Oral Systemic Antibiotics and Endodontic Therapy

Oral Systemic Antibiotics and Endodontic Therapy

Globally, inappropriate use of antibiotics over several decades in healthcare and other settings has contributed to antimicrobial resistance globally. By 2019, it was estimated that 4.95 million deaths globally in 2019 were caused by 23 pathogens, with 1.27 million of these deaths directly attributable to bacterial antimicrobial resistance.1Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet 2022;399(10325):629-55. doi: 10.1016/S0140-6736(21)02724-0. Antibiotics were then widely prescribed when COVID-19 emerged, including their non-informed use for the treatment of 78% of COVID-19 patients.2Malik SS, Mundra S. Increasing Consumption of Antibiotics during the COVID-19 Pandemic: Implications for Patient Health and Emerging Anti-Microbial Resistance. Antibiotics (Basel) 2022;12(1):45. doi: 10.3390/antibiotics12010045. Unfortunately, the COVID-19 era heralded in rapid increases in several multi-drug resistant microorganisms, most of which fall under the CDC list of ‘Urgent and Serious Threats’.3Lai CC, Chen SY, Ko WC, Hsueh PR. Increased antimicrobial resistance during the COVID-19 pandemic. Int J Antimicrob Agents 2021;57(4):106324. doi: 10.1016/j.ijantimicag.2021.106324.^,4Centers for Disease Control and Prevention. COVID-19: U.S. Impact on Antimicrobial Resistance, Special Report 2022. https://www.cdc.gov/drugresistance/covid19.html. Furthermore, existing data indicates increasing levels of antimicrobial resistance for periodontopathogens and pathogens involved in endodontic infections.5Segura-Egea JJ, Martín-González J, Jiménez-Sánchez MDC et al. Worldwide pattern of antibiotic prescription in endodontic infections. Int Dent J 2017;67(4):197-205. doi: 10.1111/idj.12287. Guidance on the prophylactic use of antibiotics related to systemic conditions, as well as their use associated with oral surgery, endodontic therapy and other types of treatment, have been issued by numerous national and international medical and dental organizations.6Lockhart PB, Malavika P, Tampi MPH et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling. J Am Dent Assoc 2019;150(11):906-21.e12. ^,7American Dental Association. Antibiotic Stewardship: Antibiotics for therapeutic use, 2022. https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/antibiotic-stewardship.^,8Sollecito TP, Abt E, Lockhart PB et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners—A report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2015;146(1):11-16 e8. doi:10.1016/j.adaj.2014.11.012.^,9Canadian Dental Association. CDA position statements. 2022. https://www.cda-adc.ca/en/about/position_statements/infectiveendocarditis/.^,10Canadian Dental Association. Consensus Statement: Dental Patients with Total Joint Replacement. Ottawa, ON: CDA; 2016. https://www.cda-adc.ca/en/about/position_statements/jointreplacement/.^,11Scottish Dental Clinical Effectiveness Programme. Drug Prescribing for Dentistry: Dental Clinical Guidance. 2022 https://www.sdcep.org.uk/published-guidance/.^,12Duncan HF, Kirkevang LL, Peters OA et al. Treatment of pulpal and apical disease: The European Society of Endodontology (ESE) S3-level clinical practice guideline. Int Endod J 2023;56:238-95.^,13Segura-Egea JJ, Gould K, Şen BH et al. European Society of Endodontology position statement: The use of antibiotics in endodontics. Int Endod J 2018;51:20-5.^,14American Association of Endodontists. Position Statement: AAE Guidance on the Use of Systemic Antibiotics in Endodontics. J Endod 2017;43(9):1409-13. https://doi.org/10.1016/j.joen.2017.08.015.^,15American Association of Endodontists. Endodontics and Antibiotic Update, Fall 2019. https://www.aae.org/specialty/wp-content/uploads/sites/2/2019/12/ecfe-fall-2019-May-2021.pdf. In this article, we will review current guidelines from the American Dental Association (ADA) and the American Association of Endodontists (AAE) on the adjunctive use of antibiotics during endodontic therapy, before reviewing current findings and antibiotic stewardship.

