Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling
This review and summarization was conducted by Umair Akbar, from Virginia Healthy Smiles, Inc. The original source of the information is located here. Virginia Healthy Smiles, a non-profit focused on education and evidence-based dental practice, was founded by Hira Ansari.
Reference: Lockhart, Peter B., et al. “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.” The Journal of the American Dental Association 150.11 (2019): 906-921.
The American Dental Association Council on Scientific Affairs and the Center for Evidence-Based Dentistry convened an expert panel to conduct a systematic review and formulate clinical recommendations for the use of antibiotics in the treatment of symptomatic irreversible pulpitis with or without symptomatic apical periodontitis, pulp necrosis, or localized acute apical abscess.
Types of Studies Reviewed
• To find data on the advantages and dangers of antibiotic usage, the authors searched the literature in MEDLINE, Embase, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature.
• They utilized the Evidence-to-Decision framework and the Grading of Recommendations Assessment, Development, and Evaluation technique to assess the evidence’s certainty.
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.
Conclusion and Practical Implications
• Dental pain and intraoral swelling are not only a concern for dental providers but are also the most cited oral health−related reasons for a patient contacting an emergency department (ED) or physician
• Although a number of countries and clinical practice guideline development groups have produced recommendations on the use of systemic antibiotics to treat pulpal and periapical infections, there are no guidelines from the American Dental Association (ADA) for dentists in the United States
• Owing to major public health and cost-related concerns, the appropriate use of antibiotics has become a critical issue in the health care agenda
Scope, Purpose, and Target Audience
• The purpose of this guideline is to assist clinicians and patients in determining the appropriate use of systemic antibiotics for the urgent management of the following target conditions: SIP with or without SAP, PN-SAP, and pulp necrosis and localized acute apical abscess (PN-LAAA)
• This guideline focuses on immunocompetent adult patients (18 years or older) with the target conditions and without additional comorbidities.
• Although these recommendations are intended primarily for use by general dentistists, they also may be used by specialty dentists, dental educators, dental therapists, emergency and primary care physicians, infectious disease specialists, physician assistants, nurse practitioners, pharmacists, and policy makers.
How to Use These Recommendations and GPS
• The expert panel graded the strength of recommendations to provide clinicians, patients, and policy makers with orientation as to how to proceed in the face of the recommendation statement
Recommendations in settings in which DCDT is not immediately available
• The use of antibiotics may result in little to no difference in beneficial outcomes (low certainty) but could result in a potentially large increase in harm outcomes (moderate certainty).
• Although patients’ values and preferences (PVP) will likely vary owing to access-to-care issues, the panel considered values/preference to be a crucial factor for decision making.
• There is a high chance for an underestimation of the burden of antibiotics prescribed by dentists. The panel calculated an adjusted estimate to illustrate the burden and rated the certainty of these estimates down owing to serious issues of indirectness.
Recommendations in settings in which DCDT is immediately available
• For immunocompetent adults with PN-SAP/PN-LAAA: The panel judged that the anticipated desirable effects of antibiotics as adjuncts to DCDT to be negligible.
• The use of antibiotics may result in little to no difference in beneficial outcomes (very low certainty) but likely result in a potentially large increase in harm outcomes (moderate certainty), warranting a strong recommendation against their use.
Pulp necrosis and Acute Apical Abscess with Systemic Involvement
• The panel provided GPS for the use of antibiotics in patients with systemic involvement, given that the role of antibiotics for this population has been extensively studied and the balance between benefits and harms when systemic involvement is present has been well established.
Summary of the rationale for the type of antibiotic and regimen
• To inform the current status of antibiotic prescribing behaviors of dentists, including antibiotic types, doses, and durations, we used a 2018 scoping review
• We also included input from stakeholders and expert panelists and data on antibiotic sensitivity
• Clinicians should proceed with nonpenicillin drug class antibiotics until further confirmation of a true penicillin allergy
• The panel suggests prescribing oral cephalexin, oral azithromycin, or oral clindamycin
• Prevention of CDI should be a community priority in addition to a hospital priority
• Estimates for pain outcomes may be influenced by the use of analgesics in both intervention and control groups
• When considering the effect of antibiotics on pain experience and intensity, the panel interpreted any improvement in pain as additional pain relief attributable to antibiotics
• Providers often prescribe antibiotics even when they are not appropriate owning to the patient’s being in severe pain and expecting antibiotics to relieve this pain
Scope, purpose, target audience
• The scope of this guideline is limited to immunocompetent adults.
