Tooth Extraction Antibiotics Methotrexate and Biologics

jamieA

I'm in need of a tooth extraction. A tooth I have a crown on which had been root treated many years ago has apparently developed a significant infection. Strangely I only ever had 2 teeth with crowns and the same thing happened with the other about 6 years ago.

I've spoken to my rheumatology clinic and they advise I need to come off both MTX and adalimumab for two weeks before and two weeks after an extraction and cannot take MTX for a week after any antibiotics course finishes. That restriction doesn't apply to the biologic however.

I've had antibiotics in the past for recurring chest infections and had never thought of the implications of also taking MTX.

The extraction has been delayed as my dentist wants to talk to my cardiologist due to the fact I'm on 2 blood thinners at present so I'll be able to comply with the 2 week initial break but being off MTX and adalimumab for a month is not a prospect I'm looking forward to.

noddingtonpete

Hi @jamieA - ouch is the word that springs to mind. Definitely need to be led by the medical profession. Have you tried a search to see what others have done, I know there have been a few discussions on tooth extraction and medication.

https://community.versusarthritis.org/search?domain=all_content&query=tooth%20extraction&scope=site&source=community

I hope it goes well.

Best wishes

Peter

jamieA

Hi @noddingtonpete

Yes I've had a look at other posts regards tooth extraction but couldn't find anything definitive regarding MTX and biologics. The rheumatology nurse was quite exact with what she told me as if she was reading from script. I've had antibiotic courses before from my GP for recurring chest infections and never thought to check with rheumatology about the need to come off MTX or adalimumab. It only occurred to me this time as the dentist wanted to discuss with my cardiologist the procedure for the removal of my tooth due to the cardiac drugs I'm on. I'm currently waiting on the outcome of the discussion so have not taken my MTX or adalimumab this week.

I'm aware that tooth issues can be linked to heart issues - I've a neighbour who suffered severe heart issues after a tooth infection got into his blood stream and damaged his heart during a dental procedure.

Arthuritis

@jamieA Here’s what I would do for myself in the same situation… Kind of was, got shingles and recurrent cellulitis type skin infections common with immune suppression and insufficient of exercise due to RA.

I had to get off MTX as it’s an immune suppressant, and a bacterial infection can quickly become deadly in the immune compromised ie anyone on mtx.

Like you I was dreading the horrors of being without MTX as usually by the 6th day I am aching for my MTX fix. I figured I had no choice, I’d do it, but go back on mtx if it got unbearable.

However I know a lot more now than I did back then. While everyone’s autoimmune is different, a key indicator is your eosinophil TREND over the past 12-24 months. I noted that every time I had a bit of a flare, the count had flashed up, and around that time I had eaten something which 4-8 hours later caused the flare. It’s almost never immediate. So I cut back on all the trigger foods (they are unique to each individual, so no general list, it’s trial and error discovery). Then I found the antibiotics have an interesting effect. Penicillin based antibiotics make MTX toxic by preventing its normal removal, so you accumulate more and more and get brain fog or worse (it’s in the BNF as contraindicated, but hardly any docs know why, they just assume it’s because MTX is an immune suppressor, few know WHY MTX is contraindicated with penicillin and PPIs). The other drug usually also given, is metronidazole to combat Porphyromonas gingivalis, a common bacterium in dental abscess situations. Metro MUST be taken with food, otherwise the nausea makes MTX nausea seem like choc sprinkles. However it had an interesting side effect of damping down eosinophil activity. So in my case, fearful as I was in getting antibiotics for a nasty skin infection and being off MTX, and the prospect of agony, I found the past history of mtx damping, selective diet and metro damped down my eosinophils so much that after the skin infection cleared, I DIDNT need MTX at all, no symptoms of RA, all confirmed by hosp. For 2 years I was FREE!!! Then in Jan this year, I had a reaction to something I ate, and my eosinophils shot up, very visible on the high tech charts the hospitals now have, and back into RA city and MTX.

So I suggest you might want to check your eosinophil trends, particularly any spikes. Simplify your diet. I had to give up poultry,

fish, mangoes, beans, papaya, some avocados, cow milk products but in exchange, I was able to run and go gym weightlifting and not need any DMARDs. Hosp still can’t get over it, and did loads of tests imaging etc and flummoxed.

