Antibiotics for dental infections

[flightdoc09]

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ER doc here. Was looking for some CME. Sometimes I see patients with bad necrotizing gingivitis, sometimes a peri-apical abscess, but usually it's someone with just bad dentition and either one, or likely several bad teeth/caries. I can poke an abscess if I can see it, and I believe any necrotizing gingivitis should get chlorexidine wash prescription. I've seen some colleagues reach for augmentin or clinda for most dental problems, and my understanding is that it's a bit overkill. Can someone outline what you recommend for antibiotics in various cases. Like, when is amoxicillin or pen VK enough? When to bump to clinda, or augmentin? Or when to add metronidazole monotherapy, or in addition to augmentin? And when should antibiotics not be given at all?

Of course all these patients should see a dentist for definitive treatment, but the reality is that's just not happening. What's the best I can do for them?

Thanks.

 

[somefuturedoc]

OMFS resident. Most dental problems that come through the ED don’t need antibiotics. Pain, rampant caries, gingivitis, periapical abscesses, etc are not indications for antibiotics. They’re really only indicated in fluctuant oral infections, space infections (abscess and cellulitis), or if gingival conditions are associated with constitutional signs.

American academy of endodontics has a good guidance paper:

https://www.aae.org/specialty/wp-content/uploads/sites/2/2017/06/aae_systemic-antibiotics.pdf

 

[TanMan]

ER doc here. Was looking for some CME. Sometimes I see patients with bad necrotizing gingivitis, sometimes a peri-apical abscess, but usually it's someone with just bad dentition and either one, or likely several bad teeth/caries. I can poke an abscess if I can see it, and I believe any necrotizing gingivitis should get chlorexidine wash prescription. I've seen some colleagues reach for augmentin or clinda for most dental problems, and my understanding is that it's a bit overkill. Can someone outline what you recommend for antibiotics in various cases. Like, when is amoxicillin or pen VK enough? When to bump to clinda, or augmentin? Or when to add metronidazole monotherapy, or in addition to augmentin? And when should antibiotics not be given at all?

Of course all these patients should see a dentist for definitive treatment, but the reality is that's just not happening. What's the best I can do for them?

Thanks.

Here's a possible algorithm for oral medications (not going into the whole pain management thing since a lot of people are against opioids or anything but tylenol/ibuprofen and I don't feel like debating people on it):
Mild to moderate pain, no extraoral manifestations: Amox
Moderate to severe pain, no extraoral: Augmentin if no abscess, Clindamycin if there's an intraoral abscess
Severe pain, extraoral manifestations: Augmentin + Metronidazole or just do an IV.
If it's easier for you, just do IV/IM steroid + antibiotics and get it over with, refer to dentist to cover your bases.

I know that indiscriminate prescribing of antibiotics is frowned upon, but I assume that you're in the trenches of real world practice and if you have patients that just want you to stabilize them, even if it is temporary, then usually antibiotics, steroids, and pain meds gets the trick done until it starts hurting again.

On another note, I find that metronidazole monotherapy is ineffective for dental infections.

 

[Jaa_]

Here's a possible algorithm for oral medications (not going into the whole pain management thing since a lot of people are against opioids or anything but tylenol/ibuprofen and I don't feel like debating people on it):
Mild to moderate pain, no extraoral manifestations: Amox
Moderate to severe pain, no extraoral: Augmentin if no abscess, Clindamycin if there's an intraoral abscess
Severe pain, extraoral manifestations: Augmentin + Metronidazole or just do an IV.
If it's easier for you, just do IV/IM steroid + antibiotics and get it over with, refer to dentist to cover your bases.

I know that indiscriminate prescribing of antibiotics is frowned upon, but I assume that you're in the trenches of real world practice and if you have patients that just want you to stabilize them, even if it is temporary, then usually antibiotics, steroids, and pain meds gets the trick done until it starts hurting again.

On another note, I find that metronidazole monotherapy is ineffective for dental infections.

