Management of the Oral Infection: Part 1 a Peer-Reviewed Publication Written by Ian Shuman, DDS, MAGD, AFAAID © Stiggdriver | Dreamstime.Com © Stiggdriver

Earn 3 CE credits This course was written for dentists, dental hygienists, and assistants.

Management of the Oral Infection: Part 1 A Peer-Reviewed Publication Written by Ian Shuman, DDS, MAGD, AFAAID © Stiggdriver | Dreamstime.com © Stiggdriver

Abstract Educational Objectives Author Profile This two-part course will review the management At the conclusion of this educational Ian Shuman DDS, MAGD, AFAAID maintains a full-time general, of the acute oral infection. Part one focuses on the activity participants will be able to: reconstructive, and aesthetic dental practice in Pasadena, Maryland. essentials that must be considered when treating 1. Describe the features of oral Since 1995 Dr. Shuman has lectured and published on advanced, the dental infection including microbiology, triage, microbiology as they relate to oral minimally invasive techniques. He has taught these procedures to anatomy, and laboratory testing. It includes the infection. thousands of dentists and developed many of the methods. Dr. Shuman surgical, antibiotic, and palliative actions needed in 2. Identify the clinical issues related to has published numerous articles on topics including adhesive resin dentistry, minimally invasive restorative, cosmetic and implant dentistry. the treatment of the acute dental abscess. Part two dental infection. He is a Master of the Academy of General Dentistry, an Associate Fellow will emphasize the treatment of oral infections due to 3. Describe the various strategies for of the American Academy of Implant Dentistry, a Fellow of the Pierre fungal, viral, and bacterial organisms. treating the acute dental abscess. Fauchard Academy. Dr. Shuman was named one of the Top Clinicians in Continuing Education since 2005, by Dentistry Today.

Author Disclosure Dr. Shuman has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. INSTANT EXAM CODE 15152 Go Green, Go Online to take your course

Publication date: Feb. 2017 Supplement to PennWell Publications 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 PennWell designates this activity for 3 continuing educational credits. or services discussed in this educational activity. Heather can be reached at [email protected] Educational Disclaimer: Completing a single continuing education course does not provide enough information to result Dental Board of California: Provider 4527, course registration number CA# 03-4527-15152 in the participant being an expert in the field related to the course topic. It is a combination of many educational courses “This course meets the Dental Board of California’s requirements for 3 units of continuing education.” 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. The PennWell Corporation is designated as an Approved PACE Program Provider by the Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents Academy of General Dentistry. The formal continuing dental education programs of this the most current information available from evidence based dentistry. program provider are accepted by the AGD for Fellowship, Mastership and membership 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 maintenance credit. Approval does not imply acceptance by a state or provincial board of and improvements in oral health. dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to Registration: The cost of this CE course is $59.00 for 3 CE credits. (10/31/2019) Provider ID# 320452. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives within each biofilm substrate. Biofilm is a combination of At the conclusion of this educational activity participants will bacteria, extracellular DNA, protein, and polysaccharides that be able to: rapidly accumulate intraorally. If left undisturbed for several 1. Describe the features of oral microbiology as they relate to days, a biofilm may contain up to 1011 microorganisms/mL.7 In oral infection. relation to this fact, oral hard tissue disease in the form of apical 2. Identify the clinical issues related to dental infection. periodontal infection and marginal periodontitis has been as- 3. Describe the various strategies for treating the acute dental sociated with 200 to 500 bacterial species.8,9,10 abscess. Bacterial interaction within a biofilm may either boost or suppress metabolic activity that leads to dental infection. Many Abstract factors regulate the number and types of oral bacteria within This two-part course will review the management of the acute biofilm including the complexity of the flora, bacterial reten- oral infection. Part one focuses on the essentials that must be tion and interaction, native resistance, saliva, hygiene, and diet. considered when treating the dental infection including micro- For example, a carbohydrate-rich diet favors bacteria such as biology, triage, anatomy, and laboratory testing. It includes the Streptococcus mutans, an organism that causes dental caries. surgical, antibiotic, and palliative actions needed in the treat- Diet consistency is also important because coarser foods can ment of the acute dental abscess. Part two will emphasize the help to eliminate lodged food particles and disrupt the biofilm treatment of oral infections due to fungal, viral, and bacterial that can support microorganisms. In addition, oral bacteria have organisms. regional preferences vis-à-vis tissue adherence; Streptococcus salivarius is found primarily on the tongue while S. mutans and Introduction Streptococcus sanguis typically adhere to hard surfaces.11 The frequency of periapical abscess is supported by a volume The presence of systemic disease also influences the oral of statistical proof. The results of a nine-year retrospective microbial population. Host defense mechanisms can be com- study (2000–2008) of hospital admissions showed that more promised by conditions such as diabetes, heart failure, chronic than 61,000 hospitalizations in the United States were directly lung disease, lymphoproliferative disorders, renal failure, related to dental infection in the form of periapical abscess.1 malnutrition and alcoholism, among others. This compromise Sixty-six patient deaths were attributed to these infections.2 of the immune function can lead to a reduction in phagocytic Using the Nationwide Inpatient Sample of the Healthcare Cost activity, pulmonary clearance and circulation, among others. and Utilization Project, a 2007 study conducted by Allareddy Immunosuppressant medications that are cytotoxic also reduce et al,3 it was found that there were 7,886 hospitalizations for host defense mechanisms and increase the risk of infection. periapical abscess in the United States, amounting to total hos- Prolonged systemic antibiotic therapy reduces normal bacte- pital costs of $105.8 million. rial flora, resulting in the selection of resistant flora and/or The Global Burden of Disease Study in 2010 showed that the emergence of competing fungal organisms. Other factors cleft lip/palate, edentulism, oral cancer, caries, and periodontal associated with oral infection include age, behavioral consid- disease accounted for over 18 million disability-adjusted life erations, drug abuse, the social environment, and the patient’s years.4 Evaluation of the global burden of oral diseases such psychological status. as caries, periodontal disease, and cancer showed a marked A further consideration is the concept of virulence. increase of 45.6% from 1990 to 2010, on par with major non- Virulence is a harmful quality possessed by microorganisms communicable diseases such as diabetes.3 Dentists are usu- that can cause disease. It involves the invasive nature of the ally the first to see patients with early odontogenic infections. organism and the detrimental toxins and/or metabolic and Therefore, it is vital that they be prepared to evaluate and treat enzymatic byproducts produced in the course of the infectious problems before they become severe enough to demand hospi- process. Infection involves the interactions of microbial popu- talization.5 lations, microbial virulence, and host defenses. Intraorally, host defenses are part of the mucosal immune system, an important The complexities of oral infection factor in the prevention of oral and systemic infection. This sys- Enormous numbers of pathogenic bacteria, nonpathogenic tem includes advantageous elements to protect the host against bacteria, and fungal organisms naturally colonize the oral mu- invading pathogens that include the resistance to tear and com- cous membranes. Numerous transient and potentially infective pression forces provided by the lamina propria.12 Colonization organisms (e.g., viruses) can be present as well. Opportunistic is minimized by cell shedding from the surface layer and by microorganisms such as Escherichia coli, Streptococcus pneu- salivary secretion. Beside mechanical protection,chemical pro- moniae, Staphylococcus©PENNWELL®2017 aureus, and Klebsiella pneumoniae can tection is present in the form of an elaborate immune system. cause systemic versus oral disease.6 One example is the production of lymphoid cells producing With respect to oral hard tissue, multiple bacterial interac- immunoglobulins. In addition, serum proteins such as hista- tions exist within the diverse dental microenvironments and mine, prostaglandins and lymphokines are released as a result

