Download Management of the Oral Infection: Part 1

Earn
3 CE credits
Management of the
Oral Infection: Part 1
A Peer-Reviewed Publication
Written by Ian Shuman, DDS, MAGD, AFAAID
Abstract
This two-part course will review the management
of the acute oral infection. Part one focuses on the
essentials that must be considered when treating
the dental infection including microbiology, triage,
anatomy, and laboratory testing. It includes the
surgical, antibiotic, and palliative actions needed in
the treatment of the acute dental abscess. Part two
will emphasize the treatment of oral infections due to
fungal, viral, and bacterial organisms.
Educational Objectives
At the conclusion of this educational
activity participants will be able to:
1.Describe the features of oral
microbiology as they relate to oral
infection.
2.Identify the clinical issues related to
dental infection.
3.Describe the various strategies for
treating the acute dental abscess.
© Stiggdriver | Dreamstime.com
This course was
written for dentists,
dental hygienists,
and assistants.
Author Profile
Ian Shuman DDS, MAGD, AFAAID maintains a full-time general,
reconstructive, and aesthetic dental practice in Pasadena, Maryland.
Since 1995 Dr. Shuman has lectured and published on advanced,
minimally invasive techniques. He has taught these procedures to
thousands of dentists and developed many of the methods. Dr. Shuman
has published numerous articles on topics including adhesive resin dentistry, minimally invasive restorative, cosmetic and implant dentistry.
He is a Master of the Academy of General Dentistry, an Associate Fellow
of the American Academy of Implant Dentistry, a Fellow of the Pierre
Fauchard Academy. Dr. Shuman was named one of the Top Clinicians in
Continuing Education since 2005, by Dentistry Today.
Author Disclosure
Dr. Shuman has no commercial ties with the sponsors or the providers
of the unrestricted educational grant for this course.
INSTANT EXAM CODE 15152
Go Green, Go Online to take your course
Publication date: Feb. 2017
Expiration date: Jan. 2020
Supplement to PennWell Publications
PennWell designates this activity for 3 continuing educational credits.
Dental Board of California: Provider 4527, course registration number CA# 03-4527-15152
“This course meets the Dental Board of California’s requirements for 3 units of continuing education.”
The PennWell Corporation is designated as an Approved PACE Program Provider by the
Academy of General Dentistry. The formal continuing dental education programs of this
program provider are accepted by the AGD for Fellowship, Mastership and membership
maintenance credit. Approval does not imply acceptance by a state or provincial board of
dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to
(10/31/2019) Provider ID# 320452.
This educational activity was developed by PennWell’s Dental Group with no commercial support.
This course was written for dentists, dental hygienists and assistants, from novice to skilled.
Educational Methods: This course is a self-instructional journal and web activity.
Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services
discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had
any input into the development of course content.
Requirements for Successful Completion: To obtain 3 CE credits for this educational activity you must pay the required
fee, review the material, complete the course evaluation and obtain a score of at least 70%.
CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with products
or services discussed in this educational activity. Heather can be reached at [email protected]
Educational Disclaimer: Completing a single continuing education course does not provide enough information to result
in the participant being an expert in the field related to the course topic. It is a combination of many educational courses
and clinical experience that allows the participant to develop skills and expertise.
Image Authenticity Statement: The images in this educational activity have not been altered.
Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and represents
the most current information available from evidence based dentistry.
Known Benefits and Limitations of the Data: The information presented in this educational activity is derived from the
data and information contained in reference section. The research data is extensive and provides direct benefit to the patient
and improvements in oral health.
Registration: The cost of this CE course is $59.00 for 3 CE credits.
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by
contacting PennWell in writing.
Abstract
L®
This two-part course will review the management of the acute
oral infection. Part one focuses on the essentials that must be
considered when treating the dental infection including microbiology, triage, anatomy, and laboratory testing. It includes the
surgical, antibiotic, and palliative actions needed in the treatment of the acute dental abscess. Part two will emphasize the
treatment of oral infections due to fungal, viral, and bacterial
organisms.
within each biofilm substrate. Biofilm is a combination of
bacteria, extracellular DNA, protein, and polysaccharides that
rapidly accumulate intraorally. If left undisturbed for several
days, a biofilm may contain up to 1011 microorganisms/mL.7 In
relation to this fact, oral hard tissue disease in the form of apical
periodontal infection and marginal periodontitis has been associated with 200 to 500 bacterial species.8,9,10
Bacterial interaction within a biofilm may either boost or
suppress metabolic activity that leads to dental infection. Many
factors regulate the number and types of oral bacteria within
biofilm including the complexity of the flora, bacterial retention and interaction, native resistance, saliva, hygiene, and diet.
For example, a carbohydrate-rich diet favors bacteria such as
Streptococcus mutans, an organism that causes dental caries.
Diet consistency is also important because coarser foods can
help to eliminate lodged food particles and disrupt the biofilm
that can support microorganisms. In addition, oral bacteria have
regional preferences vis-à-vis tissue adherence; Streptococcus
salivarius is found primarily on the tongue while S. mutans and
Streptococcus sanguis typically adhere to hard surfaces.11
The presence of systemic disease also influences the oral
microbial population. Host defense mechanisms can be compromised by conditions such as diabetes, heart failure, chronic
lung disease, lymphoproliferative disorders, renal failure,
malnutrition and alcoholism, among others. This compromise
of the immune function can lead to a reduction in phagocytic
activity, pulmonary clearance and circulation, among others.
Immunosuppressant medications that are cytotoxic also reduce
host defense mechanisms and increase the risk of infection.
Prolonged systemic antibiotic therapy reduces normal bacterial flora, resulting in the selection of resistant flora and/or
the emergence of competing fungal organisms. Other factors
associated with oral infection include age, behavioral considerations, drug abuse, the social environment, and the patient’s
psychological status.
A further consideration is the concept of virulence.
Virulence is a harmful quality possessed by microorganisms
that can cause disease. It involves the invasive nature of the
organism and the detrimental toxins and/or metabolic and
enzymatic byproducts produced in the course of the infectious
process. Infection involves the interactions of microbial populations, microbial virulence, and host defenses. Intraorally, host
defenses are part of the mucosal immune system, an important
factor in the prevention of oral and systemic infection. This system includes advantageous elements to protect the host against
invading pathogens that include the resistance to tear and compression forces provided by the lamina propria.12 Colonization
is minimized by cell shedding from the surface layer and by
salivary secretion. Beside mechanical protection,chemical protection is present in the form of an elaborate immune system.
