Questions for OMF residents- on 3rd molar surgery

[Smilemaker100]

I just completed Dr Jay B.Reznick's (an OMF) online CE course (available on the DentalTown website) entitled "Practical Oral Surgery for the General Dentist-Impacted Third Molars". I was just curious about what comments/opinions you may have on the following:

Subject # 1: Peridex Pre and Post Op for 3rd molar exos

Dr Reznick strongly suggests prescribing Peridex bid for two days prior to surgery (removal of 3rd molars) followed by Peridex bid for one week. He claims that studies have shown less incidence of post operative infections/dry socket.

I haven't personally seen a dentist prescribe Peridex pre and post op for wisdom teeth removal but I have seen that occur for some implant surgery cases I have observed/assisted .

Subject # 2: To Suture or Not to Suture

Dr Reznick claims that there is less pain and swelling when extraction sites are left open even in cases of surgical exos with flaps. He also mentions that studies have shown that a distal wedge which is performed distal to the second molar and approximated, will heal better by second intention than typical flap approximation . He goes on to mention that there is a better drainage wth the distal wedge technique.

I personally have not performed the distal wedge technique for flap closures nor have I seen other generalists do this either.

Subject # 3: Antibiotics

Dr Reznick doesn't recommend the prescription of antibiotics for young healthy adults that have had surgical exos of wisdom teeth. He advises against it because he claims that it is needless and you are only exposing the patient to the risk of having antibiotic resistant bacteria. He strongly suggests prescriptions of antibiotics for surgical exos in older adults.

I routinely prescribe antibiotics in surgical exos whether the patient is a young or older adult.

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[scalpel2008]

I just completed Dr Jay B.Reznick's (an OMF) online CE course (available on the DentalTown website) entitled "Practical Oral Surgery for the General Dentist". I was just curious about what comments/opinions you may have on the following:

Subject # 1: Peridex Pre and Post Op for 3rd molar exos

Dr Reznick strongly suggests prescribing Peridex bid for two days prior to surgery (removal of 3rd molars) followed by Peridex bid for one week. He claims that studies have shown less incidence of post operative infections/dry socket as well as less requirement for antibiotics even for a surgical extraction.

I haven't personally seen a dentist prescribe Peridex pre and post op for wisdom teeth removal but I have seen that occur for some implant surgery cases I have observed/assisted .

Subject # 2: To Suture or Not to Suture

Dr Reznick claims that there is less pain and swelling when extraction sites are left open even in cases of surgical exos with flaps. He also mentions that studies have shown that a distal wedge which is performed distal to the second molar and approximated, will heal better by second intention than typical flap approximation . He goes on to mention that there is a better drainage wth the distal wedge technique.


Subject # 3: Antibiotics

Dr Reznick doesn't recommend the prescription of antibiotics for young healthy adults that have had surgical exos of wisdom teeth. He advises against it because he claims that it is needless and you are only exposing the patient to the risk of having antibiotic resistant bacteria. He strongly suggests prescriptions of antibiotics for surgical exos in older adults.

The questions you have posed could be justified either way. Regarding peridex, the study that comes to mind is by Peter Larsen that showed a statistically significant decrease in dry socket. There is no harm in using peridex. I don't use prophylactic peridex or post operative peridex unless i see significant pre existing inflammation (pericoronitis, bad periodontal disease with inflamed gingiva). I am still not convinced that a dry socket has much of microbiological component to it. I know there are studies that indicate this might be true but I believe it to be more of a mechanical (expulsion of clot) or risk factor (smoking leading to decreased healing potential and blood supply) phenomenon.
Regarding suturing, we just discussed Waite's article in another thread and beat it to death. My take is that I don't like the V shaped incision and my distobuccal hockey stick style flap does better with a quick stitch. Unless the site is infected, there's nothing to drain so I don't understand what he means by that.
Regarding abx, it's clearly been documented that if at all, only prophylactic abx are beneficial. Even that is controversial. I don't give pre (unless for SBE prophylaxis)or post op abx for extraction on non infected third molars, even in older patients. If they are immunocompromised or uncontrolled diabetics, I consider it.

