Bill Klaproth (Host): [Mic bleed] This is an AAOMS On the Go podcast. I'm Bill Klaproth and with me is Dr. Jas Dillon who is here to discuss do OMSs really need antibiotics for what they do? Dr. Dillon, great to see you.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Hi Bill. Thanks for having me.

Host: Yeah,it's a pleasure to talk with you again, and we appreciate your time. So let me ask you this. Why do we care about antibiotics in OMS?

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: This has been my sort of pet project and some people will say I'm like on a little antibiotic crusade and we'll talk about why as we progress, but much more so, because globally we're very concerned about antibiotic resistance, and whatever we can do as a specialty to circumvent that is incredibly important to society.

Host: So can you give us the history then of antibiotics just quickly? So we know how we got to where we're at.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Yeah, it's super interesting. You were just saying you'd been to London for the first time. I'm from London. Well, Alexandra Fleming discovered Penicillin in 1928 at a university in London, St. Mary's hospital. Just totally random. He went for vacation, came back. His lab was in total disarray. And he looked at some Petri dishes and where there was some mold present, certain bacteria, staphylococcus and streptococcus did not grow. So he did a few studies and he found, Hey, this thing is interesting. And he named it penicillin. But that's all he did, nothing fancy. And then fast forward a decade later at Oxford University, several people worked on this drug. And they worked in mice and found out that actually it did work. And then they treated a police officer, a Constable, who subsequently died because they couldn't produce enough penicillin.

And it turned out you needed 2000 liters of mold to create one tablespoon of active drug. So what did these guys do is 1939, 1940, there's a big thing happening in the world at the time. It's a war. And so they went over to the United States, where they worked with scientists and industry to actually purify this drug. And the world's first patient who was treated with penicillin was a woman who her name was Ann Miller and she was dying from a miscarriage and she was treated with penicillin. And she was actually given almost half of the entire United States' penicillin, that they had made at that time, which is a tablespoon.

And the reason why I bring this up is because majority of people for world wars actually died from infection, not from the injury of war. And so world war one, 18% of the soldiers died from infections in the trenches and that decreased to 1% after penicillin was discovered. So at the beginning of the war they were making 400 million units of penicillin. But at the end of the war, it was 650 billion units a month. So this is a big deal.

Host: They really learned how to step it up. So did Ann Miller, did she survive?

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: She survived. She passed away at the age of like 92, 93 only a few years ago. Good question.

Host: And thank you, penicillin. And thank you, Alexander Fleming for going on vacation.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: And actually

Host: Right? Is that the moral of the story? Go on

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Go on vacation. But for he discovery, they got a Nobel prize. These people won the Nobel prize in medicine.

Host: So I think that's an interesting point that you bring up about the soldiers in the war. You would think that it was the severity of their wounds, but I never really thought about infection so the doctors could put them back together, but then you've got open wounds and then you get an infection.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Absolutely. They're in the trenches. You know, at those times, tooth infection, just a little nick sitting in the trenches, it's wet. That is what resulted in sepsis and death of the soldiers more than all the ballistics. Yeah.

Host: You're a wealth of knowledge. You are giving us a great history lesson. So I love that. Thank you so much. Okay. So this term apocalypse pig. What is this?

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Well, so obviously since that time in 1928, we have got so used to giving antibiotics that they are pretty much given like Smarties or candies in this country, but not all over the world. So you have countries that you can just go buy them in any drugs, not even a drug store, you can buy them around the corner. You say, I have a sore throat, I need an antibiotic. And so like in Bogata, even in New York, you can pick them up in pet stores. You can pick them up and there was a very interesting article in the New England Journal of Medicine of a actually a military person in the US who had multi-drug resistant sinusitis, because what he was doing is, he was treating his antibiotic. He was treating his sinus infection with pet antibiotics. And what it said is, Hey, we all know about it it's quick. It's easy. We're traveling a lot. We can pick them up. And so the apocolyse pigs came about because in 2015 there was an article published that in China, this, mutation came out, it's called the Mcl-1 and this mutation was to cluster it. Cholesterol is one of our last known drug for gram negative bacteria. So they published it. And that was very early in November and quickly the antibiotic resistance went from December and into Denmark.

And then to the United States and that resistance is tracked throughout the world. So that's why we call it the apocalypse pig, because it came up in a meat markets in China. A little scary. Now we think about COVID subsequently. Yeah.

Host: Right. So, antibiotic drug resistance. What happens? If we get too much of it in our bodies it no longer works?

