Earn

3 CE credits
This course was
written for dentists,
dental hygienists,
and assistants.

Management of the
Oral Infection: Part 1

© Stiggdriver | Dreamstime.com
A Peer-Reviewed Publication
Written by Ian Shuman, DDS, MAGD, AFAAID

Abstract Educational Objectives Author Profile

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.
At the conclusion of this educational Ian Shuman DDS, MAGD, AFAAID maintains a full-time general,
activity participants will be able to: reconstructive, and aesthetic dental practice in Pasadena, Maryland.
1. Describe the features of oral Since 1995 Dr. Shuman has lectured and published on advanced,
microbiology as they relate to oral minimally invasive techniques. He has taught these procedures to
infection. thousands of dentists and developed many of the methods. Dr. Shuman
has published numerous articles on topics including adhesive resin den-
2. Identify the clinical issues related to
tistry, minimally invasive restorative, cosmetic and implant dentistry.
dental infection. He is a Master of the Academy of General Dentistry, an Associate Fellow
3. Describe the various strategies for of the American Academy of Implant Dentistry, a Fellow of the Pierre
treating the acute dental abscess. 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 hhodges@pennwell.com
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.
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.
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 micro-
biology, triage, anatomy, and laboratory testing. It includes the
surgical, antibiotic, and palliative actions needed in the treat-
ment of the acute dental abscess. Part two will emphasize the
treatment of oral infections due to fungal, viral, and bacterial
L®
organisms.
Introduction
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
EL
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
NW
periapical abscess in the United States, amounting to total hos-
pital 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 non-
EN
communicable diseases such as diabetes.3 Dentists are usu-
ally 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 hospi-
talization.5
The complexities of oral infection
©P
Enormous numbers of pathogenic bacteria, nonpathogenic
bacteria, and fungal organisms naturally colonize the oral mu-
cous membranes. Numerous transient and potentially infective
organisms (e.g., viruses) can be present as well. Opportunistic
microorganisms such as Escherichia coli, Streptococcus pneu-
moniae, Staphylococcus aureus, and Klebsiella pneumoniae can
cause systemic versus oral disease.6
With respect to oral hard tissue, multiple bacterial interac-
tions exist within the diverse dental microenvironments and
2 www.DentalAcademyOfCE.com
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 as-
sociated with 200 to 500 bacterial species.8,9,10
17
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 reten-
tion and interaction, native resistance, saliva, hygiene, and diet.
20
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 com-
promised 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 bacte-
rial 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 consid-
erations, 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 popu-
lations, 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 sys-
tem includes advantageous elements to protect the host against
invading pathogens that include the resistance to tear and com-
pression 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 pro-
tection 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 hista-
mine, prostaglandins and lymphokines are released as a result
of inflammation. There are also cellular defenses dependent
on receptors, phagocytes, and lymphocytes (e.g., B and T
cells).13,14,15
Triage
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
are tender, enlarged, indurated, or fixed suggest the presence of
infection. Infection and swelling of the pterygomandibular, para-
pharyngeal (lateral pharyngeal and retropharyngeal), peritonsil-
lar 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

and mortality. The treating clinician must recognize the sig-
nificance 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 pa-
tient who presents with pallor, reporting a rapidly increasing
17
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

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 breath-
ing or swallowing, fever (with chills or cold sweats), a thready
pulse with lethargy and/or altered consciousness, trismus, a
20
the mouth, the sublingual space and the submylohyoid (fig-
ure 1). It is an aggressive, rapidly spreading cellulitis without
lymphadenopathy and with the potential for airway obstruc-
tion. It requires careful monitoring and rapid intervention for
prevention of asphyxia and aspiration pneumonia. Clinical

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.
Anatomic considerations
EL
A basic understanding of head and neck anatomy including the
location of lymph nodes and fascial spaces is useful in determin-
ing the relative risk associated with infection. Lymph nodes that
L®
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

Figure 1: Ludwig’s Angina

NW

Sublingual
gland
EN

Tongue

Geniohyoid Submandibular
muscle space
Sublingual space

Supramylohyoid
portion of Submaxillary
submandibular space
©P

space

Mylohyoid muscle
Mylohyoid muscle
Submandibular
gland

Inframylohyoid portion
of submandibular space Superficial fascial layer
Digastric muscle (anterior belly)

www.DentalAcademyOfCE.com 3
Figure 2: Temporal Spaces Managing the dental abscess
The dental abscess develops as a result of bacterial invasion of
the pulp and ultimately, the alveolar bone. Therefore, the pre-
vention of caries is still the best first line of defense against the
Temporalis muscle
development of the dental abscess. The other effective preven-
Superficial temporal space • Infra temporal space tive measure against dental caries and dentoalveolar abscess is
Temporal Deep temporal space • Lies posterior to maxilla proper dental hygiene. This includes brushing teeth after meals
fascia
• Bottom portion of the and regular dental check-ups. ADA Dental Practice Param-

