin- or penicillin-resis-tant Gram-negative bacteria, cefoxitin has also been shown to be effective.36 The reader should refer to this and other guidelines for the latest information and proper dosing for the adult patient.

Antibiotics may also need to be prescribed to children with infection, although the dosage will be lower, as it based on body weight. Several rules exist to compute the dosage of a drug for a child, the most common being Clark’s Rule and Young’s Rule (tables 2 and 3) and empiric antibiotic options are available (table 4). The American Academy of Pediatric Dentistry has published prescription guidelines for children needing antibiotic coverage.37 The reader should refer to this and other guidelines for the latest information and proper dosing for the pediatric patient.

Table 2: Clark’s Rule for Pediatric Dosing39

Child’s Weight lb. (or kg) X Adult Dose = Child’s Dose150 lb. (or 70 kg)

Table 3: Young’s Rule for Pediatric Dosing39

Adult Dose X (Age ÷ (Age+12)) = Child's Dose

Table 4. Empiric Antibiotics of Choice for Odontogenic Infections38

Antibiotic DosageChildren Adults

Penicillin VK ≤ 12 years: 25-50 mg/kg body weight in equally divided doses q6-8h for at least 7 days; maximum dose: 3g/day

> 12 years: 500 mg q6h for at least 7 days

Clindamycin 08-25mg/kg in 3-4 equally divided doses

150-450 mg/ g6h for at least 7 days; maximum dose: 1.8 g/day

Cephalexin (Keflex) 25-50 mg/kg/day in divided doses q6h Severe infection: 50-100 mg/kg/day in divided doses q6h; maximum dose 3 g/24h

250-1000 mg q6h; maximum dose 4g/day

Amoxicillin < 40 kg: 20-40 mg/kg/day in divided doses q8h > 40 kg: 250-500 mg q8h or 875 mg q12h for at least 7 days; maxi-mum dose 2 g/day

> 40kg: 250-500 mg q8h or 875 mg q12h for at least 7 days: maximum dose: 2 g/day

Amoxicillin/clavulanic acid (Augmentin®)

< 40 kg: 20-40 mg/kg/day in divided doses q8h > 40kg: 250-500 mg q8h or 875 mg q12h for at least 7 days: maxi-mum dose: 2 g/day

> 40kg: 250-500 mg q8h or 875 mg q12h for at least 7 days; maximum dose: 2 g/day


Management of the dental infection can also be treated based on time of involvement. Emergent infections can be treated with penicillin V, amoxicillin, clindamycin, or a first-generation cephalosporin.40 If there is no improvement within the first 24 to 36 hours, clindamycin or amoxicillin/clavulanic acid combination (Augmentin) may then be considered. An-other consideration is to begin antibiotic therapy with a loading oral dose two times the standard maintenance dose so that a therapeutic blood level is achieved faster than what would be expected with an initial maintenance dose.41, 42

Despite the effectiveness of the penicillin-based antibiotics, they should be used with caution in patients with compromised renal function or in individuals with a history of seizures or significant GI hypersensitivity to antibiotics.43 Mild adverse GI reactions (e.g., nausea, diarrhea) are not uncommon with the penicillin antibiotics. True penicillin allergy is rare with the estimated frequency of anaphylaxis in one to five per 10,000 cases of penicillin therapy.44 Hypersensitivity is the more com-mon and most important adverse reaction resulting in nausea, vomiting, pruritus, urticaria, wheezing, laryngeal edema and ultimately, cardiovascular collapse. In these patients, clindamy-cin is recommended; however it can cause nausea, vomiting, diarrhea, and abdominal pain, and has been associated with the development of pseudomembranous colitis.45 Consequently, it is contraindicated in these patients as well as patients with a history of regional enteritis or ulcerative colitis. In addition, clindamycin should be used cautiously in the patient with liver disease.46