2 www.DentalAcademyOfCE.com of inflammation. There are also cellular defenses dependent are tender, enlarged, indurated, or fixed suggest the presence of on receptors, phagocytes, and lymphocytes (e.g., B and T infection. Infection and swelling of the pterygomandibular, para- cells).13,14,15 pharyngeal (lateral pharyngeal and retropharyngeal), peritonsil- lar and cervical spaces, and the infratemporal or parotid space is Triage considered high risk and necessitates urgent intervention. The majority of acute oral infections are self-limiting and can Another potentially life threatening ailment is cellulitis. be managed with minimal intervention. However, some types Cellulitis is a spreading bacterial infection just below the of oral infection can be associated with significant morbidity skin surface (i.e., the fascial planes) most commonly caused and mortality. The treating clinician must recognize the sig- by Streptococcus pyogenes or S. aureus.16 Ludwig’s angina, a nificance of the history and clinical signs. This information cellulitis-causing condition, arises from the oral cavity. This is vital in the diagnosis of the disease process and providing infection most commonly originates from an infected second appropriate triage for the patient. For example, consider a pa- or third mandibular molar tooth invading the submandibular tient who presents with pallor, reporting a rapidly increasing space. This space consists of two compartments in the floor of swelling under the jaw into the neck or superiorly into the eye the mouth, the sublingual space and the submylohyoid (fig- (suggesting spread beyond the oral cavity). This coupled with ure 1). It is an aggressive, rapidly spreading cellulitis without other local and systemic symptoms such as difficulty breath- lymphadenopathy and with the potential for airway obstruc- ing or swallowing, fever (with chills or cold sweats), a thready tion. It requires careful monitoring and rapid intervention for pulse with lethargy and/or altered consciousness, trismus, a prevention of asphyxia and aspiration pneumonia. Clinical changing pain quality (i.e., change of pain from a mild ache signs include upward and backward displacement of the tongue to a severe throb), and dehydration should be considered for and bilateral submandibular swelling extending inferiorly into urgent oral surgical or medical referral as these clinical signs the anterior neck to the clavicles and dysphagia. and symptoms indicate systemic toxicity. Another example of an anatomic area of great importance in life-threatening infection is the infratemporal space (figure 2). Anatomic considerations Infection of the maxillary molars can invade the infratemporal A basic understanding of head and neck anatomy including the space with a possible risk of spread to the orbit and ascension location of lymph nodes and fascial spaces is useful in determin- to the cavernous sinus via the venous plexus in the ovale and ing the relative risk associated with infection. Lymph nodes that spinosum foramen.17

