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

Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults

BACKGROUND

Dental pain can have a detrimental effect on quality of life. Symptomatic apical periodontitis and acute apical abscess are common causes of dental pain and arise from an inflamed or necrotic dental pulp, or infection of the pulpless root canal system. Clinical guidelines recommend that the first-line treatment for these conditions should be removal of the source of inflammation or infection by local operative measures, and that systemic antibiotics are currently only recommended for situations where there is evidence of spreading infection (cellulitis, lymph node involvement, diffuse swelling) or systemic involvement (fever, malaise). Despite this, there is evidence that dentists frequently prescribe antibiotics in the absence of these signs. There is concern that this could contribute to the development of antibiotic-resistant bacteria. This review is the second update of the original version first published in 2014.

OBJECTIVES

To evaluate the effects of systemic antibiotics provided with or without surgical intervention (such as extraction, incision and drainage of a swelling, or endodontic treatment), with or without analgesics, for symptomatic apical periodontitis and acute apical abscess in adults.

SEARCH METHODS

We searched Cochrane Oral Health's Trials Register (26 February 2018 (discontinued)), CENTRAL (2022, Issue 10), MEDLINE Ovid (23 November 2022), Embase Ovid (23 November 2022), CINAHL EBSCO (25 November 2022) and two trials registries, and performed a grey literature search. There were no restrictions on language or date of publication.

SELECTION CRITERIA

Randomised controlled trials of systemic antibiotics in adults with a clinical diagnosis of symptomatic apical periodontitis or acute apical abscess, with or without surgical intervention (considered in this situation to be extraction, incision and drainage, or endodontic treatment) and with or without analgesics.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the results of the searches against inclusion criteria, extracted data and assessed risk of bias. We used a fixed-effect model in the meta-analysis as there were fewer than four studies. We contacted study authors to request missing information. We used GRADE criteria to assess the certainty of the evidence.

MAIN RESULTS

There was one new completed trial on this topic since the last update in 2018. In total, we included three trials with 134 participants. Systemic antibiotics versus placebo with surgical intervention and analgesics for symptomatic apical periodontitis or acute apical abscess One trial (72 participants) compared the effects of a single preoperative dose of clindamycin versus a matched placebo when provided with a surgical intervention (endodontic chemo-mechanical debridement and filling) and analgesics to adults with symptomatic apical periodontitis. We assessed this study at low risk of bias. There were no differences in participant-reported pain or swelling across trial arms at any time point assessed. The median values for pain (numerical rating scale 0 to 10) were 3.0 in both groups at 24 hours (P = 0.219); 1.0 in the antibiotic group versus 2.0 in the control group at 48 hours (P = 0.242); and 0 in both groups at 72 hours and seven days (P = 0.116 and 0.673, respectively). The risk ratio of swelling when comparing preoperative antibiotic to placebo was 0.50 (95% confidence interval (CI) 0.10 to 2.56; P = 0.41). The certainty of evidence for all outcomes in this comparison was low. Two trials (62 participants) compared the effects of a seven-day course of oral phenoxymethylpenicillin (penicillin VK) versus a matched placebo when provided with a surgical intervention (total or partial endodontic chemo-mechanical debridement) and analgesics to adults with acute apical abscess or symptomatic necrotic tooth. Participants in both trials also received oral analgesics. We assessed one study at high risk of bias and the other at unclear risk of bias. There were no differences in participant-reported pain or swelling at any time point assessed. The mean difference for pain (short ordinal numerical scale 0 to 3, where 0 was no pain) was -0.03 (95% CI -0.53 to 0.47) at 24 hours; 0.32 (95% CI -0.22 to 0.86) at 48 hours; and 0.08 (95% CI -0.38 to 0.54) at 72 hours. The standardised mean difference for swelling was 0.27 (95% CI -0.23 to 0.78) at 24 hours; 0.04 (95% CI -0.47 to 0.55) at 48 hours; and 0.02 (95% CI -0.49 to 0.52) at 72 hours. The certainty of evidence for all the outcomes in this comparison was very low. Adverse effects, as reported in two studies, were diarrhoea (one participant in the placebo group), fatigue and reduced energy postoperatively (one participant in the antibiotic group) and dizziness preoperatively (one participant in the antibiotic group). Systemic antibiotics without surgical intervention for adults with symptomatic apical periodontitis or acute apical abscess We found no studies that compared the effects of systemic antibiotics with a matched placebo delivered without a surgical intervention for symptomatic apical periodontitis or acute apical abscess in adults.

AUTHORS' CONCLUSIONS

The evidence suggests that preoperative clindamycin for adults with symptomatic apical periodontitis results in little to no difference in participant-reported pain or swelling at any of the time points included in this review when provided with chemo-mechanical endodontic debridement and filling under local anaesthesia. The evidence is very uncertain about the effect of postoperative phenoxymethylpenicillin for adults with localised apical abscess or a symptomatic necrotic tooth when provided with chemo-mechanical debridement and oral analgesics. We found no studies which compared the effects of systemic antibiotics with a matched placebo delivered without a surgical intervention for symptomatic apical periodontitis or acute apical abscess in adults.

Antibiotics Prescribing Pattern and Quality of Prescribing in Croatian Dental Practices-5-Year National Study

PURPOSE

Antibiotic resistance is one of the biggest threats to global health today. The aim of this study was to analyze antibiotic prescribing patterns and quality of prescribing in Croatian dental practices over a 5-year period.

METHODS

This is a retrospective observational study based on the analysis of the electronic prescriptions (medicines in ATC groups J01 and P01) from dental practices in Croatia prescribed from 1 January 2015 to 31 December 2019. Prescriptions were retrieved from the Croatian Health Insurance Fund (HZZO). The analyses included the number of prescriptions, type and quantity of prescribed drugs, indication, and the patient's and prescriber's characteristics.

RESULTS

The consumption increased from 1.98 DID in 2015, to 2.10 DID in 2019. The most prescribed antibiotic was Amoxicillin with clavulanic acid followed by Amoxicillin, Clindamycin, Metronidazole and Cefalexin. The analyses showed that 29.79% of antibiotics were not prescribed in accordance with the contemporary guidelines for the proper use of antibiotics. Additionally, 22% of antibiotics were prescribed in inconclusive indications.

CONCLUSION

The research showed an increase in antibiotic consumption over five years along with unnecessary prescribing of antibiotics in cases with no indications for its use. The development of national guidelines for antibiotic use is necessary.

WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections

The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes. This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.

Barriers and facilitators to guideline concordant dental antibiotic prescribing in the United States: A qualitative study of the National Dental PBRN

OBJECTIVES

While factors contributing to dental antibiotic overprescribing have previously been described, previous work has lacked any theoretical behavior change framework that could guide future intervention development. The purpose of this study was to use an evidence-based conceptual model to identify barriers and facilitators of appropriate antibiotic prescribing by dentists as a guide for future interventions aimed at modifying antibiotic prescribing.

METHODS

Semi-structured interviews were conducted with dentists from the National Dental Practice Based Research Network (PBRN) exploring patient and practice factors perceived to impact antibiotic prescribing. Audio-recorded telephone interviews were transcribed and independently coded by three researchers. Themes were organized around the COM-B model to inform prospective interventions.

RESULTS

73 of 104 dentists (70.1%) were interviewed. Most were general dentists (86.3%), male (65.7%), and white (69.9%). Coding identified three broad targets to support appropriate dental antibiotic prescribing among dentists: (1) increasing visibility and accessibility of guidelines, (2) providing additional guidance on antibiotic prescribing in dental scenarios without clear guidelines, and (3) education and communication skills-building focused on discussing appropriate antibiotic use with patients and physicians.

CONCLUSIONS

The findings from our study are consistent with other studies focusing on antibiotic prescribing behavior in dentists. Understanding facilitators and barriers to dental antibiotic prescribing is necessary to inform targeted interventions to improve appropriate antibiotic prescribing. Future interventions should focus on implementing multimodal strategies to provide the necessary support for dentists to judiciously prescribe antibiotics.