A highly controversial concern is the interaction between oral contraceptives and antibiotics. For years, the medical community has been advised that this interaction can lead to breakthrough pregnancy. With the exception of rifampin-like drugs used primarily to treat tuberculosis, there is a lack of scientific evidence supporting the ability of commonly pre-scribed antibiotics, including all those routinely employed in outpatient dentistry, to either reduce blood levels and/or the effectiveness of oral contraceptives.47 To date, all clinical trials studying the effects of concomitant antibiotic therapy (with the exception of rifampin and rifabutin) have failed to demon-strate an interaction. A 10-year retrospective study by Toh et al. found no association found between concomitant antibiotic use and the risk of breakthrough pregnancy among oral con-traceptive users.48 Therefore, dentists are now being advised that there is no need to warn women taking the combined oral contraceptive pill of the routine need to use additional con-traceptive measures while taking courses of broad spectrum antibiotics.49

Prolonged use of any antibiotic may produce an oral yeast infection.50 Listed precautions, contraindications, potential risks (e.g., in pregnant patients) and known drug interactions (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs] reduce the bioavailability of some but not all antibiotics) should be re-viewed prior to prescribing. It should also be fully appreciated

that improper prescription of antibiotic continues to be a prime contributor to the development of antibiotic resistance.51

Palliative careThe management of acute dental infection should also incor-porate palliative measures. No special precautions need be considered for hydration or nutrition unless retropharyngeal swelling prevents intake, in which case the patient should be immediately hospitalized. A soft diet is recommended during recovery from incision and drainage or tooth extraction. Pain management should include over-the-counter pain medication as well as cases requiring prescriptions that include NSAIDs and opioid analgesics.

Analgesics for acute painAcute pain arising from oral infections may present from mild to severe. Analgesics used in the management of mild to moder-ate acute pain include acetaminophen, aspirin, and NSAIDs.52 Cox-2 inhibitors are also effective, however, they must be used with caution due to recently identified cardiovascular adverse reactions.53 Moderate pain can be controlled by opioids or tramadol and these are often combined with acetaminophen or NSAIDs.54

A recent systematic review indicates that a 50% or greater reduction in severe pain following oral surgery can be achieved with 400 mg of ibuprofen, 50 mg of diclofenac, 120 mg of etori-coxib, 60 mg of codeine with 1000 of mg acetaminophen, 400 mg of celecoxib (Celebrex), and 500 or 550 mg of naproxen.55,56 Pain relief greater than eight hours can be achieved with 120 mg of etoricoxib, 500mg of diflunisal, 10 mg of oxycodone plus 650 mg of acetaminophen, 500 or 550mg of naproxen, and 400 mg of celecoxib. The study authors note that adverse events were more likely to be associated with the aspirin and opioids.

Patients sometimes misuse over-the-counter pain medica-tions,57 and prescription medications, when taken in combination with over-the-counter medications, can lead to toxicity. In 2014, the FDA published a drug safety caution regarding the prescrip-tion of opioids containing acetaminophen due to the potential for acetaminophen-related hepatotoxicity.58 The maximum amount of acetaminophen (in combination with opioids) is 325 mg when taken every four to six hours. Support for this alert comes in part from a study of unintentional acetaminophen overdose. In data collected by querying the French Pharmacovigilance database over a nine-month period, 13 patients were identified as having mild unspecific clinical symptoms and 4 of 10 had abnormal liver enzyme activity. The median dose of acetaminophen was 137mg/kg per 24 hours.59

Opioids also have potential for misuse. It is estimated that dentists prescribe approximately 12% of all opioids dispensed in the United States.60 The potential for misuse and toxicity of all pain relievers can be reduced by limiting the amount prescribed, performing a preassessment for potential drug interactions, and careful prescribing in patients with coexisting medical problems


(e.g. liver abnormality, kidney disease, stomach ulcers, alcohol-ism, anticoagulant therapy, hemorrhagic disorders, allergy, de-pression) and pregnancy. Effective opioid management includes patient education, monitoring for substance abuse, and appro-priate referral if abuse is suspected. For the pregnant or nursing female patient with abscess, a physician consult is recommended before prescribing drugs for pain management.61

According to Dental Management of the Medically Compro-mised Patient, aspirin and ibuprofen should be avoided through-out pregnancy; however, acetaminophen can be prescribed any time during pregnancy.56 For this and other prescribing recom-mendations, the reader must contact the patient’s obstetrician for treatment and prescribing approval.