 

[Smilemaker100]

The questions you have posed could be justified either way. Regarding peridex, the study that comes to mind is by Peter Larsen that showed a statistically significant decrease in dry socket. There is no harm in using peridex. I don't use prophylactic peridex or post operative peridex unless i see significant pre existing inflammation (pericoronitis, bad periodontal disease with inflamed gingiva). I am still not convinced that a dry socket has much of microbiological component to it. I know there are studies that indicate this might be true but I believe it to be more of a mechanical (expulsion of clot) or risk factor (smoking leading to decreased healing potential and blood supply) phenomenon.
Regarding suturing, we just discussed Waite's article in another thread and beat it to death. My take is that I don't like the V shaped incision and my distobuccal hockey stick style flap does better with a quick stitch. Unless the site is infected, there's nothing to drain so I don't understand what he means by that.
Regarding abx, it's clearly been documented that if at all, only prophylactic abx are beneficial. Even that is controversial. I don't give pre (unless for SBE prophylaxis)or post op abx for extraction on non infected third molars, even in older patients. If they are immunocompromised or uncontrolled diabetics, I consider it.

Thanks, for those interesting replies. Could you please cite which Peter Larsen and Waite's articles you are referring to?

 

[scalpel2008]

Thanks, for those interesting replies. Could you please cite which Peter Larsen and Waite's articles you are referring to?

Larsen and Bonine http://download.journals.elsevierhealth.com/pdfs/journals/1079-2104/PIIS1079210405802732.pdf


Waite

http://download.journals.elsevierhealth.com/pdfs/journals/0278-2391/PIIS0278239105019920.pdf

i don't know if you can open these or not. if you can't then the larsen article is in OOOOE February 1995 and the waite article is in JOMS April 2006

 

[toofache32]

Why do you routinely give antibiotics for extractions? Antibiotics should never be given without an indication. For some reason dentists have always been antibiotic-happy and hand them out for any complaint.

The patient population I see routinely has small amounts of pus in the sockets when I extract teeth. If they're healthy & non-diabetic I don't even give antibiotics to these always. In general antibiotics are only an adjunct to the treatment of infections.....cold steel and sunshine. I will end my rant now.

 

[Smilemaker100]

Why do you routinely give antibiotics for extractions? Antibiotics should never be given without an indication. For some reason dentists have always been antibiotic-happy and hand them out for any complaint.

The patient population I see routinely has small amounts of pus in the sockets when I extract teeth. If they're healthy & non-diabetic I don't even give antibiotics to these always. In general antibiotics are only an adjunct to the treatment of infections.....cold steel and sunshine. I will end my rant now.

You didn't read that properly- I said I routinely give antibiotics for SURGICAL exos - in other words, exos which involve flaps and bone removal.

I try to avoid overmedicating whenever possible.

 

[Smilemaker100]

Larsen and Bonine http://download.journals.elsevierhealth.com/pdfs/journals/1079-2104/PIIS1079210405802732.pdf


Waite

http://download.journals.elsevierhealth.com/pdfs/journals/0278-2391/PIIS0278239105019920.pdf

i don't know if you can open these or not. if you can't then the larsen article is in OOOOE February 1995 and the waite article is in JOMS April 2006

Thanks. Unfortunately, the OOOOE article you mentioned is not available online unless you're a subscriber so I'll have to head to the university health science library (which I look forward to every time 😀 ).

 

[Extraction]

You didn't read that properly- I said I routinely give antibiotics for SURGICAL exos - in other words, exos which involve flaps and bone removal.

I try to avoid overmedicating whenever possible.

That's still overmedicating in my book.

 

[Doggie]

That's still overmedicating in my book.

DO you have your own book like Ellis, or are you just pulling **** out of your @ss as usual?

 

[toofache32]

Go easy guys....she's a chick.

 

[rrc]

You guys realize that if you dont give antibiotics for 3rd molars then the patient is going to be calling you in the wee hours of the morning for anything that to them resembles an infection. Usually being a piece of dinner stuck in there. Any if you tell them this, they will not believe you. Also, if they get a dry socket, they will immediately think it's because no antibiotics were prescribed.

I think it's funny when people talk about overuse of antibiotics and resistance and all that. Penicillin was the first antibiotic that was discovered and we are still using it successfully.

Also, people get their wisdom teeth out ONE TIME in their entire lives. A single five day course of antibiotics is not going to cause a resistant flesh eating bacteria to devour their face.

 

[scalpel2008]

You guys realize that if you dont give antibiotics for 3rd molars then the patient is going to be calling you in the wee hours of the morning for anything that to them resembles an infection. Usually being a piece of dinner stuck in there. Any if you tell them this, they will not believe you. Also, if they get a dry socket, they will immediately think it's because no antibiotics were prescribed.