Clinical Practice Guidelines: Oral systemic antibiotics as adjuncts in endodontics

The ADA published evidence-based Clinical Practice Guidelines (CPG) in 2019, as well as a chairside guide, on the use of oral systemic antibiotics for the urgent management of symptomatic irreversible pulpitis with or without symptomatic apical periodontitis, pulp necrosis and symptomatic apical periodontitis, pulp necrosis and localized acute apical abscesses.6Lockhart PB, Malavika P, Tampi MPH et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling. J Am Dent Assoc 2019;150(11):906-21.e12. ^,16American Dental Association. 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. Chairside Guide on Antibiotic Use. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/ada_chairside_guide_antibiotics_ta.pdf?rev=d23ac4651660443a9ba33d925f97ecd7&hash=522B2C21AF012B519419FA7E6C836F4B. The guideline addresses immunocompetent patients 18 years-of-age and older; it does not address patients with co-morbidities or cellulitis. Information contained in the guideline includes the following:

• Oral systemic antibiotics are not recommended for patients with pain only that is caused by symptomatic irreversible pulpitis with/without symptomatic apical periodontitis. It is recommended that the patient be advised to call if their condition becomes more severe deteriorates or if treatment is not possible within 1-2 days of a referral.
• Oral systemic antibiotics are not recommended for patients with pain only that is caused by pulp necrosis and symptomatic apical periodontitis if they are receiving immediate definitive treatment.
• If immediate definitive treatment is not provided for patients with pain only that is caused by pulp necrosis and symptomatic apical periodontitis, a delayed prescription for oral systemic antibiotics should be given to the patient along with directions to fill the prescription if symptoms become worse and they suffer swelling or purulence.
• For patients experiencing pain and swelling with pulp necrosis and a localized acute apical abscess and they are receiving immediate definitive treatment, oral systemic antibiotics are recommended only if there is systemic involvement.
• Oral systemic antibiotics are recommended if patients experiencing pain and swelling with pulp necrosis and a localized acute apical abscess will not receive immediate definitive treatment.
• Antibiotics are recommended when there is systemic involvement such as malaise or fever or when the risk of experiencing progression to systemic involvement is high. (Table 1)6Lockhart PB, Malavika P, Tampi MPH et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling. J Am Dent Assoc 2019;150(11):906-21.e12. ^,16American Dental Association. 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. Chairside Guide on Antibiotic Use. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/ada_chairside_guide_antibiotics_ta.pdf?rev=d23ac4651660443a9ba33d925f97ecd7&hash=522B2C21AF012B519419FA7E6C836F4B.

The ADA chairside guide provides two flow charts showing the CPG recommendations for immediate and delayed definitive treatment.6Lockhart PB, Malavika P, Tampi MPH et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling. J Am Dent Assoc 2019;150(11):906-21.e12. ^,16American Dental Association. 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. Chairside Guide on Antibiotic Use. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/ada_chairside_guide_antibiotics_ta.pdf?rev=d23ac4651660443a9ba33d925f97ecd7&hash=522B2C21AF012B519419FA7E6C836F4B.

Adjunctive use of oral systemic antibiotics in immunocompromised patients
The AAE provided guidance on the use of systemic antibiotics in endodontics in a position paper published in 2017 and published an update on indications for the adjunctive use of antibiotics in 2019 that includes information regarding immunocompromised patients.14American Association of Endodontists. Position Statement: AAE Guidance on the Use of Systemic Antibiotics in Endodontics. J Endod 2017;43(9):1409-13. https://doi.org/10.1016/j.joen.2017.08.015.^,15American Association of Endodontists. Endodontics and Antibiotic Update, Fall 2019. https://www.aae.org/specialty/wp-content/uploads/sites/2/2019/12/ecfe-fall-2019-May-2021.pdf. Adjunctive antibiotics are indicated for this patient group when they have acute apical abscesses with localized fluctuant swellings and systemic disease causing them to be immunocompromised.15American Association of Endodontists. Endodontics and Antibiotic Update, Fall 2019. https://www.aae.org/specialty/wp-content/uploads/sites/2/2019/12/ecfe-fall-2019-May-2021.pdf. Further, acute apical abscesses with systemic involvement, and advancing infections and persistent infections, are indications for adjunctive antibiotics.

