The Curbsiders (00:00.266) All right, Paul, I'm gonna start off with a classic. So Paul, what is the best time to see the dentist? See, I overheard the answer to this, which is a shame. And you must know this. Yeah. It's gotta be 230. Now, Paul, that's an old standard, but I wanted to hit you with the newer one. So Paul, my dentist has hung a TV on his office ceiling so that his patients would watch shows online while he worked. You know what he's calling it? Give me a second.

The Curbsiders (00:32.302) trying to make like a Roku thing work. No, tell me. Netflix and drill. That's great. That would be hilarious in like 2015, but still fairly solid.

The Curbsiders (00:47.15) Curbsiders podcast is for entertainment, education, and information purposes only, and the topics discussed should not be used solely to diagnose, treat, cure, or prevent any diseases or conditions. For the more of the views and statements expressed on this podcast are solely those of those and should not be interpreted per se, official policy or position of any entity aside from possibly cash-like more hospital and affiliate outreach programs. If indeed there are any, in fact there are none. Pretty much we are responsible if you screw up. You should always do your own homework and let us know when more... Welcome back to the Curbsiders. I'm Dr. Matthew Franquatto here with America's primary care physician, Dr. Paul Nelson-Williams.

Hi, Paul. Hey, Matt. How are you? I'm good. We've been hanging out for like two hours already. This was a great episode. We had a fantastic guest, Dr. Lisa Simon, who was a dentist in a former life, now an internist. And so who better to talk to us about just, you know, we talk about dental pain, how to care for the mouth and gums. We talked about TMJ. I mean, so much on this, Paul. We talked about a lot of the medication.

stuff that comes up for us when we're sending patients to the dentist. So this is just such a high yield episode. But Paul, before we get to that, before I read the guest bio, can you please tell the audience what is it that we do on Curbsiders? I genuinely had a moment of panic and flop sweat that I wasn't going to get a chance to say it, but we are the Internal Medicine Podcast. We use expert interviews to bring you clinical profiles and practice changing knowledge. And as you mentioned, you're going to tell us about Dr. Lisa Simon, who was a tremendous guest and spoke.

clearly and coherently about a lot of topics that I was terrified of. Now I feel marginally better. So Matt, why don't you tell us more about her? Yes, so our guest, Dr. Lisa Simon, MD, DMD, is a physician, dentist, and health services researcher. She has been passionate about advancing oral health equity through clinical innovation and research since she decided to apply to medical school while working as a dentist in a federally qualified health center. She is a faculty member at Harvard Medical School.

and the Harvard School of Dental Medicine and Practices Primary Care at Brigham and Women's Hospital. And what a fantastic guest she is. I should remind the audience that this and most episodes are available for CME through VCU Health at curb And I also wanted to thank all of our patrons. If you haven't joined yet, you are really missing out. Patreon.com slash curbsiders. Paul, what are we doing on there?

The Curbsiders (03:12.79) We are running cases past each other. We're talking about things that we're excited about outside of medicine, but also things that we're excited about in medicine. We're just getting to know each other. We're just a bunch of friends hanging out, talking shop, which is good, because I don't have any friends. So up until the Patreon, it was just you. And now I have a broader community. So thank you for paying to be my friend. This really helps support the show. And there are bonus episodes on there.

that come out twice a month. By the time this airs, there's probably going to be about 20 bonus episodes. As we're recording this, we've recorded 17 or 18 so far, Paul. This is another place to get some really just shorter episodes recapping things where Paul and I try to go in a little more depth onto things we covered in the show. And also we answer some listener questions, talk about picks of the week. It's a lot of fun. So check it out patreon.com slash curbsiders.

Lisa, thank you so much for joining us. And we are very excited to talk to you about this topic. But first, the audience, they need to know what hobby or interest you have outside of medicine. Probably my biggest hobby is marathoning and training for marathons. I live in Boston, which is a really good city for it. This will be my fourth Boston marathon that I'm running this year. And I ran commute across town every day when I was in residency. Oh, boy. That is hardcore.

So this is like rain or shine, snow, sleet and hail. This is like my compulsion. And it's also a really excellent form of exercise because when the quickest way to get home is to continue running, you continue running. There you go. Do you enjoy this? I'm asking you someone, by the way, who's run marathons. I know Matt has too. We're all in academic medicine. I feel like this tracks entirely. Yes. I both hate it at times and also enjoy it and spend for sure the last like,

45 minutes of every marathon really questioning my entire personality and like what led me to make the decisions I made But then like immediately want to sign up for another one. So, yep. Yep I'm sure that's true of most like just this act of self-adulation and then you just do it all over again for no compelling reason and are you are you like an elite level runner at this point like if you ask like an actual like

The Curbsiders (05:29.606) more serious runner about this, the answer like always has to be no, unless you're very, very good. I would say I'm like a decent hobby jogger, which is that I am capable of qualifying for the Boston Marathon, which is the whole thing that it's like not worth knowing about or caring about. Um, but I am certainly not in the like super duper fast woman range, which I would consider like a sub three hour marathon. I am not there. Okay. Well still qualifying for Boston's no joke. I, that is, that is no joke. Yeah. I qualify every year.

at Boston, but always fail to achieve my goal and always bonk on Heartbreak Hill. So I've had like many unpleasant Boston marathon experiences where I see all of my friends and family at the end and I'm like dying by the time I get there. I've never had like a positive Boston marathon, but. Well, I hope. Four times the charm. I hope this is gonna be the year for you, this coming Patriots Day.

You know, Paul, I don't know if you're going to ask about favorite failure now. It sounds like we might have just heard that. But what do you want to ask before we get on to the end? Set me up for success, Matt. Just sort of quashing the question, but also bring it up at the same time. But yeah, Lisa, we always like to ask any particular piece of advice that you like to give your trainees or learners or people that you work with, or favorite advice that you've received as a learner? That's a really great and difficult question. My training path was not what I expected. I did not.

go to dental school anticipating that more than a decade later, I would be finishing internal medicine residency. So I think I try and bring a sense of equanimity about like how circuitous life can be and that things aren't linear and you can be a learner and a teacher all at once as much as possible. But that having been said, I am very happy not to be in training anymore. Yeah, it felt long just going through one degree program, let alone two and...

Congrats for having gone through all that. But we're lucky and the audience is lucky because now you have all this great knowledge that you can share on this topic and you can especially speak to us as internists trying to learn about it. I can spare all your listeners from having to go to dental school, which I don't recommend. Yeah, listening to like a one hour podcast seems a lot easier than going to dental school. The tuition is a lot lower also. Okay.

The Curbsiders (07:48.674) Can, by the way, can Paul and I text you all our primary care dental questions from now on just going forward? Frankly speaking, I live for this. This is my actual joy in life is to get both barely identifiable, back of mouth, weird iPhone photos and then also questions that are blatantly personal that people are texting me that are not about their patients. Absolutely. Yeah. All right. So fine. So you've answered both questions. Paul and I can ask you our own dental problems going forward. Just weird.

dark pink selfies of indeterminate structures. That just sounds great. It could be a lot worse than selfies other people get. Let's do a case, Paul. Would you read? Sure, I'd be happy to tell you about Bob, who is a 20 year old gentleman who smokes and is otherwise healthy. He comes to your urgent care clinic, complaining of one week of worsening pain in the back of his upper right jaw. You explain, and Bob probably knows this already, that you are not a dentist. So it is hard for us to offer our specific dental advice. We are talking offline that I think.