ConclusionDentists face an important responsibility when treating the oral infection. An understanding of oral microbiology, laboratory assessment tools, and head and neck anatomy is necessary. The importance of triage based on patient presentation and treat-ment strategies are critical. In addition, the appropriate pre-scription of medication is of paramount importance in avoiding potential morbidity and mortality.

Bibliography1. Shah A, Leong K, Lee MK, Allareddy V. Outcomes of hospitalizations

attributed to periapical abscess from 2000-2008: a longitudinal trend analysis. J Endod. 2013;39(9):1104-1110.

2. Allareddy V, Lin CY, Shah A, et al. Outcomes in patients hospitalized for periapical abscess in the United States: an analysis involving the use of a nationwide inpatient sample. J Am Dent Assoc. 2010;141(9):1107-1116.

3. Jin LJ, Lamster IB, Greenspan JS, Pitts NB, Scully C, Warnakulasuriya S. Global burden of oral diseases: emerging concepts, management and interplay with systemic health. Oral Dis. 2015. doi: 10.1111/odi.12428.

4. Petersen PE, Ogawa H. The global burden of periodontal disease: towards integration with chronic disease prevention and control. Periodontol 2000. 2012;60(1):15-39

5. Palmer NA, Pealing R, Ireland RS, Martin MV. A study of therapeutic antibiotic prescribing in National Health Service general dental practice in England. Br Dent J. 2000;188(10):554-558.

6. Ogawa T, Ikebe K, Enoki K, Murai S, Maeda Y.Investigation of oral opportunistic pathogens in independent living elderly Japanese. Gerodontology. 2012 Jun;29(2): e229-33

7. Donlan RM, Costerton JW. Biofilms: Survival Mechanisms of Clinically Relevant Microorganisms. Clin Microbiol Rev. 2002 Apr; 15(2): 167–193.

8. Moore W. The bacteria of periodontal disease. Periodontol. 2000 5:66-77. 9. Cross B, Faustoferri RC, Quivey RG Jr. What are We Learning and

What Can We Learn from the Human Oral Microbiome Project? Curr Oral Health Rep. 2016 Mar;3(1):56-63.

10. Hovav AH. Dendritic cells of the oral mucosa. Mucosal Immunol. 2014;7(1):27–37.

11. Marcotte H, Lavoie MC. Oral Microbial Ecology and the Role of Salivary Immunoglobulin A. Microbiol Mol Biol Rev. 1998 Mar; 62(1): 71–109.

12. Georgiev VS. Mucosal Immune System. In: National Institute of Allergy and Infectious Diseases, NIH, Volume 2: Impact on Global Health. New York, New York: Humana Press; 2009: 675-682.

13. van Unen V, Li N, Molendijk I, et al. Mass Cytometry of the Human Mucosal Immune System Identifies Tissue- and Disease-Associated Immune Subsets. Immunity. 2016;44(5):1227-1239.

14. Dwivedy A, Aich P. Importance of innate mucosal immunity and the promises it holds. Int J Gen Med. 2011; 4:299–311.

15. Cellulitis. The Free Dictionary website. http://medical-dictionary.

thefreedictionary.com/cellulitis. Accessed May 25, 2016.16. Mesgarzadeh AH, Ghavimi MA, Gok G, Zarghami A. Infratemporal

space infection following maxillary third molar extraction in an uncontrolled diabetic patient. J Dent Res Dent Clin Dent Prospects. 2012;6(3):113-115.

17. Baron EJ, Miller JM, Weinstein MP, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (ISDA) and the American Society for Microbiology (ASM)(a). Clin Infect Dis. 2013;57(4):e22–e121.