Oral systemic antibiotic selection and dosing

Guidance on appropriate prescribing is provided for the type of adjunctive antibiotic and dosage for recognized endodontic indications, and on the need
for clinicians to consider the risk/benefit, the individual patient’s health status, medications, and allergies.15American Association of Endodontists. Endodontics and Antibiotic Update, Fall 2019. https://www.aae.org/specialty/wp-content/uploads/sites/2/2019/12/ecfe-fall-2019-May-2021.pdf. ^,16American Dental Association. 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. Chairside Guide on Antibiotic Use. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/ada_chairside_guide_antibiotics_ta.pdf?rev=d23ac4651660443a9ba33d925f97ecd7&hash=522B2C21AF012B519419FA7E6C836F4B. For patients who are not allergic to penicillin, oral amoxicillin (500 mg, tid, for 3-7 days) or oral penicillin V potassium (500 mg, qid, for 3-7 days) is recommended as a first-line treatment.16American Dental Association. 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. Chairside Guide on Antibiotic Use. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/ada_chairside_guide_antibiotics_ta.pdf?rev=d23ac4651660443a9ba33d925f97ecd7&hash=522B2C21AF012B519419FA7E6C836F4B. If ineffective, either of these medications can be combined with the use of oral metronidazole (500 mg, tid for 7 days), or, replaced with oral amoxicillin and clavulanate (500/125 mg, tid for 7 days).16American Dental Association. 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. Chairside Guide on Antibiotic Use. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/ada_chairside_guide_antibiotics_ta.pdf?rev=d23ac4651660443a9ba33d925f97ecd7&hash=522B2C21AF012B519419FA7E6C836F4B.

For patients allergic to penicillin, and if there is a history of anaphylaxis, angioedema, or hives with penicillin, ampicillin, or amoxicillin, then oral azithromycin (loading dose of 500 mg on day 1, followed by 250 mg for an additional 4 days or oral clindamycin (300 mg, qid, 3-7 days) is recommended. If there is no history of anaphylaxis, angioedema, or hives with penicillin, ampicillin, or amoxicillin, oral cephalexin (500 mg, qid for 3-7 days) is recommended. If first-line treatment fails, it can be complemented with oral metronidazole (500 mg, tid for 7 days).16American Dental Association. 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. Chairside Guide on Antibiotic Use. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/ada_chairside_guide_antibiotics_ta.pdf?rev=d23ac4651660443a9ba33d925f97ecd7&hash=522B2C21AF012B519419FA7E6C836F4B.

Important Considerations and Cautions

The shortest effective dose of antibiotics should be taken, and the AAE guidelines recommend first obtaining a microbiological analysis, when possible, before prescribing antibiotics.15American Association of Endodontists. Endodontics and Antibiotic Update, Fall 2019. https://www.aae.org/specialty/wp-content/uploads/sites/2/2019/12/ecfe-fall-2019-May-2021.pdf. ^,16American Dental Association. 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. Chairside Guide on Antibiotic Use. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/ada_chairside_guide_antibiotics_ta.pdf?rev=d23ac4651660443a9ba33d925f97ecd7&hash=522B2C21AF012B519419FA7E6C836F4B. Longer-duration medication with oral systemic antibiotics is associated with increases in antimicrobial resistance. Patients should be instructed to cease antibiotic use 1 day after symptoms have resolved. Patients must always be informed about potential adverse events and side effects of medications, including antibiotics, and be monitored either remotely or in the dental office. Adverse events for both penicillin and amoxicillin include gastrointestinal disturbance, hepatic toxicity and severe allergic reactions (including anaphylaxis).16American Dental Association. 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. Chairside Guide on Antibiotic Use. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/ada_chairside_guide_antibiotics_ta.pdf?rev=d23ac4651660443a9ba33d925f97ecd7&hash=522B2C21AF012B519419FA7E6C836F4B. The risk of gastrointestinal adverse events is lower for amoxicillin than for Pen V.