Figure 1: Ludwig’s Angina

Sublingual gland

Tongue

Geniohyoid Submandibular muscle space Sublingual space

Supramylohyoid portion of Submaxillary submandibular space space

Mylohyoid muscle Mylohyoid muscle Submandibular gland

Inframylohyoid portion Super cial fascial layer of submandibular space©PENNWELL®2017Digastric muscle (anterior belly)

www.DentalAcademyOfCE.com 3 Figure 2: Temporal Spaces Managing the dental abscess The dental abscess develops as a result of bacterial invasion of the pulp and ultimately, the alveolar bone. Therefore, the prevention of caries is still the best first line of defense against the Temporalis muscle development of the dental abscess. The other effective preven- Super cial temporal space • Infra temporal space tive measure against dental caries and dentoalveolar abscess is Temporal Deep temporal space • Lies posterior to maxilla fascia proper dental hygiene. This includes brushing teeth after meals • Bottom portion of the and regular dental check-ups. ADA Dental Practice Param- Sphenoid bone deep temporal space Infratemporal eters suggest that the dentist should utilize treatments designed space • Source of infection- Zygomatic Maxillary third molars to “reduce pulpal symptoms and/or protect the pulpal tissue arch of the tooth with pulpitis.”22 The document recommends that Lateral pterygoid management of the dental abscess should be considered as fol- muscle lows: nonsurgical approaches (e.g., antibiotics), chemothera- Masseteric Hamular process peutic modalities, dental restorations, endodontic therapy, space tooth extraction and surgery.16 However, with any acute infec- Medial tion, prior to the initiation of an antibiotic, purulence must be pterygoid Masseler muscle eliminated via surgical drainage. muscle

Pterygomandibular space Incision and drainage Drainage of odontogenic purulence can be accomplished through pulpal access, surgical incision, or tooth extraction. Mandible 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 Laboratory considerations soft rubber tubing, placed inside a wound to drain fluid (figure Minor oral infections can be well managed empirically without 3). The drain is sutured into place with a patent opening, al- culture if attention is paid to three important considerations: lowing fluids to drain from the infection site. In addition, the infection origin, involved anatomy and bacterium most likely infected site can be decontaminated by irrigation with a saline involved. Most oral infections are odontogenic, superficial in solution (typically 60–100 ml) or chlorhexidine mixed with sa- nature, and in the majority of patients caused by Streptococcus line if necessary. The patient should be advised to: avoid touch- bacteria. Infection by anaerobic bacteria such as Staphylococ- ing the area after surgery, apply firm direct pressure for 30–60 cus, Neisseria, and others can also occur, though with much minutes, use a moistened tea bag to control bleeding, avoid less frequency.18,19 the application of ice, and not apply heat until three days have Infections that do not respond to routine antibiotic therapy passed to avoid spread of the infection. The drain is removed as require identification of the culprit microorganism(s) by way soon as drainage output is minimal or has ceased. of laboratory evaluation. This provides the greatest precision in selecting appropriate antibiotic coverage. As a rule, a culture Figure 3: 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- A. B. 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,©PENNWELL®2017 it is best to refer to a specialist for collection, further lab evaluation, and subsequent dental or medical treatment. C. D.

4 www.DentalAcademyOfCE.com Antibiotics Azithromycin, a structural derivate of erythromycin, has also In most instances, antibiotics should only be prescribed for been recommended as an option for the treatment of mild to mod- the dental abscess when the infection has spread beyond the erate bacterial infection.35 It has a broader spectrum of activity, radicular area, causing local involvement and/or systemic symp- increased bioavailability, and fewer gastrointestinal (GI) effects. toms.24 Once the infection spreads beyond the radicular area, the For the patient with identified cephalosporin- or penicillin-resis- involved bacteria typically include a combination of anaerobic tant Gram-negative bacteria, cefoxitin has also been shown to be and aerobic organisms. This change in bacterial composition