I have since found that activated eosinophils are well recognised as being a key source of autoimmune conditions and triggered by allergies and parasites. This is in research papers, but NOT ONE clinician of all those I met, has spoken of it, or made the connection. Yet it’s in their clinical literature and plainly visible in the blood tests. They all harp on about CRP & ESR, but these are for acute injury, not useful for steering or prediction. I found in my case keeping below 0.2x10^9/L meant no symptoms, below .1, no need for meds, and horrors at above .4

Now listen to this Zoe podcast with a Stanford U Prof of Rheumatology, and the wisdom gleaned from her patients and a Dutch double blind controlled trial on how to avoid RA pain:

https://podcasts.apple.com/gb/podcast/zoe-science-nutrition/id1611216298?i=1000696532853

Discuss with a doc that actually THINKS, and can explains the MECHANISMS, if they just parrot the party line, they won’t be able to help you navigate, and you need to find another.

Note in my case, finding the trigger foods was quite a lengthy meticulous process full of surprises. Eg, wild Norwegian cod & salmon would trigger my RA, but a Big Mac didn’t! I put it down to a reversal during covid. I never ate junk or unhealthy, and for some reason I had become allergic to all the healthy stuff, but fine with junk! I had to fast, clear out everything and eat a small sample of just one thing, wait 24hrs to discover if it was on the good list or bad list.

Hope that helps. I am still on my journey to try to re-establish what I lost on 20 Jan 2025

Arthuritis

https://patient.gastro.org/six-food-elimination-diet-sfed/

Seems some US clinicians have already researched & documented the trial and error diet change process I had to discover on my own…

@jamieA

@Trish9556

@frogmorton

Sorry the @frogmorton link doesn’t work reliably… see above many tries later it randomly pops up!

I hope that what I discover, can be reused by others so they do not have to rediscover or re-invent.

We only have each other for support.

Arthuritis

Reminds me of the struggle to convince anyone in the NHS that loss of smell was very likely cerveza sickness in 2020… it was only generally accepted many months after all EU had it as a key differentiating symptom and NICE/NHS website only recognised it towards end 2022… far from the claim that the UK was leading anything… unless leading from the rear. Streeting needs ministers like Drs Alexander Fleming, Barry Marshall, John Lykoudis, Jenner pioneers that paid attention, thought critically and not wrapped up in corporate sponsored group think.

Arthuritis

This chart since my diagnosis, has been highly predictive. Everytime it’s above .25 I start having RA symptoms, with intensity rapidly increasing above .25. Below .25 the symptoms are undetectable and only briefly pop up if I eat something from my forbidden list. If I keep below .2 I don’t even need any DMARDs

As you can see, as of 26 Nov 2024, I was in a great place, and even the radiologist was amazed despite having serologically confirmed RA, I had no trace of active disease.

Then on 20Jan it all went wrong, and on 7 Feb I had to get tested to restart MTX, (amber 0.4), and trying to re-establish what I had stumbled on in March 2023.

BTW this is an NHS chart, from a system that some hospitals bought a license for, after NHS HM Govt wasted £12bn trying to re-invent it, failing, and then sweeping under the carpet. Would have been cheaper to buy the license. Like trying to invent your own MS Excel vs license a copy at a negotiated bulk price. Reminds me of Post Office Horizon project. Unless citizens, patients and taxpayers push back and hold the budget holders accountable this huge waste of money will carry on, at a time when we really can’t afford such waste.

During my self induced remission I no doubt saved the NHS money, and my full time work paid additional taxes, all of which I was happy to do, but can’t now, unless the NHS adopts a better approach to health.

jamieA

Well I'm now into my last week of being off MTX and adalimumab and I've got to say it's been a hard slog. If I'd any doubts that the medication was making a difference before I don't now. The way the timing of my tooth extraction worked out I'll have been off MTX for 4 weeks and adalimumab for 5 weeks when I can finally start them again this coming Thursday. I'd had a stock of 30/500 cocodamol at home after a repeat prescription blunder last year and I've just about used them all up. I'm hoping the benefits of restarting the medication are quickly realised.