Bill Klaproth: This is OMS Voices, an AAOMS podcast. I’m Bill Klaproth. And with me is Dr. Erin Sheffield, who is here to discuss dental extractions, infections and the use of antibiotics. Dr. Sheffield, thank you for being here.

Dr. Erin Sheffield: Hi, Bill. Thanks for having me.

Bill Klaproth: You bet. So let’s talk about this. Let me ask you this first. What are some common reasons for tooth removal? When does a tooth need to be extracted?

Dr. Erin Sheffield: Well, teeth are commonly removed for severe extensive decay, broken or severely fractured teeth, or a lot of people think about impacted wisdom teeth.

Bill Klaproth: Yeah, that’s one of the common ones, for sure. So, what is a simple tooth extraction?

Dr. Erin Sheffield: It’s simple. A routine extraction is essentially when we can just wiggle the tooth out. And that can often be done by either a general dentist or family dentist, or also by your oral surgeon.

Bill Klaproth: So that’s like when you’re a kid and you didn’t want to go to the dentist to get your tooth pulled and you start eating apples. Like, come on, man. Just come out on your own.

Dr. Erin Sheffield: That’d be a simple home extraction, I guess.

Bill Klaproth: Yeah. The old string on the door. Right. Which is really, nobody really does that.

Dr. Erin Sheffield: My mom used to do it.

Bill Klaproth: What?

Dr. Erin Sheffield: It can work in the right location.

Bill Klaproth: Wow. Okay. We are learning things here today on the AAOMS podcast, people. So, then what is a surgical tooth extraction?

Dr. Erin Sheffield: Surgical tooth extraction is a more difficult or complicated extraction, and it requires either an incision in the gum, removal of bone or maybe cutting the tooth or maybe all of those things. And then occasionally we will place sutures with those. I have a lot of patients who come to me, and they say in frustration, like, why can’t my dentist just do this? But your dentist is usually going to refer you to an oral and maxillofacial surgeon if they have concerns about the complexity of the removal. They want to ensure that the tooth is removed or managed with the highest level of expertise. And that’s what we as oral and maxillofacial surgeons can do.

Bill Klaproth: So, when it comes to the simple extraction, if you will, generally a dentist can do that, wiggle it, and it’ll come out. Is that right?

Dr. Erin Sheffield: Oftentimes, yes.

Bill Klaproth: So then how common are infections after a dental extraction and what are the signs of an infection?

Dr. Erin Sheffield: Well, surprisingly, dental infections after oral surgery or tooth extractions are extremely rare. So, unless they’re extremely difficult extractions, something like deeply impacted teeth, or maybe you have a medical condition that makes you more prone to infection, maybe an autoimmune condition, most patients will not develop an infection after, especially a simple extraction. And many won’t even require an antibiotic. But it can happen. So, there are some things to watch for. So, really bad foul breath. More than just your normal, you know, morning bad breath. A really bad bitter or foul taste. Things like fevers, pain. Now, this is tricky. A lot of the signs of infection are similar to having an extraction. So, pain, swelling. Things like that can develop just because you had surgery and from inflammation. But when those things are getting worse, instead of getting better over time, those are all concerning. And then especially if you started having swelling into the neck or into the glands of the neck or extensive facial swelling, those are all things that are concerning and you’d want to speak to your surgeon.

Bill Klaproth: Is there a timeframe for that? If it doesn’t get better within a few days or a week, is that when it’s time to call the OMS?

Dr. Erin Sheffield: I always tell my patients that pain and swelling after the surgery are going to get worse within about the first two to four days. So, if you’ve got past that point and things are getting worse, that’s definitely something we want to see or talk to.

Bill Klaproth: Absolutely. So, then you did mention antibiotics. What role do antibiotics play in preventing infection?

Dr. Erin Sheffield: So, antibiotics may be prescribed to patients undergoing extractions to prevent complications from infection or can be given after if an infection develops. And these antibiotics can be given either before, during or after the surgery. There are certain kinds of antibiotics that are most effective. We call them beta-lactam antibiotics. Penicillin is one you think of most commonly, and these are considered to be the most effective antibiotics in preventing and treating dental oral infections. So, this is something that is really important to know. A lot of people are allergic to penicillin or actually think they’re allergic to penicillin. Only about 1 percent of people who are allergic actually are. So, this is difficult for us sometimes to treat these effectively or to prevent infections when you take an alternative one, because you think you’re allergic. So, I always encourage my patients unless they’ve had a severe anaphylactic reaction to penicillin to actually consider speaking to their physician or their allergist about allergy testing, because this is really important information for their general health.