• It is possible to have 1 of the following conditions and be able to respond to a bacterial challenge: AIDS, HIV with a CD4 T cell count below 200 cells per cubic millimeter, or HIV with an AIDS-defining opportunistic illness.
Evidence and outcomes informing this guideline
• Complete list of outcomes for community-associated Clostridioides difficile infection (CDI): total analgesics used, total number of nonsteroidal ant-inflammatory drugs used, progression of disease to more severe state (malaise, trismus, fever, cellulitis, additional dental visit, and additional medical visit), cost-effectiveness of antibiotics to treat symptomatic irreversible pulpitis with or without symptomatic apical periodontitis, hospitalizations, and outcomes of dental procedures
• List of outcomes of anaphylaxis: allergic reaction to antibiotics, allergic reaction associated with a dental prescription, anaphylenephrine, fatal anaphyllaxis due to antibiotics
• Includes evidence from randomized controlled trials and observational studies to inform this guideline, in that order of priority
Moving from evidence to decisions
• The expert panel formulated recommendations using the GRADE evidence-to-decision framework, facilitated by a methodologist (M.P.T.)
• This framework considers 8 factors
• importance of the health care problem
• magnitude of desirable effects, magnitude of undesirable effects, certainty in the evidence
• patient’s values and preferences
• balance of desirable versus undesirable effects
• acceptability
• feasibility
• Finally, the panel decided the direction and strength of the recommendation
Footnotes
• The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.
• Methodologists from the American Dental Association Center for Evidence-Based Dentistry led the development of the systematic review and clinical practice guideline in collaboration with the expert panel.
Clinical pathway for treatment of immunocompetent adult patients seeking treatment in a dental setting with a pulpal or periapical condition
• DCDT refers to pulpotomy, pulpectomy, nonsurgical root canal treatment, or incision for drainage abscess
• Only clinicians who are authorized or trained to perform the specified treatment should do so
• For adult patients with pulp necrosis and symptomatic apical periodontitis, a delayed prescription should be provided if DCDT is not immediately available
• Dentists should instruct patients to discontinue antibiotics 24 h after their symptoms resolve, irrespective of reevaluation after 3 d
• Amoxicillin is preferred over penicillin because it is more effective against various gram-negative anaerobes and is associated with lower incidence of gastrointestinal adverse effects
• Bacterial resistance rates for azithromycin are higher than for other antibiotics, and clindamycin substantially increases the risk of developing Clostridioides difficile infection even after a single dose
Summary of clinical recommendations for the urgent management of symptomatic irreversible pulpitis with or without symptomatic apical periodontitis
• Pulpal and periapical conditions often seek treatment for pain, intraoral swelling, or both.
• Even when definitive, conservative dental treatment (DCDT) is not an option, antibiotics are often prescribed, either alone or as an adjunct to DCDT.
LAgP differs from CP by localization to incisors and first molars, early onset and rapid progression in adolescents and young adults, and a 10-fold higher prevalence in populations of African or Middle Eastern origin.
• The bacterium Aggregatibacter actinomycetemcomitans and hyperresponsive neutrophils are frequently observed.
• Progression of attachment loss is strongly associated with presence of the JP2 genotype of Aggregatibacter actinomycetemcomitans, Streptococcus parasanguinis, and Filifactor alocis is present in sites prior to bone loss in a longitudinal study of localized aggressive periodontitis
Conclusion – What’s new?
We discovered no new RCTs to add to the 3 reported in the 2 prior systematic reviews. 8 observational studies showed adverse results.
Do antibiotics help tooth discomfort and intraoral swelling?
We used RCT data to investigate the advantages of antibiotics for tooth pain and intraoral edema with and without DCDT. Antibiotics with or without DCDT may enhance or decrease discomfort or intraoral edema after 24 to 7 days (very low to low certainty).
Antibiotics for tooth discomfort and intraoral swelling: harmful?
To estimate antibiotic hazards, we used data from 3 RCTs and 8 observational studies. Observational studies suggested antibiotics may cause Clostridioides difficile infections (overgrowth of a life-threatening bacteria after antibiotic use) and antibiotic-resistant infections (in which antibiotics become less effective at killing bacteria), while RCTs suggested antibiotics may cause diarrhea and malaise. Antibiotic use definitely causes minor to moderate individual harms (low certainty) and potentially large community harms (very low to moderate certainty).
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