is a effective.36 The reader should refer to this and other guidelines for complication that can significantly alter the relative virulence of the latest information and proper dosing for the adult patient. the infection and complicate antibiotic selection. An important Antibiotics may also need to be prescribed to children with consideration when using antibiotics is microbial resistance.25 infection, although the dosage will be lower, as it based on body The best approach for curtailing resistance is to prescribe a high weight. Several rules exist to compute the dosage of a drug for dose of antibiotic for as short a course as possible. a child, the most common being Clark’s Rule and Young’s Rule The choice of antibiotic is largely empirical because the (tables 2 and 3) and empiric antibiotic options are available (table science supporting the efficacy of one antibiotic or treatment 4). The American Academy of Pediatric Dentistry has published regimen over another is presently not definitive. This is due to prescription guidelines for children needing antibiotic coverage.37 the confusion posed by a number of methodological problems The reader should refer to this and other guidelines for the latest associated with the published research. These include issues information and proper dosing for the pediatric patient. related to study design and choice of outcome measures.26 In general, penicillin is often the first drug of choice for dental Table 2: Clark’s Rule for Pediatric Dosing39 infections. An article by Olsen and Winkelhoff describes acute Child’s Weight lb. (or kg) X Adult Dose = Child’s Dose oral infections that can spread extraorally, recommending peni- 150 lb. (or 70 kg) cillin (when suspicion of methicillin-resistant S. aureus is low).27 Historically, antibiotic use has included the use of the Table 3: Young’s Rule for Pediatric Dosing39 penicillins, including penicillin V (table 1).28,29 Amoxicillin is favored as the drug of first choice due to its broad spectrum Adult Dose X (Age ÷ (Age+12)) = Child's Dose of action against many gram positive and negative bacteria.30 If there is a history of antimicrobial resistance, metronida- Table 4. Empiric Antibiotics of Choice for Odontogenic Infections38 zole31 (although the drug itself has also been associated with Antibiotic Dosage increased resistance32) or amoxicillin combined with clavu- Children Adults lanic acid should be considered.33 For individuals allergic to the Penicillin VK ≤ 12 years: 25-50 mg/ > 12 years: 500 mg penicillin-based antibiotics, clindamycin can be prescribed.34 kg body weight in q6h for at least 7 Clindamycin is effective against both aerobic and anaerobic equally divided doses days q6-8h for at least 7 days; bacteria and penetrates bone readily. maximum dose: 3g/day Clindamycin 08-25mg/kg in 3-4 150-450 mg/ g6h Table 1: Empiric Antibiotics of Choice for Odontogenic Infections38 equally divided doses for at least 7 days; Type of Infection Antibiotic of Choice maximum dose: 1.8 Early (first 3 days of infection) Penicillin VK, amoxicillin g/day Clindamycin Cephalexin (Keflex) 25-50 mg/kg/day in 250-1000 mg q6h; Cephalexin (or other first-generation divided doses q6h maximum dose 4g/ cephalosporin)1 Severe infection: day No improvement in 24-36 Beta-lactamase-stable antibiotic: 50-100 mg/kg/day hours Clindamycin or amoxicillin/clavu- in divided doses q6h; lanic acid (Augmentin®) maximum dose 3 g/24h Penicillin allergy Clindamycin Amoxicillin < 40 kg: 20-40 mg/kg/ > 40kg: 250-500 mg Cephalexin (if penicillin allergy is day in divided doses q8h q8h or 875 mg q12h not anaphylactiod type) > 40 kg: 250-500 mg for at least 7 days: Clarithromycin (Biaxin®)2 q8h or 875 mg q12h for maximum dose: 2 Late (>3 days) Clindamycin at least 7 days; maxi- g/day Penicillin VK-metronidazole, mum dose 2 g/day amoxicillin-metronidazole Amoxicillin/ < 40 kg: 20-40 mg/kg/ > 40kg: 250-500 mg Penicillin allergy Clindamycin clavulanic acid day in divided doses q8h q8h or 875 mg q12h 1 For better patient compliance, second-generation cephalosporins (cefctor: cefuroxime) at twice (Augmentin®) for at least 7 days; daily dosing has been used. > 40kg: 250-500 mg 2 A. macrolide useful in patients allergic to penicillin, given as twice daily dosing for better patient q8h or 875 mg q12h for maximum dose: 2 compliance. at least 7 days: maxi- g/day Adapted from Drug Information handbook for Dentistry; Richard Wynn, Timothy Meiller, Harold Crossley, 12th Edition mum dose: 2 g/day

