Question: Tooth or Foot First?

[Kooky Korky]

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.

[Kooky Korky, BSN, RN]

11 hours ago, Rose_Queen said:

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.

I thought about that, too, but neither surgeon was for it. The bacterial migration thing, I guess.

[beachbabe86]

On 1/9/2020 at 2:10 AM, Kooky Korky said:

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.

I, too, thought, oh a joke!

[adventure_rn, MSN, NP]

40 minutes ago, beachbabe86 said:

I, too, thought, oh a joke!

A dentist and a podiatrist walk into a bar...

[Lunah, MSN, RN]

Top down, for sure! The mouth and all its glorious bacteria is so much closer in proximity to the control center (brain/heart/lungs). I also thought about infective endocarditis and all those risks. The mouth is often an overlooked source of issues. This is why people with diabetes really need annual dental visits at a minimum, too — gingivitis can hamper good control of sugars.

[Kooky Korky, BSN, RN]

On 1/9/2020 at 3:19 AM, adventure_rn said:

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!

Thanks, that is most helpful.

[Kooky Korky, BSN, RN]

On 1/9/2020 at 3:37 AM, Jedrnurse said:

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.

I'd say they are equal in priority.

The ortho thing involves bone, with attendant risk of osteomyelitis.

However, it turns out the pt might not have to have the foot done. Might be able to get a shoe that will allow good pressure relief and prevent recurrent ulcer.