- Email: [email protected]
SWALLOWED PROSTHESES
COMMENTARIES
presents a critical summary of Lodi and colleagues’1 Cochrane review assessing the use of antibiotics to prevent complications following tooth extractions—specifically, third molars. Unfortunately, the Cochrane review title used by its authors, “Antibiotics to Prevent Complications Following Tooth Extractions,” and their conclusion that they “did not support routine prescription of antibiotic prophylaxis for healthy people undergoing extraction of third molars” do not seem consistent with their findings. Simply stated, the fact that the authors found a significant reduction in the risk of both infection and alveolar osteitis, along with a significant reduction in pain experience postoperatively, seems very much worth the risk of “mild and transient antibiotic-related adverse events.” We all understand there is some risk of contributing to antibiotic resistance each time antibiotics are prescribed. Therefore, to minimize this risk, as well as risks such as minor or severe allergic reaction, nausea and/or vomiting, prophylactic perioperative antibiotics often are used to reduce antibiotic exposure. Numerous articles in the oral and maxillofacial surgery literature in the past decade have shown favorable outcomes for prophylactic perioperative antibiotic use for third-molar surgery, which often is limited to a single preoperative dose, sometimes a dose or two postoperatively or, less often, an empirical five- to seven-day postoperative course.2-5 Based on the findings of this Cochrane review, prophylactic antibiotic use for third-molar removal is successful by definition because it reduces risks of adverse surgical outcomes—infection, dry socket and pain—which are important to patients and surgeons. These goals are accomplished with minimal and temporary antibiotic side effects. I think I speak for most oral and maxillofacial surgeons in this country, as well as our patients, when I suggest that appropriate but minimal use of
916
JADA 145(9) http://jada.ada.org
prophylactic antibiotics for thirdmolar removal is beneficial. Andrew Hartwig, DDS, PhD Private Practice Oral & Maxillofacial Surgery Iowa City, Iowa 1. Lodi G, Figini L, Sardella A, Carrassi A, Del Fabbro M, Furness S. Antibiotics to prevent complications following tooth extractions. Cochrane Database Syst Rev 2012;11:CD003811. 2. Piecuch JF. What strategies are helpful in the operative management of third molars? J Oral Maxillofac Surg 2012;70(9)(suppl 1):25-32. 3. López-Cedrun JL, Pijoan JI, Fernández S, Santamaria J, Hernandez G. Efficacy of amoxicillin treatment in preventing postoperative complications in patients undergoing third molar surgery: a prospective, randomized, double-blind controlled study. J Oral Maxillofac Surg 2011;69(6):e5-e14. 4. Monaco G, Tavernese L, Agostini R, Marchetti C. Evaluation of antibiotic prophylaxis in reducing postoperative infection after mandibular third molar extraction in young patients. J Oral Maxillofac Surg 2009;67(7):1467-1472. 5. Ren YF, Malmstrom HS. Effectiveness of antibiotic prophylaxis in third molar surgery: a meta-analysis of randomized controlled clinical trials. J Oral Maxillofac Surg 2007;65(10): 1909-1921.
