Pre-dental antibiotics

Re: Pre-dental antibiotics

sophia guymer — Tue, 20 Apr 2010 19:11:32 GMT

[quote user="Evelyn Barbour-Hill"]

And if they suffered terribly for days and days, it rather suggests the antibiotic wasn't doing anything, doesn't it?

However, I imagine both ladies were fairly intelligent and well-educated people, so they would be fairly conscientious with their oral hygiene; so they would not be likely to get abscesses of periodontic origin. I am guessing that they had abscesses of endodontic origin; that's different, and there could be good reason to give days of antibiotic first, although even then they ought to have had some drainage established if possible, to take the pressure off. Did they eventually have the teeth extracted, or did they have endodontic treatment?

[/quote]

I am not sure about their dental hygiene, to be honest, I know of at least one of them that she won't go to the dentist unless something is wrong as she is scared so it is quite possible it was of periodontic origin. I do know though that the antibiotics did work, the swelling went down (no drainage!) and as far as I know the teeth were extracted but to be perfectly honest, it is possible I just assumed they were.

[quote user="Evelyn Barbour-Hill"]

If it's painful, and you relieve the pain, wouldn't it be the analgesic that's done the good?

[/quote]

Yes I agree but my line of thought was, with the analgesics you are just treating the symptoms, with the antibiotics you treat the cause. I am beginning to understand, that is not true.

[quote user="Evelyn Barbour-Hill"]And, I suppose, working only two mornings a week, if you try and do things a little bit differently then the boss or some other vet comes along and countermands you in your absence?[/quote]

Yes very much so and I have no longer (may be it will come back if/when I start working more again) got the confidence to fight my corner so I just let things go. As you say, I am not there enough to change things. (mental note: must check with the others IF they actually still do give antibiotics pre dental! )

Anyway thanks for your patients!

Sophia

Re: Pre-dental antibiotics

Evelyn Barbour-Hill — Mon, 19 Apr 2010 23:26:22 GMT

[quote user="sophia guymer"]Gingivitis due to bacterial infection in a mouth full of tartar with retreating gums, I am only a 'plep' so that is just about the only words I would use for it. I call it 'a bad mouth' [/quote]

Well, "bad mouth" is not a bad name. (If I can be excessively pedantic for a moment, that would probably be periodontitis, not just gingivitis. It is actually an important distinction.)

[quote user="sophia guymer"]What I meant with solve most of the infection, was that I thought the antirobe actually managed to get 'in there' (to the infection in the gums) and kill of the bacteria pretty much as in other infection sites. Which is why I said I didn't understand why you are selecting for resistance.[/quote]

Well, it would be wonderful if you could cure gingivitis or periodontitis with antibiotic. Unfortunately you can't.

In gingivitis or periodontitis, the bacteria are in the plaque..... roughly speaking, down the side of the tooth between the tooth and the periodontium. Not necessarily invading the tissues much. There are hundreds of different species. It's a whole mini-world. Now let us assume that your systemic antibiotic does actually penetrate in adequate concentration to the bacteria in the depths of the plaque (which it probably doesn't). There will be a large number of species that are simply not susceptible and they will continue to thrive. There may be some species that are entirely susceptible and no individual at all can develop resistance; they might all be killed. There will be many species that are variably susceptible, but in which some are capable of developing resistance; of these, many will be killed leaving the resistant ones. So, after your antibiotic course (assuming it did anything) you still have a vast number of bacteria all resistant to the antibiotic, which will rapidly multiply to make up the vacancies left by those that were killed.

[quote user="sophia guymer"] But how would you get rid of said resistent bacteria afterwards as I would use the same antibiotic post dental, that antibiotic would obviously not work then either for these bact.[/quote]

Well, yes, that's rather the point of not encouraging resistance. But are you sure you want an antibiotic post dental?

You get rid of bacteria in periodontal disease by mechanical removal...... coupled sometimes with a certain amount of chlorhexidine in deeper pockets. Sometimes you might use special slow-release antibiotic preparations instilled into deeper pockets, after scrupulous mechanical cleansing. That's done a bit in human dentistry and it's fearfully expensive. Since Doxirobe (and that was expensive enough) was withdrawn we don't do it in small animals.