18. Bahl R, et al. Odontogenic infections: Microbiology and management. Contemp Clin Dent. 2014 Jul-Sep; 5(3): 307–311.

19. Flynn TR, Shanti RM, Hayes C. Severe odontogenic infections, part 2: Prospective outcomes study. J Oral Maxillofac Surg. 2006; 64:1104–13.

20. Brook I. Diagnosis and Management of Anaerobic infections of the Head and Neck. Ann Otol Rhin Layngol 101:9-16, 1992.

21. Pulpitis. The American Dental Association website. http://www.ada.org/en/science-research/dental-practice-parameters/pulpitis. Accessed May 29, 2016

22. Ayad W, Jöhren P, Dieckmann J. Results of a comparative prospective randomized study of surgical removal of mandibular wisdom teeth with and without rubber drainage. Fortschr Kiefer Gesichtschir. 1995; 40:134-6.

23. Dar-Odeh NS, Abu-Hammad OA, Al-Omiri MK, Khraisat AS, Shehabi AA. Antibiotic prescribing practices by dentists: a review. Ther Clin Risk Manag. 2010; 6:301-306.

24. Robertson D, Smith AJ. The microbiology of the acute dental abscess. J Med Microbiol. 2009;58(Pt 2):155-162.

25. Hohl T, Whitacre R, Hooley J, Williams B. A Self-Instructional Guide: Diagnosis and Treatment of Odontogenic Infections. Seattle, Washington: Stoma Press; 1983

26. Olsen I, van Winkelhoff AJ. Acute focal infections of dental origin. Periodontol 2000. 2014;65(1):178-89.

27. Yagiela JA, Dowd FJ, Neidle EA. Pharmacology and Therapeutics for Dentistry. 5th ed. St. Louis, Missouri: Mosby; 2004.

28. American Academy of Pediatric Dentistry reference manual 2014-2015. Pediatr Dent. 2014-2015;36 (6 Suppl):284-286.

29. Lewis MA, McGowan DA, MacFarlane TW. Short-course high-dosage amoxycillin in the treatment of acute dentoalveolar abscess. Br Dent J. 19869;161(8):299–302.

30. Kuriyama T, Absi EG, Williams DW, Lewis MA. An outcome audit of the treatment of acute dentoalveolar infection: impact of penicillin resistance. Br Dent J. 2005;198(12):759-763.

31. Roche Y, Yoshimori RN. In-vitro activity of spiramycin and metronidazole alone or in combination against clinical isolates from odontogenic abscesses. J Antimicrob Chemother. 1997;40(3):353–357.

32. Lewis MA, Carmichael F, MacFarlane TW, Milligan SG. A randomised trial of co-amoxiclav (Augmentin) versus penicillin V in the treatment of acute dentoalveolar abscess. Br Dent J. 1993;175(5):169–174.

33. Gilmore WC, Jacobus NV, Gorbach SL, Doku HC, Tally FP. A prospective double-blind evaluation of penicillin versus clindamycin in the treatment of odontogenic infections. J Oral Maxillofac Surg. 1988;46(12):1065–1070.

34. Kuriyama T, Karasawa T, Nakagawa K, Saiki Y, Yamamoto E, Nakamura S. Bacteriologic features and antimicrobial susceptibility in isolates from orofacial odontogenic infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;90(5):600–8.

35. Murdoch DA. Gram-Positive Anaerobic Cocci. Clin Microbiol Rev. 1998;11(1):81–120.

36. American Academy of Pediatric Dentistry Council on Clinical Affairs. Guideline on Use of Antibiotic Therapy for Pediatric Dental Patients. http://www.aapd.org/media/policies_guidelines/g_antibiotictherapy.pdf/. Published 2001. Accessed July 31, 2016.