One example is the production of lymphoid cells producing
immunoglobulins. In addition, serum proteins such as histamine, prostaglandins and lymphokines are released as a result
17
At the conclusion of this educational activity participants will
be able to:
1. Describe the features of oral microbiology as they relate to
oral infection.
2. Identify the clinical issues related to dental infection.
3. Describe the various strategies for treating the acute dental
abscess.
20
Educational Objectives
Introduction
EN
NW
EL
The frequency of periapical abscess is supported by a volume
of statistical proof. The results of a nine-year retrospective
study (2000–2008) of hospital admissions showed that more
than 61,000 hospitalizations in the United States were directly
related to dental infection in the form of periapical abscess.1
Sixty-six patient deaths were attributed to these infections.2
Using the Nationwide Inpatient Sample of the Healthcare Cost
and Utilization Project, a 2007 study conducted by Allareddy
et al,3 it was found that there were 7,886 hospitalizations for
periapical abscess in the United States, amounting to total hospital costs of $105.8 million.
The Global Burden of Disease Study in 2010 showed that
cleft lip/palate, edentulism, oral cancer, caries, and periodontal
disease accounted for over 18 million disability-adjusted life
years.4 Evaluation of the global burden of oral diseases such
as caries, periodontal disease, and cancer showed a marked
increase of 45.6% from 1990 to 2010, on par with major noncommunicable diseases such as diabetes.3 Dentists are usually the first to see patients with early odontogenic infections.
Therefore, it is vital that they be prepared to evaluate and treat
problems before they become severe enough to demand hospitalization.5
©P
The complexities of oral infection
Enormous numbers of pathogenic bacteria, nonpathogenic
bacteria, and fungal organisms naturally colonize the oral mucous membranes. Numerous transient and potentially infective
organisms (e.g., viruses) can be present as well. Opportunistic
microorganisms such as Escherichia coli, Streptococcus pneumoniae, Staphylococcus aureus, and Klebsiella pneumoniae can
cause systemic versus oral disease.6
With respect to oral hard tissue, multiple bacterial interactions exist within the diverse dental microenvironments and
2www.DentalAcademyOfCE.com
of inflammation. There are also cellular defenses dependent
on receptors, phagocytes, and lymphocytes (e.g., B and T
cells).13,14,15
20
EL
Anatomic considerations
L®
The majority of acute oral infections are self-limiting and can
be managed with minimal intervention. However, some types
of oral infection can be associated with significant morbidity
and mortality. The treating clinician must recognize the significance of the history and clinical signs. This information
is vital in the diagnosis of the disease process and providing
appropriate triage for the patient. For example, consider a patient who presents with pallor, reporting a rapidly increasing
swelling under the jaw into the neck or superiorly into the eye
(suggesting spread beyond the oral cavity). This coupled with
other local and systemic symptoms such as difficulty breathing or swallowing, fever (with chills or cold sweats), a thready
pulse with lethargy and/or altered consciousness, trismus, a
changing pain quality (i.e., change of pain from a mild ache
to a severe throb), and dehydration should be considered for
urgent oral surgical or medical referral as these clinical signs
and symptoms indicate systemic toxicity.
17
Triage
are tender, enlarged, indurated, or fixed suggest the presence of
infection. Infection and swelling of the pterygomandibular, parapharyngeal (lateral pharyngeal and retropharyngeal), peritonsillar and cervical spaces, and the infratemporal or parotid space is
considered high risk and necessitates urgent intervention.
Another potentially life threatening ailment is cellulitis.
Cellulitis is a spreading bacterial infection just below the
skin surface (i.e., the fascial planes) most commonly caused
by Streptococcus pyogenes or S. aureus.16 Ludwig’s angina, a
cellulitis-causing condition, arises from the oral cavity. This
infection most commonly originates from an infected second
or third mandibular molar tooth invading the submandibular
space. This space consists of two compartments in the floor of
the mouth, the sublingual space and the submylohyoid (figure 1). It is an aggressive, rapidly spreading cellulitis without
lymphadenopathy and with the potential for airway obstruction. It requires careful monitoring and rapid intervention for
prevention of asphyxia and aspiration pneumonia. Clinical
signs include upward and backward displacement of the tongue
and bilateral submandibular swelling extending inferiorly into
the anterior neck to the clavicles and dysphagia.
Another example of an anatomic area of great importance in
life-threatening infection is the infratemporal space (figure 2).
Infection of the maxillary molars can invade the infratemporal
space with a possible risk of spread to the orbit and ascension
to the cavernous sinus via the venous plexus in the ovale and
spinosum foramen.17
A basic understanding of head and neck anatomy including the
location of lymph nodes and fascial spaces is useful in determining the relative risk associated with infection. Lymph nodes that
NW
Figure 1: Ludwig’s Angina
©P
EN
Sublingual
gland
Tongue
Geniohyoid
muscle
Supramylohyoid
portion of
submandibular
space
Submaxillary
space
Mylohyoid muscle
Mylohyoid muscle
Inframylohyoid portion
of submandibular space
www.DentalAcademyOfCE.com
Digastric muscle (anterior belly)
Submandibular
space
Sublingual space
Submandibular
gland
Superficial fascial layer
3
Managing the dental abscess
Temporalis muscle
Superficial temporal space
Temporal
fascia
Deep temporal space
Sphenoid bone
Infratemporal
space
Zygomatic
arch
• Infra temporal space
• Lies posterior to maxilla
• Bottom portion of the
deep temporal space
• Source of infectionMaxillary third molars
Masseteric
space
20
Lateral
pterygoid
muscle
Hamular process
L®
Medial
pterygoid
muscle
Masseler
muscle
Incision and drainage
Pterygomandibular
space
Drainage of odontogenic purulence can be accomplished
through pulpal access, surgical incision, or tooth extraction.