Most of us in primary care become lightly panicked with dental concerns, but we say that we're happy to take a look and see if we can help while we're sort of trying to get him situated with more perhaps appropriate care. On examination, we don't see any gum swelling. We don't see any facial swelling, he doesn't have any fever. Otherwise, we're just kind of poking around in there and seeing what there is to see. So why don't we start with that? Can you tell us maybe a better approach in terms of beginning an examination for someone coming in with possible dental pain than just kind of shining a light and poking with a tongue depressor? Yes, so the first thing I would do is just validate

Like for anyone who is listening to this and feels bad that they don't know about oral health, it is not your fault. It is not a part of the medical school curriculum. It's not a part of our internal medicine residency for a large part. And that is because we have a lot of other competing priorities. So it's okay, we will work through it together. The fact that you are willing to go ahead and look in the mouth is already making progress. If you feel confident about the things you're seeing, that's really excellent. And the way I would recommend looking at this is first, as this case kind of makes clear,

the medical components of the case. I think sometimes people hear it's a dental problem and kind of freeze and don't think about vital signs or how sick, not sick, the sort of classic stuff that we know to think about. So this guy we're meeting, his vital signs are stable, he's afebrile, he does not appear sick. There we go, that's great. Moving on from there, I think the thing to do is like any other physical problem-focused physical exam you're going to do is to do it in a methodical way, do it the same way every time, and that way you can be confident that you're not missing anything.

The Curbsiders (10:12.918) So in this particular case, you know, it's okay to kind of stretch the lips out. People's lips tend to be pretty stretchy. And so you can really get a decent visualization. If you're in an exam room that has the light that you might use for a pelvic exam, that can be very helpful to kind of hang over your shoulder. And then you can get a little bit better light. If you don't have that, like you're in a hospital room or you're just in a less well equipped clinic, you can use your iPhone light. I do that all the time. I'm sure lots of people do that for like the JVP also. So shine a light in there, see what you can see.

things to look for when it comes to identifying a problem tooth. Because the thing is you may see, you've got this upper right quadrant pain, there may be a bunch of teeth there, maybe several of them look grossly decayed or fractured. There are things you can do to narrow down which tooth is causing the problem. One thing to know is that the only sensation that teeth are going to transmit is pain. The way you're going to do this is by invoking pain. It's important to empower your patient by telling them that as a warning beforehand. Then you can do things like,

Palpating on the gingiva above the tooth, that would be looking for any sort of abscess that gives you a sense of which tooth is a problem. The other things to do would be tapping on the teeth. So the periodontal ligament that kind of holds the tooth in place. Any sort of stretching at all will cause it to be exquisitely sensitive. Like think about when you get like a raspberry seed in your teeth, it feels like a boulder. So people are very sensitive, that will give you a sense. And you can also test for mobility because that same inflammation will make the tooth a little wiggly.

The other thing to know is that if you aren't sure which tooth is causing the problem, the treatment from a medical perspective is probably going to be the same. So you can give yourself a little bit of grace there because ultimately this is someone who needs to see a dentist too. What about, I saw something about like looking for like, like a bubble around the tooth. I wasn't exactly sure what was meant by that. Can you expound on that a little bit?

Yeah, I feel like this is actually something that I hear more from patients, which is you might get a story from someone who has more chronic or subacute tooth pain, where they'll say like, oh, I had really bad tooth pain, and then a bubble showed up on my gum, or a zit popped on my gum, and then the pain felt better. And what that is actually a sinus tract that's fistulizing from the abscess inside the bone to the outside of the mouth. And that produces a huge amount of relief when it fistulizes, because it can give that drainage and relieve the pressure.

The Curbsiders (12:29.87) People might say like, oh, now I have a bad taste in my mouth or something because they're tasting the pus. But that is kind of what you might see as a bubble on the gum would be a fistula tract. Paul, I didn't think ahead of time how gross this episode was going to be. I hope no one is eating lunch right now. I was fully prepared for this to be a fairly gross episode, but that's OK. I did want to ask, so my role on the show was just to be the dumb one. So.

Can you just talk me through what your differential diagnosis would be here? I know this sounds like a dumb question, but I know there's cavities, and then gingivitis is a thing I've heard about, and then I don't know what else kind of goes on in the mouth. Someone comes in with sort of tooth pain. What sort of things should we be thinking about? Is there a long list, or are there big things that I'm missing there? Just sort of talk us through at least your initial approach and how you kind of triage stuff. Yeah, this is not a dumb question. And I'm going to put aside all of the more interesting pathologies that might be associated with medical conditions, or just might be like,

other stuff. Because the reality is that most dental problems, and certainly if you're getting a focal dental problem like this patient is describing, you know this is a tooth problem. And it's probably going to be either a gum problem, i.e. the attachment of the tooth to the bone inside the gums, or a tooth problem. And they end up manifesting pretty much the same way. So gingivitis just means inflammation of the gums themselves. The gums don't attach the tooth to the bone. They don't do anything except like...

look nice. It can certainly be uncomfortable if someone has gingivitis, but it's not going to make your teeth loose. It's not going to make your teeth fall out. Once you start getting infection that goes deeper, then you're talking about periodontitis, which is inflammation that actually results in bone loss around the tooth. Ultimately, people can have their tooth become very loose. The tooth can look longer, which is sort of where long the tooth comes from. And it can be more uncomfortable. People can have kind of abscesses related to the loss of bone.

But by far the most common thing, especially in a younger or healthier population like the patient we're seeing, is going to be tooth decay. So the outside layer of the tooth is enamel, which is stronger than bone. The inside layer of the tooth is dentin, which is also stronger than bone but not as strong as enamel. So once you get a bacteria turning your sugar in your mouth into acid and breaking through that enamel, it spreads more quickly in the dentin. And then the very inside of the tooth, which is the neurovascular bundle, which dentists...

The Curbsiders (14:51.586) for some anti-intellectual reason called the pulp. Once it enters the pulp, it spreads into the nerve. The nerve, as I mentioned before, can only feel pain. So that is the sort of primary symptom someone will experience. And it's also sort of this delicious feast for the bacteria. They proliferate and spread. It ascends up the tooth into the roots or down if it's in your mandible, and that causes the abscess and infection. And the only core takeaway I would note there is that if someone comes to you and they are having tooth pain.

And I don't mean the kind where like, if you drink coffee and it's very hot, you feel some pain or something like that. But if someone is like in pain when they wake up for some sustained period of time, that is a tooth that is going to need either a root canal or an extraction. Because that tells me that the infection is already in the neurovascular bundle of the tooth. A filling only replaces the enamel and dentin. So already we know we're too deep. I think that's a really helpful thing for internists to know because it helps you advise your patient.

And also because unfortunately for many, many Americans, the cost of having a more invasive procedure like a root canal is going to be prohibitive for them. And if they are going to be assisted in getting dental care, having that sense of what's in store is really helpful. Are extractions cheaper than root canals, I imagine, because you're not trying to preserve anything, you're just pulling the tooth? Yeah, they haven't really changed since the middle ages. We still use tools that...

legitimately look like pliers and like a straight edge screwdriver. Um, it's like 12 monkeys when Bruce will Bruce Wallace is pulling his teeth out. If you've Paul, do you remember that movie? No, I was more on the green day video geek stink breath. Um, none of this is okay. Apologies, Dr. Simon. I'm so sorry. Oh, you're doing great. That was perfect level. And also I, uh, it's amazing with these two references of passing by. I feel like I know every other.

negative dental reference, though my personal favorite is Steve Martin in Little Shop of Horrors. Oh, that's great. Yeah. Bruce Willis, you know, he's paranoid in 12 Monkeys and he I think it's actually happening, but he thinks that there's that, you know, they have something in his teeth. So he pulls, he pulls his teeth out. No anesthesia with pliers or something. We can just polish off this bingo card mentioned Marathon Man and the movie Bug. And I think we've sort of crossed most of the things off the list at this point.