37. Commonly Prescribed Medications in Pediatric Dentistry. DentalCare.com. http://www.dentalcare.com/media/en-US/education/ce336/ce336.pdf. Revised January 8, 2016. Accessed May 30, 2016

38. http://www.dentalcare.com/media/en-US/education/ce336/ce336.pdf Accessed May 30, 2016

39. Clarks rule and Youngs rule. Pharmacy Tech Study website. http://www.


pharmacy-tech-study.com/dosecalculation.html. Accessed May 29, 2016.

40. Gilbert DN, Mollering RC, Eliopouos GM, Sande MA. The Sanford Guide to Antimicrobial Therapy 2006. 36th ed. Sperryville, Virginia: Antimicrobial Therapy; 2006: 33.

41. Antibiotics and the Treatment of Endodontic Infections. American Association of Endodontics. https://www.aae.org/uploadedfiles/publications_and_research/endodontics_colleagues_for_excellence_newsletter/summer06ecfe.pdf. Published Summer 2006. Accessed June 02, 2016

42. Arduino PG, Tirone F, Schiorlin E, Esposito M. Single preoperative dose of prophylactic amoxicillin versus a 2-day postoperative course in dental implant surgery: A two-centre randomised controlled trial. Eur J Oral Implantol. 2015;8(2):143-9.

43. Blumenthal KG, Shenoy ES, Hurwitz S, Varughese CA, Hooper DC, Banerji A. Effect of a drug allergy educational program and antibiotic prescribing guideline on inpatient clinical providers' antibiotic prescribing knowledge. J Allergy Clin Immunol Pract. 2014;2(4):407-13

44. Bhattacharya S. The facts about penicillin allergy: a review. J Adv Pharm Technol Res. 2010; 1(1):11–17.

45. Raab W. Acute side effects of erythromycin, lincomycin and clindamycin. Int J Clin Pharmacol Biopharm. 1977 Feb;15(2):90-7.

46. Zimmerman HJ. Clindamycin. Hepatic injury from antimicrobial agents. InL Zimmerman HJ. Hepatotoxicity: the adverse effects of drugs and other chemicals on the liver. 2nd ed. Philadelphia, Pennsylvania: Lippincott, 1999: 592

47. DeRossi SS, Hersh EV. Antibiotics and oral contraceptives. Dent Clin North Am. 2002;46(4):653-64.

48. Toh S, Mitchell AA, Anderka M, de Jong-van den Berg LT, Hernández-Díaz S; National Birth Defects Prevention Study. Antibiotics and oral contraceptive failure - a case-crossover study. Contraception. 2011;83(5):418-25.

49. Taylor J, Pemberton MN. Antibiotics and oral contraceptives: new considerations for dental practice. Br Dent J. 2012;212(10):481-3.

50. Verdugo F, Laksmana T, Uribarri A. Systemic antibiotics and the risk of superinfection in peri-implantitis. Arch Oral Biol. 2016; 64:39-50.

51. Carey B, Cryan B. Antibiotic misuse in the community—a contributor to resistance? Ir Med J. 2003, 96(2):43-4, 46.

52. Becker DE. Pain management: Part 1: Managing acute and postoperative dental pain. Anesth Prog. 2010; 57(2):67–79.

53. Huber MA, Terezhalmy GT. The use of COX-2 inhibitors for acute dental pain: A second look. J Am Dent Assoc. 2006;137(4):480-7.

54. Rosenblum A, Marsch LA, Joseph H, Portenoy RK. Opioids and the treatment of chronic pain: Controversies, current status, and future directions. Exp Clin Psychopharmacol. 2008;16(5):405–416.

55. Eccleston C. Post-operative pain management. Cochrane Database Syst Rev. 2011;(10): ED000033. doi: 10.1002/14651858.ED000033.

56. Moore RA, Derry S, McQuay HJ, Wiffen PJ. Single dose oral analgesics for acute postoperative pain in adults. Cochrane Database Syst Rev. 2015;(10):CD011407. doi: 10.1002/14651858.CD011407.pub2.