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Yeah. So, the bugs are clever, you know, so even from 30,000 years ago, we now know when we look at Arctic pembra, that these bacteria have intrinsic genes that allow them to adapt. So there are actually bacteria out there that have resistance of antibiotics that we don't even know about those antibiotics right now. So they have the capacity when you hit them with a penicillin, they have the capacity to produce something that will resist that. And that's the issue is when we take them, the antibiotics can resist what we're doing and there's some fabulous studies have shown that in 11 days there was a big Petri dish study shown. It was like a size of a table. And this group that published in Science.

They had an antibiotic that went from 1% potency to a thousand percent potency and they just recorded the speed at which bugs, which has e-coli went to the center. And the e-coli was able to overcome a thousand percent potency of antibiotic in 11 days. And that just shows that if we're just giving them, we are developing resistance and we transmit that resistance into the community and into society.

Host: So when we pass along to other people, we pass along that resistance.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: into the community. Yep.

Host: So then what is antibiotic stewardship?

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: So really stewardship is thinking about the right antibiotic, the right dose, the right time and the right duration. And it really makes you think that you have a cold. Most colds are virus, you don't need an antibiotic. You don't need to go, Hey, I've got a sore throat. I need an antibiotic. No, you don't. And as maxillofacial surgeons, we contribute so much to society and this is a sort of sidebar thing because we give so but so much that it's important for us to also think, do we need to prescribe that? Probably not.

Host: So the OMS community really is in this together, as far as this stewardship, to be aware of antibiotic drug resistance.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Yeah.

Host: So we don't foster more of it which doesn't help anyone.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: A hundred percent and in the United States alone, drug resistance related illnesses cost $4.6 billion a year. That's a lot of money.

Host: So I know most us, me included with my kids, we need an antibiotic. Um, You don't need a, come on doc, give me the antibiotic. You deal with that all the time. Right? So it's sometimes hard to say, listen, I'm not going to prescribe an antibiotic for this. Here's why.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: And then the problem is, is that we have to societaly all own that because it can't be then that you don't prescribe it, but you'll go oh, I'll go to the guy down the corner and the guy down the corner, prescribes it and he'll get me one. And that doesn't help us as a group.

Host: Right. Okay. So that's why I said we're kind of all in this together, okay. So, as we talk about stewardship then, do we need antibiotics for routine oral surgical procedures. And what about a wisdom teeth and dental implants? How about that?

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Great question. I would say AAOMS has several committees. It was a committee on outcomes assessment, committee on anesthesia and practice parameters. And they wanted to ask that question because so many of our OMSs are in the community and we're sitting in our academic towers and they look at us and say, Hey, what you do out there is not what the real world does. And we're in that situation. Whereas if we don't give it and we have an infection, the guy down the road says you should have given an antibiotic.

And so what AAOMS did is they said, Hey, let's ask these community people to participate in some research, which they did, and they collected the data. Now the data is interesting. It's, it's almost 2000 subjects, and it did show that if you give an antibiotic post operatively, so after you've done the procedure; it does decrease the risk of infection by 51%, but I want to preface this by saying that that was the majority of the infections were a dry socket. Dry sockets are treated with local measures, not antibiotics in general.

And you needed to treat a hundred people with an antibiotic to prevent a major serious event. So the study was just looking at what are people's practices. It didn't ask people to do anything special. It's just do what you normally do. We just want to look at your data. And so I would say that if somebody is completely healthy, it's your 16 year old having their wisdom teeth out; there's no indication to give that person an antibiotic. I know some people will argue with me, but I'm happy to take them to that challenge. Yeah. Implants. Big data, Cochrane reviews. A single tooth implant in a healthy individual does not need an antibiotic. If you are going to bone graft at the same time, you're placing multiple, a single dose is all you need. And this, we're talking about healthy people. And that's what we've seen in trauma in our trauma data, throughout, really all the things we're doing for maxillofacial surgery; single doses are usually going to be fine and that's seen in literature in general surgery and other surgical specialties.

Host: So then when is an antibiotic called for?

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Yeah. So a perioperative dose, meaning you're going to go and have a procedure. It's very reasonable and data shows it decreases infection to have a single dose. But let's talk about infection and antibiotic. Right. So osteomyelitis is a bone infection and in very debilitating, maxillofacial osteomyelitis. We have standardly taken information from the orthopedic literature where we've talked about giving these patients intravenous antibiotics through a PICC line, at least six weeks up to three months in some cases. And actually in my own institution, we looked at this and based upon all this stewardship, I personally stopped giving IV antibiotics for osteomyelitis probably in about 2010 ish. Talking to my infectious diseases colleagues, you know, osteomylitis is a surgical disease and we did this and we looked at our data. And what we found is that oral antibiotics were just as efficacious. And there's a now orthopedic studies published in New England Journal of Medicine that have shown exactly the same thing. And that oral antibiotics work, it's a surgical disease. Cut out the dead bone.