Effectiveness of Oral Cephalexin-Clavulanic Acid, Cefuroxime, and Amoxicillin-Clavulanic Acid in the Management of Dental Infections: A Real-World, Retrospective, Electronic Medical Record-Based Study in India

BACKGROUND

Despite multiple antibiotics being available to manage dental infections (DI), there is lack of data comparing commonly prescribed antibiotics in India.

OBJECTIVES

The aim of this study was to evaluate the real-world effectiveness and tolerability of cephalexin-clavulanic acid fixed-dose combination (cephalexin CV FDC) in contrast with amoxicillin-clavulanic acid (co-amoxiclav FDC) and cefuroxime among patients with dental infections (odontogenic) in India.

METHODS

This retrospective, multi-centric, observational, real-world electronic medical record (EMR)-based study was conducted between January 2022 and December 2022. The EMRs of 355 adults with DI receiving oral cephalexin CV, co-amoxiclav, or cefuroxime were categorized into two distinct groups: Group I (Test Group) with patients prescribed cephalexin extended release 375/750 mg along with clavulanic acid 125 mg; and Group II (Comparator Group) with patients prescribed co-amoxiclav 625 mg (500 mg amoxicillin + 125 mg clavulanic acid) or cefuroxime (250 mg/500 mg).

RESULTS

Toothache was the most common complaint, reported by 95.5% of patients, followed by swelling (46.8%), tooth sensitivity (35.5%), pus discharge (33.0%), redness and halitosis (30.4% each). Dental caries was observed in 81.1% of patients. Clinical improvement, defined as improvement/partial resolution of infection-related clinical signs and symptoms (composite measure of pain, swelling, fever, requirement of additional antimicrobial therapy) as per dentists' judgment, was recorded in 98.3% of patients with cephalexin CV, 96.8% of patients with co-amoxiclav, and 98.9% of patients treated with cefuroxime within 10 days. Time (days) to clinical improvement was numerically lesser among patients receiving cephalexin CV (4.6 ± 2.0) compared with cefuroxime (4.9 ± 2.1) and co-amoxiclav (5.0 ± 2.6). All treatments were well tolerated.

CONCLUSION

Cephalexin CV was as effective as co-amoxiclav and cefuroxime, with faster clinical improvement and better resolution of certain symptoms.

Prevalence of unnecessary antibiotic prescriptions among dental visits, 2019

OBJECTIVE

The US National Action Plan for Combating Antibiotic-Resistant Bacteria established a goal to decrease unnecessary outpatient antibiotic use by 50%. However, data to inform this goal have been limited to medical settings and have not included dental prescribing. Thus, we sought to identify the proportion of antibiotics prescribed inappropriately by dentists to inform outpatient stewardship efforts.

METHODS

Cross-sectional analysis of 2019 Veterans' Affairs (VA) national electronic health record data. Antibiotics prescribed by dentists were evaluated for appropriateness based on 2 definitions: one derived from current guidelines (consensus-based recommendations) and the other based on relevant clinical literature (nonconsensus). A clustered binomial logistic regression model determined factors associated with discordant prescribing.

RESULTS

In total, 92,224 antibiotic prescriptions (63% amoxicillin; mean supply, 8.0 days) were associated with 88,539 dental visits. Prophylaxis for complications in medically compromised patients was associated with the most (30.9%) antibiotic prescriptions, followed by prevention of postsurgical complications (20.1%) and infective endocarditis (18.0%). At the visit level, 15,476 (17.5%) met the consensus-based definition for appropriate antibiotic usage and 56,946 (64.3%) met the nonconsensus definition.

CONCLUSIONS

More than half of antibiotics prescribed by dentists do not have guidelines supporting their use. Regardless of definition applied, antibiotics prescribed by dentists were commonly unnecessary. Improving prescribing by dentists is critical to reach the national goal to decrease unnecessary antibiotic use.

Antibiotic Prescribing in Dental Medicine-Best Practices for Successful Implementation

With rising rates of antimicrobial resistance throughout the world, it is time to revisit antibiotic prescribing policies and practices, and dentistry is an important area for focused intervention, as it accounts for up to 15% of all antimicrobial prescriptions. In this narrative review, we have analyzed the current state of the knowledge, attitudes, and practice regarding antimicrobial use among dental professionals, and we have identified a set of seven recurring themes that drive inappropriate antibiotic prescribing in dental medicine. These include: 1. Prescribing antibiotics to delay or avoid dental treatment. 2. Overlooking the 5Ds-dental treatment (source control), dental condition (indication), drug (antibiotic choice), dose, and duration. 3. Relying on education from the distant past and on previous experience. 4. The heterogeneity of (too many) guideline recommendations leads to confusion and over-prescribing. 5. Decreased access to guideline information in private practice. 6. Psychological factors such as pressure to prescribe, comfort prescribing and the weekend effect, and 7. Feeling removed from antimicrobial resistance and externalizing responsibility. Based on the existing knowledge, we propose a framework based on four key pillars for focused intervention: 1. Education. 2. Internalizing responsibility. 3. Recognizing recurring counter-productive practices, and 4. Addressing recurring counter-productive practices. This framework can be applied in different dental settings to ensure best practices for the successful implementation of rational antimicrobial prescribing.

Systemic Antibiotic Use in Acute Irreversible Pulpitis: Evaluating Clinical Practices and Molecular Insights

This scoping review systematically evaluates the use of systemic antibiotics in treating acute irreversible pulpitis, integrating clinical practice patterns with recent molecular insights. We analyzed clinical evidence on antibiotic prescription trends among dental professionals and examined molecular research advancements in relation to pulpitis. This review is intended to bridge the gap between clinical practice and molecular research, guiding more evidence-based approaches to treating acute irreversible pulpitis. Electronic databases were searched for relevant articles published in English based on the objective of the review. A second search using all identified keywords and index terms was undertaken across all the included databases. In addition, a reference list of identified articles was searched. Studies including original research, systematic reviews, meta-analyses, clinical trials, and observational and retrospective studies, all written in English and published from 2010 onwards, were included, and an analysis of the text words contained in the titles and abstracts of the retrieved papers and of the index terms used to describe the articles was performed. A total of N = 53 articles were selected. Altogether, N = 43 (76.79%) articles were cross-sectional studies, N = 4 (11.11%) were systematic reviews, and N = 3 (5.36%) were guidelines. The most frequent level of evidence was level VI (N = 43 (76.79%). The mean percentage of dentists who prescribed antibiotics to treat acute irreversible pulpitis was 23.89 ± 23.74% (range: 0.05-75.7). Similarly, for specialists, it was 22.41 ± 15.64 (range 2.2-50.4), and the percentage for undergraduates was 17.52 ± 20.59 (range 0-62.6). The significant developments in research models for pulpitis research and the characterisation of biomarkers have led to better management strategies. Concurrently, significant advancements in molecular research provide new understandings of pulpitis, suggesting alternative therapeutic approaches. Although there are guidelines available, increased rates of antibiotic prescription are still prevalent around the globe.

Antimicrobial use practices in canine and feline dental procedures performed in primary care veterinary practices in the United States

This study examined the utilization of antimicrobials in canines and felines receiving dental treatments in veterinary clinics in the United States, retrospectively. A total of 818,150 animals (713,901 procedures in dogs and 104,249 procedures in cats) underwent dental procedures under general anesthesia in 2020. These included dental prophylaxis and extractions. Patient demographic data, antimicrobial treatment, treatment duration, dose, periodontal disease score, whether tooth extractions were performed and how many extractions were performed was recorded. Our results showed that local or systemic antimicrobials were used in 116,723/713,901 (16.4%) procedures in dogs and 14,264/104,249 (14%) procedures in cats. Age, weight, extraction of one or more teeth and diagnosis of periodontal disease (any stage) were associated with increased likelihood of antimicrobial administration using univariable analysis (all P<0.001) and in the multivariable model. Clindamycin, amoxicillin-clavulanate and amoxicillin were the most common oral antimicrobials used in dogs and cats. Drugs classified as highest priority clinically important antibiotics (HPCIA) were administered to 30,960/116,723 (26.5%) of dogs and 7,469/14,264 (52%) of treated cats. The results obtained can inform interventions to optimize patient care and promote prudent use of antimicrobials during dental procedures in canine and feline patients.