17
Sphenoid bone
deep temporal space
Infratemporal eters suggest that the dentist should utilize treatments designed
space • Source of infection-
Zygomatic Maxillary third molars to “reduce pulpal symptoms and/or protect the pulpal tissue
arch of the tooth with pulpitis.”22 The document recommends that
Lateral
pterygoid management of the dental abscess should be considered as fol-
muscle
lows: nonsurgical approaches (e.g., antibiotics), chemothera-

20
Masseteric Hamular process peutic modalities, dental restorations, endodontic therapy,
space
tooth extraction and surgery.16 However, with any acute infec-
Medial tion, prior to the initiation of an antibiotic, purulence must be
pterygoid
Masseler muscle eliminated via surgical drainage.
muscle

L®
Pterygomandibular
space
Incision and drainage
Drainage of odontogenic purulence can be accomplished
through pulpal access, surgical incision, or tooth extraction.
Mandible 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
Laboratory considerations
Minor oral infections can be well managed empirically without
culture if attention is paid to three important considerations:
EL soft rubber tubing, placed inside a wound to drain fluid (figure
3). The drain is sutured into place with a patent opening, al-
lowing fluids to drain from the infection site. In addition, the
infection origin, involved anatomy and bacterium most likely infected site can be decontaminated by irrigation with a saline
involved. Most oral infections are odontogenic, superficial in solution (typically 60–100 ml) or chlorhexidine mixed with sa-
nature, and in the majority of patients caused by Streptococcus line if necessary. The patient should be advised to: avoid touch-
NW

bacteria. Infection by anaerobic bacteria such as Staphylococ-
cus, 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
EN
ing 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.
Figure 3:

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 immedi-
©P

A. B.

ate 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. C. D.