The Curbsiders (17:16.99) All right, so that's a free recommendation for the audience to watch 12 Monkeys. And Paul, what was your video that you talked about? Watch Marathon Man, not a Green Day video. But yeah, let's go, let's move forward, shall we? Yeah. Going back to the question about tooth extraction, it is a lot cheaper than a root canal. Generally, a tooth extraction is going to be in the hundreds of dollars range, usually the low hundreds. And a root canal can be, is almost certainly upwards of a thousand dollars, often several thousands.

It's also important to note that in most states, an adult on Medicaid will have a tooth extraction covered. They won't have to pay any of it. And in most states, a root canal will not be covered. So even if people had the means, they might elect to have the tooth extracted anyway. So it sounds like the differentials, like taking out any sort of other systemic medical problem, it's either coming from the tooth or coming from the gum.

and inspection will help us with that. Anything else that you recommend we do as, you know, primary care, seeing somebody like this diagnostically, or just are we into trying to manage symptoms and get them to a dentist? I think the things diagnostically I would mention are things not to do. For someone who is well appearing with stable vital signs with a story like this, you do not need to get a CBC. It does not matter what their white count is.

And you do not need to get the kind of imaging that is generally accessible to you as an internist. It is very costly and unnecessary to get something like a CT face. You know, a dental x-ray will be much more narrow, much smaller, show the area in greater detail and will actually be visible to the dentist who presumably will treat the patient, which your CT face will not be because of how our medical records don't talk to each other. Yeah, I've definitely seen in the hospital, people seem to get

Imaging that's not more than just the dental x-rays like if they're hospitalized and they have a tooth problem It's the is the panorax is that a CT or is that just like a little bit of a fancier x-ray? Yeah, it's a fancy x-ray. If you can get a panorax, that's okay. Okay. All right Yeah, I mean the reality is that probably a dentist will still want their own dental x-rays But I think a panorax definitely falls within the appropriate range rather than a CT which I would consider inappropriate Yeah, so let's talk about what?

The Curbsiders (19:35.826) What can we do to treat Bob while he's having this and before he sees a dentist for either an extraction or a root canal? Yeah. So the first thing to do to help Bob is if you can to have some sense of what dental care might be accessible to him. Unfortunately, because of the way that works in our country, that involves knowing what kind of insurance Bob has. And if he has dental insurance, dental insurance, as many people may know personally, isn't actually insurance. The way health insurance ensures you from having to spend a lot of money, it's more like a discount plan.

So even if he does have dental insurance, he may not be able to afford a treatment if he needs it. But because adult Medicaid dental benefits vary on the state level, it's probably worth looking up in the state you practice what is covered and what isn't. I do find that to be pretty helpful when it comes to patient counseling, if only because it gives you a sense of what's possible for people or an advocacy platform if you think that should change. So.

When you say a patient should go to a dentist, realizing that is an unfortunately high bar to clear for a lot of Americans, whether because they can't afford it, because there aren't enough dentists in their community or dentists in their community who accept Medicaid or whatever else, that is a challenge. And it's one that often falls on an intern's shoulders. Assuming that's something that you have the support or resources to help with, the way I think about sort of the pain relief part of this tooth infection is really threefold. There's the immediate pain relief, there's the short-term pain relief, and then there's the long-term.

pain relief. So in the immediate pain relief section, I highly encourage people to think about using like a 2% lidocaine injection to provide some local anesthesia. This can be really empowering because patients leave feeling better, which is not, you know, an experience I think we often get in the primary care setting. I see a lot of doctors' bulk when I suggest this. But I will tell you that if you can stick a needle into someone's central

veins, you can stick a smaller needle into their gums. It is not hard. It is not a particularly difficult or risky procedure. There are videos on YouTube and often you might be able to find a dental friend who would be willing to train you. And what gauge needle are you using for this? Dentists often use a 27 or a 25 gauge, but generally anything is better than nothing. If you have, if there is a large abscess, don't inject into the abscess. That will

The Curbsiders (21:58.018) But otherwise, if you can aim sort of where you think that the roots of that tooth are, which is where the nerve is gonna enter the tooth, that is a good place to try. It gets a little more complicated based on like how thick the cortical bone is in different parts of the mouth and all these other things. But I think it is almost worth attempting if you are able to practice and develop some competence in this because it is a remarkable alliance builder. It will really help your patients and it will also make subsequent pain control more effective. Okay. And what about the short-term pain control?

So in terms of short-term pain control, I would recommend 800 milligrams of ibuprofen TID and then up to three grams of acetaminophen on a daily basis with the proviso that would be for a short-term pain control and not for a longer term. And then, you know, I assume that that's gonna buy people a little bit of improvement in their discomfort for say three to four days. I again will emphasize the importance, if you can do it, of...

providing some local anesthesia because that's going to break the pain cycle and improve the efficacy of your NSAID later on. And is it safe for just tell people the topical benzocaine gel that's available, just use as much as they want? Other than in boards questions where it can cause meta I think it's generally okay. If people are using like a whole kind of bottle of the stuff from the drugstore, that would probably alarm me. And

Anything else? I mean, I feel like back at least 10 years ago, if you went to the dentist with something like this, everyone was leaving with hydrocodone, acetaminophen, or oxycodone, acetaminophen. Is that ever appropriate? Or is that something that you that you would recommend if, like, if let's say they've already been taking acetaminophen ibuprofen? You know, I was doing this when I was a dental resident in 2014. I would give routinely give people five to 10 tabs of

Vicodin when they were leaving from a routine tooth extraction. And we know better now. We know that the science shows that we can get equivalent pain control with ibuprofen, mesenaminophen. And we also know that there are demonstrable risks, not just to the patient, but to their whole families with having those opioids in the house. So I would advise against it. But I would also note that you know your patients best. So if you have a patient who is perhaps already on chronic opioids, maybe you decide that for them,

The Curbsiders (24:20.106) with their baseline opioid need, it may be superior to give them a small amount in addition. Or if someone is really suffering, maybe everyone should use their clinical judgment, but I would generally say that as a rule, I would not reach to it first, and I would do everything I could to not prescribe it if I could. Okay. And then long-term, what's the ultimate solution? Is it just surgical, essentially? The one other piece I would mention is antibiotics.

And this is a tough one because I would encourage everyone listening to prescribed antibiotics. I usually tell my patients that will buy them about four to six weeks of lasting pain control. Thinking about a tooth infection like an infection anywhere else in the body, the dental treatment is your source control. So in the absence of source control, your pain will come back. You are not curing the infection, but you are shrinking it with the antibiotic. And I do find that is remarkably helpful for keeping people functional until they can get to a dentist.

If you look at any guidelines produced by a dental organization, this is against their recommendations. But I will note that is because these are recommendations for dentists. And so they are recommendations that apply to patients who are already seeing a dentist. So I would really view an antibiotic prescription for your patient as a form of harm reduction. You are treating their pain until they can get to the definitive treatment. And I would acknowledge that, unfortunately, for a lot of our patients, that may be never.

We know that only about half of patients that go to the emergency room for a tooth pain are going to see a dentist within six months because we just don't have a dental system that can accommodate the sort of need that we end up seeing in the medical setting instead. Wow, that is nuts. So antibiotic wise, clindamycin for everybody? What do you recommend? You could do worse, but you could also go simpler. Good old penicillin VK actually works.

I was informed by like a grand professor emeritus at my residency who is that some pharmacies are no longer stocking it because it's so old and no one actually uses it anymore. So like you can try. I don't love QID dosing, but it will work and treat the infection. The one I tend to use as amoxicillin. You don't need to go with augmentin. There is no resistance for these likely polymicrobial infections. So classic amoxicillin will do it.

