If some of you are gum addicts and primarily chew sugar-free gum, or if some of you eat a lot of diabetic (artificially sweetened) products, you might have noticed that you get the runs shortly afterwards.

Here’s some evidence¹ that you’re not imagining what has been the cause of the problem. It’s only a couple of case reports, so that’s marginally better than anecdotal evidence, but still:
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1. Bauditz J, Norman K, Biering H, Lochs H, Pirlich M., Severe Weight Loss Caused by Chewng Gum, BMJ. 2008 Jan 12;336(7635):96-7. [↩]

Use of Probiotic Lactobacillus Preparation to Prevent Diarrhoea Associated With Antibiotics: Randomised Double Blind Placebo Controlled Trial

BMJ, doi:10.1136/bmj.39231.599815.55 (published 29 June 2007)

Mary Hickson, research dietitian¹, Aloysius L D’Souza, research fellow², Nirmala Muthu, research nurse³, Thomas R Rogers, professor of clinical microbiology and honorary consultant (Hammersmith Hospitals NHS Trust)⁴, Susan Want, clinical scientist⁵, Chakravarthi Rajkumar, senior lecturer², Christopher J Bulpitt, professor of geriatric medicine²

¹ Nutrition and Dietetic Research Group, Faculty of Medicine, Imperial College, London W12 0HS, ² Medicine for the Elderly, Faculty of Medicine, Imperial College, London, ³ Hillingdon Hospital, Uxbridge, ⁴ Department of Infectious Diseases and Immunity, Faculty of Medicine, Imperial College School of Medicine, London, ⁵ Microbiology Department, Hammersmith Hospital NHS Trust, London

Correspondence to: M Hickson mhickson@hhnt.nhs.uk

Objective: To determine the efficacy of a probiotic drink containing Lactobacillus for the prevention of any diarrhoea associated with antibiotic use and that caused by Clostridium difficile.

Design: Randomised double blind placebo controlled study.

Participants: 135 hospital patients (mean age 74) taking antibiotics. Exclusions included diarrhoea on admission, bowel pathology that could result in diarrhoea, antibiotic use in the previous four weeks, severe illness, immunosuppression, bowel surgery, artificial heart valves, and history of rheumatic heart disease or infective endocarditis.

Intervention: Consumption of a 100 g (97 ml) drink containing Lactobacillus casei, L bulgaricus, and Streptococcus thermophilus twice a day during a course of antibiotics and for one week after the course finished. The placebo group received a longlife sterile milkshake.

Main outcome measures:

Primary outcome: occurrence of antibiotic associated diarrhoea.

Secondary outcome: presence of  C difficile toxin and diarrhoea.

Results: 7/57 (12%) of the probiotic group developed diarrhoea associated with antibiotic use compared with 19/56 (34%) in the placebo group (P=0.007). Logistic regression to control for other factors gave an odds ratio 0.25 (95% confidence interval 0.07 to 0.85) for use of the probiotic, with low albumin and sodium also increasing the risk of diarrhoea. The absolute risk reduction was 21.6% (6.6% to 36.6%), and the number needed to treat was 5 (3 to 15). No one in the probiotic group and 9/53 (17%) in the placebo group had diarrhoea caused by C difficile (P=0.001). The absolute risk reduction was 17% (7% to 27%), and the number needed to treat was 6 (4 to 14).

Conclusion: Consumption of a probiotic drink containing L casei, L bulgaricus, and S thermophilus can reduce the incidence of antibiotic associated diarrhoea and C difficile associated diarrhoea. This has the potential to decrease morbidity, healthcare costs, and mortality if used routinely in patients aged over 50.  Lactobacillus for the prevention of any diarrhoea associated with antibiotic use and that caused by Clostridium difficile.

Design Randomised double blind placebo controlled study.

Participants 135 hospital patients (mean age 74) taking antibiotics. Exclusions included diarrhoea on admission, bowel pathology that could result in diarrhoea, antibiotic use in the previous four weeks, severe illness, immunosuppression, bowel surgery, artificial heart valves, and history of rheumatic heart disease or infective endocarditis.

Intervention Consumption of a 100 g (97 ml) drink containing Lactobacillus casei, L bulgaricus, and Streptococcus thermophilus twice a day during a course of antibiotics and for one week after the course finished. The placebo group received a longlife sterile milkshake.

Main outcome measures Primary outcome: occurrence of antibiotic associated diarrhoea. Secondary outcome: presence of C difficile toxin and diarrhoea.

Results 7/57 (12%) of the probiotic group developed diarrhoea associated with antibiotic use compared with 19/56 (34%) in the placebo group (P=0.007). Logistic regression to control for other factors gave an odds ratio 0.25 (95% confidence interval 0.07 to 0.85) for use of the probiotic, with low albumin and sodium also increasing the risk of diarrhoea. The absolute risk reduction was 21.6% (6.6% to 36.6%), and the number needed to treat was 5 (3 to 15). No one in the probiotic group and 9/53 (17%) in the placebo group had diarrhoea caused by C difficile (P=0.001). The absolute risk reduction was 17% (7% to 27%), and the number needed to treat was 6 (4 to 14).

Conclusion Consumption of a probiotic drink containing L casei, L bulgaricus, and S thermophilus can reduce the incidence of antibiotic associated diarrhoea and C difficile associated diarrhoea. This has the potential to decrease morbidity, healthcare costs, and mortality if used routinely in patients aged over 50.

© 2007 BMJ Publishing Group Ltd.

Lots of people are understandably feeling betrayed after having put the time and emotional energy into reading Frey’s memoirs only to find out that he lied. Oprah is no exception.