4 www.DentalAcademyOfCE.com
Antibiotics Azithromycin, a structural derivate of erythromycin, has also
In most instances, antibiotics should only be prescribed for been recommended as an option for the treatment of mild to mod-
the dental abscess when the infection has spread beyond the erate bacterial infection.35 It has a broader spectrum of activity,
radicular area, causing local involvement and/or systemic symp- increased bioavailability, and fewer gastrointestinal (GI) effects.
toms.24 Once the infection spreads beyond the radicular area, the For the patient with identified cephalosporin- or penicillin-resis-
involved bacteria typically include a combination of anaerobic tant Gram-negative bacteria, cefoxitin has also been shown to be
and aerobic organisms. This change in bacterial composition is a effective.36 The reader should refer to this and other guidelines for
complication that can significantly alter the relative virulence of the latest information and proper dosing for the adult patient.
the infection and complicate antibiotic selection. An important Antibiotics may also need to be prescribed to children with
consideration when using antibiotics is microbial resistance.25 infection, although the dosage will be lower, as it based on body
The best approach for curtailing resistance is to prescribe a high weight. Several rules exist to compute the dosage of a drug for
dose of antibiotic for as short a course as possible. a child, the most common being Clark’s Rule and Young’s Rule
The choice of antibiotic is largely empirical because the (tables 2 and 3) and empiric antibiotic options are available (table
science supporting the efficacy of one antibiotic or treatment 4). The American Academy of Pediatric Dentistry has published
regimen over another is presently not definitive. This is due to prescription guidelines for children needing antibiotic coverage.37
the confusion posed by a number of methodological problems The reader should refer to this and other guidelines for the latest
associated with the published research. These include issues information and proper dosing for the pediatric patient.
related to study design and choice of outcome measures.26 In
general, penicillin is often the first drug of choice for dental Table 2: Clark’s Rule for Pediatric Dosing 39
infections. An article by Olsen and Winkelhoff describes acute
oral infections that can spread extraorally, recommending peni- Child’s Weight lb. (or kg) X Adult Dose = Child’s Dose
150 lb. (or 70 kg)
cillin (when suspicion of methicillin-resistant S. aureus is low).27
Historically, antibiotic use has included the use of the Table 3: Young’s Rule for Pediatric Dosing 39
penicillins, including penicillin V (table 1).28,29 Amoxicillin is
favored as the drug of first choice due to its broad spectrum Adult Dose X (Age ÷ (Age+12)) = Child's Dose
of action against many gram positive and negative bacteria.30
If there is a history of antimicrobial resistance, metronida- Table 4. Empiric Antibiotics of Choice for Odontogenic Infections 38
zole31 (although the drug itself has also been associated with Antibiotic Dosage
increased resistance32) or amoxicillin combined with clavu- Children Adults
lanic acid should be considered.33 For individuals allergic to the Penicillin VK ≤ 12 years: 25-50 mg/ > 12 years: 500 mg
penicillin-based antibiotics, clindamycin can be prescribed.34 kg body weight in q6h for at least 7
Clindamycin is effective against both aerobic and anaerobic equally divided doses days
q6-8h for at least 7 days;
bacteria and penetrates bone readily. maximum dose: 3g/day
Clindamycin 08-25mg/kg in 3-4 150-450 mg/ g6h
Table 1: Empiric Antibiotics of Choice for Odontogenic Infections 38 equally divided doses for at least 7 days;
Type of Infection Antibiotic of Choice maximum dose: 1.8
Early (first 3 days of infection) Penicillin VK, amoxicillin g/day
Clindamycin Cephalexin (Keflex) 25-50 mg/kg/day in 250-1000 mg q6h;
Cephalexin (or other first-generation divided doses q6h maximum dose 4g/
cephalosporin) 1 Severe infection: day
No improvement in 24-36 Beta-lactamase-stable antibiotic: 50-100 mg/kg/day
hours Clindamycin or amoxicillin/clavu- in divided doses q6h;
lanic acid (Augmentin®) maximum dose 3 g/24h
Penicillin allergy Clindamycin Amoxicillin < 40 kg: 20-40 mg/kg/ > 40kg: 250-500 mg
Cephalexin (if penicillin allergy is day in divided doses q8h q8h or 875 mg q12h
not anaphylactiod type) > 40 kg: 250-500 mg for at least 7 days:
Clarithromycin (Biaxin®) 2 q8h or 875 mg q12h for maximum dose: 2
Late (>3 days) Clindamycin at least 7 days; maxi- g/day
Penicillin VK-metronidazole, mum dose 2 g/day
amoxicillin-metronidazole Amoxicillin/ < 40 kg: 20-40 mg/kg/ > 40kg: 250-500 mg
Penicillin allergy Clindamycin clavulanic acid day in divided doses q8h q8h or 875 mg q12h
1
For better patient compliance, second-generation cephalosporins (cefctor: cefuroxime) at twice (Augmentin®) > 40kg: 250-500 mg for at least 7 days;
daily dosing has been used.
2
A. macrolide useful in patients allergic to penicillin, given as twice daily dosing for better patient q8h or 875 mg q12h for maximum dose: 2
compliance.
at least 7 days: maxi- g/day
Adapted from Drug Information handbook for Dentistry; Richard Wynn, Timothy Meiller,
Harold Crossley, 12th Edition mum dose: 2 g/day

