Introduction

Acute dental pain and swelling associated with pulpal and periapical disease is extremely common. In addition to patient visits in dental offices, there were 2.43 million dental-related visits to emergency departments (ED) in the United States (U.S.) in 2014. The most common oral-health related reasons for these visits were dental pain and intraoral swelling.^16,34 Dentists and physicians often prescribe antibiotics in response to these symptoms and dentists were the third highest prescribing group for antibiotics in the U.S. ² It is estimated in reports from 2017 to 2019, between 30-85% of these prescriptions were suboptimal or not indicated. ³ Furthermore, patients’ use of antibiotics is often not ideal. Both inappropriate prescribing patterns and failure to thoroughly advise patients on the importance of using antibiotics as directed have led to an increase in the number of multi-drug resistant bacteria. According to the U.S. Centers for Disease Control and Prevention (CDC), multi-drug resistant bacteria infect more than 2.8 million Americans each year and kill at least 35,000. ^80,81 To address these concerns, the American Dental Association (ADA) recently published evidence-based clinical practice guidelines for antibiotic use in the urgent management of pulpal- and periapical-related dental pain and intraoral swelling.⁸ This course will review the evidence regarding antibiotic usage in the dental setting, discuss the mechanisms of action of antibiotics commonly used in the dental setting, and establish the rationale for the ADA guidelines and best practices for their implementation in dental practices.

Penicillin, the first commercially available antibiotic, was discovered in 1928 by Alexander Fleming.⁸ While the introduction of antibiotics revolutionized healthcare, their overuse has produced serious adverse health outcomes including adverse drug reactions, disruption of commensal flora resulting in opportunistic secondary infections and antibiotic resistance.^9-13 As the use of antibiotics increased, microorganisms developed the ability to evade the mechanisms of action of the antibiotics and/or antimicrobial agents used to combat them.¹³ The prevalence of this antimicrobial resistance has increased with the increase in antibiotic use and the genetic material coding for such resistance has been transferred amongst bacteria in the environment. This allows those microorganisms to preferentially flourish despite antibiotic therapy. Infections caused by antibiotic-resistant organisms often require use of costly and more toxic alternative therapies. In 2019 the Centers for Disease Control and Prevention (CDC) published an updated report categorizing the current antibiotic resistance threats (Figure 1).¹⁴

Figure 1. Bacteria and Fungi Listed in the 2019 AR Urgent Threats Report¹⁴

Figure 1. Bacteria and Fungi Listed in the 2019 AR Urgent Threats Report¹⁴

Currently, the main causes of antibiotic resistance include inappropriate prescribing, inadequate compliance by patients who receive antibiotic prescriptions, overuse of antibiotics in livestock farming, and environmental antimicrobial use. The CDC recommends that healthcare providers follow published clinical guidelines regarding antibiotic prescription and stewardship, perform appropriate diagnostic tests to guide antibiotic therapy, utilize anti-infective protections, and inform patients of the importance of proper antibiotic use and disposal.¹⁵ Given these concerns, it is critical that dental healthcare providers understand the risks of antibiotic resistance and the steps that can be applied to improve patient outcomes and decrease risks for the community as a whole.