There’s a part in his book describing his experience of having multiple root canals without anesthetic. This is unrealistic to most people and also probably untrue in his case. Novocaine hasn’t been used in Dentistry for decades (we use other types of local anesthetics such as lidocaine) and most root canal procedures would be excruciating without anesthetic because we’re fiddling directly with nerve tissue. There’s also the issue of the local anesthetic potentiating his drug addiction. That’s untrue because local has no addictive properties. Local anesthetic interrupts nerve conduction rather than binding to receptors in the brain like general anesthetics or narcotics which make you feel stoned enough to not care about pain.

That being said, most endodontists have done some number of cases without anesthetic. For some patients, the fear of the needle outweighs the actual procedure. If you combine this fear with a tooth that is asymptomatic and already dead (no live nerve in it), it is possible to do a root canal without anesthetic. In fact, there are some cases where the tooth is so heavily infected that anesthetic wouldn’t work anyway because of the amount of pus that has gone into the gums. When these teeth are opened up and pus spews out, the patient usually feels substantial immediate relief.

There’s an E.R. Doc in my town that has been trying to alter (interfere) with a dental standard of practise. His view that Clindamycin should never be prescribed because of its link to pseudomembranous colitis is shared by many physicians. The infections that they commonly see are generally treatable by other antibiotics and so these physicians are usually able to prescribe viable alternatives to Clinda. If they are hospital-based, they also often have the luxury of being able to order and obtain results of culture and sensitivity tests quickly. They figure if they can find alternatives, dentists should also.

Pseudomembranous Colitis is a severe case of (often bloody) diarrhea. The diarrhea is a result of alterations between the balance of “good” bacteria and “bad” bacteria in the colon. Bacteria exist in all of our intestines and live within this equilibrium. The good bacteria help with some digestive processes and also some pharmacologic processes–the birth control pill relies on good bacteria to help its components get absorbed into the body.

Antibiotics either kill bacteria or stop their proliferation. Most antibiotics will significantly alter the proportion of good bacteria in the intestine. This can lead to failure of oral contraception, or as related to this topic, overgrowth of the bad bacteria.

Clostridium Difficile is a common problem in nursing homes and hospitals because of the population of immuno-compromised patients and the fact that this bacterium can be resistant to antibiotics. It is also generally considered the cause of antibiotic-induced pseudomembranous colitis. Overgrowth of this bacterium in the gut produces toxins that lead to bloody diarrhea. Persistent diarrhea that appears for no obvious reason during antibiotic therapy even up to six weeks after cessation of antibiotics can indicate that you have the condition.

Treatment for the diarrhea is the antibiotic Metronidazole, or in resistant cases, Vancomycin. It is interesting to note that Metronidazole itself can cause pseudomembranous colitis, yet it is also a treatment. As long as Metronidazole wasn’t responsible for the original bacterial imbalance, it should be effective at bringing C. Difficile levels back down.

Dental infections have been shown to be polymicrobial in nature and fuel cariogenesis, periodontal, and endodontic pathosis. Endodontic infection is the number one reason for the emergency use of antibiotics in dentistry.

Decades of microbiologic testing have found that certain species of bacteria turn up again and again in endodontic infections. Susceptibility testing by Baumgartner found that Amoxicillin (combined with Clavulinic acid) was 100% effective at killing bacteria within his study sample. Clindamycin was second at 96%¹.

In addition, there is evidence that is suggestive that teeth which have had root canal treatment in the past, and that are either recurrently or persistently infected, contain bacteria that might be better treated with Clindamycin².

With all of this taken into consideration, it is reasonable to assume that dentists will need to prescribe a significant amount of Clindamycin to control tooth abscesses. A good number of patients’ charts in my office have little stickers indicating Penicillin allergy (Amoxicillin is a type of Penicillin). This then leaves Clindamycin as the next logical choice.

To finish up, here’s the final important fact: Both Amoxicillin and Clindamycin (among other antibiotics) have been shown to contribute to the risk of developing Pseudomembranous Colitis.

With the amount of dental infection out there, we have to assume that there’s a lot of Amoxicillin and Clindamycin being prescribed by dentists. For argument sake, say the incidence of Clinda-induced colitis is 1% and there are 1000 prescriptions a week for Clinda. Ten patients a week would have some sort of diarrhea within 6 weeks of taking the antibiotic. An E.R. department would probably not see all of these patients, but they would sure see a good number of them. This then reinforces within the mind of this particular E.R. Doc, of whom I am writing, that Clinda is bad–very bad. I’m sure he doesn’t ask patients if they’ve been taking any other antibiotics, and if he does, he doesn’t realise the link these antibiotics might have to the diarrhea. He just attributes the diarrhea to something else less obvious.

This particular MD vehemently informs patients that the dentist is at fault for giving them Clindamycin and encourages them to seek further action against the dentist. This type of behaviour is unprofessional, has gone on long enough, and is going to result in action on my part.

As an aside; I recently retreated a root canal on a patient who is the husband of a physician in town. He flared up between appointments, so I prescribed Clinda for him. His wife refused to let him take the antibiotic because they had a patient once who got colitis from it. So she gave him something else (probably Clarithromycin) and the infection got worse while he was taking this other antibiotic. A week later, he was no better off. They reconsidered their choice at that time.

1. Baumgartner JC, Xia T. Antibiotic susceptibility of bacteria associated with endodontic abscesses. J Endod. 2003 Jan;29(1):44-7. [↩]
2. Molander A, Reit C, Dahlen G, Kvist T. Microbiological status of root-filled teeth with apical periodontitis. Int Endod J. 1998 Jan;31(1):1-7. [↩]