Antibiotics and Their Indication in Dentistry

by Dr. Frenda Williams, DDS

When to use antibiotics, how much to use and what type of antibiotic to use is making its way to the forefront of health care. This is due to an alarming rise in the number of antibiotic resistant superbugs. According to the Center of Disease Control and Prevention more than 2 million people in the US are hospitalized and more than 23,000 die each year from superinfections caused by antibiotic resistant bacteria. About 10% of outpatient antibiotics prescriptions are prescribed by dentists which equates to approximately 25.6 million per year. And it has been estimated that 30-50% of the scripts written by dentists were not necessary. As a result, dentists need to familiarize themselves with instances and conditions that warrant antibiotic prescriptions. With that being said let us look at a few instances.

Infective Endocarditis

In 2007 the American Heart Association changed its stance on what patients should be pre-medicated and which should not be. In fact the AHA got more specific in their guidelines and recommended that four types of patients should receive antibiotics 1 hour prior to dental treatment:

  1. Artificial  Heart valve or valve repaired with artificial material

  2. Patients with a history of infective endocarditis

  3. Patients with a cardiac transplant with abnormal valve function

  4. Patients with certain congenital heart defects

Pre-medication with antibiotics prior to dental treatment has been modified to include only those patients with serious underlying cardiac conditions that have high risk for adverse outcome.

Artificial Prosthetic Joints

Prior to 2002, it was common place for dentists to pre-medicate patients with artificial joints like hips, knees, pins etc. In 2014 the ADA, after reviewing clinical studies, concluded that patient’s with prosthetic joints do not require pre-medication. If however there is any doubt or concern it is recommend that a medical consultation form be sent to the patient’s orthopedic surgeon to determine if premedication is indicated or not.

Endodontic Pain and Abscesses

There are multiple reasons why dentist routinely prescribe antibiotics when treating endodontic problems with a patient. Some of those reasons include:

  1. Antibiotic treatment seems to work

  2. Dentist is in the habit of prescribing antibiotics when it comes to endo pain and abscesses

  3. Dentist wants to help patient especially when patient is in pain

  4. Patients expect antibiotics (This is a big one)

  5. Antibiotics are believed to prevent the spread of infection

  6. Dentists don’t want to be sued

Now that we have reviewed a few reasons why dentists prescribe antibiotics in association with endodontic pain and/or abscess, let us look at what the empirical evidence says.

  1. Antibiotics do not control or prevent localized endo pathology, including symptoms of irreversible pulpitis

  2. Antibiotics have no impact on post-surgical outcomes

  3. Antibiotics ARE indicated in a case of cellulitis/swelling

If the clinician finds that patient does require antibiotic treatment, the preferred antibiotic of choice is Penicillin due to the fact that endodontic infections are typically caused by obligate anaerobic bacteria. The penicillin class includes amoxicillin and Augmentin. If the patient has an allergy to penicillin or penicillin proves ineffective, clindamycin may be utilized. Finally, Metronidazole can also be considered alone or in combination with penicillin/amoxicillin in treating swelling associated with endodontics.

Oral Surgery Extractions

Studies show that antibiotic treatment in association with having impacted third molars removed has concluded that there are several benefits:

  1. Patients experience lower incidence of post-surgical infections

  2. Decrease likelihood of developing ‘dry socket’

  3. Less pain

  4. Less swelling

It should be noted that only about 5% of patients that have had third molars removed will develop post-operative infection. As a result, it is recommended that antibiotics not be prescribed following routine extraction of impacted third molars unless:

  1. The extraction was exceptionally difficult

  2. Patient has an underlying health problem compromising the patient’s ability to resist infection

  3. The extraction area is acutely infected

  4. Other extenuating circumstances.

Antibiotics prescribed in association with routine dental extractions is not advised unless:

  1. The extraction was exceptionally difficult

  2. Patient has an underlying health problem compromising the patient’s ability to resist infection

  3. The extraction area is acutely infected

  4. Other extenuating circumstances

The overuse of antibiotics in the pre and post treatment of dentistry is widespread and contributing to the creation of antibiotic resistant superbugs. As a result, it is advised that the clinician have a proper diagnosis of the patient’s problem and prescribe a narrow spectrum antibiotic to address the condition. Conditions that warrant antibiotic treatment include:

  • Oral infections with elevated body temperatures

  • Evidence the infection has spread systemically

  • Facial cellulitis and/or dysphagia

  • Periodontal abscess

  • Acute periodontal infection where drainage is impossible

  • ANUG

  • Sinusitis

  • Pericoronitis

Antibiotics are a powerful adjunct to be utilized with other clinical treatment and should not be solely relied on to treat dental infections.

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