Host: Okay. So I just want to circle back. In healthy people, generally, without antibiotics, the body will clear the infection on it's own.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: No.

Host: No, wrong, wrong. I I get a demerit in class. Dang it.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Depends on what the infection is. So if you have an infection, like you have a dental infection.

Host: Yes, I've had a dry socket.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Yeah a dry socket is a localized bone inflammation. So you're going to treat that, but if you actually have pus in the area, related to something dead and you have a swelling; the treatment is eliminate the source, the dead tooth something caused a problem. Clean that out. Wash the area up. As we say the solution to the pollution is dilution. So wash, wash, wash, wash and then an infected person can have an antibiotic, but if they don't have an infection and they're healthy and you're doing a procedure, you don't need to give them one. That's what we're saying.

Host: Okay. So if the person does have an infection.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: You can give them an antibiotic.

Host: You can. Yes.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Of course, I'm not here to bereach you have an infection, don't give them an antibiotic. That would be the wrong message.

Host: If they do have an infection, and you wash, wash, wash, sometimes it's okay not to give an antibiotic because?

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: So I love that question cause that's like one of my next studies, but the standard of care, if you have an infection, you get an antibiotic, in the Western world where we have access to the antibiotic. Right. There's patients, there's people in the world where they don't have access to that, they'll have wash, wash, wash. They don't get an antibiotic. And many of them are going to be okay, but that's not what we're talking about here.

Host: Okay.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Yeah. In our country, in our society, you have an infection, you're going to get an antibiotic. But if you do surgery, you wash, you clean, think about the duration of that. You want to limit how long that person's having an antibiotic to decrease the risk of you developing a resistance to the antibiotic or the side effects and the side effects like bowel infection. Those side effects are adding to costs of health care.

Host: Okay. So it is important in those instances to provide an antibiotic. Okay, very good. Do I get a star now? Do I give, do I get my demerit back?

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: You passed, you to passed. You're okay.

Host: Very good. Okay. I want to make sure. Okay. So then what do you see as the future of antibiotics in oral and maxillofacial surgery?

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Many people are thinking about this already. And I lecture on this a fair amount. I would say that I think that I would like the group as a whole to think twice about when they're giving them, so that we're not contributing to that resistance.

Host: Right? Again, it's that stewardship that

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Stewardship. Right drug, right dose, right duration.

Host: Are we building awareness on this? Are we getting the message out to our OMSs? Because this is important research and important work.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: You know, this data is published in our journal, Oral and Maxillofacial Surgery. It's published in multiple other journals, but things like this podcast and lecturing makes a big difference and it helps.

Host: Yeah. Yeah, Well, I love to hear that. That's wonderful. So Dr. Dillon, thank you so much for your time. Anything you want to add when it comes to antibiotics in the OMS?

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: The one final comment I would make is obviously everybody's talking about AI now and how AI is going to terminate us and take over our lives. And very soon you won't be sitting there. There'll be a robot sitting there

Host: Actually I am a robot Dr. Dillon.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: And I

Host: am in, I AI. The real Bill actually is a yeah.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: I should have known, but so AI is now being used to discover a newer generation of antibiotics so that where we've talked about the apocalypse and it's over and we don't have any left. AI is actually being used. And there's a brand new one that just came out this year that they're testing and it's called a bowel sin. So maybe I don't need to be preaching about this. Cause maybe as we discover it, AI will find an antibody that targets it.

Host: So the AI is helping us find a new antibiotic that may have a higher resistance to the bugs.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: Yeah. So that's what we're looking at. I would just end, by circling back to Sir Alexander Fleming, he was knighted for his discovery so in 1946, when he got his Nobel prize, he said the thoughtless person playing with penicillin treatment is morally responsible for the death of the man who finally succumbs to infection with a penicillin resistant organism. And he said, I hope the evil can be averted. So right drug, right dose, right duration.

Host: Wow. You have wrapped it up perfectly. Now that's how you do it, ladies and gentlemen. That's how you do a there.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: very

Host: Dr. Dillon, thank you so much.

Jasjit Dillon, DDS, MBBS, FDSRCS, FACS: My pleasure. Thanks much Bill.

Host: Always great to see you once. Again, that is Dr. Jas Dillon. And for more information in the full podcast library, please visit aaoms.org. And if you enjoyed this podcast, and I'm sure you did, please share it on your social channels. And be sure to subscribe so you don't miss an episode. Thanks for listening.