I think it's funny when people talk about overuse of antibiotics and resistance and all that. Penicillin was the first antibiotic that was discovered and we are still using it successfully.

Also, people get their wisdom teeth out ONE TIME in their entire lives. A single five day course of antibiotics is not going to cause a resistant flesh eating bacteria to devour their face.

I respect your opinion but I couldn't disagree more. I do not routinely give abx after wisdom teeth extractions regardless of the ostectomy extent, level of impaction, or surgical time. Rarely do I get calls from patients questioning infection. And in the rare event that I do, they usually require reassurance. I do have patients that ask me prior to the procedure whether or not they will get a prescription for abx because one of their relatives might have gone to your for their extractions and got abx. In that case all they require is is a little education as to why that's not necessary. If you are unwilling to spend a couple of minutes to explain why this is unnecessary, you are doing them a disservice by agreeing with them and giving them the rx.

point # 2: resistance is a real phenomenon. i don't know where you get your information from (20/20 vs. tabloids) but studies show that bacterial isolates from odontogenic and other infections are changing. A good reference would be Haug's article in JOMS "The Changing Face of Odontogenic Infections" Granted a lot of these changes are attributed to improvements in culture techniques and nomeclature issues, but resistance plays a major role as well. Previously apthaogenic organisms like coag neg staph are now nosocomial pathogens, although not so much in odontogenic infections. Also, virtually 50% of skin infections at our level I urban hospital are MRSA (community acquired so they are usually susceptible to Bactrim). There is a reason why rates of vanc usage, and even linezolid and synercid, is on the rise. How many patients at your institution, when admitted for an odontogenic infection, are placed solely on PCN..virtually 0. If you do then you are probably adding flagyl as well. Analogy time - if you don't pick up your dog's business in the dog park, it probably won't make much of a difference. but if everybody didn't, then you'd end up in one big pile of ****. I choose to practice evidence based medicine. 😉

 

[esclavo]

You guys realize that if you dont give antibiotics for 3rd molars then the patient is going to be calling you in the wee hours of the morning for anything that to them resembles an infection. Usually being a piece of dinner stuck in there. Any if you tell them this, they will not believe you. Also, if they get a dry socket, they will immediately think it's because no antibiotics were prescribed.

I think it's funny when people talk about overuse of antibiotics and resistance and all that. Penicillin was the first antibiotic that was discovered and we are still using it successfully.

Also, people get their wisdom teeth out ONE TIME in their entire lives. A single five day course of antibiotics is not going to cause a resistant flesh eating bacteria devour their face.

The interesting comparison is the percent of post op infection from impacted teeth removal vs the percent of persons developing an adverse reaction to an antibiotic (anaphylaxis or otherwise)... That is why I don't give antibiotics to hardly anyone....SBE (even this is a little bunk in terms of literature) and ACTIVE infection outside of the socket or someone with a small infection and very immunocompromised. I liked Ellis's article on antibiotics and mandible fractures....because the literature or debate with exodontia and antibiotics is virtually dead...

 

[dentalman]

You guys realize that if you dont give antibiotics for 3rd molars then the patient is going to be calling you in the wee hours of the morning for anything that to them resembles an infection. Usually being a piece of dinner stuck in there. Any if you tell them this, they will not believe you. Also, if they get a dry socket, they will immediately think it's because no antibiotics were prescribed.

I think it's funny when people talk about overuse of antibiotics and resistance and all that. Penicillin was the first antibiotic that was discovered and we are still using it successfully.

Also, people get their wisdom teeth out ONE TIME in their entire lives. A single five day course of antibiotics is not going to cause a resistant flesh eating bacteria to devour their face.

Prescribing antibiotics to prevent phone calls is overuse, misuse, and laziness. They need to used to prevent infections, not phone calls. Sure, some patients are always going to call in the middle of the night. If that was happening routinely with the same "feels like an infection", then you could prevent that by explaining the feelings before hand (or even better, have an auxillary do it for you.)

This is the exact over-use of antibiotics that we need to stop. Prescribing it just because you want to avoid educating the patient. Patients should know about the risk of dry socket before they leave the office.

Don't let the actions of just a few patients dictate how you give medications to every one.

 

[rrc]

Prescribing antibiotics to prevent phone calls is overuse, misuse, and laziness. They need to used to prevent infections, not phone calls.