Author’s response: I thank Dr. Hartwig for his comments. On the relative scale reported by the risk ratio (RR) in the critical summary, I do not disagree with Dr. Hartwig regarding the reduction of infectious complications when prophylactic antibiotics are prescribed. An important note is that this significantly reduced effect was observed when the risk (incidence) for patients who had prophylactic antibiotics was compared with the risk (incidence) for patients who had no prophylactic antibiotics in regard to the investigated outcome, including infection and adverse effects. The next relevant question pertains to the risk (incidence) of those complications: is it low or is it high? And, if complications occur, are they challenging or simple to manage? As the RR measures effect in the relative scale, the number needed to treat (NNT) corresponds to the absolute scale. The Cochrane review indicated that, for every 12 patients (range 10-17) for whom prophylactic antibiotics were prescribed, infection was prevented in only one patient after third-molar extraction (that is, on average, 11 patients had no real prophylactic action).1 A previously
September 2014
published systematic review on the same topic reported even higher NNT—NNT = 25—which means, on average, 25 patients should be given prophylactic antibiotics to prevent one infection.2 Evidence-based dentistry (EBD) is focused primarily on providing available scientific evidence so that clinicians are able to make more informed decisions. The presented evidence from this critical summary should be incorporated with two other EBD dimensions: patient values and practitioner competencies. It should be emphasized that the extracted evidence in this critical summary is valid for the selected population of healthy young adult participants with mostly impacted third molars extracted by oral surgeons. In theory, patients with increased risk of infection, such as those with diabetes, might experience higher benefits with prophylactic antibiotics. My conclusion is exactly the same as Dr. Hartwig’s, and it is also consistent with that of the original systematic review, that “appropriate but minimal use of prophylactic antibiotics for third-molar removal is beneficial.” Abdullah Marghalani, BDS, MSD Faculty Member Preventive Dentistry Department Umm Al-Qura University Makkah, Saudi Arabia and Pediatric Resident School of Dentistry University of Maryland Baltimore 1. Lodi G, Figini L, Sardella A, Carrassi A, Del Fabbro M, Furness S. Antibiotics to prevent complications following tooth extractions. Cochrane Database Syst Rev 2012;11:CD003811. 2. Ren YF, Malmstrom HS. Effectiveness of antibiotic prophylaxis in third molar surgery: a meta-analysis of randomized controlled clinical trials. J Oral Maxillofac Surg 2007;65(10): 1909-1921.
SWALLOWED PROSTHESES
I am writing regarding Dr. Mazen Abusamaan and colleagues’ May JADA article, “Swallowed and Aspirated Dental Prostheses and Instruments in Clinical Dental Practice”
COMMENTARIES
(Abusamaan M, Giannobile WV, Jhawar P, Gunaratnam NT. JADA 2014;145[5]:459-463). The article presents a good review of the problems one might encounter with this issue and its diagnosis, but fails to note other modalities. I trained as an oral and maxillofacial surgeon before the advent of flexible scope technology and have had attending surgeons at our institution who also were trained before this technology was available. The technique taught to them was to document the location of the dental prostheses with radiographs and, if it was in the stomach, to feed the patient absorbent cotton with ice cream. The cotton’s purpose was to form a nondigestible ball in the gastrointestinal tract, and the ice cream’s purpose was to get the cotton in the patient. I have used this technique twice in my career, both with success. The first case, approximately 25 years ago, was for a general dentist prepping a tooth for a restoration when the turbine and bur as one unit came out of the high-speed handpiece and the adolescent patient swallowed it. It was confirmed that the object was in the stomach and the patient was given absorbent cotton and ice cream. That patient passed the object in three days, without incident. The second time I had to use this technique was with my father, who was having dental implants placed by a periodontist in another state when he swallowed an implant driver. My father was 87 years of age at the time and had esophageal strictures. I did not believe he would tolerate an endoscopic retrieval, due to his age and the strictures. I had him ingest absorbent cotton and ice cream, and he passed the driver about two weeks later. The swallowed objects can be small or large. Regarding larger objects, there are many cases of partial or full dentures lodged in the pharynx. Smaller objects are more difficult and must be evaluated on a case-by-case basis. The problem with smaller objects of a dental nature is
that many times they have already entered the small bowel by the time x-rays are taken and the patient arrives at an institution that can perform the endoscopic procedure. Hopefully, this technique will provide another modality to treat this issue. Kenneth G. Miller, DDS Clarks Summit, Pa.
ANOTHER SWALLOWED OBJECT
Dr. Mazen Abusamaan and colleagues’ May JADA article, “Swallowed and Aspirated Dental Prostheses and Instruments in Clinical Dental Practice: A Report of Five Cases and a Proposed Management Algorithm (Abusamaan M, Giannobile WV, Jhawar P, Gunaratnam NT. JADA 2014;145[5]:459-463), was important and of interest to me. I treated a patient who swallowed his bridge while eating and recovered it after six weeks; I wrote a case report about it.1 The reason for my report was to show that an ingested prosthesis lodged in the ileocecal valve area could be successfully passed after six weeks without earlier medical surgical intervention. Close monitoring, along with that of a physician and proper imaging, avoided the need for surgical intervention. Obviously, each case has to be evaluated as to risks and benefits of watching and waiting according to the situation. I believe an adult who swallows a bridge deserves monitoring time of more than one week, up to six weeks, as an option in the authors’ ingested object management algorithm. Robert H. Beaumont, DMD, MSD Adjunct Assistant Professor Developmental/Surgical SciencePeriodontics School of Dentistry University of Minnesota Minneapolis 1. Beaumont RH. Retrieval of a swallowed casting 6 weeks after ingestion: a case report. Oral Surg Oral Med Oral Pathol 1987;64(3): 287-288.