Surgical incision requires that the tissue is incised and spread
with a hemostat followed by placement of a Penrose drain.23 A
Penrose drain is a surgical device, typically a strip of latex or
soft rubber tubing, placed inside a wound to drain fluid (figure
3). The drain is sutured into place with a patent opening, allowing fluids to drain from the infection site. In addition, the
infected site can be decontaminated by irrigation with a saline
solution (typically 60–100 ml) or chlorhexidine mixed with saline if necessary. The patient should be advised to: avoid touching the area after surgery, apply firm direct pressure for 30–60
minutes, use a moistened tea bag to control bleeding, avoid
the application of ice, and not apply heat until three days have
passed to avoid spread of the infection. The drain is removed as
soon as drainage output is minimal or has ceased.
EL
Mandible
Laboratory considerations
The dental abscess develops as a result of bacterial invasion of
the pulp and ultimately, the alveolar bone. Therefore, the prevention of caries is still the best first line of defense against the
development of the dental abscess. The other effective preventive measure against dental caries and dentoalveolar abscess is
proper dental hygiene. This includes brushing teeth after meals
and regular dental check-ups. ADA Dental Practice Parameters suggest that the dentist should utilize treatments designed
to “reduce pulpal symptoms and/or protect the pulpal tissue
of the tooth with pulpitis.”22 The document recommends that
management of the dental abscess should be considered as follows: nonsurgical approaches (e.g., antibiotics), chemotherapeutic modalities, dental restorations, endodontic therapy,
tooth extraction and surgery.16 However, with any acute infection, prior to the initiation of an antibiotic, purulence must be
eliminated via surgical drainage.
17
Figure 2: Temporal Spaces
©P
EN
NW
Minor oral infections can be well managed empirically without
culture if attention is paid to three important considerations:
infection origin, involved anatomy and bacterium most likely
involved. Most oral infections are odontogenic, superficial in
nature, and in the majority of patients caused by Streptococcus
bacteria. Infection by anaerobic bacteria such as Staphylococcus, Neisseria, and others can also occur, though with much
less frequency.18,19
Infections that do not respond to routine antibiotic therapy
require identification of the culprit microorganism(s) by way
of laboratory evaluation. This provides the greatest precision
in selecting appropriate antibiotic coverage. As a rule, a culture
must be taken if (1) the infection has spread to one or more fascial
planes of the head and neck, (2) initial antibiotic treatment has
failed to contain the infection, (3) the patient’s underlying health
is compromised by other conditions that affect immune response,
and (4) the patient shows evidence of systemic toxicity.20
Of the various in-office examination techniques that should
be considered in assessing infectious microorganisms, the Gram
stain may be the most useful procedure as it provides immediate results and allows determination of the type and numbers of
species involved.21 Techniques for assessing infected (purulent)
oral material include pulp chamber access of an infected tooth
with collection of the emerging pus, transmucosal aspiration,
and tissue biopsy. Unless the treating clinician is competent
with these in-office techniques, it is best to refer to a specialist
for collection, further lab evaluation, and subsequent dental or
medical treatment.
Figure 3:
A.
C.
B.
D.
4www.DentalAcademyOfCE.com
Antibiotics
In most instances, antibiotics should only be prescribed for
the dental abscess when the infection has spread beyond the
radicular area, causing local involvement and/or systemic symptoms.24 Once the infection spreads beyond the radicular area, the
involved bacteria typically include a combination of anaerobic
and aerobic organisms. This change in bacterial composition is a
complication that can significantly alter the relative virulence of
the infection and complicate antibiotic selection. An important
consideration when using antibiotics is microbial resistance.25
The best approach for curtailing resistance is to prescribe a high
dose of antibiotic for as short a course as possible.
The choice of antibiotic is largely empirical because the
science supporting the efficacy of one antibiotic or treatment
regimen over another is presently not definitive. This is due to
the confusion posed by a number of methodological problems
associated with the published research. These include issues
related to study design and choice of outcome measures.26 In
general, penicillin is often the first drug of choice for dental
infections. An article by Olsen and Winkelhoff describes acute
oral infections that can spread extraorally, recommending penicillin (when suspicion of methicillin-resistant S. aureus is low).27
Historically, antibiotic use has included the use of the
penicillins, including penicillin V (table 1).28,29 Amoxicillin is
favored as the drug of first choice due to its broad spectrum
of action against many gram positive and negative bacteria.30
If there is a history of antimicrobial resistance, metronidazole31 (although the drug itself has also been associated with
increased resistance32) or amoxicillin combined with clavulanic acid should be considered.33 For individuals allergic to the
penicillin-based antibiotics, clindamycin can be prescribed.34
Clindamycin is effective against both aerobic and anaerobic
bacteria and penetrates bone readily.
Table 1: Empiric Antibiotics of Choice for Odontogenic Infections 38
Type of Infection
Antibiotic of Choice
Early (first 3 days of infection) Penicillin VK, amoxicillin
Clindamycin
Cephalexin (or other first-generation
cephalosporin) 1
No improvement in 24-36
Beta-lactamase-stable antibiotic:
hours
Clindamycin or amoxicillin/clavulanic acid (Augmentin®)
Penicillin allergy
Clindamycin
Cephalexin (if penicillin allergy is
not anaphylactiod type)
Clarithromycin (Biaxin®) 2
Late (>3 days)
Clindamycin
Penicillin VK-metronidazole,
amoxicillin-metronidazole
Penicillin allergy
Clindamycin
For better patient compliance, second-generation cephalosporins (cefctor: cefuroxime) at twice
daily dosing has been used.
A. macrolide useful in patients allergic to penicillin, given as twice daily dosing for better patient
compliance.
Adapted from Drug Information handbook for Dentistry; Richard Wynn, Timothy Meiller,
Harold Crossley, 12th Edition
1
2
www.DentalAcademyOfCE.com
Azithromycin, a structural derivate of erythromycin, has also
been recommended as an option for the treatment of mild to moderate bacterial infection.35 It has a broader spectrum of activity,
increased bioavailability, and fewer gastrointestinal (GI) effects.
For the patient with identified cephalosporin- or penicillin-resistant Gram-negative bacteria, cefoxitin has also been shown to be
effective.36 The reader should refer to this and other guidelines for
the latest information and proper dosing for the adult patient.
Antibiotics may also need to be prescribed to children with
infection, although the dosage will be lower, as it based on body
weight. Several rules exist to compute the dosage of a drug for
a child, the most common being Clark’s Rule and Young’s Rule
(tables 2 and 3) and empiric antibiotic options are available (table
4). The American Academy of Pediatric Dentistry has published
prescription guidelines for children needing antibiotic coverage.37
The reader should refer to this and other guidelines for the latest
information and proper dosing for the pediatric patient.
