antibx for dental pain

[12R34Y]

Are you guys routinely putting people on Pen VK or clinda etc...for dental pain? We seem to have a lot of heterogeneity amongst staff/residents.

Some say that the reason you have pain (especially to percussion) that means you have a periapical abscess that you can't see externally and thus should be placed on antibiotics (in addition to our blocks/pain control/ and f/u).

Others say that simple dental pain with no visible abscess (other than tooth decay) that pain control is enough and f/u is what they really need.

Any thoughts on what you guys do?

later

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[deleted109597]

No ABx unless purulent fluid expressed.

 

[DrQuinn]

I give it.

We actually have an oral surgery residency where we're at, (I only send them patients that need procedures done) and have asked, and yes, give it. I give either Pen VK or amoxil. Clinda only for real real bad stuff that involves airway.

Q

 

[12R34Y]

so far proving my point that there i a lot of heterogeneity, but again only two responses.

Any evidence as to why you do what you do? My attendings basically just DO it their way on this issue and I hear little overwhelming evidence either way.

keep the responses coming

 

[anonymousEM]

I give pen vk because of periapical abcess as well....and the fact that I'm pretty sure most of my county patients aren't going to get into a dentist in 24 hours EVEN IF they did wake up and try to go get in line for a clinic first thing that morning. Especially since it is on the $4 list and the free list at Publix in FL , I figure they might actually take it along with their narcotics.

 

[TysonCook]

ONe thing to remember is that if your patient is lower socioeconomic status (which a lot are as dental = $$$$, even with insurance)...is that Clinda, while great for oral flora is hella-expensive, and almost nobody will get it filled. So I do Pen VK, Amox, etc as it is cheaper.

In then end which is worse, writing a script that is a easier/more appropriate/better efficacy drug, that doesn't get filled....or a inferior Abx that gets at least gets taken?

Much of what we do is decided by that simple question

 

[bartleby]

My thought is that an abscess is an abscess, ie treatment is drainage not antibiotics unless there is a related cellulitic component. Plus, most of the dental pain people I see wouldn't know a toothbrush if they slipped and fell on one in the shower. Even if they have pain in an intact tooth, it's rarely the only one.

I will give the the typical person with legit dental pain with visible surrounding swelling antibiotics. Of note this is also the person who wants the dental block so they can go home and get some sleep (dental pain is typically an evening/night shift complaint). Pen VK works fine for oral flora in uncomplicated infections, is cheap, and has a far more benign side effect profile than the expensive clindamycin.

See the following link to google scholar for a nice Journal of the Canadian Dental Assoc. meta analysis of treatment of the peri-apical abscess. They give a grade B recommendation to surgical treatment only (no abx) for an isolated peri-apical abscess.

tinyurl dot com/ytut2c (you're going to have to type it in manually)

 

[kbrown]

Have spoken to three dentists regarding this specific thing.

3/3 dentists recommend:

Motrin is enough for pain ONLY if you control infection with penicillin VK. You can of course start with T3, Vic's, Perc's whatever, but once the abx kick in (48h), then Motrin should control all.

Any suspected tooth/dental infection should ALWAYS be started on abx out of the ER. That way by the time they get to the dentist, they can actually help the pt by doing whatever procedure is required. If you don't start them on abx, then they will literally walk into the dentist, get an rx for abx and have to follow up once infection has cooled down.

jm2c,

KB

 

[mikecwru]

My dental regimen is usually motrin, pcn, and #6 vicodin. My belief is you do not need a bunch of percocet for a toothache, even a really bad toothache.

From what I remember, there is not a lot of evidence supporting abx in simple odontalgia, with the exception of people with heart murmurs, etc.

That being said, most dentists I've talked to like to have them on abx before they see them.

Habits > evidence.

mike

Have spoken to three dentists regarding this specific thing.

3/3 dentists recommend:

Motrin is enough for pain ONLY if you control infection with penicillin VK. You can of course start with T3, Vic's, Perc's whatever, but once the abx kick in (48h), then Motrin should control all.