The Curbsiders (26:39.154) And I should let you know, I was kind of kidding about the clindamycin because I was reading that it's just not recommended because of the reasons you're saying. Like amoxicillin or just plain penicillin will work. So it's often not worth like, unless they have an allergy or something, it's not worth giving clindamycin because of the risk of C. diff and just, you know, it's more collateral damage there when you're using that one. Absolutely true. What about doxycycline or other alternatives for...

for people who are penicillin allergic, do you have a favorite go-to there? Clitamycin is actually the recommended second line for penicillin allergic people, which I think sort of stands to your point, like really make sure they're penicillin allergic because we don't want to throw that around for C. diff risk. Doxycycline tends to be used more for periodontal infections, which are often spiroketal in nature, and I think it works particularly well there. There's all sorts of fancy stuff that gum dentists do who are called periodontists. They'll like inject it into the gums and stuff.

But for a routine dental infection, I would just stick to the simple things. I believe tetracyclines are a third line, but I would have to double check that. All right, so where are we at with this case, Paul? So we've sort of talked about, we're gonna try to induce pain in the teeth so we can try to localize which one it is, which usually I don't try to induce pain in my patients, but I guess this is a productive reason to do it. And then...

uh, we have to realize that dental insurance is not really going to cover the full cost. It's more of like a discount plan and that many patients, if they, if they have Medicaid, the coverage is going to vary by state. So some patients are just ultimately never going to get a root canal or a tooth extraction because a couple hundred or, you know, a thout over a thousand dollars for root canal is it might not be doable. And then if we can steal ourselves, Paul, we can do a 2% lidocaine injection.

uh, with a 25 to 27 gauge needle aim for the roots of the tooth. Don't inject into an abscess because that will not feel good for the patient. And then we can prescribe the acetaminophen, ibuprofen and antibiotics to try to buy them some time while hopefully they get into see a dentist for the definitive treatment and our antibiotics, penicillin VK, if we can find it, amoxicillin and clindamycin if they're a pen allergic and uh, Paul, let's go to the next part of the case here.

The Curbsiders (29:05.162) Sure. So let's say we've done all that for Bob, because we were very good primary care doctors. And let's say we didn't do all that. Let's say you should probably go see a dentist, Bob, and then we just sort of send him out into the world without kind of offering really any kind of assistance. Then Bob comes back to us about a week later. His face is now swollen red. He actually has trismus now, halitosis on examination. He looks dry to an examination. He's a little bit tachycardic. Maybe blood pressure a little bit lower than before. Just in general, looks uncomfortable. So it sounds now that Bob has...

progress to possibly facial cellulitis. So what do we do with that? How long should we be in sort of what's our triage process like at this point? I would say that this is where I get to be 100% an internist and 0% a dentist because if this sick person went to a dental office, they would tell him to go to an emergency department. That's good, right. Which maybe is what I would recommend too. But in general, again, I think this speaks to the fact that we cannot.

be blinded by the tooth thing. We need to actually be doctors and think about everything that's going on. This is a sick patient. It sounds like he, at the very least, needs IV fluids. And then thinking about him in terms of possible admission to the hospital, management for all his other issues. But let's go back to this mouth problem and what it could be. This could just be a routine cellulitis, possibly with a concern for bacteremia. I certainly wouldn't want blood cultures on this person if he's febrile. But there are some dental-specific issues that are true emergencies that I just want to highlight.

right now. So the first one, which I think is like a very boardsy question so people might be familiar with it, is Ludwig's angina, which is sort of this classic spread. It's usually from a mandibular molar because the roots are very close to these fascial planes that can cut off the airway. So the thing we are concerned about is that the infection spreads around the airway and can imminently cause airway compromise. So the trismus we're seeing here is very concerning. People with Ludwig's angina...

might be tripodding because they're trying to prop their airway open. They kind of have like a bullfroggy look because they're having a ton of swelling like right under their jaw. It's a pretty sort of striking clinical presentation and that is someone who needs a surgical airway right away. So this is not a dental issue anymore. It is an issue caused by a dental problem. The other emergency I would mention is cavernous sinus thrombosis, which is often from the root of a canine. They're the longest root, so they kind of get up close to where your cavernous sinus can extend.

The Curbsiders (31:16.266) That can actually just cause the infection to ascend sort of intracranially and cause thrombosis in the cavernous sinus, which can cause focal neurological deficits. Things you might see just looking at someone other than the neurodeficits would be something like flattening of their nasolabial fold. They might have a hard time opening their eye fully on that side. You're really seeing the ascending infection kind of come up their face. Terrifying, Paul. Yeah, it's one of those things where you're almost kind of reassured to see because like,

solidly not my problem at this point. Like this person needs emergency care. There's no question or debate about it. All right, so let's get on with the case, Paul. What happened to Bob here? All right, so Bob's journey, he's coming back to our office two weeks later. We appropriately sent him to the ER for concern for facial cellulitis. He looked sick. He was there, he was admitted to IV antibiotics. He was actually seen by an oral maxillofacial surgeon who extracted his lower back wisdom tooth and sent him on oral antibiotics.

He comes in, he's still having a fair amount of pain, and he says he's asking you to kind of take a look at the spot because he actually, it does hurt, and he's also sort of rinsing out blood clots that are there. So I guess we can talk about the access in a second, but before we get there, can you just tell sort of how should we advise Bob in terms of his post-operative care after this extraction, and then we can sort of talk about if this course is typical for him or not. Yeah, so I would have hoped...

though I guess it doesn't always happen, that the oral surgeon would be giving him the post-op instructions. But I think what this case is really getting at is the risk of what is colloquially called dry socket, which is when the blood clot that is covering the area where the tooth used to be falls out. And that leaves this very painful, sensitive, exposed bone.

And this is really helpful to counsel patients about because it has a pretty typical illness script, which is that someone will be feeling a little bit better and starting to heal, and maybe three or four days after they have the tooth extraction is when they experience this horrible pain, they feel a lot worse. So that sort of story makes me concerned about dry socket. It is not an infection, and it won't get better with antibiotics.

The Curbsiders (33:14.934) So often what's required is a topical treatment or like placing some iotaform gauze inside the tooth extraction site to kind of protect it while a new blood clot forms. I would not expect an internist to be able to do this, though more power to you if you can, I'm sure your patient would really appreciate it. So he's reconnected to care and he gets that taken care of. Is there any just like for someone that's had this happen, I think I do wanna get some just general

dental advice. So like, what would you tell Bob for just going forward, you know, just general things he should do to take care of his teeth? So Bob has tobacco use disorder for a myriad of reasons. I would love to counsel him about his tobacco use, but that also does improve people's oral health. From a medical perspective, thinking about if people are on a large number of medications that could be causing anticholinergic side effects, that's something that we can manage.

From a behavioral perspective, things we can counsel on would be sugar-sweetened beverages, which would certainly increase one's caries risk. Saliva is basic, so it remineralizes our teeth over time, but the frequency with which we eat things will actually prevent that and further acidify our mouth and increase our risk of caries. So if someone has a bottle of soda next to them all day long, they're gonna be constantly acidifying their mouth and increasing their caries risk. Often in someone who has sort of the signs of sugar-sweetened beverage decay,

the tooth decay on sort of part of their teeth that's closer to the gums. It's a pretty persistent pattern across all of their teeth. So that's something to know and identify. And then when it comes to diet, the typical Western diet is not good for us for a variety of reasons. But when it comes to carious risk, fermentable carbohydrates and sugar are sort of the two things to be most aware of. And if you are going to eat candy or if it happens to be Halloween, chocolate is better for you than gummy candies because the gummy candy will stick to your teeth.

though I'm being a huge hypocrite now because I eat a bunch of gummy candy downstairs before we record it. So do as I say, not as I do. Yeah, that is incredibly nice of you to share that and very honest. This is a safe space, no judgment here. I'm judging a little bit just because gummies are gross, not so much from that. They are delicious. They are wonderful. You are wrong. I wanted to ask about...