In addition, azithromycin should be prioritized over clindamycin as a substitute for penicillin.15American Association of Endodontists. Endodontics and Antibiotic Update, Fall 2019. https://www.aae.org/specialty/wp-content/uploads/sites/2/2019/12/ecfe-fall-2019-May-2021.pdf. Clindamycin, while recommended as a substitute (see above) carries with it a significant risk for Clostridioides difficile (C diff) infections that can be life-altering and fatal in some cases.15American Association of Endodontists. Endodontics and Antibiotic Update, Fall 2019. https://www.aae.org/specialty/wp-content/uploads/sites/2/2019/12/ecfe-fall-2019-May-2021.pdf. ^,17US Food and Drug Administration. CLEOCIN HCl. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/050162s102lbl.pdf. Fatal C diff infections have occurred following dental prescribing of clindamycin.18Thornhill MH, Dayer MJ, Prendergast B et al. Incidence and nature of adverse reactions to antibiotics used as endocarditis prophylaxis. J Antimicrob Chemotherapy 2015;70:2382-8.

Challenges and trends in dental antibiotic prescribing

Figure 1. Percentage of patients prescribed antibiotics only by a dentist

Up to over 90% of antibiotics prescribed in dentistry have been reported in the literature to potentially be inappropriate based on selection, dosing, and duration of use.19Thompson W, Teoh L, Hubbard CC et al. Patterns of dental antibiotic prescribing in 2017: Australia, England, United States, and British Columbia (Canada). Infect Control Hosp Epidemiol 2022;43(2):191-8. 10.1017/ice.2021.87.^,20Teoh L, Löffler C, Mun M et al. A Systematic Review of Dental Antibiotic Stewardship Interventions. Comm Dent Oral Epidemiol 2024. https://doi.org/10.1111/cdoe.13009^,21Gross AE, Hanna D, Rowan SA et al. Successful Implementation of an Antibiotic Stewardship Program in an Academic Dental Practice. Open Forum Infectious Diseases 2019;6:ofz067. Progress was being made on antibiotic stewardship prior to the COVID-19 pandemic, with the number of inappropriate prescriptions for antibiotics trending lower globally.21Gross AE, Hanna D, Rowan SA et al. Successful Implementation of an Antibiotic Stewardship Program in an Academic Dental Practice. Open Forum Infectious Diseases 2019;6:ofz067. ^,22Soleymani F, Pérez-Albacete Martínez C, Makiabadi M, Maté Sánchez de Val JE. Mapping Worldwide Antibiotic Use in Dental Practices: A Scoping Review. Antibiotics (Basel) 2024;13(9):859. doi: 10.3390/antibiotics13090859. However, antibiotics were prescribed during the pandemic more frequently under circumstances that included mandatory practice shut-downs, and subsequent challenges.22Soleymani F, Pérez-Albacete Martínez C, Makiabadi M, Maté Sánchez de Val JE. Mapping Worldwide Antibiotic Use in Dental Practices: A Scoping Review. Antibiotics (Basel) 2024;13(9):859. doi: 10.3390/antibiotics13090859.^,23Shah S, Wordley V, Thompson W. How did COVID-19 impact on dental antibiotic prescribing across England? Br Dent J 2020;229:601-4. https://doi.org/10.1038/s41415-020-2336-6.^,24Duncan EM, Goulao B, Clarkson J et al. 'You had to do something': prescribing antibiotics in Scotland during the COVID-19 pandemic restrictions and remobilisation. Br Dent J 2021:1-6. doi: 10.1038/s41415-021-3621-8.^,25Rabie H, Figueiredo R. Provision of dental care by public health dental clinics during the COVID-19 pandemic in Alberta, Canada. Prim Dent J 2021;10(3):47-54. doi: 10.1177/20501684211029423.^,26Sutherland S, Born K, Singhal S. Moving the needle on dental antibiotic overuse in Canada post COVID-19. Can Commun Dis Rep 2022;48(11,12):502-5.^,27Stenlund S, Huynh J, Pau C et al. Dental antibiotic use in British Columbia from 1996 through 2023. Are we backsliding? J Am Dent Assoc 2024;155(11):1-9. https://doi.org/10.1016/j.adaj.2024.10.001. These challenges included, among others, the limitations of remote care (teledentistry), reluctance on the part of patients to visit even when possible, and guidance on avoiding aerosol-generating procedures. In England, for example, the number of antibiotic prescriptions written by dentists was 25% higher in April to July 2020 compared to the same period in the prior year.23Shah S, Wordley V, Thompson W. How did COVID-19 impact on dental antibiotic prescribing across England? Br Dent J 2020;229:601-4. https://doi.org/10.1038/s41415-020-2336-6. In British Columbia, approximately half of all dentists prescribed antibiotics more frequently during the pandemic, and 18.5% of all antibiotic prescriptions were issued by dentists.27Stenlund S, Huynh J, Pau C et al. Dental antibiotic use in British Columbia from 1996 through 2023. Are we backsliding? J Am Dent Assoc 2024;155(11):1-9. https://doi.org/10.1016/j.adaj.2024.10.001. In addition, 17.5% of patients were prescribed antibiotics only by a dentist over 2021 and 2022, compared to 9.6% and 4.8%, respectively, between 2016 and 2020 and between 1996 and 2000. (Figure 1)