Changes in antibiotic prescribing by dentists in the United States, 2012-2019

OBJECTIVES

Dentists prescribe 10% of all outpatient antibiotics in the United States and are the top specialty prescriber. Data on current antibiotic prescribing trends are scarce. Therefore, we evaluated trends in antibiotic prescribing rates by dentists, and we further assessed whether these trends differed by agent, specialty, and by patient characteristics.

DESIGN

Retrospective study of dental antibiotic prescribing included data from the IQVIA Longitudinal Prescription Data set from January 1, 2012 to December 31, 2019.

METHODS

The change in the dentist prescribing rate and mean days' supply were evaluated using linear regression models.

RESULTS

Dentists wrote >216 million antibiotic prescriptions between 2012 and 2019. The annual dental antibiotic prescribing rate remained steady over time (P = .5915). However, the dental prescribing rate (antibiotic prescriptions per 1,000 dentists) increased in the Northeast (by 1,313 antibiotics per 1,000 dentists per year), among oral and maxillofacial surgeons (n = 13,054), prosthodontists (n = 2,381), endodontists (n = 2,255), periodontists (n = 1,961), and for amoxicillin (n = 2,562; P < .04 for all). The mean days' supply significantly decreased over the study period by 0.023 days per 1,000 dentists per year (P < .001).

CONCLUSIONS

From 2012 to 2019, dental prescribing rates for antibiotics remained unchanged, despite decreases in antibiotic prescribing nationally and changes in guidelines during the study period. However, mean days' supply decreased over time. Dental specialties, such as oral and maxillofacial surgeons, had the highest prescribing rate with increases over time. Antibiotic stewardship efforts to improve unnecessary prescribing by dentists and targeting dental specialists may decrease overall antibiotic prescribing rates by dentists.

To prescribe or not to prescribe? A review of the Prescribing Competencies Framework for dentistry

OBJECTIVES

Dentists in Australia are the second largest prescriber group, and are generally not formally taught how to prescribe. The objective of this review is to describe the Prescribing Competencies Framework and its relevance to dentistry.

DATA

The four-model stage of prescribing by Coombes and colleagues, and the seven competencies within the Prescribing Competencies Framework devised by the Australian National Prescribing Service MedicineWise, are discussed and applied to dentistry.

SOURCES AND STUDY SELECTION

Each of the seven competencies are analysed and detailed in the context of clinical dental practice. Competencies 1-5 describe the skillset and tasks required by dentists to safely prescribe, whereas Competencies 6 and 7 describe the clinical environment and recommended resources to support dentists to prescribe safely and effectively.

CONCLUSIONS

The Prescribing Competencies Framework provides an overview of safe and effective prescribing. Prescribing is a process, and a separate skillset to clinical dentistry. The process involves information gathering, clinical assessment, effective communication and review of the patient. Access to timely and appropriate resources and relevant electronic sources of health information for clinicians are important to provide the support required for better informed prescribing decisions. The framework describes a patient-centered prescribing process, and ultimately prescribing should be a shared decision between the dentist and the patient.

CLINICAL SIGNIFICANCE

Safe and effective prescribing is an integral part of dentistry and dentists are the second largest prescriber group. However, dentists display high rates of inappropriate and unnecessary prescribing, and to minimise errors, the Prescribing Competencies Framework has been established. This article details how the Framework applies to clinical practice dentistry.

Antibiotic Prescription Patterns for Endodontic Procedures in India: A Knowledge, Attitude, and Practices (KAP) Survey

Objective The purpose of this study is to evaluate the antibiotic prescription patterns of endodontists, general dentists, and other dental specialists for endodontic procedures in India by using the knowledge, attitude, and practices (KAP) survey method. Methods This cross-sectional study was carried out from February 2022 to May 2022 and involved dentists across India. A self-made questionnaire survey was created to judge the knowledge of various dental practitioners, which includes general dentists, endodontists, other dental specialists, and post-graduates with regard to antibiotic usage guidelines for endodontic purposes. A total of about 310 dental practitioners were surveyed across India. The questionnaire was circulated via social platforms such as WhatsApp, Instagram, and Facebook Messenger. Statistical analysis Data for KAP regarding antibiotic prescription patterns among general dentists, endodontists, other dental specialists, and postgraduates were entered into Microsoft Excel and analyzed using IBM SPSS Statistics for Windows, Version 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). Descriptive statistics of the study population were examined. The level of statistical significance was determined at p<0.05. Results For the percentage of patients who were prescribed systemic antibiotics every day for endodontic reasons, about 38.6% (119) responded 0-10% and 27.3% (84) responded 10-30%. For the order of antibiotics that they prefer from most to least, about 85.4% (263) responded amoxicillin > metronidazole > doxycycline > azithromycin > clindamycin > ciprofloxacin. For the question of whether they use local antibiotics, about 35% answered yes of which 25% were endodontists, 2% were general dentists, 5% were other dental specialists, and 3% were post-graduates. About 77.3% of the total participants were unaware of the antimicrobial stewardship concept and AwaRe classification from WHO. About 53.2% (164) attended CDE programs with regard to antibiotic usage. Conclusion It is evident from the results of the present study that there is over-prescription of antibiotics by practitioners especially by general dentists without following proper guidelines for endodontic treatments. More emphasis should be made on the proper prescription pattern of antibiotics, proper understanding of endodontic diagnosis, and the need for antibiotics at the undergraduate level. In addition, proper awareness, as well as proper prescription of antibiotics, should be made for existing dental professionals.

Assessment of the Quality of Current American Dental Association Clinical Practice Guidelines

INTRODUCTION

The American Dental Association (ADA) defines evidence-based dentistry (EBD) as "an approach to oral healthcare that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the oral and medical condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences." Clinical practice guidelines (CPGs) are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options. Therefore, ADA CPGs are the most rigorous examples of EBD to inform clinical practice. CPGs should be of the highest level of quality to ensure the appropriateness and timeliness of clinical recommendations.

OBJECTIVES

The aim of this study was to measure the methodological rigor and transparency of the ADA CPGs.

METHODS

Each ADA CPG was appraised by 4 independent assessors using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Quantitative quality scores were obtained for 6 domains and overall quality. In addition, assessors provided a qualitative analysis by providing comments for each item and an appraisal of the full recommendation.

RESULTS

A quality score of 75% was used as the threshold for high-quality guidelines. Using this metric, 6 of the current 10 current ADA CPGs were considered to be of high quality, 1 was slightly below the quality threshold, and 3 were considered marginal. Even among those evaluated to be high quality in overall assessment, certain domains did not reach the quality threshold of 75%.

CONCLUSION

Overall, the ADA CPGs collectively provide high-quality guidance for the clinician. While the AGREE appraisal guidelines have been used in CPG development since 2016, there is still room for improvement in certain domains (i.e., stakeholder involvement, rigor of development, applicability, and editorial independence).

KNOWLEDGE TRANSFER STATEMENT

The results of this study summarize the methodological rigor and transparency of the 10 current ADA clinical practice guidelines. Since adoption of AGREE standards (2016), CPGs have been uniformly of high quality. The quality of older CPGs was somewhat lower but overall deemed acceptable. Thus, ADA CPGs may be used with confidence to inform practitioners of treatment options supported by rigorous evidence-based dentistry standards. However, there is still room for improvement in methodological quality.

Clostridioides difficile infection following dental antibiotic prescriptions in a cohort of US veterans

Among 108 (0.05% of cohort) US veterans with a Clostridioides difficile infection (CDI) within 30 days of a dental antibiotic prescription, 80% of patients received guideline-discordant antibiotics. Half had chronic gastrointestinal illness potentially exacerbating their CDI risk. More efforts are needed to improve antibiotic stewardship.

Dental antibiotics and referrals in general medical practice: Wales 1974-2017

OBJECTIVES

This study aimed to explore trends and predictors for antibiotic prescriptions and referrals for patients seeking dental care at General Medical Practitioners (GMPs) over a 44-year period in Wales, UK.