The Curbsiders (35:29.642) I know seltzer, club soda, the non-sugary kind are very popular now. So people are sipping on those all day instead of Mountain Dew and they think they're doing for their diabetes or pre-diabetes that's helping. But what about for the teeth? Is that acceptable or should you just drink plain water? It's true that the carbonation in water is carbonic acid. It is acidified relative to regular water.

But it's really the sugar in soda that is then fermented into acid that is like right on your tooth surface by these bacteria that is going to cause the problem. So generally speaking, I think it's totally fine. And I also drink a lot of seltzer. And it seems like in general, just like any kind of foods that like get caked in your teeth that are like carbohydrate rich are just bad for the teeth. Is that is that being too simplistic or no pretzels? Like, that's why. Because my I remember.

My wife was telling me, she's like, the dentist told her not to eat pretzels. I never thought of like pretzels as being like a food that would cause cavities, but I guess they are one of those foods that gets, just gets caked in there. And yeah, I don't know if I have like a vendetta specifically against pretzels, but certainly if you're, if you're going to snack, we're advised, you know, like something that is less carbohydrate rich, so you can have some cheese or something like that instead of a bunch of crackers. But, but I also think, you know, you can brush afterwards. You can try and.

eat meals instead of frequent snacks, there are other ways to mediate your risk. Okay. Paul, you're going to bear with me for one, maybe at least one more question in this area. Are there any foods that people just think are great for their teeth, but that they're just commonly eating or anything in general that people, it's just a total blind spot where people are doing something that's terrible for their teeth? Because I think most people know sugar cavities.

Not that I can think of. I will also admit that as a former public health dentist and someone who really does not believe that shame is a particularly good behavioral motivator, I'm not gonna tell people what to eat. They're gonna eat. We know this in medicine. This is not gonna change people's diets. Come as you are, do the best you can, we'll sort it out. If you're worried about what foods are more cryogenic for you, that probably means your teeth are in better shape. You're probably fine, that's exactly right. All right, last question.

The Curbsiders (37:44.106) So Paul and I both, we love coffee. Should we brush our teeth before or after coffee? And I don't really understand why this is a big deal. But again, this is something that kept popping up when I read about oral care, oral health, preparing for this. Whenever you will fit tooth brushing into your routine, that is fine. I can't imagine like drinking coffee immediately after brushing my teeth just because the mint flavor would not do it for me. Either is fine. You will get staining on your teeth.

and that is also okay. If you are gonna do something like over the counter whitening strips, those will make your teeth temporarily more porous. They are both effective, but if you do things like drink dark red wine or drink a lot of coffee while using them, they can paradoxically stain your teeth more. So that would be a time I would have stained from coffee. Otherwise I would not survive without coffee. So drink as much as you want.

Yeah, the brushing before and after coffee is funny to me because I drink coffee 10 hours out of the day. I would be brushing my teeth endlessly if there was, it doesn't even matter what the answer would be. So it's going to happen when it happens. I also get that question a lot with flossing versus brushing first. And again, the answer is, however it works for you, it is fine. No one is ever going to fund that RCT. There is no big floss to fund that RCT. So do whatever works well for you. Well, and let's finish off the trifecta while we're here then. And then mouthwash. So I've heard.

Don't use it because it washes the toothpaste off your teeth. So what is the party line on using mouthwash? And if we do, which one should we be using? I feel like mouthwash is the oral care component that I care the least about, personally. I don't think it, I mean, none of them really have a demonstrable effectiveness in sort of an empirical literature sense. But it's the one that I think is least important. Flossing and brushing are directly removing things from your teeth in a very mechanical way.

The Curbsiders (39:35.722) There are some very high fluoride mouth washes that your dentist may prescribe for you or for your kids if they have high carious risk. Other than that, consider it a self-care treat, but I wouldn't put it on my list of like desert island must haves. That's good, Paul. Thank you. See, you're in the spirit of it now. That's good. I like it. I care about my teeth and I also deeply enjoy mouthwash for some reason. So I just want to see if I'm justified doing so or if at least this is just all bonus apparently.

This is a very personal topic. We're all revealing things about ourselves. I mean, a friend was asking. Yeah. OK, Paul, let's hear about Alma, who I think might have a gum problem. Alma does. So Alma is a 38-year-old patient with a history of tobacco use. She also has Strogan syndrome. And she's presenting with a bothersome dry mouth and sensitive bleeding gums. She takes a combined oral contraceptive pill. She takes amitriptyline for longstanding sciatica. And she's taking.

the occasional antistimine for hay fever. We look in her mouth, we see gingivitis, we see gum recession, and we see a little bit of a brown coating on her tongue. With her chogrens in and of itself, she has risk for dry mouth. So I guess what other things should we think about for patients reporting dry mouth or xerostomia? What else should we be going after? So first I would just mention sort of what the clinical exam might show you for dry mouth. Patients like Om might report that they have to take a lot of sips of water or it feels like their tongue is stuck to the top of their mouth or they have to pause while they're speaking. And then if you examine the mouth,

the tongue might lose its papilla and actually look kind of shiny. It could literally be reflective when you shine your smartphone flashlight at it. You may find that the lips themselves are kind of stuck to the gums or there's some desquamation. Just everything will look kind of like dry and cakey in a pretty obvious way. I mentioned before this kind of tooth decay that happens on every tooth right by the gums, which people sometimes get from drinking a lot of sugar sweetened beverages, but that's also the exact area.

where people with dry mouth will have very severe tooth decay. And that's because they don't have that basic saliva to bathe their teeth and deacidify their mouths. So they're also at higher risk of tooth decay in addition to all the symptoms they have from their dry mouth. When it comes to other things that can cause dry mouth, obviously this is a patient with an autoimmune condition where like one of the main symptoms is dry mouth, but she also has a number of other risk factors. Smoking can contribute, especially to subjective experience of dry mouth.

The Curbsiders (41:55.906) She's on amitriptyline, which can have off-target anticholinergic effects that could cause this. And antihistamines, the same thing, depending on sort of how targeted they are. The other thing I would mention, especially in your older patients, is that polypharmacy is one of the biggest causes of serostomia. So you may not be able to find a single-offending medication.

But if this is something that's genuinely affecting your patient's quality of life, it's probably worth taking a step back and thinking if you want to do any deep prescribing, sort of in the holistic context of your patient's overall wellbeing. Is alcohol another one of the things that really like causes dry mouth? Or does that affect things? That's an interesting question. I haven't seen that myself, but to be honest, I'm not sure. We can of course try to adjust her meds, but.

Maybe she's willing to stop taking the antihistamines, but the amitriptyline really helps, so doesn't want to come off that. Let's talk about the dry mouth first. What else would you do for that? So the super easy stuff is lifestyle things like having a water bottle all times and taking frequent small sips of water. For people who are a little more symptomatic, biotin provides a range of products. So they have both kind of a gel that

provides an approximation of saliva or a rinse that does similarly, people can kind of develop their own opinions on what works. You can recommend that people suck on a candy, a sugar-free candy. Please advise them to use a sugar-free candy. They are already at high risk of tooth decay. That is no good. But a sugar-free candy can help kind of elicit more salivary flow and that can be helpful for some people. And then sort of at the most extreme end would be something like a cholinergic medication like piolo carpein.

which absolutely works but has a number of very undesirable off-target effects. And frankly, I have never seen someone stick with taking Pylocarpeen because it causes such severe sweating. It's really not something people tend to enjoy. But it is like the last possibility if people are really having bad dry mouth. Interesting. I don't know if you feel comfortable prescribing it, Paul. Have you? No, I have not yet pulled the trigger on Pylocarpeen, I'm afraid to say. Yeah, I'd probably...