Bill Klaproth: So, how do antibiotics generally work and what considerations will an OMS take into account when prescribing antibiotics?

Dr. Erin Sheffield: So, antibiotics work by killing the bacteria that cause infections or by slowing their growth. But many times, infections will clear up themselves. So, I’ll tell my patients, most simple extractions, even if there was an infection in that tooth will resolve on their own because the source, which was the tooth has been removed. So, it’s kind of like if you had a splinter in your finger, and it got a little irritated, inflamed or infected. We could keep throwing antibiotics at it, but that’s kind of silly once we get that splinter out, that infection will probably go away. And that’s the same thing with our mouths. Most of the time, just getting the offending tooth out of there is going to take care of the problem.

Bill Klaproth: Do most people automatically ask for antibiotics?

Dr. Erin Sheffield: I think that there’s a really big misperception out there that if you have oral surgery, you have to have an antibiotic. I’ve seen lots of comments, maybe on social media, or just patients talking to me who are surprised or even saying the wrong thing was done because they weren’t prescribed an antibiotic, but the actual use of antibiotics in oral surgery is pretty low. It’s usually a low necessity. The other thing I see a lot of people will take them inappropriately. You know, you definitely want to be taking antibiotics as recommended by your doctor. You really don’t want to find, you know, Grandma’s leftover Z-pack or something and take a day or so of that, just because you think you have an infection, you know. If you take the antibiotics in a way that’s not indicated, either the wrong one or for the wrong dose or the wrong amount of time, all those things can actually contribute to a bigger problem with infection, either for you or with antibiotic resistance in our community.

Bill Klaproth: Right. Stay away from Grandma’s Z-pack. Keep your hands off.

Dr. Erin Sheffield: Leave it in the cupboard. Grandma’s Z-pack should have been used fully and gone anyway. Should never have been there for you to find.

Bill Klaproth: Yeah, Grandma should’ve thrown it out.

Dr. Erin Sheffield: She should have used it all until it was gone.

Bill Klaproth: That’s right. So, when should a patient see an OMS for dental extraction? I feel like people would be referred to the OMS. Do they go on their own?

Dr. Erin Sheffield: So, occasionally people self-refer to an oral and maxillofacial surgeon. People with like wisdom teeth that they know have to come out. Those are easy for us to accept, but most of the time we do work on a referral basis. So, I get a lot of patients who try to skip their general dentist and they want to just come straight to me, or they want me to become kind of their primary care dentist. But most of the time we work on a referral basis, simply because I want to know that they have seen the dentist, that they’ve come up with a good long-term plan for the tooth, and I want to verify that the tooth actually does need to be removed before they come see me.

Bill Klaproth: All right. Well, this has been really interesting. Dr. Sheffield, thank you so much. So, when it comes to dental extractions, infections and the use of antibiotics, anything you want to add?

Dr. Erin Sheffield: I think what I would want patients to understand is that you may be surprised how rarely antibiotics are needed. So, if you didn’t receive an antibiotic, either with extraction or preventively that doesn’t necessarily mean something wrong or bad happened just because you’d received them before or heard about a friend who had received them. Every case is different. And we really want to make those decisions carefully and from a data- and research-driven approach. And so, really talking to your surgeon is the best way to determine if you need to have an antibiotic or not.

Bill Klaproth: Right because there is that perception, “Give me the antibiotic.”

Dr. Erin Sheffield: Yes. And I think they are actually quite often over-prescribed in dentistry. And that’s something that I’m a really big advocate for and that we’re working to educate people on because we are seeing the negative effects that antibiotics can have either on single patients. You know, people don’t always realize that there are complications or severe side effects that can happen with antibiotics. They’re not without complication or risk. And also from a global health perspective, antibiotic resistance is on the rise and it is a severe threat that, you know, we can’t quite fully comprehend. But we really want to be careful in the antibiotics we use and prescribe so that when we do have those serious infections, they will not become life-threatening because we, you know, we’ve overused the antibiotics that we have.

Bill Klaproth: Yeah. Good information and well said, Dr. Sheffield. Thank you so much. We appreciate it.

Dr. Erin Sheffield: Thank you.

Bill Klaproth: And once again, that is Dr. Erin Sheffield. And for more information

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