Authors’ response: We greatly appreciate the interest generated by our article underscoring the critical
JADA 145(9)
importance of the proper management of swallowed or aspirated dental instruments. We thank Drs. Beaumont and Miller for their thoughtful comments and are grateful for this opportunity to respond to their opinions. Dr. Beaumont shared his experience with spontaneous passage of a bridge six weeks after ingestion and Dr. Miller with using a cotton ball and ice cream to help bind ingested dental instruments. Both dentists advocated using conservative management rather than endoscopic intervention. We do not recommend using anecdotes to determine management algorithms. As proposed in our systematic management algorithm based on expertise in the treatment of the gastrointestinal tract, any sharp object is at very high risk of causing perforation with catastrophic consequences. All sharp objects (for example, dental drill bits, screwdrivers, etc.) require immediate removal. It is possible objects can pass spontaneously; however, a risk-benefit analysis would always favor early endoscopic removal of an object capable of serious complications in up to 35 percent of cases. Specifically, as mentioned in our article, objects greater than 2.5 centimeters in diameter and greater than 6 cm in length are unlikely to leave the stomach and therefore should be retrieved endoscopically. Aspirated objects always require emergent retrieval given compromise of breathing. Blunt instruments less than 2.5 cm in diameter and less than 6 cm in length can be observed conservatively with clinical and radiological assessment of passage. If the object is freely mobile, normal gastrointestinal motility will deliver the object into the colon within a week in most people. Once the object is in the colon, the risk of perforation is lower and likelihood of passage is high. When an object is localized to one segment of the bowel for a prolonged period (for example, more than one week), the risk of bowel ul-
http://jada.ada.org
September 2014
919
presents a critical summary of Lodi and colleagues’1 Cochrane review assessing the use of antibiotics to prevent complications following tooth extractions—specifically, third molars. Unfortunately, the Cochrane review title used by its authors, “Antibiotics to Prevent Complications Following Tooth Extractions,” and their conclusion that they “did not support routine prescription of antibiotic prophylaxis for healthy people undergoing extraction of third molars” do not seem consistent with their findings. Simply stated, the fact that the authors found a significant reduction in the risk of both infection and alveolar osteitis, along with a significant reduction in pain experience postoperatively, seems very much worth the risk of “mild and transient antibiotic-related adverse events.” We all understand there is some risk of contributing to antibiotic resistance each time antibiotics are prescribed. Therefore, to minimize this risk, as well as risks such as minor or severe allergic reaction, nausea and/or vomiting, prophylactic perioperative antibiotics often are used to reduce antibiotic exposure. Numerous articles in the oral and maxillofacial surgery literature in the past decade have shown favorable outcomes for prophylactic perioperative antibiotic use for third-molar surgery, which often is limited to a single preoperative dose, sometimes a dose or two postoperatively or, less often, an empirical five- to seven-day postoperative course.2-5 Based on the findings of this Cochrane review, prophylactic antibiotic use for third-molar removal is successful by definition because it reduces risks of adverse surgical outcomes—infection, dry socket and pain—which are important to patients and surgeons. These goals are accomplished with minimal and temporary antibiotic side effects. I think I speak for most oral and maxillofacial surgeons in this country, as well as our patients, when I suggest that appropriate but minimal use of
916
JADA 145(9) http://jada.ada.org
prophylactic antibiotics for thirdmolar removal is beneficial. Andrew Hartwig, DDS, PhD Private Practice Oral & Maxillofacial Surgery Iowa City, Iowa 1. Lodi G, Figini L, Sardella A, Carrassi A, Del Fabbro M, Furness S. Antibiotics to prevent complications following tooth extractions. Cochrane Database Syst Rev 2012;11:CD003811. 2. Piecuch JF. What strategies are helpful in the operative management of third molars? J Oral Maxillofac Surg 2012;70(9)(suppl 1):25-32. 3. López-Cedrun JL, Pijoan JI, Fernández S, Santamaria J, Hernandez G. Efficacy of amoxicillin treatment in preventing postoperative complications in patients undergoing third molar surgery: a prospective, randomized, double-blind controlled study. J Oral Maxillofac Surg 2011;69(6):e5-e14. 4. Monaco G, Tavernese L, Agostini R, Marchetti C. Evaluation of antibiotic prophylaxis in reducing postoperative infection after mandibular third molar extraction in young patients. J Oral Maxillofac Surg 2009;67(7):1467-1472. 5. Ren YF, Malmstrom HS. Effectiveness of antibiotic prophylaxis in third molar surgery: a meta-analysis of randomized controlled clinical trials. J Oral Maxillofac Surg 2007;65(10): 1909-1921.
