Only When Necessary

According to research, factors influencing clinicians' decisions to prescribe antibiotics for patients with dental pain and intraoral swelling include the desire to reduce the uncertainty associated with the "watch and wait" model, barriers in the healthcare system, gaps in knowledge or disagreement with existing guidelines, diagnostic and prognostic uncertainties, patient expectations, and access-to-care issues.¹ Moreover, the results of one study suggest that antibiotic prescriptions by dentists have increased at an alarming rate.² Achieving a more thorough understanding of when and how antibiotics should be prescribed can help to guide dentists toward using them more effectively and less frequently, providing the safest treatment for patients.

There are two basic situations in which antibiotics are used in medicine and in dentistry. The first is to prevent an infection (ie, prophylactic use), and the second is to treat an infection (ie, therapeutic use).³

Prophylactic Antibiotics

Based on the nature of the infection being prevented, prophylaxis can be classified as either primary or secondary. Primary prophylaxis is used to prevent the initial development of an infection. An example of this is the administration of antibiotics to prevent oral surgical site infections. Oftentimes, dentists employ primary prophylaxis in the treatment of healthy patients who are undergoing invasive oral health procedures, such as surgical extractions, implant placement, and endodontic procedures.⁴ However, studies have shown that the routine use of systemic antibiotics for implant placement in healthy patients is not supported⁵ and that for endodontic procedures, antibiotic prophylaxis may not even be effective in eliminating the occurrence of postoperative infections.^6,7 Primary prophylaxis is also sometimes used to reduce the risk of experiencing pain, infection, or dry socket after tooth extractions; however there is much debate as to whether this causes more harm than good.⁸

Secondary prophylaxis is used to prevent the recurrence of an infection or the development of infection at a secondary site.⁹ For example, if a patient undergoing dental surgery also possesses a high-risk cardiac condition, antibiotics may be given to prevent infective endocarditis. Historically, patients with rheumatic heart disease, coronary artery bypass graft, mitral valve prolapse, recent myocardial infarction, and total joint replacement have been prescribed antibiotics when undergoing dental surgery; however, some guidelines no longer recommend the use of antibiotic prophylaxis for patients with these conditions or only recommend its use in certain circumstances.^10,11

Therapeutic Antibiotics

In dentistry, antibiotics are prescribed therapeutically to treat odontogenic and nonodontogenic infections and can be classified as either primary or adjunctive. Primary therapy is described as first-line treatment for an infection and is rarely required in dentistry. However, dentists do regularly employ adjunctive antibiotic therapy, such as that administered in conjunction with surgical debridement to prevent the spread and systemic manifestation of endodontic infection.¹² "There are no hard-and-fast rules regarding the appropriate prescription of antibiotics," explains Peter L. Jacobsen, PhD, DDS, a private practitioner and adjunct professor at the University of the Pacific Arthur A. Dugoni School of Dentistry. "Each patient and clinical situation is unique, and science is an evolving process, so trying to create a hard-and-fast rule is a formula for creating problems instead of solutions."

There are negative consequences associated with the improper prescription of antibiotics, not only for the individual patient who is receiving them but also for the greater community as well. In individuals, antibiotics can produce adverse drug reactions ranging from minor and reversible to severely debilitating or fatal.¹³ In addition, antibiotics can weaken the barrier function of an individual's colonic microbiota, resulting in potentially life-threatening opportunistic bacterial infections, such as Clostridium difficile.^14,15

More broadly speaking, the overuse of antibiotics contributes to antibiotic resistance among bacteria, which is a growing concern.¹⁶ One way to slow the spread of resistant bacteria is through improved stewardship of antibiotics. This involves using them more carefully to reduce the overall number of prescriptions. With an estimated 7% to 10% of the world's antibiotic prescriptions originating from dental practices and as many as 80% of those prescribed unnecessarily, dentistry has an important role to play.¹⁷ To help clinicians better understand the factors involved in the decision to prescribe antibiotics in different clinical situations, the American Dental Association (ADA) and other agencies have developed guidelines.

Regarding the urgent management of pulpal- and periapical-related dental pain and intraoral swelling, the ADA only recommends prescribing antibiotics for immunocompetent adult patients with pulp necrosis and localized acute apical abscess in settings in which definitive, conservative dental treatment is not available. In settings in which definitive, conservative dental treatment is available, the ADA's expert panel suggests not prescribing antibiotics for immunocompetent adult patients with symptomatic irreversible pulpitis with or without symptomatic apical periodontitis, pulp necrosis and symptomatic apical periodontitis, or pulp necrosis and localized acute apical abscess because of the potentially negligible benefit and likelihood of significant harm associated with their use.¹