Table 2: Clark’s Rule for Pediatric Dosing 39
Child’s Weight lb. (or kg) X Adult Dose = Child’s Dose
150 lb. (or 70 kg)
Table 3: Young’s Rule for Pediatric Dosing 39
Adult Dose X (Age ÷ (Age+12)) = Child's Dose
Table 4. Empiric Antibiotics of Choice for Odontogenic Infections 38
Antibiotic
Dosage
Children
Adults
Penicillin VK
≤ 12 years: 25-50 mg/
> 12 years: 500 mg
kg body weight in
q6h for at least 7
equally divided doses
days
q6-8h for at least 7 days;
maximum dose: 3g/day
Clindamycin
08-25mg/kg in 3-4
150-450 mg/ g6h
equally divided doses for at least 7 days;
maximum dose: 1.8
g/day
Cephalexin (Keflex) 25-50 mg/kg/day in
250-1000 mg q6h;
divided doses q6h
maximum dose 4g/
day
Severe infection:
50-100 mg/kg/day
in divided doses q6h;
maximum dose 3 g/24h
Amoxicillin
< 40 kg: 20-40 mg/kg/ > 40kg: 250-500 mg
day in divided doses q8h q8h or 875 mg q12h
for at least 7 days:
> 40 kg: 250-500 mg
q8h or 875 mg q12h for maximum dose: 2
g/day
at least 7 days; maximum dose 2 g/day
Amoxicillin/
< 40 kg: 20-40 mg/kg/ > 40kg: 250-500 mg
clavulanic acid
day in divided doses q8h q8h or 875 mg q12h
(Augmentin®)
for at least 7 days;
> 40kg: 250-500 mg
q8h or 875 mg q12h for maximum dose: 2
g/day
at least 7 days: maximum dose: 2 g/day
5
Management of the dental infection can also be treated
based on time of involvement. Emergent infections can be
treated with penicillin V, amoxicillin, clindamycin, or a firstgeneration cephalosporin.40 If there is no improvement within
the first 24 to 36 hours, clindamycin or amoxicillin/clavulanic
acid combination (Augmentin) may then be considered. Another consideration is to begin antibiotic therapy with a loading
oral dose two times the standard maintenance dose so that a
therapeutic blood level is achieved faster than what would be
expected with an initial maintenance dose.41, 42
Despite the effectiveness of the penicillin-based antibiotics,
they should be used with caution in patients with compromised
renal function or in individuals with a history of seizures or
significant GI hypersensitivity to antibiotics.43 Mild adverse
GI reactions (e.g., nausea, diarrhea) are not uncommon with
the penicillin antibiotics. True penicillin allergy is rare with the
estimated frequency of anaphylaxis in one to five per 10,000
cases of penicillin therapy.44 Hypersensitivity is the more common and most important adverse reaction resulting in nausea,
vomiting, pruritus, urticaria, wheezing, laryngeal edema and
ultimately, cardiovascular collapse. In these patients, clindamycin is recommended; however it can cause nausea, vomiting,
diarrhea, and abdominal pain, and has been associated with the
development of pseudomembranous colitis.45 Consequently,
it is contraindicated in these patients as well as patients with
a history of regional enteritis or ulcerative colitis. In addition,
clindamycin should be used cautiously in the patient with liver
disease.46
A highly controversial concern is the interaction between
oral contraceptives and antibiotics. For years, the medical
community has been advised that this interaction can lead to
breakthrough pregnancy. With the exception of rifampin-like
drugs used primarily to treat tuberculosis, there is a lack of
scientific evidence supporting the ability of commonly prescribed antibiotics, including all those routinely employed in
outpatient dentistry, to either reduce blood levels and/or the
effectiveness of oral contraceptives.47 To date, all clinical trials
studying the effects of concomitant antibiotic therapy (with
the exception of rifampin and rifabutin) have failed to demonstrate an interaction. A 10-year retrospective study by Toh et
al. found no association found between concomitant antibiotic
use and the risk of breakthrough pregnancy among oral contraceptive users.48 Therefore, dentists are now being advised
that there is no need to warn women taking the combined oral
contraceptive pill of the routine need to use additional contraceptive measures while taking courses of broad spectrum
antibiotics.49
Prolonged use of any antibiotic may produce an oral yeast
infection.50 Listed precautions, contraindications, potential
risks (e.g., in pregnant patients) and known drug interactions
(e.g., nonsteroidal anti-inflammatory drugs [NSAIDs] reduce
the bioavailability of some but not all antibiotics) should be reviewed prior to prescribing. It should also be fully appreciated
that improper prescription of antibiotic continues to be a prime
contributor to the development of antibiotic resistance.51
Palliative care
The management of acute dental infection should also incorporate palliative measures. No special precautions need be
considered for hydration or nutrition unless retropharyngeal
swelling prevents intake, in which case the patient should be
immediately hospitalized. A soft diet is recommended during
recovery from incision and drainage or tooth extraction. Pain
management should include over-the-counter pain medication
as well as cases requiring prescriptions that include NSAIDs
and opioid analgesics.
Analgesics for acute pain
Acute pain arising from oral infections may present from mild
to severe. Analgesics used in the management of mild to moderate acute pain include acetaminophen, aspirin, and NSAIDs.52
Cox-2 inhibitors are also effective, however, they must be used
with caution due to recently identified cardiovascular adverse
reactions.53 Moderate pain can be controlled by opioids or
tramadol and these are often combined with acetaminophen or
NSAIDs.54
A recent systematic review indicates that a 50% or greater
reduction in severe pain following oral surgery can be achieved
with 400 mg of ibuprofen, 50 mg of diclofenac, 120 mg of etoricoxib, 60 mg of codeine with 1000 of mg acetaminophen, 400
mg of celecoxib (Celebrex), and 500 or 550 mg of naproxen.55,56
Pain relief greater than eight hours can be achieved with 120
mg of etoricoxib, 500mg of diflunisal, 10 mg of oxycodone plus
650 mg of acetaminophen, 500 or 550mg of naproxen, and 400
mg of celecoxib. The study authors note that adverse events
were more likely to be associated with the aspirin and opioids.