The Curbsiders (44:03.678) I'd probably stop at the sugar-free candy and biotin gel and rinses, those sort of things. Are there competing brands or does biotin just have like, is that like the top? I'm very embarrassed that I think there might just be like a biotin monopoly or at the very least I don't know what else it would be called. Okay. So maybe it's one of these things like Kleenex where it has become the name like by market absorption or something. Understood. But that is usually what I would call it.

patients too. Okay. And now she has bleeding gums. So other than fixing the dry mouth, when people have, you know, inflamed gums, what else do you think about there? And what can we do for that? Or what can we advise that they do? Yeah. So Paul mentioned gingivitis earlier, and this sounds a lot like gingivitis. You really can't tell the difference between gingivitis and periodontitis without doing like a close up periodontal exam, which I would not expect.

or want any internist to do. But in the absence of tooth looseness or other symptoms, this seems very gingivitis-y. And that's often focal inflammation from the plaque or bacterial biofilm on the teeth causing irritation in the gums. So having improved dental hygiene can perfectly clear up a gingivitis. There is usually no need for a specialized treatment. And you can counsel patients on that. There are other individual risk factors.

Um, so higher levels of estrogen are actually associated with gingivitis. So you may see pregnant people or people going through puberty who are going to have higher rates of gingivitis, at least transiently. And this person was taking oral contraception. It does that also potentially have the same risk? We've talked about OCPs a lot recently, Paul, or just hormone therapy a lot recently, and it hasn't come up. I don't believe so. Okay.

All right. So it's so kind of this, the treatment for largely the treatment for gingivitis and periodontitis, which probably we as internists can't tell the difference of too much, uh, is just, just oral hygiene, fix the dry, fix the dry mouth, make sure they're brushing and flossing. And if they, if they prefer to use mouthwash, they can use mouthwash and, uh, tell them to stay away from the foods we talked about that, that are, are no good for the teeth. Is that.

The Curbsiders (46:20.838) Is that a fair summary? Anything else I'm missing with how to fix the gingivitis that someone's suffering from? I feel like I would probably be a bad dentist if I didn't mention an extremely rare but sort of more interesting version of gingivitis, which is sometimes called trench mouth or Vincent angina, not to be confused with Ludwig angina. But this is an acute bacterial infection that causes like...

very painful and kind of supertive gingivitis across the whole mouth, often in young men. It was called trench mouth, I think, because there was a lot of it in World War I. This often happens in the setting of very poor oral hygiene. People will have systemic symptoms, so fever, tachycardia, feeling kind of crummy. I have never seen this in person, even though I've cared for a lot of patients at very high risk of it. I do not know if you will, but it does exist, and if you do see it, you can feel gratified if you identified it. But it is not something I'd expect people to

It's got a really cool name, also sounds super gross, but thank you for mentioning that. Cool names and gross facts are my stock in trade. Can I ask, not related to the case necessarily, but while we're in gum land, I feel like there's certain medications we should at least be mindful of as internists that can have like gum side effects that I don't think about very often. Are there any sort of culprit meds that we should think about? Like gingival hyperplasia I feel like is a known side effect for...

some of the meds that we may see. I didn't mean to, I know this is not sort of part of this particular case, but are there any medications that you're prompt just to at least do a gum exam or be mindful of stuff that someone would have gum concerns? Yeah, I'm happy to mention sort of the most common ones. So the one that I've actually seen in clinical practice is nifedipine and some of the other calcium channel blockers. Antipyelactic drugs are the other more common cause. And they can be very real and very prominent.

depending on how important the medication is to your patient and may or may not be something you can manage. The treatment is usually to stop the medication, but you can also have the gums be occasionally excised by a dentist or oral surgeon if the patient needs to take the medication. And I actually had a patient who had terrible gingival hyperplasia on his nifedipine and then ultimately was able to tolerate taking only 2.5 milligrams of it, along with an ARB and that worked for him and his gums went back to normal.

The Curbsiders (48:39.842) So it does regress. It does. Okay. And is it typically painful or is it just sort of just enlarged? No, it's just enlarged. It looks pretty distinctive. It's kind of like bulbous because it's like this hypertrophic tissue. There is some association with oral hygiene, so you can sort of counsel people to really be pretty vigilant about tooth brushing, but it's kind of a surprising side effect. Okay. You know, someone I saw at CashLac, in let's say the not too distant past,

a person who was, it was a middle-aged, middle-aged woman. She was coming in, she was having some pain in her face, like just right in front of her ear. She wasn't really calling it jaw pain. She was sort of just saying, I have some pain here. And she just like kind of pointing there where her jaw meets her skull, saying that she's having some pain. She's really stressed at work and wondering if she has an ear infection. So she asked me to look in her ear.

and I looked in her ear, her ear looked fine, her sinuses looked fine, she wasn't having any like sinus symptoms. I was thinking it was TMJ is kind of what I was settling on, but I'm never really sure, like I don't think I ever really learned, had a lecture on TMJ before and I've looked it up a little bit myself, but what do you have a spiel on that and like how you approach it or how you diagnose it? I do, and I find it to be extraordinarily common. I think it's one of those things where if you start asking patients about it or like sort of doing a review of systems, which you should.

don't necessarily need to do, it will come up. But I like that, first of all, you exonerated every other possible pain. So you proved she didn't have dental pain, and sinus pain is the other common sort of great fraud that can show as tooth pain in the medical office. But when it comes to TMJ pain, the TMJ is a pretty cool joint. It has two compartments, and it can both sort of open and close like a hinge, but also slide forward and back because it has these two compartments, which is pretty neat.

But it also means it's rather complicated and has this kind of like finicky, poorly perfused cartilaginous disc in the middle. Though, to be honest, I think a lot of TMJ dysfunction is sort of more in the category of like amorphous aches and pains and that we don't really understand how individuals process their lived experience of pain and things are complicated and some of it is from muscles and some of it might not be and like who even knows and I definitely approach it in that way.

The Curbsiders (51:02.814) with a lot of validation with talking to patients about what they've experienced helps them. Often I'll hear patients say like, I'm afraid to eat a steak, like I have stopped eating hard foods. So that's gonna decrease the quality of their diet. But also it means like they're not even really like exercising any of those muscles or sort of developing a program to help. So things I will mention, the first is to consider getting a night guard. There is no real evidence that the...

$200 one from your dentist is better than the $20 one from the drugstore. And it certainly feels better to have discovered that you can't tolerate a night guard and will throw the $20 drugstore one across your room instead of the $200 one. So I always recommend people start there. That helps really by just kind of unseating your jaw a little bit and putting in a different resting position. So you're not clenching quite so hard. It doesn't do any other sort of magical thing.

Heat and cold therapy can be very helpful in the area where people are feeling the most sensitivity. And believe it or not, there are physical therapy exercises for your jaw. You can demonstrate how to do this. One thing you can advise patients to kind of measure how wide they can comfortably open their mouth. I know this is very silly. You will feel silly doing this. You'll be silly demonstrating to your patient, but they can actually measure using their hands. They might be able to comfortably open their mouth to two finger widths, like fit between their teeth.

