Dental pain and swelling a common reason for patients requesting emergency appointments with both dental and medical providers. Antibiotics are often prescribed by dentists and doctors to relieve dental pain and swelling and in the USA general and speciality dentists and the third highest prescribers of antibiotics in outpatient settings.  Research has suggested that about 30% of dental antibiotic prescriptions are not indicated or sub optimal.  With increasing concerns about the development of bacterial resistance a greater focus on the appropriate use of antibiotics is needed.

The aim 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:

1. Symptomatic irreversible pulpitis (SIP) with or without symptomatic apical pulpitis (SAP)
2. Pulp necrosis and symptomatic apical periodontitis (PN-SAP) and
3. Pulp necrosis and localized acute apical abscess (PN-LAAA)

with or without access to immediate definitive, conservative (tooth-preserving) dental treatment (DCDT) (that is, pulpotomy, pulpectomy, nonsurgical root canal treatment, or incision and drainage)

Methods

The guideline was developed in accordance with the Appraisal of Guidelines for Research and Evaluation Reporting II  and Guidelines International Network-McMaster Guideline Development  checklists.   An expert panel and methodologists met face to face on two occasions. At the first meeting the panellist’s conflicts of interest were reviewed and the scope, purpose, target audience, and clinical questions were defined.  The second meeting facilitated by a methodologist the panel formulated the recommendations and good practice statements (GPS) using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework.

Results

• A number of recommendations and good practice statements (GPS) were made to guide decisions about antibiotic use for immunocompetent adults (most typical patients) with the target conditions.
• Five clinical recommendations were made for urgent situations in dental settings where definitive, conservative dental treatment (DCDT) is and is not immediately available.

DCCT immediately available

Recommendations	Certainty of evidence	Strength of recommendation
The expert panel suggests dentists do not prescribe oral systemic antibiotics as an adjunct to definitive, conservative dental treatment for immunocompetent adults with symptomatic irreversible pulpitis with or without symptomatic apical periodontitis.	Very low	Conditional
The expert panel recommends dentists do not prescribe oral systemic antibiotics as an adjunct to definitive, conservative dental treatment for immunocompetent adults with pulp necrosis and symptomatic apical periodontitis or localized acute apical abscess.	Very low	Strong

• Good practice statement:
• The expert panel suggests dentists perform urgent, definitive, conservative dental treatment in conjunction with prescribing oral amoxicillin (500 mg, 3 times per day, 3–7 d) or oral penicillin V potassium (500 mg, 4 times per day, 3–7 d) for immunocompetent adults with pulp necrosis and acute apical abscess with systemic involvement. If the clinical condition worsens or if there is concern for deeper space infection or immediate threat to life, refer for urgent evaluation.

DCCT Not immediately available

Recommendations	Certainty of evidence	Strength of recommendation
The expert panel recommends dentists do not prescribe oral systemic antibiotics for immunocompetent adults with symptomatic irreversible pulpitis with or without symptomatic apical periodontitis. Clinicians should refer patients for definitive, conservative dental treatment while providing interim monitoring.	Low	Strong
The expert panel suggests dentists do not prescribe oral systemic antibiotics for immunocompetent adults with pulp necrosis and symptomatic apical periodontitis. Clinicians should refer patients for definitive, conservative dental treatment while providing interim monitoring. If definitive, conservative dental treatment is not feasible, a delayed prescription for oral amoxicillin (500 mg, 3 times per d, 3–7 d) or oral penicillin V potassium (500 mg, 4 times per d, 3–7 d) should be provided.	Very low	Conditional
The expert panel suggests dentists prescribe oral amoxicillin (500 mg, 3 times per d, 3–7 d) or oral penicillin V potassium (500 mg, 4 times per d, 3–7 d) for immunocompetent adults with pulp necrosis and localized acute apical abscess. Clinicians also should provide urgent referral as definitive, conservative dental treatment should not be delayed.	Very low	Conditional

Good practice statement:

• The expert panel suggests dentists prescribe oral amoxicillin (500 mg, 3 times per d, 3–7 d) or oral penicillin V potassium (500 mg, 4 times per d, 3–7 d) for immunocompetent adults with pulp necrosis and acute apical abscess with systemic involvement. Clinicians also should provide urgent referral as definitive, conservative dental treatment should not be delayed. If the clinical condition worsens or if there is concern for deeper space infection or immediate threat to life, refer patient for urgent evaluation.

Key points

• 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 who are not severely immunocompromised.
• If a patient’s condition progresses to systemic involvement, showing signs of fever or malaise, then dentists should prescribe antibiotics.

Comments

This guideline has been developed following recognised international standards and outlines a number of recommendation and good practice statements. The extensive documentation is available to download from the American Dental Association’s Center for Evidence-based Dentistry website.   In addition to the full guideline a number of other resources are available including helpful chairside guides and flow diagrams.  The recommendation in the guideline are similar to those from other groups such as the American Association of Endodontists and the Scottish Dental Clinical Effectiveness Programme.

Links

Primary Paper

Lockhart PB, Tampi MP, Abt E, Aminoshariae A, Durkin MJ, Fouad AF, Gopal P, Hatten BW, Kennedy E, Lang MS, Patton LL, Paumier T, Suda KJ, Pilcher L, Urquhart O, O’Brien KK, Carrasco-Labra A. 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. J Am Dent Assoc. 2019 Nov;150(11):906-921.e12. doi: 10.1016/j.adaj.2019.08.020. PubMed PMID: 31668170.

Other references

ADA Center for Evidence-based Dentistry – Antibiotic Use for the Urgent Management of Dental Pain and Intra-oral Swelling Clinical Practice Guideline (2019)

ADA Center for Evidence-based Dentistry -Guidelines page