Best Practices for Antibiotic Prescribing for the Acute Management of Pulpal and Periapical Related Dental Pain

As part of the development of the ADA’s clinical practice guidelines, the expert panel reviewed four questions:⁷

Question 1: For immunocompetent adults with SIP with or without SAP, should we recommend the use of oral systemic antibiotics compared with the nonuse of oral systemic antibiotics to improve health outcomes?

Based upon current evidence, the expert panel recommends that dentists do not prescribe oral systemic antibiotics for immunocompetent adults with SIP with or without SAP. It is recommended that clinicians refer patients for definitive conservative dental treatment (DCDT) and provide interim monitoring. The ADA currently recommends that practitioners do not use antibiotics in immunocompetent adults with SIP with or without SAP. It found that the use of antibiotics may result in little to no difference in beneficial outcomes but were likely to result in a potentially large increase in harmful outcomes, which warrants a strong recommendation against their use.

Question 2: For immunocompetent adults with PN-SAP or PN-LAAA, should we recommend the use of oral systemic antibiotics compared with the nonuse of oral systemic antibiotics to improve health outcomes?

For patients with PN-SAP based upon current evidence, the expert panel recommends that dentists do not prescribe oral systemic antibiotics. It is recommended that clinicians refer patients for definitive conservative dental treatment (DCDT) and provide interim monitoring. If DCDT is not feasible, it is recommended that a delayed prescription for oral amoxicillin (500 mg, three times daily for 3-7 days) or oral penicillin V potassium (500mg, four times daily for 3-7 days) be provided. In immunocompetent adults with PN-SAP or PN-LAAA, the ADA clinical guidelines suggest use of a delayed prescription if patients’ symptoms worsen or DCDT has yet to be initiated after 24 to 48 hours. In addition, clinicians should provide urgent referral so that DCDT is not unduly delayed.

For patients with PN-LAAA based upon current evidence, the expert panel recommends that dentists prescribe oral systemic antibiotics if immediate DCDT is not available. While the beneficial effects of oral systemic antibiotics are low, the risks of progression to systemic involvement with PN-LAAA was deemed great enough to warrant prescriptions without immediate access to DCDT. The prescription regimen recommended by the expert panel stated that oral amoxicillin (500 mg, three times daily for 3-7 days) or oral penicillin V potassium (500mg, four times daily for 3-7 days) be provided.

Question 3: For immunocompetent adults with PN-SAP and PN-LAAA, should we recommend the use of oral systemic antibiotics compared with the nonuse of oral systemic antibiotics as adjuncts to DCDT to improve health outcomes?

The expert panel recommends that dentists do not prescribe systemic antibiotics for immunocompetent patients with PN-SAP or PN-LAAA as an adjunct to DCDT. Based upon findings that the use of antibiotics for immunocompetent adults with PN-SAP and PN-LAAA as adjunctive therapy in conjunction with DCDT may result in little to no difference in beneficial outcomes, but were likely to result in a potentially large increase in harmful outcomes, the ADA clinical guidelines issued a strong recommendation against antibiotic use.

Question 4: For immunocompetent adults with SIP with or without SAP, should we recommend the use of oral systemic antibiotics compared with the nonuse of oral systemic antibiotics as adjuncts to DCDT to improve health outcomes?

Based upon current evidence, the expert panel recommends that dentists do not prescribe oral systemic antibiotics for immunocompetent patients with SIP with or without SAP as an adjunct to DCDT. In patients with SIP with or without SAP, the use of adjunctive antibiotics with DCDT were found to generally result in little to no difference in beneficial outcomes, but were likely to result in a potentially large increase in harm outcomes. The results of this literature review suggested that a strong recommendation against their use is pertinent in these cases. Additionally, physiologically, patients with SIP with or without SAP the inflamed pulpal tissue is not associated with infection and/or necrosis, which is further biologic rationale to avoid using antibiotics for such patients.