Patients sometimes misuse over-the-counter pain medications,57 and prescription medications, when taken in combination
with over-the-counter medications, can lead to toxicity. In 2014,
the FDA published a drug safety caution regarding the prescription of opioids containing acetaminophen due to the potential for
acetaminophen-related hepatotoxicity.58 The maximum amount
of acetaminophen (in combination with opioids) is 325 mg when
taken every four to six hours. Support for this alert comes in part
from a study of unintentional acetaminophen overdose. In data
collected by querying the French Pharmacovigilance database
over a nine-month period, 13 patients were identified as having
mild unspecific clinical symptoms and 4 of 10 had abnormal
liver enzyme activity. The median dose of acetaminophen was
137mg/kg per 24 hours.59
Opioids also have potential for misuse. It is estimated that
dentists prescribe approximately 12% of all opioids dispensed in
the United States.60 The potential for misuse and toxicity of all
pain relievers can be reduced by limiting the amount prescribed,
performing a preassessment for potential drug interactions, and
careful prescribing in patients with coexisting medical problems
6www.DentalAcademyOfCE.com
(e.g. liver abnormality, kidney disease, stomach ulcers, alcoholism, anticoagulant therapy, hemorrhagic disorders, allergy, depression) and pregnancy. Effective opioid management includes
patient education, monitoring for substance abuse, and appropriate referral if abuse is suspected. For the pregnant or nursing
female patient with abscess, a physician consult is recommended
before prescribing drugs for pain management.61
According to Dental Management of the Medically Compromised Patient, aspirin and ibuprofen should be avoided throughout pregnancy; however, acetaminophen can be prescribed any
time during pregnancy.56 For this and other prescribing recommendations, the reader must contact the patient’s obstetrician
for treatment and prescribing approval.
Conclusion
Dentists face an important responsibility when treating the oral
infection. An understanding of oral microbiology, laboratory
assessment tools, and head and neck anatomy is necessary. The
importance of triage based on patient presentation and treatment strategies are critical. In addition, the appropriate prescription of medication is of paramount importance in avoiding
potential morbidity and mortality.
Bibliography
1. Shah A, Leong K, Lee MK, Allareddy V. Outcomes of hospitalizations
attributed to periapical abscess from 2000-2008: a longitudinal trend
analysis. J Endod. 2013;39(9):1104-1110.
2. Allareddy V, Lin CY, Shah A, et al. Outcomes in patients hospitalized for
periapical abscess in the United States: an analysis involving the use of a
nationwide inpatient sample. J Am Dent Assoc. 2010;141(9):1107-1116.
3. Jin LJ, Lamster IB, Greenspan JS, Pitts NB, Scully C, Warnakulasuriya
S. Global burden of oral diseases: emerging concepts, management and
interplay with systemic health. Oral Dis. 2015. doi: 10.1111/odi.12428.
4. Petersen PE, Ogawa H. The global burden of periodontal disease: towards
integration with chronic disease prevention and control. Periodontol 2000.
2012;60(1):15-39
5. Palmer NA, Pealing R, Ireland RS, Martin MV. A study of therapeutic
antibiotic prescribing in National Health Service general dental practice in
England. Br Dent J. 2000;188(10):554-558.
6. Ogawa T, Ikebe K, Enoki K, Murai S, Maeda Y.Investigation of oral
opportunistic pathogens in independent living elderly Japanese.
Gerodontology. 2012 Jun;29(2): e229-33
7. Donlan RM, Costerton JW. Biofilms: Survival Mechanisms of Clinically
Relevant Microorganisms. Clin Microbiol Rev. 2002 Apr; 15(2): 167–
193.
8. Moore W. The bacteria of periodontal disease. Periodontol. 2000 5:66-77.
9. Cross B, Faustoferri RC, Quivey RG Jr. What are We Learning and
What Can We Learn from the Human Oral Microbiome Project? Curr
Oral Health Rep. 2016 Mar;3(1):56-63.
10. Hovav AH. Dendritic cells of the oral mucosa. Mucosal Immunol.
2014;7(1):27–37.
11. Marcotte H, Lavoie MC. Oral Microbial Ecology and the Role of Salivary
Immunoglobulin A. Microbiol Mol Biol Rev. 1998 Mar; 62(1): 71–109.
12. Georgiev VS. Mucosal Immune System. In: National Institute of Allergy
and Infectious Diseases, NIH, Volume 2: Impact on Global Health. New
York, New York: Humana Press; 2009: 675-682.
13. van Unen V, Li N, Molendijk I, et al. Mass Cytometry of the Human
Mucosal Immune System Identifies Tissue- and Disease-Associated
Immune Subsets. Immunity. 2016;44(5):1227-1239.
14. Dwivedy A, Aich P. Importance of innate mucosal immunity and the
promises it holds. Int J Gen Med. 2011; 4:299–311.
15. Cellulitis. The Free Dictionary website. http://medical-dictionary.
www.DentalAcademyOfCE.com
thefreedictionary.com/cellulitis. Accessed May 25, 2016.
16. Mesgarzadeh AH, Ghavimi MA, Gok G, Zarghami A. Infratemporal
space infection following maxillary third molar extraction in an
uncontrolled diabetic patient. J Dent Res Dent Clin Dent Prospects.
2012;6(3):113-115.
17. Baron EJ, Miller JM, Weinstein MP, et al. A guide to utilization of
the microbiology laboratory for diagnosis of infectious diseases: 2013
recommendations by the Infectious Diseases Society of America (ISDA)
and the American Society for Microbiology (ASM)(a). Clin Infect Dis.
2013;57(4):e22–e121.
18. Bahl R, et al. Odontogenic infections: Microbiology and management.
Contemp Clin Dent. 2014 Jul-Sep; 5(3): 307–311.
19. Flynn TR, Shanti RM, Hayes C. Severe odontogenic infections, part 2:
Prospective outcomes study. J Oral Maxillofac Surg. 2006; 64:1104–13.
20. Brook I. Diagnosis and Management of Anaerobic infections of the Head
and Neck. Ann Otol Rhin Layngol 101:9-16, 1992.
21. Pulpitis. The American Dental Association website. http://www.ada.
org/en/science-research/dental-practice-parameters/pulpitis. Accessed
May 29, 2016
22. Ayad W, Jöhren P, Dieckmann J. Results of a comparative prospective
randomized study of surgical removal of mandibular wisdom teeth with
and without rubber drainage. Fortschr Kiefer Gesichtschir. 1995; 40:1346.