www.DentalAcademyOfCE.com 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 first-
generation 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. An-
other 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 com-
mon and most important adverse reaction resulting in nausea,
vomiting, pruritus, urticaria, wheezing, laryngeal edema and
ultimately, cardiovascular collapse. In these patients, clindamy-
cin 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 pre-
scribed 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 demon-
strate 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 con-
traceptive 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 con-
traceptive 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 re-
viewed prior to prescribing. It should also be fully appreciated
6 www.DentalAcademyOfCE.com
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 incor-
porate 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 moder-
ate 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 etori-
coxib, 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 medica-
tions,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 prescrip-
tion 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
(e.g. liver abnormality, kidney disease, stomach ulcers, alcohol-
ism, anticoagulant therapy, hemorrhagic disorders, allergy, de-
pression) and pregnancy. Effective opioid management includes
patient education, monitoring for substance abuse, and appro-
priate 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 Compro-
mised Patient, aspirin and ibuprofen should be avoided through-
out pregnancy; however, acetaminophen can be prescribed any
time during pregnancy.56 For this and other prescribing recom-
mendations, 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 treat-
ment strategies are critical. In addition, the appropriate pre-
scription of medication is of paramount importance in avoiding
potential morbidity and mortality.
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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.
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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
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21. Pulpitis. The American Dental Association website. http://www.ada.
org/en/science-research/dental-practice-parameters/pulpitis. Accessed
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23. Dar-Odeh NS, Abu-Hammad OA, Al-Omiri MK, Khraisat AS, Shehabi
AA. Antibiotic prescribing practices by dentists: a review. Ther Clin Risk
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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,
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26. Olsen I, van Winkelhoff AJ. Acute focal infections of dental origin.
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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
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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.
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37. Commonly Prescribed Medications in Pediatric Dentistry. DentalCare.
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38. http://www.dentalcare.com/media/en-US/education/ce336/ce336.pdf
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39. Clarks rule and Youngs rule. Pharmacy Tech Study website. http://www.
 pharmacy-tech-study.com/dosecalculation.html. Accessed May 29,
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40. Gilbert DN, Mollering RC, Eliopouos GM, Sande MA. The Sanford
Guide to Antimicrobial Therapy 2006. 36th ed. Sperryville, Virginia:
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41. Antibiotics and the Treatment of Endodontic Infections. American
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newsletter/summer06ecfe.pdf. Published Summer 2006. Accessed June
02, 2016
42. 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.
43. 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
44. Bhattacharya S. The facts about penicillin allergy: a review. J Adv Pharm
Technol Res. 2010; 1(1):11–17.
45. Raab W. Acute side effects of erythromycin, lincomycin and clindamycin.
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46. Zimmerman HJ. Clindamycin. Hepatic injury from antimicrobial
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Lippincott, 1999: 592
47. DeRossi SS, Hersh EV. Antibiotics and oral contraceptives. Dent Clin
North Am. 2002;46(4):653-64.
48. Toh S, Mitchell AA, Anderka M, de Jong-van den Berg LT, Hernández-
Díaz S; National Birth Defects Prevention Study. Antibiotics and
oral contraceptive failure - a case-crossover study. Contraception.
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49. Taylor J, Pemberton MN. Antibiotics and oral contraceptives: new
considerations for dental practice. Br Dent J. 2012;212(10):481-3.
50. Verdugo F, Laksmana T, Uribarri A. Systemic antibiotics and the risk of
superinfection in peri-implantitis. Arch Oral Biol. 2016; 64:39-50.
51. Carey B, Cryan B. Antibiotic misuse in the community—a contributor to
resistance? Ir Med J. 2003, 96(2):43-4, 46.
52. Becker DE. Pain management: Part 1: Managing acute and postoperative
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53. 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.
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
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for acute postoperative pain in adults. Cochrane Database Syst Rev.
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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
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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.
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60. Role of dentists in reducing prescription drug abuse. California Dental
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Health Sciences; 2012
Author Profile
Ian Shuman DDS, MAGD, AFAAID maintains a full-time general, recon-
structive, 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 Fel-
low of the American Academy of Implant Dentistry, a Fellow of the Pierre Fau-
chard 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.

Online Completion 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
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Questions
1. The outcome for patients hospital- periodontal disease accounted for 4. In regard to oral soft tissue, which
ized for periapical abscess in the over how many disability-adjusted of the following organisms do not
United States was evaluated with life years. colonize the oral mucous membranes:
7,886 hospitalizations amounting a. 18 a. pathogenic bacteria
to total hospital charges of $105.8 b. 18,000 b. non-pathogenic bacteria
c. 180,000 c. fungal organisms
million using research from the: d. 18,000,000 d. plasmodians
a. CAMBRA
b. North American Medical and Research 3. From 1990 to 2010, evaluation of the 5. Which of the following opportunis-
Foundation global burden of oral diseases such tic microorganisms mentioned in
c. National Science Foundation
d. Nationwide Inpatient Sample of the Healthcare as caries, periodontal disease, and this course can cause systemic versus
Cost and Utilization Project cancer showed a marked increase by: oral disease:
a. 10.2% a. Verrucomicrobium mrhankii
2. The Global Burden of Disease Study b. 45.6% b. Cyanobacter cornii
in 2010 showed that cleft lip/palate, c. 34.9% c. Klebsiella pneumoniae
edentulism, oral cancer, caries, and d. 83.2% d. Fusobacterium preponderii