METHODS

This retrospective observational study analysed data from the nationwide Secure Anonymised Information Linkage Databank of visits to GMPs. Read codes associated with dental diagnoses were extracted from 1974-2017. Data were analysed using descriptive statistics, univariate and multivariable logistic regression.

RESULTS

Over the 44-year period, there were a total of 160,952 antibiotic prescriptions and 2,947 referrals associated with a dental attendance. Antibiotic prescriptions were associated with living in the most deprived (OR 0.91, 95% CI 0.89-0.93) or rural (OR 0.83, 95% CI 0.82-0.84) areas, whereas referrals were associated with living in an urban area (OR 2.16, 95% CI 1.99-2.35) or rural and less deprived area (OR 1.71, 95% CI 1.26-2.33). The number of antibiotic prescriptions decreased over time whereas the number of referrals increased.

CONCLUSIONS

These changes coincide with dental attendance rates at GMPs over the same period and indicate that appointment outcome and repeat patient attendance are linked. Rurality and deprivation may also influence care provided.

CLINICAL SIGNIFICANCE

General medical practices are not the most appropriate place for patients seeking dental care to attend, and efforts should be made to change current practice and policy to support patients to seek care from dental practices. When patients do seek dental care from GMPs they should be encouraged to refer the patient to a dentist rather than prescribe antibiotics as an important element of national antimicrobial stewardship efforts, as well as to discourage repeat attendance.

The use of antibiotics in acute oral health patients presenting at public dental clinics in the Western Sydney region

BACKGROUND

There is a limited need for antibiotics when treating oral health problems, yet they are often prescribed, increasing risk of antimicrobial resistance (AMR). With AMR a threat to public health, the objectives of this study were to assess the frequency, suitability, and factors associated with antibiotic prescriptions for acute dental problems across Greater Western Sydney public dental clinics.

METHODS

Patients' reason for attending, details of any antibiotics use, and the treating dental practitioner's clinical examination and diagnosis were compared to current prescribing guidelines, and logistic regression was used to identify predictors of antibiotic prescription.

RESULTS

In all, 1,071 patients participated in the study, and 15.9% reported to using antibiotics for their dental problem. Over three-quarters obtained the antibiotics from their general medical practitioner (GMP). A high prevalence of antibiotics were not indicated for the patient's complaint (71.8%) including for those with a history of extraction, pain, or intraoral swelling, who had significantly higher odds of antibiotic prescription (OR > 9). The antibiotic type prescribed was generally suitable.

CONCLUSIONS

In summary, the data suggest that the majority of antibiotics were inappropriately prescribed for the patient's dental complaints and there is a need for interventions to improve compliance with antibiotic prescribing guidelines.

Ex vivo evaluation of antibiotic sensitivity in samples from endodontic infections

Objective

To develop an in vitro model for real-time monitoring of endodontic biofilm growth and evaluate the ex vivo effect of antibiotics on biofilm growth.

Material and Methods

Root canal samples were taken from 40 patients and inoculated into 96-well plates in a system that measures biofilm growth through electrical impedance. Biofilm bacterial composition at the genus and species level was analyzed by Illumina sequencing. ANCOM-BC corrected data were used to compare bacterial composition after antibiotic treatment through compositional analysis, and to compare microbiological with clinical data.

Results

The stationary phase was reached at 8 hours. The biofilm formed had a similar bacterial composition to the inoculum, and Enterococcus faecalis was virtually absent from the samples. The bacterial composition and the effect of antibiotics were sample-dependent. Metronidazole was the antibiotic that most inhibited biofilm formation and azithromycin the one that inhibited it in the highest percentage of cases. The antibiotic effect could not be related to the biofilm original bacterial composition.

Conclusions

The impedance system allowed real-time monitoring of endodontic biofilm formation, and we propose it as a model for ex vivo evaluation of the whole biofilm susceptibility to antimicrobials, as opposed to evaluating antibiotic sensitivity of specific bacterial isolates.

Managing Oral Health in the Context of Antimicrobial Resistance

The oral microbiome plays a major role in shaping oral health/disease state; thus, a main challenge for dental practitioners is to preserve or restore a balanced oral microbiome. Nonetheless, when pathogenic microorganisms install in the oral cavity and are incorporated into the oral biofilm, oral infections, such as gingivitis, dental caries, periodontitis, and peri-implantitis, can arise. Several prophylactic and treatment approaches are available nowadays, but most of them have been antibiotic-based. Given the actual context of antimicrobial resistance (AMR), antibiotic stewardship in dentistry would be a beneficial approach to optimize and avoid inappropriate or even unnecessary antibiotic use, representing a step towards precision medicine. Furthermore, the development of new effective treatment options to replace the need for antibiotics is being pursued, including the application of photodynamic therapy and the use of probiotics. In this review, we highlight the advances undergoing towards a better understanding of the oral microbiome and oral resistome. We also provide an updated overview of how dentists are adapting to better manage the treatment of oral infections given the problem of AMR.

Moving the needle on dental antibiotic overuse in Canada post COVID-19

Antimicrobial resistance due to over-prescribing in health care, including in dentistry, has been acknowledged as one of the top ten threats to global health by the World Health Organization. Dentistry is responsible for approximately 10% of antibiotics prescribed worldwide and research has shown up to 80% of antibiotics prescribed by dentists may be unnecessary. During the early months of the coronavirus disease 2019 pandemic, when dental offices handled only dental emergencies, it is probable that antibiotics were prescribed more readily and for longer duration to defer treatment for non-urgent cases. These unprecedented times strengthened the realization that strong dental antimicrobial stewardship practises are required in Canada to keep antimicrobial overuse under control. In countries, such as the United Kingdom and Australia, significant work is ongoing in this regard. Canada has made progress in developing tools for antimicrobial stewardship specifically for physicians in community settings, where the vast majority of antibiotics are prescribed, and it is now time to pay attention to antimicrobial stewardship in the field of dental care. Investments in developing a national level dental prescription database, along with monitoring, education and feedback mechanisms, can strongly support moving the needle on dentist-driven antibiotic overuse in Canada.

Three-dimensional characterization of naturally developed early caries lesions using high-resolution micro-computed tomography

OBJECTIVES

The goal of this micro-Computed-Tomography (μCT) study was to characterize the structural parameters of natural, early proximal enamel caries lesions and correlate them with two-dimensional radiographic findings.

METHODS

Extracted human premolar teeth with ICDAS score 2 proximal lesions were examined using visual-tactile, μCT and simulated bitewing radiographs (BTX). Sound enamel and caries-lesions' structural and mineral density (MD) parameters were analyzed which included surface layer (SL) status and thickness, depth of lesion, and MD.

RESULTS

Thirty-six extracted premolars with 54 proximal early enamel caries lesions were analyzed. Lesions varied notably in lesion depth and MD. SL thickness ranged between 20 and 139μm. Three teeth (5.6%) had micro-cavitations upon the μCT examination despite being "clinically" non-cavitated. Cavitation status had no significant association with μCT nor BTX radiographic depth. Depth of lesions correlated weakly but statistically significantly with mineral loss (ML) at body of lesion (r=0.301, p=0.027). SL thickness also correlated negatively with ML at SL (r=-0.501, p&lt;0.001).

CONCLUSIONS

Early proximal enamel lesions with ICDAS 2 score as determined by visual-tactile examination exhibited a wide range of lesion parameters and cavitation status when examined by μCT. Visual-tactile examination may fail to detect micro-cavitations in enamel surface that are detectable by μCT.

CLINICAL SIGNIFICANCE

Clinicians have direct access to early proximal enamel lesions during orthodontic separation, exfoliation, extraction or restoration of adjacent teeth. This study invites the clinician to consider more decisive management options in high risk individuals (e.g. micro-invasive techniques), given the finding of vast structural variability of such lesions.

Antibiotic Prescription During Endodontic Treatment: Knowledge and Practices of Dental Interns in Saudi Arabia

BACKGROUND

Antibiotics are widely used in dental practice, especially for endodontic infections. The present survey aimed to investigate the knowledge and practices of dental interns in Saudi Arabia regarding antibiotic prescription for endodontic treatment.