www.DentalAcademyOfCE.com 5 Management of the dental infection can also be treated that improper prescription of antibiotic continues to be a prime based on time of involvement. Emergent infections can be contributor to the development of antibiotic resistance.51 treated with penicillin V, amoxicillin, clindamycin, or a first- generation cephalosporin.40 If there is no improvement within Palliative care the first 24 to 36 hours, clindamycin or amoxicillin/clavulanic The management of acute dental infection should also incor- acid combination (Augmentin) may then be considered. An- porate palliative measures. No special precautions need be other consideration is to begin antibiotic therapy with a loading considered for hydration or nutrition unless retropharyngeal oral dose two times the standard maintenance dose so that a swelling prevents intake, in which case the patient should be therapeutic blood level is achieved faster than what would be immediately hospitalized. A soft diet is recommended during expected with an initial maintenance dose.41, 42 recovery from incision and drainage or tooth extraction. Pain Despite the effectiveness of the penicillin-based antibiotics, management should include over-the-counter pain medication they should be used with caution in patients with compromised as well as cases requiring prescriptions that include NSAIDs renal function or in individuals with a history of seizures or and opioid analgesics. significant GI hypersensitivity to antibiotics.43 Mild adverse GI reactions (e.g., nausea, diarrhea) are not uncommon with Analgesics for acute pain the penicillin antibiotics. True penicillin allergy is rare with the Acute pain arising from oral infections may present from mild estimated frequency of anaphylaxis in one to five per 10,000 to severe. Analgesics used in the management of mild to moder- cases of penicillin therapy.44 Hypersensitivity is the more com- ate acute pain include acetaminophen, aspirin, and NSAIDs.52 mon and most important adverse reaction resulting in nausea, Cox-2 inhibitors are also effective, however, they must be used vomiting, pruritus, urticaria, wheezing, laryngeal edema and with caution due to recently identified cardiovascular adverse ultimately, cardiovascular collapse. In these patients, clindamy- reactions.53 Moderate pain can be controlled by opioids or cin is recommended; however it can cause nausea, vomiting, tramadol and these are often combined with acetaminophen or diarrhea, and abdominal pain, and has been associated with the NSAIDs.54 development of pseudomembranous colitis.45 Consequently, A recent systematic review indicates that a 50% or greater it is contraindicated in these patients as well as patients with reduction in severe pain following oral surgery can be achieved a history of regional enteritis or ulcerative colitis. In addition, with 400 mg of ibuprofen, 50 mg of diclofenac, 120 mg of etori- clindamycin should be used cautiously in the patient with liver coxib, 60 mg of codeine with 1000 of mg acetaminophen, 400 disease.46 mg of celecoxib (Celebrex), and 500 or 550 mg of naproxen.55,56 A highly controversial concern is the interaction between Pain relief greater than eight hours can be achieved with 120 oral contraceptives and antibiotics. For years, the medical mg of etoricoxib, 500mg of diflunisal, 10 mg of oxycodone plus community has been advised that this interaction can lead to 650 mg of acetaminophen, 500 or 550mg of naproxen, and 400 breakthrough pregnancy. With the exception of rifampin-like mg of celecoxib. The study authors note that adverse events drugs used primarily to treat tuberculosis, there is a lack of were more likely to be associated with the aspirin and opioids. scientific evidence supporting the ability of commonly pre- Patients sometimes misuse over-the-counter pain medica- scribed antibiotics, including all those routinely employed in tions,57 and prescription medications, when taken in combination outpatient dentistry, to either reduce blood levels and/or the with over-the-counter medications, can lead to toxicity. In 2014, effectiveness of oral contraceptives.47 To date, all clinical trials the FDA published a drug safety caution regarding the prescrip- studying the effects of concomitant antibiotic therapy (with tion of opioids containing acetaminophen due to the potential for the exception of rifampin and rifabutin) have failed to demon- acetaminophen-related hepatotoxicity.58 The maximum amount strate an interaction. A 10-year retrospective study by Toh et of acetaminophen (in combination with opioids) is 325 mg when al. found no association found between concomitant antibiotic taken every four to six hours. Support for this alert comes in part use and the risk of breakthrough pregnancy among oral con- from a study of unintentional acetaminophen overdose. In data traceptive users.48 Therefore, dentists are now being advised collected by querying the French Pharmacovigilance database that there is no need to warn women taking the combined oral over a nine-month period, 13 patients were identified as having contraceptive pill of the routine need to use additional con- mild unspecific clinical symptoms and 4 of 10 had abnormal traceptive measures while taking courses of broad spectrum liver enzyme activity. The median dose of acetaminophen was antibiotics.49 137mg/kg per 24 hours.59 Prolonged use of any antibiotic may produce an oral yeast Opioids also have potential for misuse. It is estimated that infection.50 Listed precautions, contraindications, potential dentists prescribe approximately 12% of all opioids dispensed in risks (e.g., in pregnant patients) and known drug interactions the United States.60 The potential for misuse and toxicity of all (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs] reduce pain relievers can be reduced by limiting the amount prescribed, the bioavailability of some but not all antibiotics) should be re- performing a preassessment for potential drug interactions, and viewed prior to prescribing. It should also be fully appreciated careful prescribing in patients with coexisting medical problems