23. Dar-Odeh NS, Abu-Hammad OA, Al-Omiri MK, Khraisat AS, Shehabi
AA. Antibiotic prescribing practices by dentists: a review. Ther Clin Risk
Manag. 2010; 6:301-306.
24. Robertson D, Smith AJ. The microbiology of the acute dental abscess. J
Med Microbiol. 2009;58(Pt 2):155-162.
25. Hohl T, Whitacre R, Hooley J, Williams B. A Self-Instructional
Guide: Diagnosis and Treatment of Odontogenic Infections. Seattle,
Washington: Stoma Press; 1983
26. Olsen I, van Winkelhoff AJ. Acute focal infections of dental origin.
Periodontol 2000. 2014;65(1):178-89.
27. Yagiela JA, Dowd FJ, Neidle EA. Pharmacology and Therapeutics for
Dentistry. 5th ed. St. Louis, Missouri: Mosby; 2004.
28. American Academy of Pediatric Dentistry reference manual 2014-2015.
Pediatr Dent. 2014-2015;36 (6 Suppl):284-286.
29. Lewis MA, McGowan DA, MacFarlane TW. Short-course high-dosage
amoxycillin in the treatment of acute dentoalveolar abscess. Br Dent J.
19869;161(8):299–302.
30. Kuriyama T, Absi EG, Williams DW, Lewis MA. An outcome audit
of the treatment of acute dentoalveolar infection: impact of penicillin
resistance. Br Dent J. 2005;198(12):759-763.
31. Roche Y, Yoshimori RN. In-vitro activity of spiramycin and
metronidazole alone or in combination against clinical isolates from
odontogenic abscesses. J Antimicrob Chemother. 1997;40(3):353–357.
32. Lewis MA, Carmichael F, MacFarlane TW, Milligan SG. A randomised
trial of co-amoxiclav (Augmentin) versus penicillin V in the treatment of
acute dentoalveolar abscess. Br Dent J. 1993;175(5):169–174.
33. Gilmore WC, Jacobus NV, Gorbach SL, Doku HC, Tally FP. A
prospective double-blind evaluation of penicillin versus clindamycin
in the treatment of odontogenic infections. J Oral Maxillofac Surg.
1988;46(12):1065–1070.
34. Kuriyama T, Karasawa T, Nakagawa K, Saiki Y, Yamamoto E, Nakamura
S. Bacteriologic features and antimicrobial susceptibility in isolates from
orofacial odontogenic infections. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2000;90(5):600–8.
35. Murdoch DA. Gram-Positive Anaerobic Cocci. Clin Microbiol Rev.
1998;11(1):81–120.
36. American Academy of Pediatric Dentistry Council on Clinical Affairs.
Guideline on Use of Antibiotic Therapy for Pediatric Dental Patients.
http://www.aapd.org/media/policies_guidelines/g_antibiotictherapy.
pdf/. Published 2001. Accessed July 31, 2016.
37. Commonly Prescribed Medications in Pediatric Dentistry. DentalCare.
com. http://www.dentalcare.com/media/en-US/education/ce336/
ce336.pdf. Revised January 8, 2016. Accessed May 30, 2016
38. http://www.dentalcare.com/media/en-US/education/ce336/ce336.pdf
Accessed May 30, 2016
39. Clarks rule and Youngs rule. Pharmacy Tech Study website. http://www.
7
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
pharmacy-tech-study.com/dosecalculation.html. Accessed May 29,
2016.
Gilbert DN, Mollering RC, Eliopouos GM, Sande MA. The Sanford
Guide to Antimicrobial Therapy 2006. 36th ed. Sperryville, Virginia:
Antimicrobial Therapy; 2006: 33.
Antibiotics and the Treatment of Endodontic Infections. American
Association of Endodontics. https://www.aae.org/uploadedfiles/
publications_and_research/endodontics_colleagues_for_excellence_
newsletter/summer06ecfe.pdf. Published Summer 2006. Accessed June
02, 2016
Arduino PG, Tirone F, Schiorlin E, Esposito M. Single preoperative dose
of prophylactic amoxicillin versus a 2-day postoperative course in dental
implant surgery: A two-centre randomised controlled trial. Eur J Oral
Implantol. 2015;8(2):143-9.
Blumenthal KG, Shenoy ES, Hurwitz S, Varughese CA, Hooper DC,
Banerji A. Effect of a drug allergy educational program and antibiotic
prescribing guideline on inpatient clinical providers' antibiotic prescribing
knowledge. J Allergy Clin Immunol Pract. 2014;2(4):407-13
Bhattacharya S. The facts about penicillin allergy: a review. J Adv Pharm
Technol Res. 2010; 1(1):11–17.
Raab W. Acute side effects of erythromycin, lincomycin and clindamycin.
Int J Clin Pharmacol Biopharm. 1977 Feb;15(2):90-7.
Zimmerman HJ. Clindamycin. Hepatic injury from antimicrobial
agents. InL Zimmerman HJ. Hepatotoxicity: the adverse effects of drugs
and other chemicals on the liver. 2nd ed. Philadelphia, Pennsylvania:
Lippincott, 1999: 592
DeRossi SS, Hersh EV. Antibiotics and oral contraceptives. Dent Clin
North Am. 2002;46(4):653-64.
Toh S, Mitchell AA, Anderka M, de Jong-van den Berg LT, HernándezDíaz S; National Birth Defects Prevention Study. Antibiotics and
oral contraceptive failure - a case-crossover study. Contraception.
2011;83(5):418-25.
Taylor J, Pemberton MN. Antibiotics and oral contraceptives: new
considerations for dental practice. Br Dent J. 2012;212(10):481-3.
Verdugo F, Laksmana T, Uribarri A. Systemic antibiotics and the risk of
superinfection in peri-implantitis. Arch Oral Biol. 2016; 64:39-50.
Carey B, Cryan B. Antibiotic misuse in the community—a contributor to
resistance? Ir Med J. 2003, 96(2):43-4, 46.
Becker DE. Pain management: Part 1: Managing acute and postoperative
dental pain. Anesth Prog. 2010; 57(2):67–79.
Huber MA, Terezhalmy GT. The use of COX-2 inhibitors for acute
dental pain: A second look. J Am Dent Assoc. 2006;137(4):480-7.