- pain severity should not drive antibiotic choice. Pain without fluctuance/purulence etc.. is not an indication for abx.
- there is no reason to switch from empiric Augmentin to clinda based on the presence of an abscess (unless you are trying to cover for MRSA which is usually not causative of dental abscess OR there is an allergy OR you ordered sensitivities- though by the time they return its almost always a moot point) Augmentin generally has better coverage for oral flora
- if you're at the point where you're considering steroids you should get source control with drainage or admit and escalate care (ie airway concern)

 

[TanMan]

- pain severity should not drive antibiotic choice. Pain without fluctuance/purulence etc.. is not an indication for abx.
- there is no reason to switch from empiric Augmentin to clinda based on the presence of an abscess (unless you are trying to cover for MRSA which is usually not causative of dental abscess OR there is an allergy OR you ordered sensitivities- though by the time they return its almost always a moot point) Augmentin generally has better coverage for oral flora
- if you're at the point where you're considering steroids you should get source control with drainage or admit and escalate care (ie airway concern)

I agree in that it shouldn't, but there's a difference between what's done in the ER in my area v. what we should really be doing. It appears to work for them to get them stable enough to see a dentist (or they just end up going back once it stops working). There's a definite disconnect on what should be done v. what's being done (at least in my area). They should really just be seeing a dentist to get treated properly, otherwise, we're not treating the source of the problem, if it is an odontogenic problem.

 

[flightdoc09]

In the military system, I can usually get a patient seen by a dentist within 24 hours for anything particularly bad. Unless there's an abscess, I often just block them with bupivacaine and give them ibuprofen and tylenol.

But out in the community, there are a decent number of patients where the ER is their dentist. And they lack the means to pay for a dentist. Some places have charitable dental organizations, but not very common. I try hard to not give antibiotics unless I really think someone has a bacterial infection that would benefit.

I guess the question then becomes is there zero benefit to giving antibiotics for a pulpitis from, what I suspect is, a cavity causing it?

 

[nade0016]

Sort of disappointed at the dental professionals on here. The ADA had stated that Clinda is not really indicated anymore. While not eliminated from the algorithm our ED and most in our area have stopped using Clinda almost all together. The antibiogram shows that Clinda has less than 30% effective for oral bacteria in my area. That might not be true everywhere but I believe dentists and providers in general have over used Clinda so we are getting to that point. It now has a Blackbox warning about C. Diff.

Our current algorithm: Essentially, Amox, Augmentin, Azith +/- Metro, and finally Moxi or another fluro. Cephalosporins do fit in here but I have not introduced them in to my practice yet. I have both a hospital and office based practices.

I hope this helps a little and I understand that there are differences nationally. This is just what we are seeing in the upper midwest.

1. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling​

   Lockhart, Peter B. et al.
   The Journal of the American Dental Association, Volume 150, Issue 11, 906 - 921.e12

 

[TanMan]

Sort of disappointed at the dental professionals on here. The ADA had stated that Clinda is not really indicated anymore. While not eliminated from the algorithm our ED and most in our area have stopped using Clinda almost all together. The antibiogram shows that Clinda has less than 30% effective for oral bacteria in my area. That might not be true everywhere but I believe dentists and providers in general have over used Clinda so we are getting to that point. It now has a Blackbox warning about C. Diff.

Our current algorithm: Essentially, Amox, Augmentin, Azith +/- Metro, and finally Moxi or another fluro. Cephalosporins do fit in here but I have not introduced them in to my practice yet. I have both a hospital and office based practices.

I hope this helps a little and I understand that there are differences nationally. This is just what we are seeing in the upper midwest.

1. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling​

   Lockhart, Peter B. et al.
   The Journal of the American Dental Association, Volume 150, Issue 11, 906 - 921.e12

It is medical and dental professionals alike. Usually, they bring in a pre-printed packet about the medications that they were given (usually tylenol #3 + clinda tid x7d) , and what "pulpitis is". Some ERs do 2g IM amp here too. They used ampicillin IM for a long time here then realized it stopped working. Hence, they started doing clindamycin. I see Lincomycin IM done as well here. I do think it is regional as some medication combinations are more prevalent in different parts of the country. I get a lot of referrals from the ER/Urgent Care so I figure I'd share what they are doing

I've tried azithromycin and found that it is very ineffective.