6 www.DentalAcademyOfCE.com (e.g. liver abnormality, kidney disease, stomach ulcers, alcohol- thefreedictionary.com/cellulitis. Accessed May 25, 2016. ism, anticoagulant therapy, hemorrhagic disorders, allergy, de- 16. Mesgarzadeh AH, Ghavimi MA, Gok G, Zarghami A. Infratemporal space infection following maxillary third molar extraction in an pression) and pregnancy. Effective opioid management includes uncontrolled diabetic patient. J Dent Res Dent Clin Dent Prospects. patient education, monitoring for substance abuse, and appro- 2012;6(3):113-115. priate referral if abuse is suspected. For the pregnant or nursing 17. Baron EJ, Miller JM, Weinstein MP, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 female patient with abscess, a physician consult is recommended recommendations by the Infectious Diseases Society of America (ISDA) before prescribing drugs for pain management.61 and the American Society for Microbiology (ASM)(a). Clin Infect Dis. According to Dental Management of the Medically Compro- 2013;57(4):e22–e121. 18. Bahl R, et al. Odontogenic infections: Microbiology and management. mised Patient, aspirin and ibuprofen should be avoided through- Contemp Clin Dent. 2014 Jul-Sep; 5(3): 307–311. out pregnancy; however, acetaminophen can be prescribed any 19. Flynn TR, Shanti RM, Hayes C. Severe odontogenic infections, part 2: time during pregnancy.56 For this and other prescribing recom- Prospective outcomes study. J Oral Maxillofac Surg. 2006; 64:1104–13. 20. Brook I. Diagnosis and Management of Anaerobic infections of the Head mendations, the reader must contact the patient’s obstetrician and Neck. Ann Otol Rhin Layngol 101:9-16, 1992. for treatment and prescribing approval. 21. Pulpitis. The American Dental Association website. http://www.ada. org/en/science-research/dental-practice-parameters/pulpitis. Accessed May 29, 2016 Conclusion 22. Ayad W, Jöhren P, Dieckmann J. Results of a comparative prospective Dentists face an important responsibility when treating the oral randomized study of surgical removal of mandibular wisdom teeth with infection. An understanding of oral microbiology, laboratory and without rubber drainage. Fortschr Kiefer Gesichtschir. 1995; 40:134- 6. assessment tools, and head and neck anatomy is necessary. The 23. Dar-Odeh NS, Abu-Hammad OA, Al-Omiri MK, Khraisat AS, Shehabi importance of triage based on patient presentation and treat- AA. Antibiotic prescribing practices by dentists: a review. Ther Clin Risk ment strategies are critical. In addition, the appropriate pre- Manag. 2010; 6:301-306. 24. Robertson D, Smith AJ. The microbiology of the acute dental abscess. J scription of medication is of paramount importance in avoiding Med Microbiol. 2009;58(Pt 2):155-162. potential morbidity and mortality. 25. Hohl T, Whitacre R, Hooley J, Williams B. A Self-Instructional Guide: Diagnosis and Treatment of Odontogenic Infections. 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Global burden of oral diseases: emerging concepts, management and amoxycillin in the treatment of acute dentoalveolar abscess. Br Dent J. interplay with systemic health. Oral Dis. 2015. doi: 10.1111/odi.12428. 19869;161(8):299–302. 4. Petersen PE, Ogawa H. The global burden of periodontal disease: towards 30. Kuriyama T, Absi EG, Williams DW, Lewis MA. An outcome audit integration with chronic disease prevention and control. Periodontol 2000. of the treatment of acute dentoalveolar infection: impact of penicillin 2012;60(1):15-39 resistance. Br Dent J. 2005;198(12):759-763. 5. Palmer NA, Pealing R, Ireland RS, Martin MV. A study of therapeutic 31. Roche Y, Yoshimori RN. In-vitro activity of spiramycin and antibiotic prescribing in National Health Service general dental practice in metronidazole alone or in combination against clinical isolates from England. Br Dent J. 2000;188(10):554-558. odontogenic abscesses. J Antimicrob Chemother. 1997;40(3):353–357. 6. Ogawa T, Ikebe K, Enoki K, Murai S, Maeda Y.Investigation of oral 32. Lewis MA, Carmichael F, MacFarlane TW, Milligan SG. A randomised opportunistic pathogens in independent living elderly Japanese. trial of co-amoxiclav (Augmentin) versus penicillin V in the treatment of Gerodontology. 2012 Jun;29(2): e229-33 acute dentoalveolar abscess. Br Dent J. 1993;175(5):169–174. 7. Donlan RM, Costerton JW. Biofilms: Survival Mechanisms of Clinically 33. Gilmore WC, Jacobus NV, Gorbach SL, Doku HC, Tally FP. A Relevant Microorganisms. Clin Microbiol Rev. 2002 Apr; 15(2): 167– prospective double-blind evaluation of penicillin versus clindamycin 193. in the treatment of odontogenic infections. J Oral Maxillofac Surg. 8. Moore W. The bacteria of periodontal disease. Periodontol. 2000 5:66-77. 1988;46(12):1065–1070. 9. Cross B, Faustoferri RC, Quivey RG Jr. What are We Learning and 34. Kuriyama T, Karasawa T, Nakagawa K, Saiki Y, Yamamoto E, Nakamura What Can We Learn from the Human Oral Microbiome Project? Curr S. Bacteriologic features and antimicrobial susceptibility in isolates from Oral Health Rep. 2016 Mar;3(1):56-63. orofacial odontogenic infections. Oral Surg Oral Med Oral Pathol Oral 10. Hovav AH. Dendritic cells of the oral mucosa. Mucosal Immunol. Radiol Endod. 2000;90(5):600–8. 2014;7(1):27–37. 35. Murdoch DA. Gram-Positive Anaerobic Cocci. Clin Microbiol Rev. 11. Marcotte H, Lavoie MC. Oral Microbial Ecology and the Role of Salivary 1998;11(1):81–120. Immunoglobulin A. Microbiol Mol Biol Rev. 1998 Mar; 62(1): 71–109. 36. American Academy of Pediatric Dentistry Council on Clinical Affairs. 12. Georgiev VS. Mucosal Immune System. In: National Institute of Allergy Guideline on Use of Antibiotic Therapy for Pediatric Dental Patients. and Infectious Diseases, NIH, Volume 2: Impact on Global Health. New http://www.aapd.org/media/policies_guidelines/g_antibiotictherapy. York, New York: Humana Press; 2009: 675-682. pdf/. Published 2001. Accessed July 31, 2016. 13. van Unen V, Li N, Molendijk I, et al. Mass Cytometry of the Human 37. Commonly Prescribed Medications in Pediatric Dentistry. DentalCare. Mucosal Immune System Identifies Tissue- and Disease-Associated com. http://www.dentalcare.com/media/en-US/education/ce336/ Immune Subsets. Immunity. 2016;44(5):1227-1239. ce336.pdf. Revised January 8, 2016. Accessed May 30, 2016 14. Dwivedy A, Aich P. Importance of innate mucosal immunity and the 38. http://www.dentalcare.com/media/en-US/education/ce336/ce336.pdf promises it holds. Int J Gen Med. 2011; 4:299–311. Accessed May 30, 2016 15. Cellulitis. The Free Dictionary website. http://medical-dictionary. 39. Clarks rule and Youngs rule. Pharmacy Tech Study website. http://www.

