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Endodontics and Antibiotic Update - dental abscess antibiotic guidelines

Endodontics and Antibiotic Update-dental abscess antibiotic guidelines

and Antibiotic
Fall 2019
Colleagues for Excellence
Published for the Dental Professional Community by the
ENDODONTICS: Colleagues for Excellence
Estimates suggest that pulpal disease may affect up to 30% of the world's population. When left unchecked,
pulpal disease lends itself to a reduced quality of life by means of increased pain, loss of physiologic function and
compromised anatomical form of the affected dentition. Scientific literature consistently highlights the undeniable
benefits of antibiotic use in treatment of disease control, more specifically odontogenic bacterial infections. However,
the value of these drugs in preventing serious health complications is not always congruent with safety; because their
use can be undermined by disruptive prescribing practices and behaviors that lead to misuse of antibiotics and their
associated adverse effects (1).
Guidelines for proper prescription of antibiotics in helping to manage polymicrobial infections have remained
consistent throughout the endodontic literature, although recent updates warrant mention, according to a new report
by the American Dental Association (17). Classic literature consistently illustrates that a regimen of systemic oral
antibiotics is not indicated for a small localized swelling in the absence of systemic signs and symptoms of infection or
spread of infection (2). A recent Cochrane Database Systematic review showed that antibiotics were of no additional
therapeutic benefit for healing of a localized periapical abscess. Outcomes of pain and infection were dependent
upon drainage being relieved through access or incision and drainage (3). Evidence shows that antibiotics are an
adjunct in the management of periradicular infections. In an effort to save the natural dentition, effective treatment of
odontogenic infections must include removal of the reservoir of infection through endodontic treatment.
Endeavors to better identify factors influencing safe and recommended antibiotic prescribing regimens have
galvanized worldwide attention, with the World Health Organization leading the way to safeguard against antibiotic
resistance (4). The role of dentistry in the phenomenon of antibacterial resistance from over prescribing has yet to
be quantified but cannot be denied. According to the Centers for Disease Control, in 2011 dental professionals wrote
Chart 1. Oral antibiotic prescribing by provider type -- United States, 2011
Primary Care Physicians 134.9 568
Physician Assistants and Nurse
Practitioners 38.5 222
Surgical Specialties 23.0 187
Dentistry 20.8 233
Emergency Medicine 14.7 454
Dermatology 8.5 746
Obstetrics/Gynecology 7.2 191
Other 25.7 124
All Providers 273.3 300
Chart 2. Oral antibiotic prescribing by provider type -- United States, 2016
For each provider specialty, number of prescriptions and rate per provider
Primary Care Physicians 106.3 448
Physician Assistants and Nurse
Practitioners 68.4 395
Surgical Specialties 19.3 217
Dentistry 25.7 210
Emergency Medicine 14.7 454
Dermatology 6.9 608
Obstetrics/Gynecology 6.0 160
Other 22.9 110
All Providers 270.2 296
Endodontics and Antibiotic Update
nearly 21 million prescriptions.
(Chart 1, reference 5) Almost 50% of those antibiotics were either prescribed or used incorrectly. These statistics
create a stark reality of the concern needed for proper prescription guidelines to be upheld (6). Data from the same
CDC database highlights an alarming upward trend. In 2016, nearly 26 million oral systemic antibiotic prescriptions
were written by dentists alone. That's nearly 10% of all prescriptions written in the outpatient setting by the provider
types as classified by the American Medical Association (Chart 2, reference 5). This pattern is mirrored in British
Columbia, Canada, where, from 1996 to 2013 antibiotic prescriptions by physicians decreased, whereas that of
dentists increased by more than 62.2% (7). More conservative estimates of prescribing habits of a specific cohort of
U.S. dentists showed the rate of antibiotic prescribing practices by general dentists remained stable during the three-
year study period (2013-2015), and despite a slight decrease in antibiotics used for indeterminate and prophylaxis
purposes, approximately 14% of antibiotic prescriptions were deemed inappropriate, based on the antibiotic
prescribed, antibiotic treatment duration or both indicators (8).