Author’s response: I thank Dr. Hartwig for his comments. On the relative scale reported by the risk ratio (RR) in the critical summary, I do not disagree with Dr. Hartwig regarding the reduction of infectious complications when prophylactic antibiotics are prescribed. An important note is that this significantly reduced effect was observed when the risk (incidence) for patients who had prophylactic antibiotics was compared with the risk (incidence) for patients who had no prophylactic antibiotics in regard to the investigated outcome, including infection and adverse effects. The next relevant question pertains to the risk (incidence) of those complications: is it low or is it high? And, if complications occur, are they challenging or simple to manage? As the RR measures effect in the relative scale, the number needed to treat (NNT) corresponds to the absolute scale. The Cochrane review indicated that, for every 12 patients (range 10-17) for whom prophylactic antibiotics were prescribed, infection was prevented in only one patient after third-molar extraction (that is, on average, 11 patients had no real prophylactic action).1 A previously
September 2014
published systematic review on the same topic reported even higher NNT—NNT = 25—which means, on average, 25 patients should be given prophylactic antibiotics to prevent one infection.2 Evidence-based dentistry (EBD) is focused primarily on providing available scientific evidence so that clinicians are able to make more informed decisions. The presented evidence from this critical summary should be incorporated with two other EBD dimensions: patient values and practitioner competencies. It should be emphasized that the extracted evidence in this critical summary is valid for the selected population of healthy young adult participants with mostly impacted third molars extracted by oral surgeons. In theory, patients with increased risk of infection, such as those with diabetes, might experience higher benefits with prophylactic antibiotics. My conclusion is exactly the same as Dr. Hartwig’s, and it is also consistent with that of the original systematic review, that “appropriate but minimal use of prophylactic antibiotics for third-molar removal is beneficial.” Abdullah Marghalani, BDS, MSD Faculty Member Preventive Dentistry Department Umm Al-Qura University Makkah, Saudi Arabia and Pediatric Resident School of Dentistry University of Maryland Baltimore 1. Lodi G, Figini L, Sardella A, Carrassi A, Del Fabbro M, Furness S. Antibiotics to prevent complications following tooth extractions. Cochrane Database Syst Rev 2012;11:CD003811. 2. Ren YF, Malmstrom HS. Effectiveness of antibiotic prophylaxis in third molar surgery: a meta-analysis of randomized controlled clinical trials. J Oral Maxillofac Surg 2007;65(10): 1909-1921.