Oral systemic antibiotics prescribed for endodontic infections

The purpose of endodontic therapy is to thoroughly debride the root canal system, enabling resolution of the infection and healing. For localized endodontic infections treated appropriately, there is no additional benefit with the use of antibiotics.14American Association of Endodontists. Position Statement: AAE Guidance on the Use of Systemic Antibiotics in Endodontics. J Endod 2017;43(9):1409-13. https://doi.org/10.1016/j.joen.2017.08.015.^,28Henry M, Reader A, Beck M. Effect of penicillin on postoperative endodontic pain and swelling in symptomatic necrotic teeth. J Endod 2001;27(2):117-23.^,29Agnihotry A, Thompson W, Fedorowicz Z et al. Antibiotic use for irreversible pulpitis. Cochrane Database Syst Rev 2019;5(5):CD004969. doi: 10.1002/14651858.CD004969.pub5. Nonetheless, antibiotics have been inappropriately prescribed globally for endodontic infections, as with other indications.5Segura-Egea JJ, Martín-González J, Jiménez-Sánchez MDC et al. Worldwide pattern of antibiotic prescription in endodontic infections. Int Dent J 2017;67(4):197-205. doi: 10.1111/idj.12287.^,30Contaldo M, D'Ambrosio F, Ferraro GA et al. Antibiotics in Dentistry: A Narrative Review of the Evidence beyond the Myth. Int J Environ Res Public Health 2023;20(11):6025. doi: 10.3390/ijerph20116025.^,31Lang PM, Jacinto RC, Dal Pizzol TS et al. Resistance profiles to antimicrobial agents in bacteria isolated from acute endodontic infections: systematic review and meta-analysis. Int J Antimicrob Agents 2016;48(5):467-74. doi: 10.1016/j.ijantimicag.2016.08.018. In one retrospective review of more than 470,000 dental visits within the Veterans Administration, 28%, 17% and 12% of patients with an acute apical abscess, apical periodontitis and irreversible pulpitis, respectively, received antibiotics within 7 days before or after a dental visit.32Carlsen DB, Durkin MJ, Gibson G et al. Concordance of antibiotic prescribing with the American Dental Association acute oral infection guidelines within Veterans' Affairs (VA) dentistry. Infect Control Hosp Epidemiol 2021;42(12):1422-30. doi: 10.1017/ice.2021.16. Almost half of patients with these conditions were prescribed antibiotics for at least 8 days. In an analysis of dental insurance data on antibiotic prescribing by dentists in Wisconsin, endodontic therapy visits accounted for between 11% and 12% of ‘dental antibiotic visits’ for 2018 through 2021.33Wisconsin Department of Health Services. Healthcare-Associated Infections Prevention Program. Trends in Dental Antibiotic Prescribing in Wisconsin 2018–2021. P-03383A (11/2023). https://www.dhs.wisconsin.gov/publications/p03383a.pdf. In addition, endodontists and oral surgeons consistently had the highest prescribing rates, and increasing prescribing rates, between 2018 and 2021.