[quote user="sophia guymer"]Well to be truthfull I suppose in people it would only be an abscess that I have 'experience' with. They won't even attempt to remove the problem tooth until the infection is no longer visibly there. (thankfully I have not had to have it done myself but one of our nurses has had the problem twice now in diff teeth and one of the mums at my sons's school ditto, they suffer terribly for days and days!)[/quote]

Well, an abscess is a different situation altogether, but I still wouldn't approve of that approach....... assuming the abscess is of periodontic origin. If you've got a festering splinter, you pull it out: you don't give days of antibiotic first. maybe dentists are paranoid about being sued if the patient gets endocarditis ten years later? I wonder if your friends' dentists were just giving placebo antibiotic until they could conveniently fit in an appointment? Or maybe they went to A and E and got the well-known 3 Ps treatment?

And if they suffered terribly for days and days, it rather suggests the antibiotic wasn't doing anything, doesn't it?

[quote user="sophia guymer"][quote user="Evelyn Barbour-Hill"]What exactly is it you are hoping to keep under control?[/quote] The bacterial infection, the pain caused by it (always with painrelief of course), the systematic problems caused by it (renal, heart or am I clutching at straws here?) [/quote]

If it's painful, and you relieve the pain, wouldn't it be the analgesic that's done the good?

Systemic problems? Often quoted, and a bit of a worry, but precious little evidence that they actually occur in the normal cat and dog. You create a bacteraemia when you treat teeth, sure, but you get one when you brush your teeth and even when you eat. And if you are concerned about larger or worse degrees of bacteraemia due to the heavy weight of plaque in the mouth, isn't the best plan to get rid of said plaque as soon as possible by the most effective means?

[quote user="sophia guymer"]And another theory smashed!?? I was convinced that antirobe was much better. May be I should say, I was made to believe. [/quote]

Oh. Yeah. Sorry about that. We all believed it for a little while, because the manufacturers told us so.

[quote user="sophia guymer"]Just with changing from 'being a vet' to 'being a mum who works only 2 am a week as a vet' I have also lost a lot of confidence, knowledge and ability to find time to read up on things so I try to listen to other people much more than I used to do. Not sure if that is working out [/quote]

Yes, I can see what you mean. And, I suppose, working only two mornings a week, if you try and do things a little bit differently then the boss or some other vet comes along and countermands you in your absence?

Re: Pre-dental antibiotics

Evelyn Barbour-Hill — Mon, 19 Apr 2010 21:11:12 GMT

[quote user="Hanna Bennett"]Does that mean my 'copping out' use of Convenia in evil cat dentals is not completely out of order then?[/quote]

No, completely in order......... when antibiotic treatment is required

Re: Pre-dental antibiotics

Hanna Bennett — Mon, 19 Apr 2010 19:52:39 GMT

[quote user="Evelyn Barbour-Hill"]

One more comment Clindamycin doesn't actually have any advantage over clavulanate-amoxycillin, in terms of efficacy against oral bacteria. Again, I can't quote references offhand, but the work has been done.

[/quote]

Does that mean my 'copping out' use of Convenia in evil cat dentals is not completely out of order then?

Re: Pre-dental antibiotics

sophia guymer — Mon, 19 Apr 2010 15:09:48 GMT

[quote user="Evelyn Barbour-Hill"]

Well.......... what do you mean by "solve most of the infection"? So it depends what dental disease you are talking about.

[/quote] Gingivitis due to bacterial infection in a mouth full of tartar with retreating gums, I am only a 'plep' so that is just about the only words I would use for it. I call it 'a bad mouth'

What I meant with solve most of the infection, was that I thought the antirobe actually managed to get 'in there' (to the infection in the gums) and kill of the bacteria pretty much as in other infection sites. Which is why I said I didn't understand why you are selecting for resistance.

[quote user="Evelyn Barbour-Hill"]

You give your antibiotic, and, assuming it kills some bacteria, the ones it kills are those that are susceptible to it. At the end of the course you have a bacterial population with a higher proportion resistant to said antibiotic. The longer the course, the greater the selection. Then when you finally do your procedure the bacteria you liberate into the blood are all resistant to your antibiotic.

