Question: Tooth or Foot First?

[Kooky Korky, BSN, RN]

Had an interesting question come up on Rounds.

The patient needs some tooth surgery (root canal) and a podiatric/orthopedic surgery. Question arose of which to do first.

One foot surgeon said he thought the dental surgery should be done first.

Another surgeon (Ortho) said probably the foot first.

The reason: One surgeon recalled a patient she'd had once who had a spinal infection. The reason for it was believed to be that bacteria from the patient's mouth had migrated to the spine and set up infection there.

It doesn't seem unreasonable that bacteria would move about and cause infection in what might have been a weak area but I don't know any factual information.

Any anecdotal experiences here? I am asking our medical librarian for help finding articles. I am just wondering if any of you might have encountered anything like this. Thanks.

[adventure_rn, MSN, NP]

Not sure if this helps, but in the peds cardiac world, we were always really OCD about dental care because cardiac kids are at increased risk for infective endocarditis related to both cavities and dental procedures.

If we knew a kid was going to be listed for transplant, we always tried to get anticipated dental procedures (i.e. wisdom teeth removal) out of the way first, since we didn't want to risk their new heart getting infected; granted, post-transplant they'd be at an even greater risk since they'd be on immunosuppresant anti-rejection meds...

Not exactly the same concept, but related?

It does make a little more sense in cardiac, though, since the blood vessels at the tooth return blood (and bacteria) directly to the heart. The bacteria then making it all the way to the bone seems like a little more of a stretch.

Our CT surgeons always talked about how bacteria preferentially colonize synthetic materials like plastic over natural tissue (which has biological defense mechanisms). Perhaps if you did have bacteria floating around in the blood post dental-procedure, they might opportunistically colonize fresh sutures or any implants/hardware?

The mouth is incredibly dirty, and there really isn't any way to sterilely prep it like you do other parts of the body. I suppose that's why surgeons worry more about cross contamination from dental work than other types of surgery.

If you find anything out, keep us posted!

[Jedrnurse, BSN, RN]

Sounds like a more straightforward question of priority. Not knowing what the foot problem was, I'd assume that the oral surgery should go first, as it was probably a higher risk condition.

["nursy", RN]

It is relatively routine to prescribe antibiotics during dental procedures after you have had a prosthetic implanted (i.e. knee replacement). The thinking is that bacteria can migrate from dental infections to the prosthetic, causing infections. So in that vein, you would want to do dental first, make sure everything is healed up, no infections, then proceed with ortho.

[Davey Do]

For whatever it's worth, I agree with the tooth treatment first for the reasons given: the migration of bacteria thing.

In no way do I wish to derail this subject, but I would like to give my perspective on Kooky Korky's eye-catching title to this thread:

I saw "Question: Tooth or Foot First?" and immediately thought of the Age Old Question: "Which came first- the chicken or the egg?"

For Tooth or Foot First?, I had my answer ready: The tooth came first, preceded by the mouth, so early man had a place in which to put his foot.

Okay, thanks. And now, back to our program.

[MelEpiRN]

I've seen multiple people with brain abscesses and the cause was infected dentition. It definitely migrates. I'm no surgeon, but I can see why they'd opt for fixing the dental issues first.

[Rose_Queen, BSN, MSN, RN]

My OR frequently works with surgeons to complete multiple surgeries at the same time in order not to give a patient multiple anesthetic encounters. Granted, the root canal could likely be done under local, but it is nice to cluster care.

[AnnieNP, MSN, NP]

6 hours ago, Davey Do said:

For whatever it's worth, I agree with the tooth treatment first for the reasons given: the migration of bacteria thing.

In no way do I wish to derail this subject, but I would like to give my perspective on Kooky Korky's eye-catching title to this thread:

I saw "Question: Tooth or Foot First?" and immediately thought of the Age Old Question: "Which came first- the chicken or the egg?"

For Tooth or Foot First?, I had my answer ready: The tooth came first, preceded by the mouth, so early man had a place in which to put his foot.

Okay, thanks. And now, back to our program.

I've missed you!!!!

[Horseshoe, BSN, RN]

I would wonder about pain. Anybody ever had excruciating tooth pain that just popped up on a weekend? Dental pain can be absolutely unbearable. Better to take care of it first before it becomes an emergency.

Also, the comments about dental bacterial conditions affecting other systems are valid as this is a well documented risk.

[Twinmom06, ASN, APN]

I know for kidney listed transplant candidates, (former dialysis nurse) that dental issues will get someone removed from the list. Same with hearts.

[MunoRN, RN]

I would guess the ortho surgery has the potential for the need to install hardware (screws, etc) which is contraindicated in the case of a potentially active tooth infection, which would be why a root canal would be indicated, so generally the dental issue would have to be dealt with prior to ortho.

[Kooky Korky, BSN, RN]

12 hours ago, Davey Do said:

For whatever it's worth, I agree with the tooth treatment first for the reasons given: the migration of bacteria thing.

In no way do I wish to derail this subject, but I would like to give my perspective on Kooky Korky's eye-catching title to this thread:

I saw "Question: Tooth or Foot First?" and immediately thought of the Age Old Question: "Which came first- the chicken or the egg?"

For Tooth or Foot First?, I had my answer ready: The tooth came first, preceded by the mouth, so early man had a place in which to put his foot.

Okay, thanks. And now, back to our program.

LOL

We needed a good joke and here it is!

3 hours ago, Twinmom06 said:

I know for kidney listed transplant candidates, (former dialysis nurse) that dental issues will get someone removed from the list. Same with hearts.

Wow, I had no idea. Thanks for the info!