METHODS

The present online questionnaire-based, cross-sectional study involved dental interns in private and public dental schools, Saudi Arabia. A pre-validated questionnaire was distributed to 900 dental interns via different social media platforms. The questionnaire consisted of 16 close-ended questions related to participants' demographic data and knowledge and practices of antibiotic prescription in context of endodontic treatments. Data were managed and analyzed using IBM-SPSS version 25, and Chi-square test was used to compare between the groups.

RESULTS

A total of 555 dental interns completed the questionnaire, giving a response rate of 61.1%. Overall, the surveyed participants revealed inadequate knowledge and unnecessary use of antibiotics during endodontic procedures. While majority of the participants (75.3%) correctly identified the first choice of antibiotics during endodontic treatments, a considerable proportion of the participants did not recognize the clinical indications of antibiotics in endodontic patients. Additionally, around one-fifth (18.9%) of the participants were unaware of the potential side effects of the prescribed antibiotics.

CONCLUSION

The present survey revealed unsatisfactory knowledge and practices of antibiotic prescription in context of endodontic therapy among Saudi dental interns. Therefore, dental schools in Saudi Arabia should address such a gap through updating the curriculum and integrating real-world clinical scenarios using problem-based learning. Additionally, periodic continuous education courses aiming at improving dental professionals' knowledge about antibiotics and their clinical uses for endodontic therapy are highly encouraged.

Optimum length of treatment with systemic antibiotics in adults with dental infections: a systematic review

Introduction Guidelines on the length of treatment of dental infections with systemic antibiotics vary across different countries. We aimed to determine if short-duration (3-5 days) courses of systemic antibiotics were as effective as longer-duration courses (≥7 days) for the treatment of dental infections in adults in outpatient settings.Methods We searched Ovid Medline, Ovid Embase, Cochrane, trials registries, Google Scholar and forward and backward citations for studies published between database inception and 30 March 2021. All randomised clinical trials (RCT) and non-randomised trials which compared length of treatment with systemic antibiotics for dental infections in adults in outpatient settings published in English were included.Results One small RCT met our defined inclusion criteria. The trial compared three-day versus seven-day courses of amoxicillin in adults with odontogenic infection requiring tooth extraction. There was no significant difference between groups in terms of participant-reported pain or clinical assessment of wound healing.Discussion While a number of observational studies were supportive of shorter-course therapy, only one small RCT concluded that a three-day course of amoxicillin was clinically non-inferior versus seven days for the treatment of odontogenic infection requiring tooth extraction. Limited conclusions on shorter-course therapy can be drawn from this study as all participants commenced amoxicillin two days before tooth extraction which is not common clinical practice. The variability in guidelines for use of antimicrobials in dental infections suggests that guidelines are based on local or national historical practice and indicates the need for further research to determine the optimum length of treatment. RCTs are required to investigate if short-duration courses of antibiotics are effective and to provide evidence to support consistent guidance for dental professionals.

Host mRNA Analysis of Periodontal Disease Patients Positive for Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans and Tannerella forsythia

Periodontal disease is a frequent pathology worldwide, with a constantly increasing prevalence. For the optimal management of periodontal disease, there is a need to take advantage of actual technology to understand the bacterial etiology correlated with the pathogenic mechanisms, risk factors and treatment protocols. We analyzed the scientific literature published in the last 5 years regarding the recent applications of mRNA analysis in periodontal disease for the main known bacterial species considered to be the etiological agents: Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans and Tannerella forsythia. We identified new pathogenic mechanisms, therapeutic target genes and possible pathways to prevent periodontal disease. The mRNA analysis, as well as the important technological progress in recent years, supports its implementation in the routine management of periodontal disease patients.

Dentists’ Habits of Antibiotic Prescribing May be Influenced by Patient Requests for Prescriptions

Objective

This study evaluates dentists' antibiotic prescribing habits and the frequency of facing patient pressure for prescriptions.

Methods

An online anonymous survey was used to collect data on antibiotic prescribing practices, including prescribing unnecessary antibiotics if requested by patients.

Results

The study population included 345 dentists; 227 (65.8%) were females and 118 (34.2%) were males. 54 (15.7%) reported that they prescribed unnecessary antibiotics more than once per week, 47 (13.6%) once per month, 135 (39.1%) rarely, and 109 (31.6%) never prescribed unnecessary antibiotics. 117 (33.9%) reported being pressured by patients to prescribe unnecessary antibiotics more than once per week. 110 (31.9%) reported being pressured by patients to do so at least once per month. There was a statistical difference between the two genders (P < 0.001) in reporting that patients pressured them to prescribe antibiotics when antibiotics were not necessary for treatment or prophylactic purposes and in prescribing unnecessary antibiotics sometimes if requested by a patient (P=0.008). In addition, there was a statistical difference in dentists' confidence in their knowledge and practice in the area of antibiotic prescribing (P < 0.001).

Conclusions

The results show that unnecessary antibiotic prescribing by dentists can be influenced by patient pressure.

Alternative Antibiotics in Dentistry: Antimicrobial Peptides

The rise of antibiotic resistant bacteria due to overuse and misuse of antibiotics in medicine and dentistry is a growing concern. New approaches are needed to combat antibiotic resistant (AR) bacterial infections. There are a number of methods available and in development to address AR infections. Dentists conventionally use chemicals such as chlorohexidine and calcium hydroxide to kill oral bacteria, with many groups recently developing more biocompatible antimicrobial peptides (AMPs) for use in the oral cavity. AMPs are promising candidates in the treatment of (oral) infections. Also known as host defense peptides, AMPs have been isolated from animals across all kingdoms of life and play an integral role in the innate immunity of both prokaryotic and eukaryotic organisms by responding to pathogens. Despite progress over the last four decades, there are only a few AMPs approved for clinical use. This review summarizes an Introduction to Oral Microbiome and Oral Infections, Traditional Antibiotics and Alternatives & Antimicrobial Peptides. There is a focus on cationic AMP characteristics and mechanisms of actions, and an overview of animal-derived natural and synthetic AMPs, as well as observed microbial resistance.

Evaluation of antibiotic prescribing for ambulatory patients seeking primary dental care services in a public hospital in Ghana: a clinical audit study

Background

One in 10 of all antibiotic prescriptions globally are for dental conditions with 80% of them being inappropriate, making it a potential driver of antimicrobial resistance.

Objectives

To evaluate the appropriateness of antibiotic use among ambulatory patients seeking dental care services in a public hospital in Ghana.

Methods

A retrospective clinical audit was conducted by extracting the medical records of all patients seeking dental care at the ambulatory care clinic of Keta Municipal Hospital (KMH) from January 2020 to December 2020 using the hospital’s electronic database. Descriptive statistics, bivariate and multivariate analysis were performed on the data collected.

Results

Overall, 1433 patient medical records were extracted from the database within the study period. The mean age of the patients identified was 39.9 years with almost two-thirds being female. The majority (91.1%, n = 1306) of them were attended to by a dental nurse. In total, 88.6% (n = 1269) of the patients received antibiotics and 87.5% (n = 1254) of antibiotics prescribed were non-compliant with Ghana Standard Treatment Guidelines. Three-quarters of the dental conditions were managed with dual antibiotics comprising amoxicillin and metronidazole. Antibiotic prescription was associated with age, gender, type of prescriber and type of dental condition diagnosed.

Conclusions

There is a high usage of antibiotics for dental conditions managed at the outpatient section of the hospital and most are inappropriate. Development of local guidelines supported by education of dental clinicians on empirical use of antibiotics is a suitable target for the antimicrobial stewardship team to address in KMH.

Private Practice Dentists Improve Antibiotic Use After Dental Antibiotic Stewardship Education from Infectious Diseases Experts

Background

Private practice dentists represent 72% of United States dentists. We conducted a prospective cohort study of private practice dentists comparing antibiotic use before and after dental antibiotic stewardship education by infectious diseases (ID) antibiotic stewardship experts.

Methods

Study phases were as follows: phase 1 (preeducation), 3 months of retrospective antibiotic data and a presurvey assessed baseline antibiotic knowledge; phase 2 (education), dentists attended 3 evening Zoom sessions; phase 3, (posteducation/interventions), 3 months of prospective audits with weekly feedback; phase 4, postsurvey and recommendations to reach more dentists.