[/quote]I do understand that, (no offence taken by the way) but I suppose I am not quite there yet with why it makes that much difference when you do it, as these bact were already resistant to the said antibiotic anyway. But I suppose the point is that they would then not be in such a high percentage? But how would you get rid of said resistent bacteria afterwards as I would use the same antibiotic post dental, that antibiotic would obviously not work then either for these bact. I sort of suspect I am being really dim

[[quote user="Evelyn Barbour-Hill"]

I'm not sure what you mean by that. What do you mean by "an infected mouth?

[/quote]]

Well to be truthfull I suppose in people it would only be an abscess that I have 'experience' with. They won't even attempt to remove the problem tooth until the infection is no longer visibly there. (thankfully I have not had to have it done myself but one of our nurses has had the problem twice now in diff teeth and one of the mums at my sons's school ditto, they suffer terribly for days and days!)

[quote user="Evelyn Barbour-Hill"]What exactly is it you are hoping to keep under control?[/quote] The bacterial infection, the pain caused by it (always with painrelief of course), the systematic problems caused by it (renal, heart or am I clutching at straws here?) [quote user="Evelyn Barbour-Hill"]One more comment Clindamycin doesn't actually have any advantage over clavulanate-amoxycillin, in terms of efficacy against oral bacteria[/quote]

And another theory smashed!?? I was convinced that antirobe was much better. May be I should say, I was made to believe. Sometimes I don't really know Who to believe!! (that sounds like I don't trust what you said, didn't mean it like that. Just with changing from 'being a vet' to 'being a mum who works only 2 am a week as a vet' I have also lost a lot of confidence, knowledge and ability to find time to read up on things so I try to listen to other people much more than I used to do. Not sure if that is working out

Thanks for taking the time to explain things that may be really obvious to you!

Sophia

Re: Pre-dental antibiotics

Clive Ansell — Mon, 19 Apr 2010 09:15:55 GMT

We will be doing the procedure tomorrow, which is as soon as possible. Practice is closed from 1200 Saturday until 0830 Monday, with myself and other staff away for the weekend, in any event I don't stay on after hours without being paid to carry out routine procedure. The clients are unable to attend today, so tomorrow it is. Costs are an issue too, so unlikely to pay for ooh care or transfer to the ooh provider.

This animal has been neglected over a months to years time frame, so another 3 - 4 days is really neither here nor there. He has been prescribed Amox/Clav, Metronidazole, Metacam, and Tramadol, so I hope he is feeling more comfortable and the infection is being reduced. I have my doubts they will turn up, they have a history of not showing and of being serial bad debtors.

Re: Pre-dental antibiotics

Evelyn Barbour-Hill — Sun, 18 Apr 2010 23:26:03 GMT

[quote user="Michael Woodhouse"]Why so? I can't think of anything worse than a dental on either a Friday night or a Saturday afternoon! You need to get out more![/quote]

Possibly so. I have just had a fine two days off though, with the missus. First to Manchester to the Don McCullin exhibition (he is just such a brilliant b/w photographer) then down to the Great Wen.

Anyway, it's because of the abscess and the pain all over the maxilla, which obviously are very recent, that I'd be doing it as soon as possible.

Re: Pre-dental antibiotics

Michael Woodhouse — Sun, 18 Apr 2010 21:29:26 GMT

[quote user="Evelyn Barbour-Hill"]I would be doing that dog, if not on Friday night at least on Saturday afternoon.[/quote]

Why so? I can't think of anything worse than a dental on either a Friday night or a Saturday afternoon! You need to get out more!

The condition has clearly been going on for many months [or years] what difference is 4 days going to make to the dog?

I can put no science behind it but dogs with really manky teeth seem to 'perk up' with a week of antibiotics, I would assume this made the GA a lower risk. I fully appreciate that more definitive treatment is still required!

Re: Pre-dental antibiotics

Evelyn Barbour-Hill — Sun, 18 Apr 2010 18:20:40 GMT

[quote user="Clive Ansell"] the other reason of course is logistics; given it is Friday night the next available operating slot in Tuesday, 4 days time (If they turn up??).[/quote]

Yes of course that's very sensible especially if you are suspecting osteomyelitis.

