An Early Bite with Dr. John Paul: “Why Won’t You Give Me an Antibiotic?”

By Dr. John Paul, FDA Editor

Have any of you heard this today?

“Doc, I’m calling you at home after hours because I’ve got this toothache again. This time it’s been hurting about a month and it’s just killing me. You’ve got to call me in an antibiotic.”

Here’s my answer:

“Mrs. Gruntbuns, back when Mr. Fleming found penicillin, antibiotics seemed like magic. You give people a pill and their problems went away. While that was the net effect, what really happened was the drug killed enough of the infection that your body could heal itself. The drugs were so new that they wiped out every bacteria they came in contact with. It’s important to remember over time that changes. The more often bacteria contacts a drug that does not completely wipe them out, the more they develop resistance to the drug until that drug becomes harmless to the bacteria.

“We’ve talked about this before. That antibiotic I gave you last time was to help you get by until you got a real treatment. Once a tooth is infected enough that you have symptoms, there is no way for your body to heal it after a little help from a drug. You’ll need a real treatment like a root canal or an extraction to remove the source of the infection before you can heal. The more times you get a drug without the real treatment, the more the bugs get a chance to become resistant.

“Tomorrow morning I can get you an appointment with an endodontist or an oral surgeon. Which would you prefer?”

Have a question you have a tough time answering? Send it to Dr. Paul at jpaul@bot.floridadental.org.

An Early Bite with Dr. John Paul: “Why Do I Have to Take Antibiotics Before My Dental Appointment?”

By Dr. John Paul, FDA Editor

How many of your patients complain when you prescribe their prophylactic antibiotics? In my practice, it’s all of them. No one complains about the drugs they think will make them feel better, but when they perceive no problem, they want no cure.

“It’s four big old horse pills that make me gag, I can never remember them and I read that it’s bad to take too many antibiotics. Why do I have to take them every time I come to the dentist?”

“Mrs. Gruntbuns, you’re right, it’s bad to take medicines you don’t need and it is four large pills. If it’s just the pills and remembering, we can get you a liquid (but it costs more and won’t last on the shelf) and we can call to remind you. If you need the medicine though, it might just be the difference between life and death, or at least between a relatively comfortable life and misery.

“Not as many people need or are prescribed an antibiotic before dental care today as when I started practice. Science has shown us some situations aren’t a risk while others remain. If you are likely to get an infection in your heart or on an artificial piece of equipment, then you should have an antibiotic before we do any procedure that may cause bleeding and let germs enter your blood stream.

“Remember, you have that artificial valve in your heart — that’s a place where bacteria can land and live, and since the artificial valve doesn’t have a blood supply, giving you antibiotics to kill the bugs that start living there is no easy matter. It won’t just be a couple of pills, but days in the hospital. I like you too much to risk you going to the hospital just because you had your teeth cleaned.”

Have a question you have a tough time answering? Send it to Dr. Paul at jpaul@bot.floridadental.org.

An Early Bite with Dr. John Paul: “How Safe Are Dental X-rays? Why do I Have to Get Them Every Year?”

By Dr. John Paul, FDA Editor

Lately, I’ve had a run of patients who are reluctant to have — or are flat-out refusing — dental radiographs. I’ve let a few patients go because I believe it is beneath the standard of care to routinely practice without the aid of radiographs; although, I think they should be prescribed for each case and use the ALARA principle (As Little As Reasonably Acceptable). I try to use the refusal as the introduction to a conversation with the patient.

“Dr. Paul, I don’t want any X-rays today.”

“Mrs. Gruntbuns, why don’t you want any X-rays today?”

“They cost too much and there’s too much radiation.”

“Mrs. Gruntbuns, radiographs are important enough to me to evaluate your health that I will take them for you today at no charge. Will that change your mind?”

“No, radiation makes people sick, it gives them cancer and I don’t want any radiation.”

“Mrs. Gruntbuns, dental radiographs (X-rays) are safe when used properly. With the X-rays I take during a checkup, you get about 1/600th of the amount of radiation1 you can expect to receive just from walking around — it’s even less because you walk around outdoors in Florida. Because you take good care of your teeth, do all the things we ask you to do at home and come in as often as we ask for professional maintenance, we have prescribed radiographs for you every two years. This is the bonus you get for keeping up your oral health. You are at low risk of decay or gum disease, and unless something changes, we won’t change by taking more radiographs.”

Most patients accept the radiographs when they find out I think they are important enough to take them for free. I only offer this to a patient one time. I have released several patients (less than 10) for refusing radiographs because I believe this patient is asking me to provide care with one hand tied behind my back and one eye closed. Some days I do miracle dentistry, but I don’t have time to do tricks. I hope this patient didn’t leave my office for yours.

Have a question you have a tough time answering? Send it to Dr. Paul at jpaul@bot.floridadental.org.
1The amount of radiation is based on an article in JADA, September 2011, Volume 142, Issue 9, Pg. 1101.  

An Early Bite with Dr. John Paul: “I’m Gonna Pierce My Tongue!”

By Dr. John Paul, FDA Editor

Having had more than my share of stitches and staples, I really can’t imagine electively poking holes in my person. You can imagine my dismay and confusion when someone comes in with a new piece of tongue jewelry or a glitter booger (that thing stuck through their nose, cheek, lip).

I’d love to get my two cents worth in before the assault takes place.

“Now, Ms. Gruntbuns, let me get this straight — you want to get your tongue pierced?

“Aren’t you the one who cringes while sitting in my chair and nearly faints when you get an injection? You do realize they are going to use a much bigger needle and you will not be numb? They will hold your tongue still with a big pair of pliers — remember your delicate gag reflex? — and then jam the needle right through. Then, they’ll put in the barbell, pat you on your head and send you home. Remember all those cavities we keep filling, and the bugs that cause them? They are gonna make a beeline for this new hole in your tongue and unless you are very lucky, you will have a swollen tongue from the injury and the infection that follows.

“If you are still set on adorning yourself with tongue jewelry, there is one more thing you must know. I have never seen a patient with tongue jewelry who doesn’t play with it. You flick it in and out against your teeth and bite on it, and eventually you break teeth, or fillings or crowns. There’s no warranty on restorations if you have tongue jewelry. There’s also no warranty if you have a glitter booger that wears out tooth surface or gum. Now would be a great time to let this fad pass you by.”

Have a question you have a tough time answering? Send it to Dr. Paul at jpaul@bot.floridadental.org.