Results

Fifteen dentists participated. Ten had practiced >20 years. Presurvey, 14 were unfamiliar with dental stewardship. The number of antibiotic prescriptions pre/post decreased from 2124 to 1816 (P < .00001), whereas procedures increased from 8526 to 9063. Overall, appropriate use (prophylaxis and treatment) increased from 19% pre to 87.9% post (P < .0001). Appropriate prophylaxis was 46.6% pre and 76.7% post (P < .0001). Joint implant prophylaxis decreased from 164 pre to 78 post (P < .0001). Appropriate treatment antibiotics pre/post improved 5-fold from 15% to 90.2% (P = .0001). Antibiotic duration pre/post decreased from 7.7 days (standard deviation [SD], 2.2 days) to 5.1 days (SD, 1.6 days) (P < .0001). Clindamycin use decreased 90% from 183 pre to 18 post (P < .0001). Postsurvey responses recommended making antibiotic stewardship a required annual continuing education. Study participants invited ID antibiotic stewardship experts to teach an additional 2125 dentists via dental study clubs.

Conclusions

After learning dental antibiotic stewardship from ID antibiotic stewardship experts, dentists rapidly optimized antibiotic prescribing. Private practice dental study clubs are expanding dental antibiotic stewardship training to additional dentists, hygienists, and patients across the United States.

Post-Operative Endodontic Pain Management: An Overview of Systematic Reviews on Post-Operatively Administered Oral Medications and Integrated Evidence-Based Clinical Recommendations

Endodontic treatment comprises the overall management of pre-, intra- and post-operative symptoms, including post-operative endodontic pain, considered as a complication susceptible of chronicization. Post-operative pain is very common and highly unpreventable and has a multi-factorial etiology and a potential pathogenic link to the acute inflammation of the periapical area, secondary to localized chemical, mechanical, host and/or microbial damage occurring during endodontic treatment. Considering the multitude of heterogeneous technical and pharmacological approaches proposed to control post-operative endodontic pain, the present study primarily comprised an overview of systematic reviews of systematic reviews of randomized clinical trials, summarizing findings on post-operatively administered oral medications for post-operative endodontic pain control, in order to note the most effective type and dosage of such drugs. Secondarily, a narrative review of the current evidence on technical solutions to be observed during endodontic treatment procedures, to control post-operative pain, was conducted to provide integrated evidence-based clinical recommendations for optimal post-operative endodontic pain management.

Opportunities for penicillin allergy evaluation in dental clinics

OBJECTIVE

To evaluate opportunities for assessing penicillin allergies among patients presenting to dental clinics.

DESIGN

Retrospective cross-sectional study.

SETTING

VA dental clinics.

PATIENTS

Adult patients with a documented penicillin allergy who received an antibiotic from a dentist between January 1, 2015, and December 31, 2018, were included.

METHODS

Chart reviews were completed on random samples of 100 patients who received a noncephalosporin antibiotic and 200 patients who received a cephalosporin. Each allergy was categorized by severity. These categories were used to determine patient eligibility for 3 testing groups based on peer-reviewed algorithms: (1) no testing, (2) skin testing, and (3) oral test-dose challenge. Descriptive and bivariate statistics were used to compare facility and patient demographics first between true penicillin allergy, pseudo penicillin allergy, and missing allergy documentation, and between those who received a cephalosporin and those who did not at the dental visit.

RESULTS

Overall, 19% lacked documentation of the nature of allergic reaction, 53% were eligible for skin testing, 27% were eligible for an oral test-dose challenge, and 1% were contraindicated from testing. Male patients and African American patients were less likely to receive a cephalosporin.

CONCLUSIONS

Most penicillin-allergic patients in the VA receiving an antibiotic from a dentist are eligible for penicillin skin testing or an oral penicillin challenge. Further research is needed to understand the role of dentists and dental clinics in assessing penicillin allergies.

Toward the development of an antibiotic stewardship competency in dental education

Antimicrobial resistance was recently described by the World Health Organization (WHO) as "a clear and present danger to global health." It is well documented that this resistance is significantly driven by the overuse and inappropriate use of antibiotics. Impactful change can only come from the adoption of antibiotic stewardship practices in all aspects of health care. With dentistry responsible for approximately 10% of all prescribed antibiotics in the United States, there is a potential to be acutely impactful with adequate interventions. After extensively reviewing the most current national and international literature on the topic, we identified that predoctoral dental education provides a potentially impactful opportunity to introduce and support the development of responsible antibiotic practices. To that extent, we developed a detailed framework of antibiotic stewardship competencies to promote responsible best practices among dental students.

Outcomes to evaluate care for adults with acute dental pain and infection: a systematic narrative review

OBJECTIVE

To identify outcomes reported in peer-reviewed literature for evaluating the care of adults with acute dental pain or infection.DesignSystematic narrative review.

SETTING/PARTICIPANTS

Primary research studies published in peer-reviewed literature and reporting care for adults with acute dental pain or infection across healthcare settings. Reports not in English language were excluded.

STUDY SELECTION

Seven databases (CINAHL Plus, Dentistry and Oral Sciences Source, EMBASE, MEDLINE, PsycINFO, Scopus, Web of Science) were searched from inception to December 2020. Risk of bias assessment used the Critical Appraisal Skills Programme checklist for randomised controlled trials and Quality Assessment Tool for Studies of Diverse Design for other study types.

OUTCOMES

Narrative synthesis included all outcomes of care for adults with acute dental pain or infection. Excluded were outcomes about pain management to facilitate treatment, prophylaxis of postsurgical pain/infection or traumatic injuries.

RESULTS

Searches identified 19 438 records, and 27 studies (dating from 1993 to 2020) were selected for inclusion. Across dental, pharmacy, hospital emergency and rural clinic settings, the studies were undertaken in high-income (n=20) and low/middle-income (n=7) countries. Two clinical outcome categories were identified: signs and symptoms of pain/infection and complications following treatment (including adverse drug reactions and reattendance for the same problem). Patient-reported outcomes included satisfaction with the care. Data collection methods included patient diaries, interviews and in-person reviews.

DISCUSSION

A heterogeneous range of study types and qualities were included: one study, published in 1947, was excluded only due to lacking outcome details. Studies from dentistry reported just clinical outcomes; across wider healthcare more outcomes were included.

CONCLUSIONS

A combination of clinical and patient-reported outcomes are recommended to evaluate care for adults with acute dental pain or infection. Further research is recommended to develop core outcomes aligned with the international consensus on oral health outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020210183.

Wide Cost Variations Observed in Antibiotics and Analgesics Prescribed for Dental Care in India: A Price and Affordability Analysis

Introduction

With high prevalence rates across the population, dental pain is the most common symptom that drives a patient to visit the dentist. Dentists prescribe analgesics and antibiotic prophylaxis apart from routine dental treatments. The increasing costs of medications are a major factor that adds to the financial burden of patients seeking oral care.

Methods

A list of antibiotics and analgesics recommended by the American Dental Association for dental pain, swelling, and post-procedural pain management was analyzed for the cost variation and cost ratio. The affordability was calculated by the World Health Organization/Health Action International (WHO-HAI) methodology. The most expensive and the least expensive brands of all drug regimens were compared.

Results

Wide cost variations were observed between the different brands of antibiotics and analgesics. The highest cost variation was found in ampicillin 500 mg injection (13579.2%). In the affordability analysis; when the most expensive brands were analyzed, the lowest-paid unskilled worker had to lose 2.1 days of wages to afford the drug regimen. The price range was widest for injection ampicillin 500 mg (Rs. 4.24-580.0) and lowest for tablet ibuprofen 400 mg (Rs. 0.7-1.6). 

Conclusion

Dental surgeons need to be well aware of the pharmacoeconomics behind medications that directly decides the affordability of treatments. Careful selection of drugs by the dentists considering their quality, availability, and costs is of pivotal importance. Prescribing generic medications and increasing the availability of drugs in public health sectors can help provide cost-effective dental care for all.