These statistics are concerning. In dentistry, antibiotic prescriptions should mainly be therapeutic based on clinical
signs, symptoms or clinical conditions. Antibiotic prescriptions may also be prophylactic with a primary focus on
prevention of infective endocarditis and or prosthetic joint implant infection. Dentists should rarely prescribe oral
systemic antibiotics for primary therapy or as a first-line treatment for an infection (9).
Influencing prescription patterns has challenges because not all clinicians have access to or actively search for the
most up to date evidence based recommendations. However, many dentists acquire knowledge through peer-reviewed
sources and educational platforms (10). Evidence further shows that information gained through these various outlets
can impact patterns and influence antibiotic stewardship leading to better prescribing habits.
This issue of Colleagues provides recommended best practices and updates within the literature on antibiotic
prescribing for clinical and nonclinical indications. Reviewing the following guidelines may help to establish general
practices to aid us in making clinical decisions regarding the use of antibiotic therapy, lending to safer and more
effective habits.
Endodontic Infection
Endodontic disease can be primary or secondary infections characterized by a polymicrobial nature which lends to
biofilm formation. Microbial biofilms in the root canal are highly complex, multi-species entities that amplify the difficulty
in eradication of the microbial biomasses. The bacterial microflora of the root canal is initially dominated by aerobes
and facultative anaerobes (11). As disease progresses, the ecology within the root canal system changes and is largely
characterized by anaerobic bacteria in primary infections. The most common species of bacteria isolated in odontogenic
infections are the anaerobic gram-positive cocci Streptococcus milleri group and Peptostreptococcus. Anaerobic gram-
negative rods, such as Bacteroides (Prevotella) also play an important role. In general, primary infection involves pulp
inflammation and root canal infection following invasion by microbes or microbial by-products, eventually resulting in
inflammation of the supporting tissues causing apical periodontitis. Secondary infection (or post-treatment infection)
occurs either as reinfection (acquired or emergent), remnant (persistent) infection or recurrent infection (re-developed
in teeth after apparent healing) in teeth that have been previously root canal treated (12). The microbial flora found
in secondary infections, typically are able to survive harsh conditions such as a wide pH range and nutrient-limited
conditions. There is a definite contrast in the microbial phenotypes in primary infections as compared to secondary
infections, more specifically the latter being predominated by gram-positive bacteria.
Whether primary or secondary involvement, infection will spread and the inflammatory response will progress until
the source of the irritation is managed or eliminated. A thorough evaluation [including past history, clinical evaluation
and relevant imaging modalities] is paramount for proper diagnosis and appropriate treatment of the source of
infection. It is imperative that the source of infection be addressed expeditiously. Placing a patient on antibiotics and
rescheduling to have the source dealt with at a later time is not sound practice and may allow the infection to worsen.
Generally, an accurate diagnosis coupled with effective endodontic treatment will decrease microbial flora sufficiently
for healing to proceed (13).
Treatment of Endodontic Infection
Objectives of endodontic treatment include removal of the etiologic agent (microbes and byproducts), debris and
inflammatory mediators from the infected root canal system (14). In essence this allows the host to regain a favorable
condition promoting health and letting the periapical tissues return to a state of reduced inflammation/infection.
Evidence based reviews highlight very specific indications for prescribing antibiotics preoperatively or postoperatively

Why is your abscess tooth not responding to antibiotics?Here are some of the things that you should do:Brush your teeth twice a day. Make sure to keep brushing for at least two minutes and use fluoride toothpaste.Use floss. ...Don’t rinse your mouth after brushing your teeth. ...Don’t consume sugary or starchy food and fizzy drinks. ...Regularly visit your dentist. ...Replace your toothbrush every few months. ...Use a fluoride mouth rinse. ...