Um, that is why I am prescribing them; to avoid infections. The avoidance of phone calls is a secondary gain. The phone call comment was not meant to say that I do it to avoid phone calls. I prescribe antibiotics to prevent complications and help increase the patient's trust. Think about it, if you dont prescribe them and they do get an infection the first thing the patient will ask is, "Why didnt this idiot prescribe these in the first place?" And trust me, word travels fast. Regardless of what you "educated" them on before hand.

Where I trained we prescribed them on every case. So does every private practitioner I personally know.

I read the literature and I know there is debate out there. I choose to continue to prescribe.

Prescribing a 5 day course of amoxicillin after removing bony impacted wisdom teeth is not overuse. Especially considering PCP's give them to a patient with a runny nose and cough 20x more often than an OS gives them out.

When my child has their wisdom teeth removed, I will give them a course of antibiotics. That is why I do this for my patients.

Again, I realize there is debate. In residency you are bound by your attendings. Every program is different and you will tend to act in accordance with where you trained, especially while still in residency where you have no autonomy.

 

[TKD]

Um, that is why I am prescribing them; to avoid infections. The avoidance of phone calls is a secondary gain. The phone call comment was not meant to say that I do it to avoid phone calls. I prescribe antibiotics to prevent complications and help increase the patient's trust. Think about it, if you dont prescribe them and they do get an infection the first thing the patient will ask is, "Why didnt this idiot prescribe these in the first place?" And trust me, word travels fast. Regardless of what you "educated" them on before hand.

Where I trained we prescribed them on every case. So does every private practitioner I personally know.

I read the literature and I know there is debate out there. I choose to continue to prescribe.

Prescribing a 5 day course of amoxicillin after removing bony impacted wisdom teeth is not overuse. Especially considering PCP's give them to a patient with a runny nose and cough 20x more often than an OS gives them out.

When my child has their wisdom teeth removed, I will give them a course of antibiotics. That is why I do this for my patients.

Again, I realize there is debate. In residency you are bound by your attendings. Every program is different and you will tend to act in accordance with where you trained, especially while still in residency where you have no autonomy.

-ok so PCP's overprescribe so we should do the same? sorry don't understand that reasoning.
-to the op - doesn't matter if it involves surgical or non-surgical extraction
-i recall a very interesting study that concluded that copious irrigation is a greater factor in future flare-ups than antibiotics. that's why i irrigate like heck when doing surgicals.
-antibiotic resistance is a real and serious threat
-if all prescribers used the once in a lifetime theory, that # rapidly multiplies.
-gotta admit on medically compromised i prescribe antibiotics more than i know is needed. but when i comes to relatively healthy, esp younger ppl - no need!!!
-with all dentistry - i agree w/ poster above - a couple minutes of consent and pre-op discussion will avoid most of your phone calls.

 

[toofache32]

....Think about it, if you dont prescribe them and they do get an infection the first thing the patient will ask is, "Why didnt this idiot prescribe these in the first place?" ...

The real question is this: Is the percentage of patients who get infections on antibiotics significantly different from the percentage of patients who get infections without antibiotics? I don't have an answer.

We also have to make sure we differentiate infection from dry socket.

 

[rrc]

The real question is this: Is the percentage of patients who get infections on antibiotics significantly different from the percentage of patients who get infections without antibiotics?

You hit the nail on the head. No one knows. Now excuse me while I sprint away from the deadly flesh eating resistant bacteria that are encompassing the walls of my practice.

 

[rrc]

-i recall a very interesting study that concluded that copious irrigation is a greater factor in future flare-ups than antibiotics. that's why i irrigate like heck when doing surgicals.

Good one. You should use copious irrigation regardless. I'd love to know how they did this study. Burn the hell out of the bone vs. irrigation. Let's see who does better.

 

[scalpel2008]

here is a study that's fairly well designed supporting why not to use post operative abx routinely. (I can't attach the article because the file is too large)

1. Poeschl PW, Eckel D, Poeschl E: Postoperative prophylactic
antibiotic treatment in third molar surgery—A necessity? J Oral
Maxillofac Surg 62:3, 2004

And here's a very good letter that responds to this study

 

[TKD]

Good one. You should use copious irrigation regardless. I'd love to know how they did this study. Burn the hell out of the bone vs. irrigation. Let's see who does better.