Supportive Home Remedies for Orofacial Pain during the Coronavirus Disease 2019 Pandemic: Their Value and Limitations

Background

The coronavirus disease 2019 (COVID-19) pandemic has impeded access to timely dental care, and there is an urgent need for adjuvant therapies that can reduce orofacial pain in emergencies.

Aims

To provide information on the benefits and limitations of eight representative home remedies as palliative care for orofacial pain during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

PubMed and Medline were electronically searched for eight home remedies for orofacial pain that can be used in COVID-19. Papers published in English in the past 30 years were considered. Among the published studies suitable for the research purpose, those in which the abstract and body text were confirmed were targeted, and duplicate studies were excluded. Finally, 86 studies were included.

Results

There is extensive and high-level scientific evidence for the application of tooth brushing and flossing, mouth rinsing with chlorhexidine, use of over-the-counter pain medication, and application of cryotherapy in emergencies. Gargling with salt water, brushing with bamboo salt, gargling with garlic juice, and oil pulling are traditional methods used for centuries. The use of natural products for orofacial pain has a significant empirical effect but has weak scientific evidence.

Conclusions

Knowing the correct application method, effects, and side effects is desirable to use these methods appropriately in emergencies. However, scientific evidence is unclear and generally lacking for home remedies to be the main treatment strategy, and there are clear limitations to their use as a single main treatment.

Appropriateness of Antibiotic Prescribing in Patients Discharged From a Community Hospital Emergency Department

IMPORTANCE: Every year, thousands of emergency department (ED) visits result in patients being discharged with oral antibiotic prescriptions. Published studies that assess the appropriateness of these antibiotic regimens are limited. PURPOSE: The purpose of this study was to examine the appropriateness of antibiotic prescriptions written for patients discharged from a community hospital’s ED. ENDPOINTS: The primary objective was to determine the overall percent of appropriate antibiotic prescriptions for patients discharged from the ED. Secondary objectives included the following: identify reasons for inappropriateness categorized by antibiotic selection, dose, duration, and allergies; identify the most common antibiotics prescribed inappropriately as well as the most common disease states that led to inappropriate prescribing of antibiotics; and analyze prescribing trends based on provider type and time of day the prescription was written. STUDY DESIGN AND METHODS: Patients eligible for inclusion were adults age 18 and older who presented to the ED during four chosen weeks in 2019 and who were discharged with oral antibiotics. Extracted electronic health record data was reviewed to identify the discharge diagnosis for each patient that meets the inclusion criteria. Pertinent information gathered from the patients’ medical records along with a validated antimicrobial assessment tool were utilized to determine the level of appropriateness of the prescribed antibiotic regimens. RESULTS: A total of 76% of the prescribed antibiotics were appropriate, 16% were inappropriate, and the remaining 8% were not assessable. Duration was the most common reason for a regimen to not be optimal. The most frequently inappropriately prescribed antibiotics included cephalexin (but it is noted cephalexin was included in almost half of the antibiotic regimens in this study), clindamycin, and azithromycin. Infections that were most frequently treated inappropriately were skin and soft tissue infections, dental infections, and sinusitis. Overall, medical residents prescribed the highest percent of appropriate regimens, and the time of day that had the highest percent of appropriate prescriptions was third shift (11 p.m. to 7 a.m.). CONCLUSION AND RELEVANCE: Almost half of all the nonoptimal antibiotic regimens had an excessive duration. Targeted local education efforts and future clinical decision support can facilitate appropriate prescribing of discharge antibiotics from the ED, ultimately improving antimicrobial stewardship within the community.

Classic vs. Novel Antibacterial Approaches for Eradicating Dental Biofilm as Adjunct to Periodontal Debridement: An Evidence-Based Overview

Periodontitis is a multifactorial chronic inflammatory disease that affects tooth-supporting soft/hard tissues of the dentition. The dental plaque biofilm is considered as a primary etiological factor in susceptible patients; however, other factors contribute to progression, such as diabetes and smoking. Current management utilizes mechanical biofilm removal as the gold standard of treatment. Antibacterial agents might be indicated in certain conditions as an adjunct to this mechanical approach. However, in view of the growing concern about bacterial resistance, alternative approaches have been investigated. Currently, a range of antimicrobial agents and protocols have been used in clinical management, but these remain largely non-validated. This review aimed to evaluate the efficacy of adjunctive antibiotic use in periodontal management and to compare them to recently suggested alternatives. Evidence from in vitro, observational and clinical trial studies suggests efficacy in the use of adjunctive antimicrobials in patients with grade C periodontitis of young age or where the associated risk factors are inconsistent with the amount of bone loss present. Meanwhile, alternative approaches such as photodynamic therapy, bacteriophage therapy and probiotics showed limited supportive evidence, and more studies are warranted to validate their efficiency.

Antibiotic Use and Misuse in Dentistry in India-A Systematic Review

Background: Infections caused by antibiotic resistance pose a serious global health threat, undermining our ability to treat common infections and deliver complex medical procedures. Antibiotic misuse, particularly in low-–middle-income countries, is accelerating this problem. Aim: The aim of this systematic review was to investigate the use and misuse of antibiotics in dentistry in India. Method: We included studies carried out on Indian populations evaluating the prescription of prophylactic or therapeutic antibiotics by dental practitioners or other healthcare providers, along with antibiotic self-medication by the general population. The primary outcome measure was prescription rate/use of antibiotics for dental/oral problems. The secondary outcome measures included indications for antibiotic use in dentistry, their types and regimens, factors influencing practitioners’ prescription patterns and any differences based on prescriber and patient characteristics. Multiple databases were searched with no restrictions on language or publication date. The quality assessment of all included studies was carried out using the AXIS tool for cross-sectional studies and the Joanna Briggs Institute checklist for qualitative studies. Results: Of the 1377 studies identified, 50 were eligible for review, comprising 35 questionnaire surveys, 14 prescription audits and one qualitative study (semi-structured interviews). The overall quality of the included studies was found to be low to moderate. The proportion of antibiotic prescriptions amongst all prescriptions made was found to range from 27% to 88%, with most studies reporting antibiotics in over half of all prescriptions; studies also reported a high proportion of prescriptions with a fixed dose drug combination. Worryingly, combination doses not recommended by the WHO AWaRe classification were being used. The rate of antibiotic self-medication reported for dental problems varied from 5% to 35%. Conclusions: Our review identified the significant misuse of antibiotics for dental diseases, with inappropriate use therapeutically and prophylactically, the use of broad spectrum and combination antibiotics not recommended by WHO, and self-medication by the general population. There is an urgent need for targeted stewardship programmes in this arena.

Pattern and Appropriateness of Antimicrobial Prescriptions for Upper Respiratory Tract and Dental Infections in Male Prisoners in Italy

BACKGROUND

This study explored the antimicrobial prescribing pattern for upper respiratory tract and dental infections in prisoners in Italy, with specific attention paid to the appropriateness of indication and its potential determinants.

METHODS

This investigation was conducted through the consultation of clinical records of adult male inmates in a prison in the south of Italy.

RESULTS

Prescription of antimicrobials for upper respiratory tract infections ranged from 41.9% in influenza diagnoses to 88% in pharyngitis diagnoses, with high prevalence also for bronchitis (73.5%) and common cold (57.7%), and those for dental infections ranged from 82% in pulp necrosis and symptomatic apical periodontitis/pulp necrosis and localized acute apical abscess diagnoses, to 85.7% in symptomatic irreversible pulpitis with or without symptomatic apical periodontitis diagnoses. The most frequently prescribed antimicrobial was amoxicillin and clavulanic acid (33.8%), followed by amoxicillin (26.5%), macrolides (19.8%) and third-generation cephalosporins (7.9%). The overall antimicrobial overprescription was 69.4%, whereas an antimicrobial prescription was provided in all 52 cases in which it was indicated. The inappropriate antimicrobial prescriptions were significantly less likely for bronchitis, influenza and symptomatic irreversible pulpitis with or without symptomatic apical periodontitis compared to common cold/pharyngitis/rhinosinusitis, and when the antimicrobial prescription was provided by medical specialists compared to prison physicians, whereas antimicrobial overprescriptions without indications were significantly more frequent in patients with underlying chronic clinical conditions.