In a review of 39 studies published between 1996 and 2022, it was found that the overall percentage of antibiotic prescriptions by dentists in cases of symptomatic AP was 25.8%, and 31.5% in cases with asymptomatic AP and a sinus tract present.34Méndez-Millán JA, León-López M, Martín-González J et al. Antibiotic Over-Prescription by Dentists in the Treatment of Apical Periodontitis: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2024;13(4):289. doi: 10.3390/antibiotics13040289. The percentage of dentists prescribing antibiotics for patients with acute apical abscess with no/mild symptoms was 47.7%, whereas in cases of acute apical abscess with moderate/severe symptoms 88.8% of dentists would prescribe antibiotics. The majority of studies, however, pre-dated current efforts and only 16 were published between 2020 to 2022.

Factors associated with inappropriate prescribing
Factors reported to result in inappropriate antibiotic prescribing include lack of knowledge and confidence.35Schneider-Smith EG, Suda KJ, Lew D et al. How decisions are made: Antibiotic stewardship in dentistry. Infect Control Hosp Epidemiol 2023;44(11):1731-6. doi: 10.1017/ice.2023.173. Concern for patient comfort, previous operative treatment failure (e.g., endodontic retreatment), the presence of an acute periodontal condition, concerns about the possibility of infection spreading and patient comfort, time pressure (e.g., insufficient time to perform definitive treatment at the same visit), and patient factors including expectations/ satisfaction and requests that they receive antibiotics, refusal of definitive treatment, and an inability to pay for definitive treatment are other factors.15American Association of Endodontists. Endodontics and Antibiotic Update, Fall 2019. https://www.aae.org/specialty/wp-content/uploads/sites/2/2019/12/ecfe-fall-2019-May-2021.pdf. ^,27Stenlund S, Huynh J, Pau C et al. Dental antibiotic use in British Columbia from 1996 through 2023. Are we backsliding? J Am Dent Assoc 2024;155(11):1-9. https://doi.org/10.1016/j.adaj.2024.10.001. ^,35Schneider-Smith EG, Suda KJ, Lew D et al. How decisions are made: Antibiotic stewardship in dentistry. Infect Control Hosp Epidemiol 2023;44(11):1731-6. doi: 10.1017/ice.2023.173.^,36Cope AL, Francis NA, Wood F, Chestnutt IG. Antibiotic prescribing in UK general dental practice: a cross-sectional study. Community Dent Oral Epidemiol 2016; 44:145–53. ^,37Abraham S, Abdulla N, Himratul-Aznita WH et al. Antibiotic prescribing practices of dentists for endodontic infections; a cross-sectional study. PLoS ONE 2020;15(12): e0244585. https://doi.org/10.1371/journal.pone.0244585. (Table 2)

Antibiotic Stewardship, programs and components

Antibiotic stewardship efforts continue globally, including guidance from dental and other organizations and the use of formal programs. One such program, the Center for Disease Control and Prevention Core Elements of Outpatient Antibiotic Stewardship Program, includes building commitment and implementing policies and procedures for antibiotic stewardship.38Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep 2016;65:1-12. doi: 10.15585/mmwr.rr6506a1.