Historically, patients with heart conditions that might predispose them to infective endocarditis who were undergoing certain dental procedures were indicated for antibiotic prophylaxis; however, in updated guidelines developed by the American Heart Association with input from the ADA, infective endocarditis prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis, including those with prosthetic heart valves, prosthetic material used for cardiac valve repair, a history of endocarditis, a cardiac transplant with valve regurgitation, and specific types of unrepaired and repaired congenital heart disease.¹⁸

Patients with prosthetic joints have also historically been prescribed antibiotics prophylactically prior to dental procedures. Although a January 2015 ADA clinical practice guideline states that "in general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection,"¹¹ according to the ADA, for patients with a history of complications associated with their joint replacement surgery who are undergoing dental procedures that include gingival manipulation or mucosal incision, prophylactic antibiotics should only be considered after consultation with the patient and his or her orthopedic surgeon.¹⁸

Generally speaking, the ADA has recommended that the profession shift away from a "just in case" approach to antibiotic prescribing to a "when absolutely needed" approach.¹ "In addition to the risks of superinfections and antimicrobial resistance, both of which should give clinicians pause, adverse effects such as allergic reactions, photosensitivity, and anaphylaxis can develop," explains Rebekah Lucier Pryles, DMD, a private practitioner in White River Junction Vermont, an assistant clinical professor at the Tufts University School of Dental Medicine, and a clinical instructor at the Harvard School of Dental Medicine.

"For patients who have an allergic or untoward reaction to a specific antibiotic, there are various alternatives that can be used," notes Mark Donaldson, PharmD, an associate principal at Vizient Pharmacy Advisory Solutions, a clinical professor at the University of Montana, and a clinical assistant professor at the Oregon Health & Science University. "For example, clindamycin is a great choice for a patient with an active odonatological infection who may be penicillin allergic."

Although there are alternatives to protect individuals with allergies when antibiotics are necessary, this does not address the bigger picture of antibiotic stewardship. "In dentistry, the most important alternative to antibiotics is not actually a pharmacologic alternative, it's the appropriate first step: good technique," explains Jacobsen, "Identifying the reason for the infection, locating it, and either incising and draining, extracting the tooth, or performing a root canal-those are the steps that actually stop an infection, not antibiotics."

Pryles concurs. "Antibiotics are adjunctive in the treatment of dental infections. Definitive treatment should be provided to patients in lieu of antibiotic therapy unless prescriptions are absolutely necessary." However, when antibiotics are necessary, who should prescribe them?

When indicated, the clinician who prescribes the antibiotics and when they are prescribed depends on a variety of factors not limited to simply which issue is being treated and its location in the body. "Oftentimes, it depends on who the patient calls first," notes Brooke Blicher, DMD, a private practitioner in White River Junction Vermont, an assistant clinical professor at the Tufts University School of Dental Medicine, and a clinical instructor at the Harvard University School of Dental Medicine. "However, I'd say that prescribing for acute infections, such as swelling secondary to endodontic infections, falls under the auspices of dental care, where a dentist should be making the diagnosis and recommending treatments, including antibiotics."

Jonathan Shapiro, DMD, a private practitioner in Manhattan Beach, California, adds, "However, if there is any doubt, or if there are underlying medical conditions that warrant input from the patient's physician, the dentist should consult with the physician." In these cases, communication between the dentist and the patient as well as between the dentist and the physician is key.

For individuals in the relatively few patient subpopulations for whom antibiotic prophylaxis is indicated prior to certain dental procedures, it is recommended to involve the patient's physician in the determination of necessity. For example, for patients with a history of complications associated with their joint replacement surgery for whom antibiotics are deemed necessary, ADA states that "it is most appropriate that the orthopedic surgeon recommend the appropriate antibiotic regimen and, when reasonable, write the prescription."¹⁸

One of the overarching goals of an inclusive, comprehensive approach to healthcare is to incorporate oral healthcare as seamlessly as possible into a patient's overall healthcare. Antibiotic stewardship is the responsibility of both dentists and physicians, and to protect patients, both must ensure that antibiotic therapy is only initiated when it is indicated and that the right drug is prescribed at the right dose for the right duration. "As I often teach my students, there is never any harm or shame in asking for help," emphasizes Donaldson. "So any time you feel uncomfortable prescribing and would like a physician's involvement-get it!"

A clear understanding of the most up-to-date evidence-based clinical guidelines is essential to appropriate antibiotic prescribing. Because there are no hard-and-fast rules, dentists must use this guidance along with their professional judgment in order to optimize their prescribing practices for each clinical situation. The best way that dentists can serve their patients is to be as educated as possible and make careful decisions regarding the necessity of antibiotics. Dentists play an integral role in their patients' overall healthcare as well as in antibiotic stewardship; therefore, the appropriate use of antibiotics is critical to delivering high-quality patient care, protecting patients by minimizing the risk for adverse events, and slowing the spread of antibiotic resistance.