Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association

Abstract

Background: An expert panel convened by the American Dental Association Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review and formulated clinical recommendations for the urgent management of symptomatic irreversible pulpitis with or without symptomatic apical periodontitis, pulp necrosis and symptomatic apical periodontitis, or pulp necrosis and localized acute apical abscess using antibiotics, either alone or as adjuncts to definitive, conservative dental treatment (DCDT) in immunocompetent adults.

Types of studies reviewed: The authors conducted a search of the literature in MEDLINE, Embase, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature to retrieve evidence on benefits and harms associated with antibiotic use. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and the Evidence-to-Decision framework.

Results: The panel formulated 5 clinical recommendations and 2 good practice statements, each specific to the target conditions, for settings in which DCDT is and is not immediately available. With likely negligible benefits and potentially large harms, the panel recommended against using antibiotics in most clinical scenarios, irrespective of DCDT availability. They recommended antibiotics in patients with systemic involvement (for example, malaise or fever) due to the dental conditions or when the risk of experiencing progression to systemic involvement is high.

Conclusion and practical implications: Evidence suggests that antibiotics for the target conditions may provide negligible benefits and probably contribute to large harms. The expert panel suggests that antibiotics for target conditions be used only when systemic involvement is present and that immediate DCDT should be prioritized in all cases.

Keywords: Antibiotics; antibiotic stewardship; clinical practice guideline; localized acute apical abscess; pulp necrosis; symptomatic apical periodontitis; symptomatic irreversible pulpitis.

Figure 1.

Clinical pathway for the treatment of immunocompetent adult patients presenting in a dental setting with a pulpal or periapical condition, where definitive conservative, dental treatment is not immediately available Footnotes. * Definitive conservative dental treatment refers to pulpotomy pulpectomy, non-surgical root canal treatment, or incision for drainage of abscess. Only clinicians who are authorized or trained to perform the specified treatments should do so. ^† Adult patients with pulp necrosis and symptomatic apical periodontitis should be instructed to call if their condition deteriorates (progression of disease to a more severe state) or if the reterral to receive definitive conservative dental treatment within 1–2 days is not possible ^‡ For adult patients with pulp necrosis and symptomatic apical periodontitis, a delayed prescription should be provided if definitive, conservative dental treatment is not immediately available. Dentists should communicate to the patient that if their symptoms worsen and they experience swelling or formulation of purulent material. the delayed prescription should be filled A delayed prescription is defined by the Centers for Disease Control and Prevention as a prescription that is used for patients with conditions that usually resolve without treatment but who can benefit from antibiotics if the conditions do not improve (Sanchez. 2016). ^§ Clinicians should reevaluate patient within 3 days (e.g., in-person visit or phone call) Dentists should instruct patients to discontinue antibiotics 24 hours after patient’s symptoms resolve, irrespective of reevaluation after three days. ^¶ Although the expert panel recommends both amoxicillin and penicillin as first-line treatments., amoxicillin is preferred over penicillin because it is more effective against various gram-negative anaerobes and its lower incidence of gastrointestinal side effects. * Bacterial resistance rates tor azithromycin are higher than for other antibiotics, and clindamycin substantially increases the risk of Clostridioides difficile infection (CDI) even after a single dose (Thornhill, 2015) Due to concerns about antibiotic resistance, patients who receive azithromycin should be instructed to closely monitor their symptoms and call a dentist or primary care provider if their infection worsens while on therapy Similarly, clindamycin has a U.S. Food and Drug Administration Black Box warning for CDI which can be fatal Patients should be instructed to call their primary care provider if they develop fever abdominal cramping, or ≥3 loose bowel movements per day (Leffler 2015) If the patient is currently taking an antibiotic within the same spectrum as the one indicated additional antibiotics do not need to be prescribed If the patient is currently taking an antibiotic outside of the spectrum as the one indicated, the intended antibiotic can still be prescribed, considering potential contraindications. An antibiotic with a similar spectrum of activity to those recommended can be continued if the antibiotic was initiated prior to patient presentation. As with any antibiotic use, the patient should be instructed on symptoms that may indicate lack of antibiotic efficacy and adverse drug events.

Figure 2.

Clinical pathway for the treatment of immunocompetent adult patients presenting in a dental setting with a pulpal or periapical condition where treatment is immediately available Footnotes * Definitive, conservative dental treatment refers to pulpotomy, pulpectomy, non-surgical root canal treatment, or incision for drainage of abscess. Only clinicians who are authorized or trained to perform the specified treatments should do so. ^† Clinicians should reevaluate patient within 3 days (e.g., in-person visit or phone call). Dentists should instruct patients to discontinue antibiotics 24 hours after patient’s symptoms resolve, irrespective of reevaluation after three days. ^‡ Although the expert panel recommends both amoxicillin and penicillin as first-line treatments, amoxicillin is preferred over penicillin because it is more efficacious against various gram-negative anaerobes and its lower incidence of gastrointestinal side effects. ^§ Bacterial resistance rates for azithromycin are higher than for other antibiotics, and clindamycin substantially increases the risk of Clostridioides difficile infection (CDI) even after a single dose (Thornhill. 2015). Due to concerns about antibiotic resistance, patients who receive azithromycin should be instructed to closely monitor their symptoms and call a dentist or primary care provider if their infection worsens while on therapy. Similarly, clindamycin has a U.S. Food and Drug Administration Black Box warning for CDI, which can be fatal. Patients should be instructed to call their primary care provider if they develop fever, abdominal cramping, or ≥3 loose bowel movements per day (Leffler, 2015). If the patient is currently taking an antibiotic within the same spectrum as the one indicated, additional antibiotics do not need to be prescribed. If the patient is currently taking an antibiotic outside of the spectrum as the one indicated, the intended antibiotic can still be prescribed, considering potential contraindications. An antibiotic with a similar spectrum of activity to those recommended can be continued if the antibiotic was initiated prior to patient presentation. As with any antibiotic use, the patient should be instructed on symptoms that may indicate lack of antibiotic efficacy and adverse drug events.