And you can say, well, maybe your goal should be you're going to stretch your mouth a little bit three times a day for five minutes. And maybe in a few weeks, your goal will be to get to three finger widths. And you're giving them something to kind of do every day to manage their pain, to help stretch those muscles. And that can genuinely be helpful for people. Lisa, I do want to ask if you could go back to your physical examination when someone's reporting something that you suspect to be TMJ dysfunction. It's I've heard. In fact, I think Watto maybe even said he heard about sticking your fingers in the patient's ear and feeling for clunking and like poke around and.

look for malocclusion so I can write that in my note, even though I don't know what to do with that information anyway. But what does someone who actually knows what they're doing look at when they're examining a patient who might have TMJ dysfunction? I think all of that is great. I will say that the experience of sticking your finger in someone's ear is intimate and this whole other level that I think the patient and myself both find very uncomfortable. It's not that it's inappropriate. It is helpful to look for clicking. Any good sort of oral facial pain specialist would tell you to do it. I just find it a difficult component to make actionable in my own clinical practice.

The Curbsiders (53:20.994) And you can also palpate. They look like deep eye contact during it. Like that would just be. They wear a glove. I don't know. Do what feels right to you. But you can also palpate just anterior to the ear, and that's often a good place to palpate for a click. Clicks are one of those things similar to MRI findings of a spine, where if you listened to healthy people, you would also have a click in about 40% of cases.

But I document it too. It helps me feel better. One thing I think can be genuinely helpful is knowing which muscles are involved in opening and closing the TMJ. There's only four of them, and you can palpate those. So two of them, the pterygoids, are actually in the back of the mouth. So you do need to put on a glove and palpate near where the mandible hits. But the others are the masseter, which is the cheek, and then the temporalis, which connects right up here. So feeling for any sort of focal tenderness there can give you a sense of what a tarygoid is.

guidance or locations for heat or cold therapy might help your patient. All right. So, so we're going to put my patient on a soft diet, or at least temporarily. Do you tell people to avoid the foods that are causing, because you want them to be able to eat steak or whatever, you know, whatever they like to eat, you want them to be able to eat it. I think a lot of this ends up being patient directed. You know, the negative consequences of doing these things are that they cause pain and we don't want our patients to experience pain. But.

If something is tolerated by them, then it's fine. Okay. So the main treatment that you're recommending, night guard, and they can do heater cold therapy, and then we can give them the exercise where they try to progressively stretch out how wide they can open their mouth, you know, two fingers by next week, try to get the three fingers. It'll feel a little weird the first time I'm counseling somebody that, but I think it sounds very practical. Definitely something you could do in primary care to tell somebody to...

practice opening their mouth wider and wider to stretch the muscles. Any, anything we're missing there? I think that's a pretty good toolkit for primary care. There are more invasive treatments. Like people do get TMJ surgeries, but I would put them kind of in the category of similar arthroscopies elsewhere, where the clinical literature is maybe not fully definitive if that is helpful in and of itself. I would try and avoid that except for the most extreme cases. All right, so let's do some quick hits here.

The Curbsiders (55:39.714) For our patients who either are going to start a bisphosphonate or are already taking a bisphosphonate, how do we counsel them when there's any kind of dental stuff planned? So the concern with a bisphosphonate, of course, is for a bisp osteonecrosis of the jaw, which is a real and horrible thing. It is much more common in people who've gotten IV bisphosphonates, for example, in the setting of bone metastases. That group does have a tangibly higher risk.

For your average patient who has osteoporosis and is taking a PO bisphosphonate, the risk tends to be pretty low. It's always great to think about, is this someone who might need a tooth extraction in the future before we start them on the bisphosphonate? Can they get that treatment? But I do occasionally see people who would really benefit for years from bisphosphonate for their osteoporosis and aren't on it because they're waiting for dental clearance and the patient doesn't have access to a dentist. I don't think that is clinical equipoise. I think that is clinically harmful.

So if you think that this is a patient who does not have dental access for whatever reason, go ahead and start them on this hospital aid if that is a medication that they need to be taking for their fracture risk. When it comes to someone who's already on it, and I think many internists might hear back that patients report that a dentist told them to, for example, take a week-long drug holiday before a filling or something like that. First of all, the risk of osteonecrosis is only from very invasive procedures like a tooth extraction, filling or cleaning does not increase your risk.

But also bisphosphonates have a half-life of six years. So taking a drug holiday for a week is not going to do anything except provide a soothing placebo effect to the dentist. So I would just advise your patient to keep on keeping on, take their bisphosphonate as prescribed, get dental care as needed. Oral hygiene seems to prevent or reduce the risk of osteoenocorrosis of the jaw slightly, but it's not a guarantor. And it's still a very rare outcome.

Overall, so if the patient has a high fracture risk, you're trying to prevent fracture, which can be life-altering, certainly life-threatening if they break a hip. Well, that's very helpful. I don't know, Paul, any follow-up questions about that before we get on to our next quick hit? Nothing is fascinating, no. All right. Paul, you know exactly what to do when you send someone to the dentist for like, they're on aspirin, they're on a pixaban, one of those, right? You know what to do?

The Curbsiders (58:03.33) I go immediately to up to date and reassure myself. But yeah, so I think we've all gotten those forms from the dental office about giving the benediction to hold certain antiplatelet medications or anticoagulants before procedures. So I guess what is the party line in terms of what needs to be held for how long and for what procedures? And I know that's a big question, but just sort of broad strokes, I think even would be helpful for our listeners. It's actually not a big question because with very few exceptions, the answer is don't hold anything, keep taking it.

There absolutely is a higher bleeding risk performing a procedure on someone who is anticoagulated, but the clotting risk for that patient is much, much higher. And usually we can control localized bleeding risk with localized hemostasis. So that might be that if someone needs to have a bunch of teeth taken out and they are on a pixaban, maybe they should come back for every single tooth and we shouldn't extract 10 all at once. Or it could be that we're going to put sutures in to help with local hemostasis instead of not doing that.

Or just having someone bite on a bunch of gauze and don't let them out of the office until we've convinced ourselves that they actually have hemostasis from that pressure. We don't need them to stop medication that we know has tangible and measurable harms even from a short-term cessation. For people who are on warfarin, there is a recommendation to try and get an INR within 48 to 72 hours because if it happens to be very super therapeutic, that is a higher risk. Fewer and fewer patients happily are on warfarin these days.

And also depending on the health system or office in which you work, this may or may not be feasible and it may or may not be visible to the dentist. So whether this gets done for your patient and whether that impedes their ability to get care they need is probably a decision you need to make with your patient and with that patient's dentist. I think I also saw something about tranexamic acid rinses. That sounded kind of fancy. I don't know if dentists are routinely doing that. Biting down on gauze seems like it'd be pretty effective.

Yeah, I feel like I'm kind of revealing my public health practice setting because trans examic acid rinses are not something I've ever tangoed with. I do a lot of like, are you still buying the gauze? Looks good. Come back in five minutes. All right. You basically answered this aspirin, antiplatelets, those things, same thing. I mean, just because you can see the area where the bleeding is occurring, you can put pressure locally. That's why we're not as worried about the bleeding at these sites in general.

The Curbsiders (01:00:23.634) Yeah, I mean, you are much less likely to have a measurable drop in hemoglobin from a tooth extraction site, even while anticoagulated, than you are to, for example, have an instant rethrombosis or a clot from your AFib or whatever else. And also the consequences of those outcomes are far worse. OK. The other quick one we wanted to ask about is, patient has history of endocarditis. Who needs antibiotics?

prophylaxis. I know that's one of the ones we would commonly prescribe for if they've had endocarditis, but who else needs it? That's great. I feel like often what I see is a patient who quote has a murmur or maybe had a murmur in childhood and has been getting amoxicillin and dental prophylaxis for like 60 years and that is not necessary. This is one of the ones for those- This 12 year old bottle sitting in their cabinet that they've been using ever since they go to the dentist.