Online Completion
54. Rosenblum A, Marsch LA, Joseph H, Portenoy RK. Opioids and the
treatment of chronic pain: Controversies, current status, and future
directions. Exp Clin Psychopharmacol. 2008;16(5):405–416.
55. Eccleston C. Post-operative pain management. Cochrane Database Syst
Rev. 2011;(10): ED000033. doi: 10.1002/14651858.ED000033.
56. Moore RA, Derry S, McQuay HJ, Wiffen PJ. Single dose oral analgesics
for acute postoperative pain in adults. Cochrane Database Syst Rev.
2015;(10):CD011407. doi: 10.1002/14651858.CD011407.pub2.
57. Denisco RC, Kenna GA, O’Neil MG, et al. Prevention of prescription
opioid abuse: the role of the dentist. J Am Dent Assoc. 2011;142(7):800-10
58. FDA Drug Safety Communication: Prescription Acetaminophen
Products to be Limited to 325 mg Per Dosage Unit; Boxed Warning Will
Highlight Potential for Severe Liver Failure. FDA website. http://www.
fda.gov/drugs/drugsafety/ucm239821.htm. Published January 13, 2011.
Accessed June 1, 2016.
59. Clement C, Scala-Bertola J, Javot L, et al. Misuse of acetaminophen in the
management of dental pain.
Pharmacoepidemiol Drug Saf. 2011;20(9):996-1000.
60. Role of dentists in reducing prescription drug abuse. California Dental
Association website. http://www.cda.org/news-events/role-of-dentistsin-reducing-prescription-drug-abuse. Published May 14, 2015. Accessed
June 01, 2016
61. Pregnancy and Breastfeeding. In: Little JW, Falace DA. Dental
Management of the Medically Compromised Patient. 8th ed. Elsevier
Health Sciences; 2012
Author Profile
Ian Shuman DDS, MAGD, AFAAID maintains a full-time general, reconstructive, and aesthetic dental practice in Pasadena, Maryland. Since 1995 Dr.
Shuman has lectured and published on advanced, minimally invasive techniques.
He has taught these procedures to thousands of dentists and developed many of
the methods. Dr. Shuman has published numerous articles on topics including
adhesive resin dentistry, minimally invasive restorative, cosmetic and implant
dentistry. He is a Master of the Academy of General Dentistry, an Associate Fellow of the American Academy of Implant Dentistry, a Fellow of the Pierre Fauchard Academy. Dr. Shuman was named one of the Top Clinicians in Continuing
Education since 2005, by Dentistry Today.
Author Disclosure
Dr. Shuman has no commercial ties with the sponsors or the providers of the
unrestricted educational grant for this course.
INSTANT EXAM CODE 15152
Use this page to review the questions and answers. Return to www.DentalAcademyOfCE.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete
the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your
answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or
printed anytime in the future by returning to the site, sign in and return to your Archives Page.
Questions
1.The outcome for patients hospitalized for periapical abscess in the
United States was evaluated with
7,886 hospitalizations amounting
to total hospital charges of $105.8
million using research from the:
a.CAMBRA
b. North American Medical and Research
Foundation
c. National Science Foundation
d. Nationwide Inpatient Sample of the Healthcare
Cost and Utilization Project
2.The Global Burden of Disease Study
in 2010 showed that cleft lip/palate,
edentulism, oral cancer, caries, and
periodontal disease accounted for
over how many disability-adjusted
life years.
4.In regard to oral soft tissue, which
of the following organisms do not
colonize the oral mucous membranes:
3. From 1990 to 2010, evaluation of the
global burden of oral diseases such
as caries, periodontal disease, and
cancer showed a marked increase by:
5.Which of the following opportunistic microorganisms mentioned in
this course can cause systemic versus
oral disease:
a.18
b.18,000
c.180,000
d.18,000,000
a.10.2%
b.45.6%
c.34.9%
d.83.2%
a. pathogenic bacteria
b. non-pathogenic bacteria
c. fungal organisms
d.plasmodians
a. Verrucomicrobium mrhankii
b. Cyanobacter cornii
c. Klebsiella pneumoniae
d. Fusobacterium preponderii
8www.DentalAcademyOfCE.com
Questions
6. Biofilm contains:
a.bacteria
b. extracellular DNA
c. intracellular DNA
d. a and b
7. Within a biofilm, interaction of
what microorganism type may either
boost or suppress metabolic activity
that leads to dental infection:
a.spirochetes
b.bacterial
c.protozoa
d.ameoba
8. Many factors regulate the number
and types of oral bacteria within
biofilm including:
a. the complexity of the flora
b. bacterial retention and interaction
c. native resistance
d. all of the above
9. Streptococcus salivarius is found
primarily on what oral structure:
a.palate
b. labial mucosa
c.tongue
d. buccal mucosa
10. Streptococcus mutans and Streptococcus sanguis typically adhere to:
a. hard surfaces
b. soft tissue
c. a and b
d. none of the above
11. Host defense mechanisms can be
compromised by which of the following conditions:
a.diabetes
b. lymphoproliferative disorders
c. renal failure
d. all of the above
12. A harmful quality possessed by
microorganisms that can cause
disease is known as:
a.virulence
b. viral spread
c. virulent reproduction
d. all of the above
13. Advantageous salivary lymphoid
cells produce:
a.Megakaryocytes
b.immunoglobulins
c. Natural Killer (NK) Cells
d.granulocytes
14. Serum proteins released as a result
of inflammation include all of the
following except:
a.histamine
b.prostaglandins
c.lymphokines
d.porphyrin
www.DentalAcademyOfCE.com
15. Lymph nodes that are tender,
enlarged, indurated or fixed suggest
the presence of:
a.infection
b. Graves disease
c.Goiter
d.cancer
in assessing infective organisms
in office, which of the following
may be considered the most useful
procedure:
a. Hygiena indicator
b. Gram stain
c. Glucose broth with Durham tubes
d. Streak-stab technique
16. Which of the following is a spreading bacterial infection just below the
skin surface:
24. Techniques for assessing purulent
material include:
17. Cellulitis is most commonly
caused by which of the following
microorganisms:
25. The best first line of defense against
the development of the dental
abscess is:
a. Acanthosis nigricans
b. Cherry hemangioma
c.Cellulitis
d. Granuloma annulare
a. Streptococcus pyogenes or Staphylococcus aureus
b. Entamoeba histolytica or Cyclospora cayetanensis
c. Giardia lamblia or Microsporidia
d. Schistosomiasis or Echinococcus granulosus
18. One of the conditions arising from
the oral cavity that spreads to the
fascial planes is known as:
a. Aarskog-Scott syndrome
b.Acromegaly
c. Ludwig’s angina
d. Angiocentric T-cell lymphoma
19. The submandibular space consists
of which two compartments in the
floor of the mouth:
a. pterygomandibularis and hyoid
b. sublingual space and submylohyoid
c. medial pterygoid and retromolar pad
d. platysma and sublingual gland
20. Complete the following statement:
The treatment of any oral infection
should begin with identification
of the culprit microorganism(s)
by way of laboratory evaluation
____________.
a. after an appropriate antibiotic regimen.
