Antibiotic stewardship also involves the responsible use of therapeutic antibiotics to treat existing infections, as it is common for clinicians to inappropriately prescribe antibiotic treatment. Some of the reasons that dentists may misuse antibiotics include inadequate knowledge about management of infections, pressure from patients requesting antibiotics, failure to consider treatments other than systemic antibiotics (e.g., surgery), belief that broad-spectrum antibiotics are the most effective treatment, and the demands of running a busy practice.18 Raising awareness about the risks of unnecessary use of antibiotics should be included as part of a dental antimicrobial stewardship strategy.19
According to the CDC,20 “appropriate antibiotic prescribing means antibiotics are only prescribed when needed, and when needed, the right antibiotic is selected and prescribed at the right dose and for the right duration” and “appropriate antibiotic prescribing should be in accordance with evidence-based national and local clinical practice guidelines, when available.
The treatment of endodontic infections is one area where dentists can exercise responsible antibiotic administration. An ADA ACE Panel Report on antibiotic use in endodontic infections21 suggests that the management of endodontic infections is best achieved through proper root canal debridement, disinfection, and drainage of the abscess and discourages the use of systemic antibiotics due to their inability to reach necrotic tissue and their contribution to antibiotic resistance and CDI. The same report found that of 391 member dentists surveyed, 51% had decreased their antibiotic prescribing patterns from 5 years ago, 43% remained similar, 2% increased their prescribing patterns, and 4% were unable to prescribe.
Dentists may want to consider the following when deciding whether or not to prescribe antibiotic treatment:2
- The overall health and immunity of the patient
- Preexisting conditions of the patient
- The type and location of the infection
- Whether the infection shows signs of spreading
- If the condition can be treated with surgical treatment
- If the patient has symptoms other than localized pain
The ADA Center for Evidence-Based Dentistry has developed a clinical practice guideline22 on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intra-oral swelling. The guideline, based on a systematic review and meta-analysis,23, 24 came to the following recommendations:
- The guideline recommends against using antibiotics for most pulpal and periapical conditions and instead recommends only the use of dental treatment and, if needed, over-the-counter pain relievers such as acetaminophen and ibuprofen.
- Instead of prescribing antibiotics, dentists should prioritize dental treatments such as pulpotomy, pulpectomy, nonsurgical root canal treatment, or incision and drainage for symptomatic irreversible pulpitis, symptomatic apical periodontitis, and localized acute apical abscess in adult patients with a normal immune response.
- If a patient’s condition progresses to systemic involvement, showing signs of fever or malaise, then dentists should prescribe antibiotics.
The ADA Center for Evidence-Based Dentistry has a page on ADA.org (ADA.org/antibiotics) with guideline- and antibiotic-related resources for dental professionals and patients, including a tool to help dentists find a guideline recommendation appropriate for their patients.