There are quite good guidelines that the ADA produces to recommend it only for a very narrow number of patients and that's patients with any sort of, I'm actually just going to read this off of their website because I think it's good to just have the specific details. It's any prosthetic cardiac valve, a prosthetic material in cardiac valve repair, a history of endocarditis, a cardiac transplant with valvular regurgitation, or an unrepaired cyanotic congenital heart disease.

So it's pretty bad, valvular things. If you have like a heart problem more generally, you are not someone who actually needs endocarditis prophylaxis. The other thing that I think is pretty interesting is that in 2014, I believe, the National Health Service in the UK basically changed the recommendations to say, no one gets endocarditis prophylaxis. Like we are done doing this. And they can do that sort of thing because you're in America, like we're all cowboys, we do whatever we want. What's interesting is,

They actually did have an increase in endocarditis risk. It was measurable. They did interrupt a time series and showed it, but relative to the overall risk of harm from the millions of people who were unnecessarily getting antibiotics before, it balanced out and they continued with the recommendation. Wow. Yeah, that is, I mean, I don't have too much of a problem with like the wet wear R stands right now because it's a small percentage of the overall population. I think other than the people that are the old holdouts that would have the...

The Curbsiders (01:02:42.538) You know, once someone's getting antibiotic, it's very hard to convince someone to stop that they don't need it anymore. Absolutely. It's like you're hoping they'll die or something. They will not be happy about it. Yeah, yeah. Which I guess leads to my follow-up question because I feel like I see that most of the patient who has a knee surgeon that for whatever reason they would trust with their life, and they're like, no, they told me I always have to get antibiotics before I get my teeth cleaned. And like they have been doing it for three decades now. So what are we doing in terms of joint replacements and antibiotic peripheral axis? Just remind me. There are no good guidelines.

In fact, I think there are consciously from either the American Orthopedic Surgery Association or the American Dental Association any guidelines, which is sort of a cowardly way of saying you probably shouldn't do it, but no one wants to tell you not to do it. I am similarly acquiescent when someone trusts their surgeon with their life, and I do not want a surgeon to yell at me because that happened enough to me in medical school. But if you are someone who can make that decision or perhaps convey the wonderful news that you don't need this medication to your patient.

that can be extraordinarily helpful. And it's certainly not something I would be proactive about prescribing. It almost certainly is not necessary and I would not recommend it. Thank you. That's very helpful. I think, Paul, I think we probably can end there. I mean, I know we're probably leaving some things on the table. Did you have anything you really had to ask? Okay, go ahead. I have to ask about my patients on medications for opioid use disorder and specifically methadone and something over for norepine. Cause that...

As a community, they are all very concerned about their oral health and often will say that it's gotten much worse since they started those medications. I'm just wondering, how can I counsel them? What does the evidence show? And sort of, is there any sort of interventions we can recommend for that particular group of patients? This is a really tough one. And it was not helped by the fact that a couple of years ago, the FDA actually released a warning stating that there was an increased risk of dental decay for patients taking Suboxone and Methadone. That having been said, I don't really buy that.

because certainly people who have serious opioid use disorder are at a way higher risk of dental decay, both because we know that people with serious substance use disorder are spending about 80% of their waking hours procuring or using their substance, which doesn't leave a lot of time for going to the dentist or taking care of your teeth, but also because the potency of those opioids is so much stronger than Suboxone or methadone. So the idea that it's these medications and the transition to

The Curbsiders (01:05:03.07) a life-saving medication that's causing the problem is a really frustrating one to me. That having been said, I would certainly validate patient's experiences. I personally feel like it's often that people enter recovery writ large, are really focused on a lot of things they haven't been able to because of their illness, one of which might be their teeth and how it makes them feel, how it reminds them of a substance use disorder or complicated feelings they might have about that, whether it impacts their employment, their relationship with others, their sense of self-esteem.

or even just pain that they weren't experiencing before. And all of those things happen concomitantly with initiating a very important lifesaving medication that they absolutely should be on for many, many reasons, whether or not it causes tooth decay. But I don't think it does. So in terms of counseling patients, getting them to the dentist is really important, both, you know,

because it's important for everyone, but especially for people who may have not had dental access for a long period of time before. And then the same recommendations as for everyone else with the proviso that you can acknowledge these folks are often at higher risk. You don't need to pin it on suboxone or methadone, but we can acknowledge that if that's their lived experience. And think about things like minimizing sugar sweetened beverage consumption, eating as healthy a diet as possible, brushing teeth twice a day, all that good stuff. That's great. It feels like it's analogous to the

60 year old patients that I'll get who are seeing a doctor for the first time in three decades. And like, I was fine until I started seeing the doctor. Like it's well, like now that you're actually focusing on your health, I think we're actually just kind of finding things that may have already been there to begin with, maybe a large part of that, but you're, but you're right. You also can't invalidate the lived experience too. That's my perspective. It is absolutely like that. And it is just as futile to try and convince someone that what they feel is not real. So I don't try, but it drives me crazy. Cause for every one person that.

decides not to take Suboxone or methadone because it might affect their teeth. That's another person who could die. Lisa, this has been a lot of fun hanging out. We are at the point where we have to let you go back to your family and ask you for some take-home points. So did you have one or two take-home points that you really wanted the audience to remember from this discussion? Sure, so the first thing I would love to emphasize is that dental insurance is an insurance. Dental access is a real crisis right now in our country.

The Curbsiders (01:07:16.166) And if you practice with a population that is on Medicaid, please know if your state has a Medicaid dental benefit or not. The second thing is to continue to be a doctor while examining the mouth, please think about the rest of your patients, too. And then to treat tooth pain, if you can learn how to do dental anesthesia, that's great. If you can avoid opioids, that's even better. And an antibiotic and ultimately a referral to the dentist are what's really necessary. All right. And did you want to give a plug to any

anything you're doing. I am not cool enough to have anything to plug. What's that website that you were involved with that has some of the free tutorials and things? I thought there was something that... Oh, yes. I would be happy to plug that. I'm sorry I forgot about it. My apologies to Smiles4Life.

I'm on the board of the only completely free CE accredited online oral health curriculum, Smiles for Life. It is targeted towards all levels of practitioners from MDs all the way on down to promotoras and community health workers. They are all available as either PowerPoints, you can be yourself, or videos and modules online. And they are a really great resource to echo many of the things I said, if they are helpful for you. All right.

This has been another episode of the Curbsiders, bringing you a little knowledge food for your brain hole. Yummy? It's a classic. Still hungry for more? Join our Patreon and get all of our episodes ad free, plus twice monthly bonus episodes at patreon.com slash curbsiders. You can find our show notes at thecurbsiders.com. And while you're there, set up our mailing list to get our weekly show notes in your inbox. This includes our Curbsiders Digest, which recaps the latest practice changing articles, guidelines, and news in internal medicine. And we're committed to high value practice changing knowledge and

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The Curbsiders (01:09:34.39) to the rest of our team, our Curbsiders team. Our production is done by the team at PodPace. Elizabeth Proto runs our social media. Chris the Chew Man Chew moderates our Discord. Jen Watto runs our Patreon. Stuart Brigham composed our theme music. And with all that, until next time, I've been Dr. Matthew Frank Watto. As always, our main Dr. Paul Nelson Williams. Thank you and goodbye.