www.DentalAcademyOfCE.com 7 pharmacy-tech-study.com/dosecalculation.html. Accessed May 29, 54. Rosenblum A, Marsch LA, Joseph H, Portenoy RK. Opioids and the 2016. treatment of chronic pain: Controversies, current status, and future 40. Gilbert DN, Mollering RC, Eliopouos GM, Sande MA. The Sanford directions. Exp Clin Psychopharmacol. 2008;16(5):405–416. Guide to Antimicrobial Therapy 2006. 36th ed. Sperryville, Virginia: 55. Eccleston C. Post-operative pain management. Cochrane Database Syst Antimicrobial Therapy; 2006: 33. Rev. 2011;(10): ED000033. doi: 10.1002/14651858.ED000033. 41. Antibiotics and the Treatment of Endodontic Infections. American 56. Moore RA, Derry S, McQuay HJ, Wiffen PJ. Single dose oral analgesics Association of Endodontics. https://www.aae.org/uploadedfiles/ for acute postoperative pain in adults. Cochrane Database Syst Rev. publications_and_research/endodontics_colleagues_for_excellence_ 2015;(10):CD011407. doi: 10.1002/14651858.CD011407.pub2. newsletter/summer06ecfe.pdf. Published Summer 2006. Accessed June 57. Denisco RC, Kenna GA, O’Neil MG, et al. Prevention of prescription 02, 2016 opioid abuse: the role of the dentist. J Am Dent Assoc. 2011;142(7):800-10 42. Arduino PG, Tirone F, Schiorlin E, Esposito M. Single preoperative dose 58. FDA Drug Safety Communication: Prescription Acetaminophen of prophylactic amoxicillin versus a 2-day postoperative course in dental Products to be Limited to 325 mg Per Dosage Unit; Boxed Warning Will implant surgery: A two-centre randomised controlled trial. Eur J Oral Highlight Potential for Severe Liver Failure. FDA website. http://www. Implantol. 2015;8(2):143-9. fda.gov/drugs/drugsafety/ucm239821.htm. Published January 13, 2011. 43. Blumenthal KG, Shenoy ES, Hurwitz S, Varughese CA, Hooper DC, Accessed June 1, 2016. Banerji A. Effect of a drug allergy educational program and antibiotic 59. Clement C, Scala-Bertola J, Javot L, et al. Misuse of acetaminophen in the prescribing guideline on inpatient clinical providers' antibiotic prescribing management of dental pain. knowledge. J Allergy Clin Immunol Pract. 2014;2(4):407-13 Pharmacoepidemiol Drug Saf. 2011;20(9):996-1000. 44. Bhattacharya S. The facts about penicillin allergy: a review. J Adv Pharm 60. Role of dentists in reducing prescription drug abuse. California Dental Technol Res. 2010; 1(1):11–17. Association website. http://www.cda.org/news-events/role-of-dentists- 45. Raab W. Acute side effects of erythromycin, lincomycin and clindamycin. in-reducing-prescription-drug-abuse. Published May 14, 2015. Accessed Int J Clin Pharmacol Biopharm. 1977 Feb;15(2):90-7. June 01, 2016 46. Zimmerman HJ. Clindamycin. Hepatic injury from antimicrobial 61. Pregnancy and Breastfeeding. In: Little JW, Falace DA. Dental agents. InL Zimmerman HJ. Hepatotoxicity: the adverse effects of drugs Management of the Medically Compromised Patient. 8th ed. Elsevier and other chemicals on the liver. 2nd ed. Philadelphia, Pennsylvania: Health Sciences; 2012 Lippincott, 1999: 592 47. DeRossi SS, Hersh EV. Antibiotics and oral contraceptives. Dent Clin Author Profile North Am. 2002;46(4):653-64. Ian Shuman DDS, MAGD, AFAAID maintains a full-time general, recon- 48. Toh S, Mitchell AA, Anderka M, de Jong-van den Berg LT, Hernández- structive, and aesthetic dental practice in Pasadena, Maryland. Since 1995 Dr. Díaz S; National Birth Defects Prevention Study. Antibiotics and Shuman has lectured and published on advanced, minimally invasive techniques. oral contraceptive failure - a case-crossover study. Contraception. He has taught these procedures to thousands of dentists and developed many of 2011;83(5):418-25. the methods. Dr. Shuman has published numerous articles on topics including 49. Taylor J, Pemberton MN. Antibiotics and oral contraceptives: new adhesive resin dentistry, minimally invasive restorative, cosmetic and implant considerations for dental practice. Br Dent J. 2012;212(10):481-3. dentistry. He is a Master of the Academy of General Dentistry, an Associate Fel- 50. Verdugo F, Laksmana T, Uribarri A. Systemic antibiotics and the risk of low of the American Academy of Implant Dentistry, a Fellow of the Pierre Fau- superinfection in peri-implantitis. Arch Oral Biol. 2016; 64:39-50. chard Academy. Dr. Shuman was named one of the Top Clinicians in Continuing 51. Carey B, Cryan B. Antibiotic misuse in the community—a contributor to Education since 2005, by Dentistry Today. 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. Author Disclosure 53. Huber MA, Terezhalmy GT. The use of COX-2 inhibitors for acute Dr. Shuman has no commercial ties with the sponsors or the providers of the dental pain: A second look. J Am Dent Assoc. 2006;137(4):480-7. unrestricted educational grant for this course.