Any suspected tooth/dental infection should ALWAYS be started on abx out of the ER. That way by the time they get to the dentist, they can actually help the pt by doing whatever procedure is required. If you don't start them on abx, then they will literally walk into the dentist, get an rx for abx and have to follow up once infection has cooled down.

jm2c,

KB

 

[anonymousEM]

regarding clinda, I learned in residency that the 150mg caps are much much much cheaper than the 300 mg capsules. Why, no idea, but it's worth looking into if you're going to RX to someone who has to pay for it out of pocket.

 

[Seaglass]

There is not a lot of evidence but what evidence there is suggests that abx don;t work to treat the infection or the pain so I don't do it. If they have something to drain I drain it, otherwise I send them to a dentist with pain control. Pubmed search: ("dental pain" or "dentalgia") AND antibiotics

Linky one - abx do not reduce pain or prevent infection

Linky - abx do not treat periapical infections

Linky 3 - abx do not reduce pain - cochrane review (1 study)

 

[docB]

I gotta admit I do give abx. No one I see will EVER see a dentist so I err toward overtreatment.

 

[bartleby]

Much of the fallout we are dealing with in regard to antibiotic resistance relates to antibiotics being prescribed on the basis of custom and habit rather than by evidence. If the dentist wants to treat the patient with antibiotics without evidence of benefit (to be clear, normal gingiva without evidence of soft tissue involvement around a tooth tender to percussive tenderness) that is up to him or her.

 

[mikecwru]

Much of the fallout we are dealing with in regard to antibiotic resistance relates to antibiotics being prescribed on the basis of custom and habit rather than by evidence. If the dentist wants to treat the patient with antibiotics without evidence of benefit (to be clear, normal gingiva without evidence of soft tissue involvement around a tooth tender to percussive tenderness) that is up to him or her.

That's nice and high and mighty.

Now a dose of reality: there is a big difference between a large amount of evidence to the contrary and a paucity of evidence either way.

Much of the medicine we practice is purely that... custom and habit and "best guess" scenarios. And the the little that is "evidence based," we could probably sit and bitch back and forth regarding the statistics and methods.

Now, for the resident and medical student out there, regardless of whether you routinely give antibiotics for this, at least consider in the back of your head a history of valvular heart disease/mumur. The patient will become transiently bacteremic while getting their nubs pulled out.

mike

 

[aphistis]

Much of the fallout we are dealing with in regard to antibiotic resistance relates to antibiotics being prescribed on the basis of custom and habit rather than by evidence. If the dentist wants to treat the patient with antibiotics without evidence of benefit (to be clear, normal gingiva without evidence of soft tissue involvement around a tooth tender to percussive tenderness) that is up to him or her.

...said the individual who I'd bet a substantial amount has never had a toothache in his life.

 

[aphistis]

Have spoken to three dentists regarding this specific thing.

3/3 dentists recommend:

Motrin is enough for pain ONLY if you control infection with penicillin VK. You can of course start with T3, Vic's, Perc's whatever, but once the abx kick in (48h), then Motrin should control all.

Any suspected tooth/dental infection should ALWAYS be started on abx out of the ER. That way by the time they get to the dentist, they can actually help the pt by doing whatever procedure is required. If you don't start them on abx, then they will literally walk into the dentist, get an rx for abx and have to follow up once infection has cooled down.

jm2c,

KB

This is right on.

 

[Seaglass]

I assume by right on you mean in line with the habitual over prescribing of antibiotics.

And I'm interested in what having had a toothache has to do with evidence based prescribing of antibiotics.

Bartleby actually makes a good point - we prescribe antibiotics too much for things that don't need them just because "everybody does it."

 

[aphistis]

I assume by right on you mean in line with the habitual over prescribing of antibiotics.

And I'm interested in what having had a toothache has to do with evidence based prescribing of antibiotics.

Bartleby actually makes a good point - we prescribe antibiotics too much for things that don't need them just because "everybody does it."

Assume away. Have a nice day.

 

[12R34Y]

Assume away. Have a nice day.

Thanks for all of the replies, but I would like aphistis to reply to the previous poster about WHY are you prescribing antibiotics.

Is there dental literature out there that shows more bias that way?

thanks
later

 

[docB]

Thanks for all of the replies, but I would like aphistis to reply to the previous poster about WHY are you prescribing antibiotics.

Is there dental literature out there that shows more bias that way?

thanks
later

We're giving antibiotics for several reasons. Many are the same reasons that no one wants to hear about from the strict EBM side and they are the same reasons that we often give antibiotics for bronchitis, pharyngitis without a throat culture and so on.