8 www.DentalAcademyOfCE.com
 Questions
6. Biofilm contains: 15. Lymph nodes that are tender, in assessing infective organisms
a. bacteria enlarged, indurated or fixed suggest in office, which of the following
b. extracellular DNA the presence of: may be considered the most useful
c. intracellular DNA a. infection
d. a and b
procedure:
b. Graves disease a. Hygiena indicator
7. Within a biofilm, interaction of c. Goiter b. Gram stain
d. cancer c. Glucose broth with Durham tubes
what microorganism type may either
16. Which of the following is a spread- d. Streak-stab technique
boost or suppress metabolic activity
that leads to dental infection: ing bacterial infection just below the 24. Techniques for assessing purulent
a. spirochetes skin surface: material include:
b. bacterial a. Acanthosis nigricans a. transmucosal aspiration
c. protozoa b. Cherry hemangioma b. pulp chamber access
d. ameoba c. Cellulitis c. tissue biopsy
d. Granuloma annulare d. all of the above
8. Many factors regulate the number
17. Cellulitis is most commonly 25. The best first line of defense against
and types of oral bacteria within
caused by which of the following the development of the dental
biofilm including: microorganisms:
a. the complexity of the flora abscess is:
a. Streptococcus pyogenes or Staphylococcus aureus a. antibiotic therapy
b. bacterial retention and interaction b. Entamoeba histolytica or Cyclospora cayetanen-
c. native resistance b. pulpotomy
sis c. caries prevention
d. all of the above c. Giardia lamblia or Microsporidia d. a and b
9. Streptococcus salivarius is found d. Schistosomiasis or Echinococcus granulosus
26. Drainage of purulence can be
primarily on what oral structure: 18. One of the conditions arising from
a. palate accomplished through the surgical
the oral cavity that spreads to the
b. labial mucosa placement of a:
fascial planes is known as: a. French catheter
c. tongue a. Aarskog-Scott syndrome
d. buccal mucosa b. closed drainage system
b. Acromegaly c. Penrose drain
10. Streptococcus mutans and Strepto- c. Ludwig’s angina d. a and b
d. Angiocentric T-cell lymphoma
coccus sanguis typically adhere to: 27. Which of the following authors
a. hard surfaces 19. The submandibular space consists
describes acute oral infections that
b. soft tissue of which two compartments in the
c. a and b can spread extraorally, recommend-
floor of the mouth:
d. none of the above a. pterygomandibularis and hyoid ing Penicillin as being the drug of
11. Host defense mechanisms can be b. sublingual space and submylohyoid first choice:
c. medial pterygoid and retromolar pad a. Presley and Martindale
compromised by which of the follow- d. platysma and sublingual gland b. Keaton and Winkler
ing conditions: c. Olsen and Winkelhoff
a. diabetes 20. Complete the following statement: d. Dreyfus and Alexander
b. lymphoproliferative disorders The treatment of any oral infection
c. renal failure should begin with identification 28. Which of the following analgesics
d. all of the above of the culprit microorganism(s) are not contraindicated during
by way of laboratory evaluation pregnancy:
12. A harmful quality possessed by a. acetaminophen
microorganisms that can cause ____________. b. aspirin
a. after an appropriate antibiotic regimen.
disease is known as: b. prior to the initiation of therapy.
c. ibuprofen
a. virulence d. b and c
c. during antibiotic therapy.
b. viral spread d. none of the above 29.Patient education, monitoring for
c. virulent reproduction
d. all of the above 21. Most oral bacterial infections are: substance abuse, and appropriate re-
a. odontogenic ferral if abuse is suspected is required
13. Advantageous salivary lymphoid b. superficial in nature for the management of which class of
cells produce: c. caused by Streptococcus bacteria. drugs:
a. Megakaryocytes d. all of the above a. Cannabinoids
b. immunoglobulins 22. As a rule, a culture must be taken b. Opioids
c. Natural Killer (NK) Cells c. NSAIDS
d. granulocytes if:
a. The infection has spread to one or more fascial d. b and c
14. Serum proteins released as a result planes of the head and neck. 30. Infection of the maxillary molars
of inflammation include all of the b. Initial antibiotic treatment has failed to contain
the infection.
can initially invade what anatomic
following except: c. The patient shows evidence of systemic toxicity. area:
a. histamine d. all of the above a. dura
b. prostaglandins b. infrahyoid
c. lymphokines 23. Of the various examination c. brain stem
d. porphyrin techniques that should be considered d. infratemporal space

www.DentalAcademyOfCE.com 9
INSTANT EXAM CODE 15152 ANSWER SHEET

Management of the Oral Infection: Part 1

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City: State: ZIP: Country:

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Lic. Renewal Date: AGD Member ID:

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1. Describe the features of oral microbiology as they relate to oral infection. 1421 S. Sheridan Rd., Tulsa, OK, 74112
2. Identify the clinical issues related to dental infection. or fax to: 918-831-9804
3. Describe the various strategies for treating the acute dental abscess.
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