57. Denisco RC, Kenna GA, O’Neil MG, et al. Prevention of prescription opioid abuse: the role of the dentist. J Am Dent Assoc. 2011;142(7):800-10

58. FDA Drug Safety Communication: Prescription Acetaminophen Products to be Limited to 325 mg Per Dosage Unit; Boxed Warning Will Highlight Potential for Severe Liver Failure. FDA website. http://www.fda.gov/drugs/drugsafety/ucm239821.htm. Published January 13, 2011. Accessed June 1, 2016.

59. Clement C, Scala-Bertola J, Javot L, et al. Misuse of acetaminophen in the management of dental pain.

Pharmacoepidemiol Drug Saf. 2011;20(9):996-1000. 60. Role of dentists in reducing prescription drug abuse. California Dental

Association website. http://www.cda.org/news-events/role-of-dentists-in-reducing-prescription-drug-abuse. Published May 14, 2015. Accessed June 01, 2016

61. Pregnancy and Breastfeeding. In: Little JW, Falace DA. Dental Management of the Medically Compromised Patient. 8th ed. Elsevier Health Sciences; 2012

Author ProfileIan Shuman DDS, MAGD, AFAAID maintains a full-time general, recon-structive, and aesthetic dental practice in Pasadena, Maryland. Since 1995 Dr. Shuman has lectured and published on advanced, minimally invasive techniques. He has taught these procedures to thousands of dentists and developed many of the methods. Dr. Shuman has published numerous articles on topics including adhesive resin dentistry, minimally invasive restorative, cosmetic and implant dentistry. He is a Master of the Academy of General Dentistry, an Associate Fel-low of the American Academy of Implant Dentistry, a Fellow of the Pierre Fau-chard Academy. Dr. Shuman was named one of the Top Clinicians in Continuing Education since 2005, by Dentistry Today.

Author DisclosureDr. Shuman has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Questions

Online CompletionUse this page to review the questions and answers. Return to www.DentalAcademyOfCE.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by returning to the site, sign in and return to your Archives Page.

1. The outcome for patients hospital-ized for periapical abscess in the United States was evaluated with 7,886 hospitalizations amounting to total hospital charges of $105.8 million using research from the:a. CAMBRAb. North American Medical and Research

Foundationc. National Science Foundationd. Nationwide Inpatient Sample of the Healthcare

Cost and Utilization Project

2. The Global Burden of Disease Study in 2010 showed that cleft lip/palate, edentulism, oral cancer, caries, and

periodontal disease accounted for over how many disability-adjusted life years. a. 18b. 18,000 c. 180,000d. 18,000,000

3. From 1990 to 2010, evaluation of the global burden of oral diseases such as caries, periodontal disease, and cancer showed a marked increase by: a. 10.2%b. 45.6%c. 34.9%d. 83.2%

4. In regard to oral soft tissue, which of the following organisms do not colonize the oral mucous membranes:a. pathogenic bacteriab. non-pathogenic bacteriac. fungal organismsd. plasmodians

5. Which of the following opportunis-tic microorganisms mentioned in this course can cause systemic versus oral disease: a. Verrucomicrobium mrhankiib. Cyanobacter corniic. Klebsiella pneumoniaed. Fusobacterium preponderii



6. Biofilm contains:a. bacteriab. extracellular DNAc. intracellular DNAd. a and b

7. Within a biofilm, interaction of what microorganism type may either boost or suppress metabolic activity that leads to dental infection:a. spirochetesb. bacterialc. protozoad. ameoba

8. Many factors regulate the number and types of oral bacteria within biofilm including: a. the complexity of the florab. bacterial retention and interactionc. native resistanced. all of the above

9. Streptococcus salivarius is found primarily on what oral structure: a. palateb. labial mucosac. tongued. buccal mucosa

10. Streptococcus mutans and Strepto-coccus sanguis typically adhere to:a. hard surfacesb. soft tissuec. a and bd. none of the above