-No one we see will have any follow up.
-Any of the means of verifying a bacterial infection in these patients would slow down the ED and be very costly putting the EP on the wrong end of utilization and administrative concerns.
-Patients expect and want antibiotics and we are personally accountable for our patient satisfaction scores but not for future resistence patterns.
-We perceive that we are at more liability risk from missing/not treating a bacterial infection than from an adverse drug reaction or future possible resistence.

Modern American medicine is designed to abuse antibiotics. All the incentives go that way. Want to fight it? Cool. But before you start with this try to get CMS from dumping on us with their "Core Measures" BS which means that every patient with a cough, wheeze, fever, vague malaise or any other symptoms gets cultures and empiric antibiotics within four hours of hitting the door.

 

[lucky_deadman]

We're giving antibiotics for several reasons. Many are the same reasons that no one wants to hear about from the strict EBM side and they are the same reasons that we often give antibiotics for bronchitis, pharyngitis without a throat culture and so on.

-No one we see will have any follow up.
-Any of the means of verifying a bacterial infection in these patients would slow down the ED and be very costly putting the EP on the wrong end of utilization and administrative concerns.
-Patients expect and want antibiotics and we are personally accountable for our patient satisfaction scores but not for future resistence patterns.
-We perceive that we are at more liability risk from missing/not treating a bacterial infection than from an adverse drug reaction or future possible resistence.

Modern American medicine is designed to abuse antibiotics. All the incentives go that way. Want to fight it? Cool. But before you start with this try to get CMS from dumping on us with their "Core Measures" BS which means that every patient with a cough, wheeze, fever, vague malaise or any other symptoms gets cultures and empiric antibiotics within four hours of hitting the door.

BRAVO!!!!!

You have hit the nail on the head for why we do most of the things we do in "the real world".

 

[aphistis]

There is not a lot of evidence but what evidence there is suggests that abx don;t work to treat the infection or the pain so I don't do it. If they have something to drain I drain it, otherwise I send them to a dentist with pain control. Pubmed search: ("dental pain" or "dentalgia") AND antibiotics

Let me make a couple comments on the abstracts you linked, but only for the sake of clarification.

Linky one - abx do not reduce pain or prevent infection

Over 1/3 of the patient pool are unaccounted for in the results of this study. In my [empirical and entirely non-evidence-based] opinion, I suspect this group draws disproportionately heavily from the experimental group compared to the placebo. If the full text indicates otherwise, I'll rescind the objection, but as it stands I don't think these results are as compelling as the abstract suggests.

Linky - abx do not treat periapical infections

This study is about *preventing* periapical disease, not treating it. It makes no distinction between different states of pulpal & periapical disease, which makes all the difference in the world. I don't give antibiotics unless I have a confident clinical diagnosis of acute periapical disease (as opposed to inflammation/necrosis confined within the tooth).

Linky 3 - abx do not reduce pain - cochrane review (1 study)

Again, this study is investigating relationships between antibiotics and pulpal inflammation, not periapical disease.

~~~

Just like anywhere else, the key lies in properly diagnosing the problem before jumping forward to treatment decisions. I don't believe, by any stretch of the imagination, that every toothache warrants antibiotics. Even when they are indicated, they're adjunctive only, to provide symptomatic relief until the tooth can be appropriately treated via endodontics or extraction. In that limited capacity, however, they're invaluable for the temporary relief they can provide.

In short--I do it because it works. Bartleby is right that pen works just fine for your run-of-the-mill oral infections. I usually give 12 vicodin 1q4 along with 21 amoxicillin 500 1q8 (for no better reason than that q4/q8 dosing is easier than q4/q6 with pen VK). It's not evidence-based, and I don't begrudge you your approach to managing dental complaints, but I'm equally comfortable with my own. Sorry if I came on a little strong in my first post to this thread.

 

[Seaglass]

Your criticisms of the articles are well taken - there really is little available data.

 

[12R34Y]

thanks for the info.

I guess it didn't sway me one way or another hugely, but maybe I'll adopt the policy of my typical homeless, horrible dentition guy gets antibx and the normal dentition well-groomed, non-homeless guy will not get antibx...........oh wait.....I don't see any of the latter.

later