Strategies include improvements in prescribing – reducing the number of prescriptions, appropriate prescribing (antibiotic selection, effective dose, minimizing duration based on results and, where appropriate, delayed prescribing), tracking and feedback, educational efforts, and availability of expertise.38Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep 2016;65:1-12. doi: 10.15585/mmwr.rr6506a1.^,39Seager JM, Howell-Jones RS, Dunstan FD et al. A Randomised Controlled Trial of Clinical Outreach Education to Rationalise Antibiotic Prescribing for Acute Dental Pain in the Primary Care Setting. Br Dent J 2006;201:217-2.^,40Chehabeddine N, Lahoud ZE, Noujeim F et al. Effect of an Educational Intervention Among Lebanese Dentists on Antibiotic Prescribing: A Randomized Controlled Study. Clin Oral Investig 2022;26:4857-69.^,41Elouafkaoui P, Young L, Newlands R et al. An Audit and Feedback Intervention for Reducing Antibiotic Prescribing in General Dental Practice: The RAPiD Cluster Randomised Controlled Trial. PLoS Med 2016;13:e1002115. doi: 10.1371/journal.pmed.1002115. ^,42Teoh L, Stewart K, Marino RJ, McCullough MJ. Improvement of Dental Prescribing Practices Using Education and a Prescribing Tool: A Pilot Intervention Study. Br J Clin Pharmacol 2021;87:152-62. (Figure 2) The appropriateness of antibiotic selection includes consideration of medication allergies. Given that most patients who report penicillin allergies are estimated not to have true allergies, before prescribing clindamycin as a substitute it is recommended to investigate whether the patient does in fact have allergies to penicillins to avoid unnecessary prescriptions of clindamycin and associated serious adverse events.14American Association of Endodontists. Position Statement: AAE Guidance on the Use of Systemic Antibiotics in Endodontics. J Endod 2017;43(9):1409-13. https://doi.org/10.1016/j.joen.2017.08.015.

Methods that have been found in individual studies to contribute to reduced prescribing and greater quality of prescribing of antibiotics (greater compliance with guidelines) include in-person (live) education, a poster format of recommendations placed on the wall chairside that can act as a reminder/ prompter, checklists, audits and feedback.21Gross AE, Hanna D, Rowan SA et al. Successful Implementation of an Antibiotic Stewardship Program in an Academic Dental Practice. Open Forum Infectious Diseases 2019;6:ofz067. ^,38Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep 2016;65:1-12. doi: 10.15585/mmwr.rr6506a1.^,39Seager JM, Howell-Jones RS, Dunstan FD et al. A Randomised Controlled Trial of Clinical Outreach Education to Rationalise Antibiotic Prescribing for Acute Dental Pain in the Primary Care Setting. Br Dent J 2006;201:217-2.^,40Chehabeddine N, Lahoud ZE, Noujeim F et al. Effect of an Educational Intervention Among Lebanese Dentists on Antibiotic Prescribing: A Randomized Controlled Study. Clin Oral Investig 2022;26:4857-69.^,41Elouafkaoui P, Young L, Newlands R et al. An Audit and Feedback Intervention for Reducing Antibiotic Prescribing in General Dental Practice: The RAPiD Cluster Randomised Controlled Trial. PLoS Med 2016;13:e1002115. doi: 10.1371/journal.pmed.1002115. ^,42Teoh L, Stewart K, Marino RJ, McCullough MJ. Improvement of Dental Prescribing Practices Using Education and a Prescribing Tool: A Pilot Intervention Study. Br J Clin Pharmacol 2021;87:152-62.^,43Haidar ZS. Antibiotic Stewardship: Integrating a Crucial Element for Dental Practices, Education, and Patient Care. Int Dent J 2023;73(5):595-7. doi: 10.1016/j.identj.2023.03.001. (Figure 3) The CDC provides several resources, and the Association for Dental Safety (formerly OSAP) provides a toolkit containing resources and links to CDC resources.44Centers for Disease Control and Prevention. Checklist for Antibiotic Prescribing in Dentistry. https://www.cdc.gov/antibiotic-use/media/pdfs/dental-fact-sheet-508.pdf?CDC_AAref_Val=https://www.cdc.gov/antibiotic-use/community/downloads/dental-fact-sheet-FINAL.pdf.^,45Association for Dental Safety. Antibiotic safety for the dental team. https://www.myads.org/antibiotic-stewardship-for-the-dental-team.