SWALLOWED PROSTHESES
I am writing regarding Dr. Mazen Abusamaan and colleagues’ May JADA article, “Swallowed and Aspirated Dental Prostheses and Instruments in Clinical Dental Practice”
COMMENTARIES
(Abusamaan M, Giannobile WV, Jhawar P, Gunaratnam NT. JADA 2014;145[5]:459-463). The article presents a good review of the problems one might encounter with this issue and its diagnosis, but fails to note other modalities. I trained as an oral and maxillofacial surgeon before the advent of flexible scope technology and have had attending surgeons at our institution who also were trained before this technology was available. The technique taught to them was to document the location of the dental prostheses with radiographs and, if it was in the stomach, to feed the patient absorbent cotton with ice cream. The cotton’s purpose was to form a nondigestible ball in the gastrointestinal tract, and the ice cream’s purpose was to get the cotton in the patient. I have used this technique twice in my career, both with success. The first case, approximately 25 years ago, was for a general dentist prepping a tooth for a restoration when the turbine and bur as one unit came out of the high-speed handpiece and the adolescent patient swallowed it. It was confirmed that the object was in the stomach and the patient was given absorbent cotton and ice cream. That patient passed the object in three days, without incident. The second time I had to use this technique was with my father, who was having dental implants placed by a periodontist in another state when he swallowed an implant driver. My father was 87 years of age at the time and had esophageal strictures. I did not believe he would tolerate an endoscopic retrieval, due to his age and the strictures. I had him ingest absorbent cotton and ice cream, and he passed the driver about two weeks later. The swallowed objects can be small or large. Regarding larger objects, there are many cases of partial or full dentures lodged in the pharynx. Smaller objects are more difficult and must be evaluated on a case-by-case basis. The problem with smaller objects of a dental nature is
that many times they have already entered the small bowel by the time x-rays are taken and the patient arrives at an institution that can perform the endoscopic procedure. Hopefully, this technique will provide another modality to treat this issue. Kenneth G. Miller, DDS Clarks Summit, Pa.
ANOTHER SWALLOWED OBJECT
Dr. Mazen Abusamaan and colleagues’ May JADA article, “Swallowed and Aspirated Dental Prostheses and Instruments in Clinical Dental Practice: A Report of Five Cases and a Proposed Management Algorithm (Abusamaan M, Giannobile WV, Jhawar P, Gunaratnam NT. JADA 2014;145[5]:459-463), was important and of interest to me. I treated a patient who swallowed his bridge while eating and recovered it after six weeks; I wrote a case report about it.1 The reason for my report was to show that an ingested prosthesis lodged in the ileocecal valve area could be successfully passed after six weeks without earlier medical surgical intervention. Close monitoring, along with that of a physician and proper imaging, avoided the need for surgical intervention. Obviously, each case has to be evaluated as to risks and benefits of watching and waiting according to the situation. I believe an adult who swallows a bridge deserves monitoring time of more than one week, up to six weeks, as an option in the authors’ ingested object management algorithm. Robert H. Beaumont, DMD, MSD Adjunct Assistant Professor Developmental/Surgical SciencePeriodontics School of Dentistry University of Minnesota Minneapolis 1. Beaumont RH. Retrieval of a swallowed casting 6 weeks after ingestion: a case report. Oral Surg Oral Med Oral Pathol 1987;64(3): 287-288.
Authors’ response: We greatly appreciate the interest generated by our article underscoring the critical
JADA 145(9)
importance of the proper management of swallowed or aspirated dental instruments. We thank Drs. Beaumont and Miller for their thoughtful comments and are grateful for this opportunity to respond to their opinions. Dr. Beaumont shared his experience with spontaneous passage of a bridge six weeks after ingestion and Dr. Miller with using a cotton ball and ice cream to help bind ingested dental instruments. Both dentists advocated using conservative management rather than endoscopic intervention. We do not recommend using anecdotes to determine management algorithms. As proposed in our systematic management algorithm based on expertise in the treatment of the gastrointestinal tract, any sharp object is at very high risk of causing perforation with catastrophic consequences. All sharp objects (for example, dental drill bits, screwdrivers, etc.) require immediate removal. It is possible objects can pass spontaneously; however, a risk-benefit analysis would always favor early endoscopic removal of an object capable of serious complications in up to 35 percent of cases. Specifically, as mentioned in our article, objects greater than 2.5 centimeters in diameter and greater than 6 cm in length are unlikely to leave the stomach and therefore should be retrieved endoscopically. Aspirated objects always require emergent retrieval given compromise of breathing. Blunt instruments less than 2.5 cm in diameter and less than 6 cm in length can be observed conservatively with clinical and radiological assessment of passage. If the object is freely mobile, normal gastrointestinal motility will deliver the object into the colon within a week in most people. Once the object is in the colon, the risk of perforation is lower and likelihood of passage is high. When an object is localized to one segment of the bowel for a prolonged period (for example, more than one week), the risk of bowel ul-
http://jada.ada.org
September 2014
919