-hey thanks for the sarcasm.
-you're thinking simple minded. i'm not talking about using high speed w/ versus w/out water. obviously always using irrigation with the high speed. but what they did was in b/w several specific steps, they stopped and flushed they heck out of it to remove debris. resulting in a very low incidence of flare-ups vs. control group. will try to find the article and enlighten you.
-in residency you are not necessarily bound by your attendings. Bring good evidence to support your actions and you're fine.
-and again, don't take notes from PCP's too much. also don't get too defensive either - this is a forum remember.

 

[rrc]

-hey thanks for the sarcasm.
-you're thinking simple minded. i'm not talking about using high speed w/ versus w/out water. obviously always using irrigation with the high speed. but what they did was in b/w several specific steps, they stopped and flushed they heck out of it to remove debris. resulting in a very low incidence of flare-ups vs. control group. will try to find the article and enlighten you.
-in residency you are not necessarily bound by your attendings. Bring good evidence to support your actions and you're fine.
-and again, don't take notes from PCP's too much. also don't get too defensive either - this is a forum remember.

Sorry about the sarcasm. It just seems like a strange study to do. I read the article on the preop abx. It makes sense I guess. There are other articles out there that say the same thing. There is some support for post op antibiotics although the majority says otherwise. Again, each practitioner will do things a little different. It's sort of like the HBO vs non-HBO argument. Hopefully a consensus can be reached at some point.

 

[esclavo]

Um, that is why I am prescribing them; to avoid infections. The avoidance of phone calls is a secondary gain. The phone call comment was not meant to say that I do it to avoid phone calls. I prescribe antibiotics to prevent complications and help increase the patient's trust. Think about it, if you dont prescribe them and they do get an infection the first thing the patient will ask is, "Why didnt this idiot prescribe these in the first place?" And trust me, word travels fast. Regardless of what you "educated" them on before hand.

Where I trained we prescribed them on every case. So does every private practitioner I personally know.

I read the literature and I know there is debate out there. I choose to continue to prescribe.

Prescribing a 5 day course of amoxicillin after removing bony impacted wisdom teeth is not overuse. Especially considering PCP's give them to a patient with a runny nose and cough 20x more often than an OS gives them out.

When my child has their wisdom teeth removed, I will give them a course of antibiotics. That is why I do this for my patients.

Again, I realize there is debate. In residency you are bound by your attendings. Every program is different and you will tend to act in accordance with where you trained, especially while still in residency where you have no autonomy.

The chance of anaphylactic or adverse reaction from antibiotic is about 14X higher in our office than infection from impacted teeth removal. How would you defend an anaphylaxis suit when most of the literature supports no antibiotics be used for wisdom tooth removal? The literature that supports antibiotic use is soo sketchy I don't think many reliable (note I said reliable evidence based practitioners) individuals would testify for but a legion would testify against such practice....literature doesn't support regular routine use of antibiotics and hopefully the practicing body will adjust to the science....

 

[scalpel2008]

The chance of anaphylactic or adverse reaction from antibiotic is about 14X higher in our office than infection from impacted teeth removal. How would you defend an anaphylaxis suit when most of the literature supports no antibiotics be used for wisdom tooth removal? The literature that supports antibiotic use is soo sketchy I don't think many reliable (note I said reliable evidence based practitioners) individuals would testify for but a legion would testify against such practice....literature doesn't support regular routine use of antibiotics and hopefully the practicing body with adjust to the science....

You know i disagree with giving abx, but just to play devil's advocate, isn't the rate of anaphylaxis with po abx extremely low as compared with IV?

 

[esclavo]

You know i disagree with giving abx, but just to play devil's advocate, isn't the rate of anaphylaxis with po abx extremely low as compared with IV?

Anaphylaxis AND adverse reaction (not otherwise classified as one of the six hypersensitivity reactions) combined... how many health forms have stated allergy to penicillin and you ask the patient what happens when they take penicillin and they say "It makes me throw up" (upset stomach, pruritis, any coincidental spot on an arm while taking an antibiotic, Cdiff, headache, dizziness)....wala you essentially have a drug that not many will subsequently give to a patient. It becomes a pseudo allergy situation because no one will give that drug....Dentists and ED physicians are largely to blame for this "spamming" of penicillin and then when a patient legitimately needs that drug you practically have to conviene a conference with 10 docs just to get the guts to give what is truly needed...or have them see an allergists and undo the cluster!@#$ that some "well meaning" dentist started by giving a drug that had no clear indication....

 

[Extraction]

DO you have your own book like Ellis, or are you just pulling **** out of your @ss as usual?

I'm holding out for more money from the publisher 😛 I'll send you an advanced copy if you're a good mutt.