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Questions 1. The outcome for patients hospital- periodontal disease accounted for 4. In regard to oral soft tissue, which ized for periapical abscess in the over how many disability-adjusted of the following organisms do not United States was evaluated with life years. colonize the oral mucous membranes: 7,886 hospitalizations amounting a. 18 a. pathogenic bacteria to total hospital charges of $105.8 b. 18,000 b. non-pathogenic bacteria million using research from the: c. 180,000 c. fungal organisms d. 18,000,000 d. plasmodians a. CAMBRA b. North American Medical and Research 3. From 1990 to 2010, evaluation of the 5. Which of the following opportunis- Foundation global burden of oral diseases such tic microorganisms mentioned in c. National Science Foundation d. Nationwide Inpatient Sample of the Healthcare as caries, periodontal disease, and this course can cause systemic versus Cost and Utilization Project cancer showed a marked increase by: oral disease: a. 10.2% a. Verrucomicrobium mrhankii 2. The Global Burden of Disease Study b. 45.6% b. Cyanobacter cornii in 2010 showed that cleft lip/palate, c. 34.9% c. Klebsiella pneumoniae edentulism, oral cancer, caries, and d. 83.2% d. Fusobacterium preponderii

8 www.DentalAcademyOfCE.com Questions 6. Biofilm contains: 15. Lymph nodes that are tender, in assessing infective organisms a. bacteria enlarged, indurated or fixed suggest in office, which of the following b. extracellular DNA the presence of: may be considered the most useful c. intracellular DNA a. infection d. a and b procedure: b. Graves disease a. Hygiena indicator 7. Within a biofilm, interaction of c. Goiter b. Gram stain d. cancer what microorganism type may either c. Glucose broth with Durham tubes boost or suppress metabolic activity 16. Which of the following is a spread- d. Streak-stab technique that leads to dental infection: ing bacterial infection just below the 24. Techniques for assessing purulent a. spirochetes skin surface: material include: b. bacterial a. Acanthosis nigricans a. transmucosal aspiration c. protozoa b. Cherry hemangioma b. pulp chamber access d. ameoba c. Cellulitis c. tissue biopsy d. Granuloma annulare d. all of the above 8. Many factors regulate the number 17. Cellulitis is most commonly and types of oral bacteria within 25. The best first line of defense against caused by which of the following the development of the dental biofilm including: microorganisms: a. the complexity of the flora abscess is: a. Streptococcus pyogenes or Staphylococcus aureus b. bacterial retention and interaction a. antibiotic therapy b. Entamoeba histolytica or Cyclospora cayetanen- b. pulpotomy c. native resistance sis d. all of the above c. caries prevention c. Giardia lamblia or Microsporidia d. a and b 9. Streptococcus salivarius is found d. Schistosomiasis or Echinococcus granulosus 26. Drainage of purulence can be primarily on what oral structure: 18. One of the conditions arising from accomplished through the surgical a. palate the oral cavity that spreads to the b. labial mucosa placement of a: fascial planes is known as: a. French catheter c. tongue a. Aarskog-Scott syndrome d. buccal mucosa b. closed drainage system b. Acromegaly c. Penrose drain 10. Streptococcus mutans and Strepto- c. Ludwig’s angina d. a and b d. Angiocentric T-cell lymphoma coccus sanguis typically adhere to: 27. Which of the following authors 19. The submandibular space consists a. hard surfaces describes acute oral infections that b. soft tissue of which two compartments in the can spread extraorally, recommend- c. a and b floor of the mouth: d. none of the above a. pterygomandibularis and hyoid ing Penicillin as being the drug of 11. Host defense mechanisms can be b. sublingual space and submylohyoid first choice: c. medial pterygoid and retromolar pad a. Presley and Martindale compromised by which of the follow- d. platysma and sublingual gland b. Keaton and Winkler ing conditions: c. Olsen and Winkelhoff a. diabetes 20. Complete the following statement: d. Dreyfus and Alexander b. lymphoproliferative disorders The treatment of any oral infection c. renal failure should begin with identification 28. Which of the following analgesics d. all of the above of the culprit microorganism(s) are not contraindicated during by way of laboratory evaluation pregnancy: 12. A harmful quality possessed by a. acetaminophen microorganisms that can cause ______. b. aspirin disease is known as: a. after an appropriate antibiotic regimen. c. ibuprofen b. prior to the initiation of therapy. d. b and c a. virulence c. during antibiotic therapy. b. viral spread d. none of the above 29.Patient education, monitoring for c. virulent reproduction substance abuse, and appropriate re- d. all of the above 21. Most oral bacterial infections are: a. odontogenic ferral if abuse is suspected is required 13. Advantageous salivary lymphoid b. superficial in nature for the management of which class of cells produce: c. caused by Streptococcus bacteria. drugs: a. Megakaryocytes d. all of the above a. Cannabinoids b. immunoglobulins 22. As a rule, a culture must be taken b. Opioids c. Natural Killer (NK) Cells c. NSAIDS d. granulocytes if: a. The infection has spread to one or more fascial d. b and c 14. Serum proteins released as a result planes of the head and neck. 30. Infection of the maxillary molars of inflammation include all of the b. Initial antibiotic treatment has failed to contain can initially invade what anatomic the infection. following except: c. The patient shows evidence of systemic toxicity. area: a. histamine d. all of the above a. dura b. prostaglandins b. infrahyoid c. lymphokines 23. Of the various examination c. brain stem d. porphyrin techniques that should be considered d. infratemporal space www.DentalAcademyOfCE.com 9 INSTANT EXAM CODE 15152 ANSWER SHEET Management of the Oral Infection: Part 1

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Course Evaluation INSTANT EXAM CODE 15152 Answer sheets can be faxed with credit card payment to 1. Were the individual course objectives met? 918-831-9804. Objective #1: Yes No Objective #2: Yes No Payment of $59.00 is enclosed. (Checks and credit cards are accepted.) Objective #3: Yes No If paying by credit card, please complete the Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. following: MC Visa AmEx Discover 2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 Acct. Number: ______Exp. Date: ______3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 Charges on your statement will show up as PennWell 4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 1. 16. 6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 2. 17. 7. Was the overall administration of the course effective? 5 4 3 2 1 0 3. 18. 8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 4. 19. 9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0 5. 20. 10. Do you feel that the references were adequate? Yes No 6. 21. 11. Would you participate in a similar program on a different topic? Yes No 7. 22. 8. 23. 12. If any of the continuing education questions were unclear or ambiguous, please list them. ______9. 24. 10. 25. 13. Was there any subject matter you found confusing? Please describe. ______11. 26. 12. 27. 14. How long did it take you to complete this course? ______13. 28. 14. 29. 15. What additional continuing dental education topics would you like to see? 15. 30. ______AGD Code 148 PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. COURSE EVALUATION and PARTICIPANT FEEDBACK PROVIDER INFORMATION RECORD KEEPING We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental association PennWell maintains records of your successful completion of any exam for a minimum of six years. Please with the course. Please e-mail all questions to: [email protected]. to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP contact our offices for a copy of your continuing education credits report. This report, which will list all does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours credits earned to date, will be generated and mailed to you within five business days of receipt. INSTRUCTIONS by boards of dentistry. All questions should have only one answer. Grading of this examination is done manually. 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The formal continuing dental education programs of this program provider are accepted by the Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/ AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from IMAGE AUTHENTICITY their state dental boards for continuing education requirements. PennWell is a California Provider. The (11/1/2015) to (10/31/2019) Provider ID# 320452 The images provided and included in this course have not been altered. California Provider number is 4527. 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