b. prior to the initiation of therapy.
c. during antibiotic therapy.
d. none of the above
21. Most oral bacterial infections are:
a.odontogenic
b. superficial in nature
c. caused by Streptococcus bacteria.
d. all of the above
22. As a rule, a culture must be taken
if:
a. The infection has spread to one or more fascial
planes of the head and neck.
b. Initial antibiotic treatment has failed to contain
the infection.
c. The patient shows evidence of systemic toxicity.
d. all of the above
23. Of the various examination
techniques that should be considered
a. transmucosal aspiration
b. pulp chamber access
c. tissue biopsy
d. all of the above
a. antibiotic therapy
b.pulpotomy
c. caries prevention
d. a and b
26. Drainage of purulence can be
accomplished through the surgical
placement of a:
a. French catheter
b. closed drainage system
c. Penrose drain
d. a and b
27. Which of the following authors
describes acute oral infections that
can spread extraorally, recommending Penicillin as being the drug of
first choice:
a. Presley and Martindale
b. Keaton and Winkler
c. Olsen and Winkelhoff
d. Dreyfus and Alexander
28. Which of the following analgesics
are not contraindicated during
pregnancy:
a.acetaminophen
b.aspirin
c.ibuprofen
d. b and c
29.Patient education, monitoring for
substance abuse, and appropriate referral if abuse is suspected is required
for the management of which class of
drugs:
a.Cannabinoids
b.Opioids
c.NSAIDS
d. b and c
30. Infection of the maxillary molars
can initially invade what anatomic
area:
a.dura
b.infrahyoid
c. brain stem
d. infratemporal space
9
INSTANT EXAM CODE 15152
ANSWER SHEET
Management of the Oral Infection: Part 1
Name:
Title:
Specialty:
Address:E-mail:
City:
State:ZIP:Country:
Telephone: Home (
)
Office (
Lic. Renewal Date:
) AGD Member ID:
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information
above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 3 CE credits. 6)
Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 800-633-1681
If not taking online, mail completed answer sheet to
PennWell Corp.
Attn: Dental Division,
1421 S. Sheridan Rd., Tulsa, OK, 74112
or fax to: 918-831-9804
Educational Objectives
1. Describe the features of oral microbiology as they relate to oral infection.
2. Identify the clinical issues related to dental infection.
3. Describe the various strategies for treating the acute dental abscess.
For IMMEDIATE results,
go to www.DentalAcademyOfCE.com to take tests online.
INSTANT EXAM CODE 15152
Course Evaluation
Answer sheets can be faxed with credit card payment to
918-831-9804.
1. Were the individual course objectives met?
Objective #1: Yes No
Payment of $59.00 is enclosed.
(Checks and credit cards are accepted.)
Objective #2: Yes No
Objective #3: Yes No
If paying by credit card, please complete the
following: MC
Visa
AmEx
Discover
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.
2. To what extent were the course objectives accomplished overall?
5
4
3
2
1
0
3. Please rate your personal mastery of the course objectives.
5
4
3
2
1
0
4. How would you rate the objectives and educational methods?
5
4
3
2
1
0
5. How do you rate the author’s grasp of the topic?
5
4
3
2
1
0
6. Please rate the instructor’s effectiveness.
5
4
3
2
1
0
7. Was the overall administration of the course effective?
5
4
3
2
1
0
8. Please rate the usefulness and clinical applicability of this course. 5
4
3
2
1
0
9. Please rate the usefulness of the supplemental webliography.
4
3
2
1
0
5
10. Do you feel that the references were adequate?
Yes
No
11. Would you participate in a similar program on a different topic?
Yes
No
Acct. Number: ______________________________
Exp. Date: _____________________
Charges on your statement will show up as PennWell
12. If any of the continuing education questions were unclear or ambiguous, please list them.
________________________________________________________________
13. Was there any subject matter you found confusing? Please describe.
_________________________________________________________________
14. How long did it take you to complete this course?
_________________________________________________________________
15. What additional continuing dental education topics would you like to see?
_________________________________________________________________
COURSE EVALUATION and PARTICIPANT FEEDBACK
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
AGD Code 148
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included
with the course. Please e-mail all questions to: [email protected].
INSTRUCTIONS
All questions should have only one answer. Grading of this examination is done manually. Participants will
receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be
mailed within two weeks after taking an examination.
COURSE CREDITS/COST
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
All participants scoring at least 70% on the examination will receive a verification form verifying 3 CE
credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/
Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact
their state dental boards for continuing education requirements. PennWell is a California Provider. The
California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00.
PROVIDER INFORMATION
PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental association
to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP
does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours
by boards of dentistry.
Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP ar www.ada.
org/cotocerp/
The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General
Dentistry. The formal continuing dental education programs of this program provider are accepted by the
AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance
by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from
(11/1/2015) to (10/31/2019) Provider ID# 320452
RECORD KEEPING
PennWell maintains records of your successful completion of any exam for a minimum of six years. Please
contact our offices for a copy of your continuing education credits report. This report, which will list all
credits earned to date, will be generated and mailed to you within five business days of receipt.
Completing a single continuing education course does not provide enough information to give the
participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of
many educational courses and clinical experience that allows the participant to develop skills and expertise.
CANCELLATION/REFUND POLICY
Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.
IMAGE AUTHENTICITY
The images provided and included in this course have not been altered.
© 2017 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell
Customer Service 800-633-1681
MOI217DIG