11. Host defense mechanisms can be compromised by which of the follow-ing conditions: a. diabetesb. lymphoproliferative disordersc. renal failured. all of the above

12. A harmful quality possessed by microorganisms that can cause disease is known as:a. virulenceb. viral spreadc. virulent reproductiond. all of the above

13. Advantageous salivary lymphoid cells produce:a. Megakaryocytesb. immunoglobulinsc. Natural Killer (NK) Cellsd. granulocytes

14. Serum proteins released as a result of inflammation include all of the following except: a. histamineb. prostaglandinsc. lymphokinesd. porphyrin

15. Lymph nodes that are tender, enlarged, indurated or fixed suggest the presence of:a. infectionb. Graves diseasec. Goiterd. cancer

16. Which of the following is a spread-ing bacterial infection just below the skin surface: a. Acanthosis nigricansb. Cherry hemangiomac. Cellulitisd. Granuloma annulare

17. Cellulitis is most commonly caused by which of the following microorganisms: a. Streptococcus pyogenes or Staphylococcus aureusb. Entamoeba histolytica or Cyclospora cayetanen-

sisc. Giardia lamblia or Microsporidiad. Schistosomiasis or Echinococcus granulosus

18. One of the conditions arising from the oral cavity that spreads to the fascial planes is known as: a. Aarskog-Scott syndromeb. Acromegalyc. Ludwig’s anginad. Angiocentric T-cell lymphoma

19. The submandibular space consists of which two compartments in the floor of the mouth:a. pterygomandibularis and hyoidb. sublingual space and submylohyoidc. medial pterygoid and retromolar padd. platysma and sublingual gland

20. Complete the following statement: The treatment of any oral infection should begin with identification of the culprit microorganism(s) by way of laboratory evaluation ____________.a. after an appropriate antibiotic regimen.b. prior to the initiation of therapy.c. during antibiotic therapy.d. none of the above

21. Most oral bacterial infections are: a. odontogenicb. superficial in naturec. caused by Streptococcus bacteria.d. all of the above

22. As a rule, a culture must be taken if:a. The infection has spread to one or more fascial

planes of the head and neck.b. Initial antibiotic treatment has failed to contain

the infection.c. The patient shows evidence of systemic toxicity.d. all of the above

23. Of the various examination techniques that should be considered

in assessing infective organisms in office, which of the following may be considered the most useful procedure: a. Hygiena indicatorb. Gram stainc. Glucose broth with Durham tubesd. Streak-stab technique

24. Techniques for assessing purulent material include: a. transmucosal aspirationb. pulp chamber accessc. tissue biopsyd. all of the above

25. The best first line of defense against the development of the dental abscess is:a. antibiotic therapyb. pulpotomyc. caries preventiond. a and b

26. Drainage of purulence can be accomplished through the surgical placement of a: a. French catheterb. closed drainage systemc. Penrose draind. a and b

27. Which of the following authors describes acute oral infections that can spread extraorally, recommend-ing Penicillin as being the drug of first choice:a. Presley and Martindaleb. Keaton and Winklerc. Olsen and Winkelhoff d. Dreyfus and Alexander

28. Which of the following analgesics are not contraindicated during pregnancy: a. acetaminophenb. aspirinc. ibuprofend. b and c

29.Patient education, monitoring for substance abuse, and appropriate re-ferral if abuse is suspected is required for the management of which class of drugs: a. Cannabinoidsb. Opioidsc. NSAIDSd. b and c

30. Infection of the maxillary molars can initially invade what anatomic area: a. durab. infrahyoidc. brain stem d. infratemporal space

Questions

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

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Educational Objectives1. Describe the features of oral microbiology as they relate to oral infection.

2. Identify the clinical issues related to dental infection.

3. Describe the various strategies for treating the acute dental abscess.

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Documents

Management of the Oral Infection: Part 1 · Earn 3 CE credits This course was written for dentists, dental hygienists, and assistants. Supplement to PennWell Publications Go Green,