No criticism of you (people can be awfully touchy on this forum ) but I would be doing that dog, if not on Friday night at least on Saturday afternoon.

[quote user="Clive Ansell"]I was always taught pre dental ab's for 5-7 days[/quote]

Who by, I wonder? I am intrigued now.

By the way...... and it has some indirect bearing on this discussion....... I presume you all read the piece by Crossley and Ide in the special issue of BVDAJ that you all received free (if you are BSAVA) last November?

Re: Pre-dental antibiotics

Evelyn Barbour-Hill — Sun, 18 Apr 2010 18:04:32 GMT

[quote user="sophia guymer"]

[quote user="Evelyn Barbour-Hill"]Yes, the pre-op course of antibiotic is not very logical - what is it trying to achieve? [/quote]

Surely the idea would be to try and solve most of the infection before you start the dental in the first place.

[/quote]

Well.......... what do you mean by "solve most of the infection"? So it depends what dental disease you are talking about.

As you know, there are huge numbers of a large number of different species of bacteria permanently resident in the mouth, and the proportions of the different species vary in plaque according to its thickness and the depth of any periodontal pocket. A five day course of broad spectrum antibiotic is going to produce just a mild downward blip in the general oral population or in the subgingival population.

If you had an osteomyelitis arising from dental disease (extreme case!) you would want an antibiotic course; if you had an abscess you might want an antibiotic course as a precaution lest it develop a cellulitis or an osteomyelits; but in either of those cases, little progress is going to be made until the source is removed: by draining the abscess, extracting the teeth involved, or treating the teeth involved by subgingival scaling, or by PBUD, or by root planing, or whatever surgical means was appropriate. Endodontic disease....... some temporary relief can be gained from antibiotic perhaps, though analgesic is always given too ; but again little progress is made until surgical treatment, even if it's just initial drainage, is commenced.

[quote user="sophia guymer"]Considering they won't touch an infected mouth in human dentistry until the infection has been sufficiently treated with antibiotics there must be some truth in that?[/quote]

I'm not sure what you mean by that. What do you mean by "an infected mouth?

[quote user="sophia guymer"]I don't really understand why it would be selecting antibiotic resistant bacteria?[/quote]

[quote user="sophia guymer"]What about the pulse treatment once monthly with antirobe on those dogs with bad mouths but dentals no option, then? It seems to keep it under control a bit? Or is that wishfull thinking? [/quote]

Mostly wishful thinking. Maybe it has a bit of an effect but the "pulse treatment" as a substitute for proper treatment is to be deplored. And again, it depends what you mean by a "bad mouth". What exactly is it you are hoping to keep under control?

Interesting thread. I hadn't realised that antibiotic use was so popular.

Re: Pre-dental antibiotics

Hannah Wynne Richards — Sat, 17 Apr 2010 09:51:28 GMT

I'm lucky in that the dental no option scenario hasn't occurred for years. I'm very lucky that a DVA is in 1st opinion practice in Haverford West, so I can send difficult anaesthetics to him, and if the animal survives the surgery, then getting rid of it's pyorrhoea is bound to extend it's life, and eliminate it's pain

Wynne

Re: Pre-dental antibiotics

Clive Ansell — Fri, 16 Apr 2010 19:49:15 GMT

I suppose it depends on the case.

I have seen a greyhound tonight that has not been to a vet for 6 years, with a terrible infected mouth that has frank purulent peridontitis and a malar abscess, plus the whole maxillary area is painful to palpation so am suspecting possible osteomyelitis too. I have started him on amox/clav and metronidazole and booked for dental work, probably total extraction, next Tuesday. In such a bad case it seems logical to me to try address some of the infection at least prior to surgery. the other reason of course is logistics; given it is Friday night the next available operating slot in Tuesday, 4 days time (If they turn up??).

I was always taught pre dental ab's for 5-7 days and have gone along with it without questioning it I suppose, but as Evelyn says ab's on the day is probably fine.

Other cases I may just give ab's on arrival or on induction, or not at all for simple scale and polish cases where there is no or little obvious infection.