A recent study highlighted disparities in prescribing behaviors with 24% of dentists responsible for almost 70% of antibiotic prescriptions during a specific period.27Stenlund S, Huynh J, Pau C et al. Dental antibiotic use in British Columbia from 1996 through 2023. Are we backsliding? J Am Dent Assoc 2024;155(11):1-9. https://doi.org/10.1016/j.adaj.2024.10.001. Audits and feedback, in combination with the use of electronic data on prescribing information (regional database of dentists), would enable targeted interventions for higher-frequency prescribers. For audit and feedback mechanisms, graphically showing the information for the individual providers and tailoring messaging for them was found in a recent study to be effective.39Seager JM, Howell-Jones RS, Dunstan FD et al. A Randomised Controlled Trial of Clinical Outreach Education to Rationalise Antibiotic Prescribing for Acute Dental Pain in the Primary Care Setting. Br Dent J 2006;201:217-2. Further methods include the use of online prescriber decision support systems for providers.41Elouafkaoui P, Young L, Newlands R et al. An Audit and Feedback Intervention for Reducing Antibiotic Prescribing in General Dental Practice: The RAPiD Cluster Randomised Controlled Trial. PLoS Med 2016;13:e1002115. doi: 10.1371/journal.pmed.1002115. In one survey in a dental school, almost 75% of the more than 200 respondents were dental students and self-reported less confidence in prescribing antibiotics than faculty and residents did, while knowledge level was similar.35Schneider-Smith EG, Suda KJ, Lew D et al. How decisions are made: Antibiotic stewardship in dentistry. Infect Control Hosp Epidemiol 2023;44(11):1731-6. doi: 10.1017/ice.2023.173. Based on the results of focus groups among the respondents, it was concluded that a clinical decision-making support tool would be beneficial for appropriate antibiotic prescribing among dental professionals and students.

Patient education
Patient education has been recommended that informs patients on appropriate antibiotic prescriptions and helps to manage patient expectations. Based on a 2024 review of 18 studies in the medical setting, it was concluded that patient education on the use of antibiotics results in more appropriate expectations. Across these studies, public health campaigns, leaflets, posters, videos and presentations were used for patient education.46Hunter CR, Owen K. Can patient education initiatives in primary care increase patient knowledge of appropriate antibiotic use and decrease expectations for unnecessary antibiotic prescriptions? Fam Pract 2024;cmae047. doi: 10.1093/fampra/cmae047. Similar tactics and materials are available for use in the dental setting, including a patient brochure available from the Centers for Disease Control and Prevention.47Centers for Disease Control and Prevention. Antibiotic use for a safe dental visit. https://www.cdc.gov/antibiotic-use/media/pdfs/au-dental-trifold-brochure-p.pdf?CDC_AAref_Val=https://www.cdc.gov/antibiotic-use/pdfs/AU-Dental-Trifold-Brochure-P.pdf. In addition, the AAE notes that patients requiring endodontic therapy can be educated on the symptoms and signs of a spreading infection and provided with a ‘delayed prescription’ in case they need to fill it.14American Association of Endodontists. Position Statement: AAE Guidance on the Use of Systemic Antibiotics in Endodontics. J Endod 2017;43(9):1409-13. https://doi.org/10.1016/j.joen.2017.08.015.

Conclusions

Antimicrobial resistance continues to increase globally, while inappropriate use of antibiotics continues to occur in healthcare and other settings. Furthermore, after a period of reductions in the use of antibiotics in healthcare, antibiotic prescribing during the COVID-19 pandemic increased under challenging circumstances. In addition, recent data suggests that this practice may have persisted.27Stenlund S, Huynh J, Pau C et al. Dental antibiotic use in British Columbia from 1996 through 2023. Are we backsliding? J Am Dent Assoc 2024;155(11):1-9. https://doi.org/10.1016/j.adaj.2024.10.001. With respect to endodontic treatment, both the ADA and AAE have provided guidelines and recommendations on the adjunctive use of oral systemic antibiotics based on the clinical situation and patient status. Antibiotic stewardship programs are helping to increase awareness and knowledge, with strategies and tactics to improve prescribing and appropriate use of antibiotics. It is incumbent upon dental professionals to practice appropriate and judicious use of oral systemic antibiotics within endodontics and dentistry in general.

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