CONCLUSIONS

A concerning widespread practice of inappropriate antimicrobial prescriptions in prisoners was found. Diagnoses-specific monitoring of antimicrobial use and prison-focused antimicrobial stewardship policies are strongly needed.

An evaluation of prophylactic and therapeutic antibiotic prescribing in Lebanese dental practice

OBJECTIVES

To evaluate antibiotic prescribing patterns and correlates among Lebanese dentists.

METHODS

A descriptive observational study was conducted, from the first of April to the end of May 2017. Dentists who specialized in oral dental surgery or general dental practitioners were eligible to participate in this study. All patients who sought consultation with the selected dentists over a 1 month period were included.

KEY FINDINGS

A total of 2323 oral and dental procedures were performed by 60 dentists; 553 antibiotic prescriptions were prescribed, representing 23.8% (52.35% for prophylactic purposes and 47.65% for curative purposes). Prophylactic indications were mainly for implant surgery (36.3%) with only 1% appropriate. Curative use was mainly for periodontal abscesses/abscesses (indeterminate) (22.8%), followed by pulpal diseases and periradicular complications (20.5%); it was appropriate in only 1.7 and 1.9% of cases respectively. Amoxicillin-clavulanic acid was the antibiotic that was mostly prescribed for both curative and prophylactic uses (57.6 and 55.9%, respectively), followed by amoxicillin for prophylactic purposes and a combination of spiramycin plus metronidazole for curative purposes. Adherence to guidelines was low for both curative and prophylactic purposes (17.4 and 21.8%, respectively), but was better in patients who were younger [adjusted odds ratio (aOR) = 0.96], male (aOR = 0.40), or had cardiac disease with moderate or high infective endocarditis risk (aOR = 21.72), and when prescribed by oral surgeons (aOR = 0.15).

CONCLUSIONS

This study showed evidence of the overuse of antibiotics among Lebanese dentists. It can serve as a basis for future studies to optimize antibiotic use among dentists in Lebanon.

Avoid the Phrase "No Drainable Fluid Collection" When Interpreting Examinations for Suspected Odontogenic Infection

The phrase "no drainable fluid collection" harbors implicit management guidelines that may be inappropriate in the setting of acute odontogenic infection. For many emergency department physicians, these words trigger a treatment plan involving antibiotics without drainage. However, many odontogenic infections require immediate drainage even when an abscess is not visible on imaging. As such, the phrase "no drainable fluid collection" should not be used when reporting on imaging obtained for odontogenic infection.

Integrating Oral Health into Primary Care

This article provides data on oral diseases as they relate to systemic health conditions. Research continues to identify biologic mechanisms that link oral diseases to systemic disease and vice versa. The Smiles for Life curriculum, developed for physicians, provides a systematic approach for incorporating an oral exam into your physical evaluation. Guidelines for the use of antibiotics for tooth pain and swelling, to prevent infective endocarditis, and for patients for total joint replacements are provided.

Association between Dental Scaling and Reduced Risk of End-Stage Renal Disease: A Nationwide Matched Cohort Study

Periodontitis is prevalent in patients with chronic kidney disease (CKD) and is also associated with kidney function decline. It is unclear whether dental scaling treatment prevents the progression of CKD. In a nationwide cohort study, Taiwan's National Health Insurance Research Database was used to select people with CKD. Propensity score-matching procedures were performed to compare the long-term risk of end-stage renal disease (ESRD) between CKD patients with and without the receipt of dental scaling. A total of 33,637 matched pairs with CKD were included, with 503,373 person-years of follow-up for analyses. Dental scaling was significantly associated with a lower risk of ESRD (adjusted hazard ratio (aHR): 0.83, 95% confidence interval (CI): 0.77-0.90). In addition, there was a dose-dependent relationship between the frequency of dental scaling and a reduced risk of ESRD. Dental scaling was also linked to reduced risks of major adverse cardiovascular events (aHR: 0.91, 95% CI: 0.87-0.95), sepsis (aHR: 0.81, 95% CI: 0.77-0.85), and all-cause mortality (aHR: 0.81, 95% CI: 0.76-0.87). Dental scaling was significantly associated with lower risks of progression to ESRD in patients with CKD. Regular dental scaling may serve as a prophylactic measure for kidney function decline.

A Survey of Systemic Antibiotic Prescription Patterns Amongst Iraqi Dentists

OBJECTIVES

The misuse of antibiotic prescriptions is a common behavior amongst dentists worldwide. Over-prescription of these agents is associated with multiple adverse effects and risk of developing bacterial resistance. The aim of this study was to assess systemic antibiotic prescription patterns amongst dentists in Iraq.

METHODS

A questionnaire-based survey was conducted in dental centres distributed in 12 Iraqi governates. The questionnaire was composed of two main sections: The first was dedicated to collecting demographic and work-related information, and the second section included questions seeking details about antibiotic prescriptions for different oral and dental conditions.

RESULTS

A total of 481 valid questionnaires were considered in the final analysis. The numbers of correct and incorrect patterns of prescribing antibiotics for different dental/oral conditions were almost equal (49.6% and 50.4%, respectively). Amongst independent variables investigated, qualification of the dentist and work domain were found to have significant associations with correct prescribing patterns (odds ratio, 1.166 and 1.197, respectively). The majority of dentists preferred amoxicillin as the first-choice antibiotic, followed by "Augmentin" (43.7% and 35.5%, respectively), whilst clarithromycin was the lowest on the list. Azithromycin was the most recommended antibiotic (55.9%) in cases of allergy to penicillin.

CONCLUSIONS

In general, antibiotics are prescribed for recommended conditions, but the prescription for nonrecommended conditions was also evident amongst Iraqi dentists. Correct pattern of antibiotic prescribing was significantly associated with specialists and those working in the academic field. Additionally, amoxicillin and its derivatives are the most preferred drugs.

Antibiotic prescription for endodontic infections among Italian dental practitioners: what is the extent of over-prescription?

Objectives: Objectives of this study were to evaluate the pattern of antibiotic prescription for endodontic infections (EIs) among Italian dental practitioners (DPs), and to explore the role of potential predictors of antibiotic over-prescription. Methods: A nationwide cross-sectional survey was conducted between 1^st April to 30^th October 2019 using a structured questionnaire. Information was gathered on demographics and professional characteristics, and practices regarding antibiotic prescription both for therapeutic and prophylactic purposes. Results: Of the 1250 invited DPs, 563 answered the general questionnaire (response rate 52.6%). The proportions of DPs who prescribed an antibiotic without indication for therapeutic and prophylactic purposes is 33.3% and 30.2%, respectively. The acute alveolar abscess without systemic involvement represents the clinical scenario at high risk of over-prescription for therapeutic purposes. Possible predictors of over-prescribing included demographics and professional characteristics, and it was found to be higher in EIs without indication than in the cases in which the prescription is indicated for therapeutic purposes. The odds of over-prescription for prophylactic purposes were higher in the cases of acute apical periodontitis and lower in the cases of symptomatic irreversible pulpitis compared with acute and chronic alveolar abscess, in which the prescription is indicated. Conclusions: The main findings of the present study provide an up-to-date insight about the pattern of antibiotic prescriptions for EIs and evidence useful to identify opportunities to reduce over-prescription among DPs through tailored interventions. The development of practical antibiotic prescribing guidelines with a clear description of indications and regimens ease of use is strongly needed.

Evaluation of the efficiency of antibiotics in treating adult patients with symptomatic apical periodontitis: A protocol for systematic review and meta-analysis

BACKGROUND

When a person feels dental pain, it brings great discomfort and damages the quality of life. Symptomatic apical periodontitis is identified as the most frequent cause that triggers dental pain. Symptomatic apical periodontitis arises from an infection or inflammation in the pulpless root canal structure. According to clinical guidelines, the primary form of therapy for such teeth entails removing the inflammation or infection source through local surgical procedures. Presently, systemic antibiotics are recommended only for cases where there is clear indication of an infectious spread or a systemic involvement. Therefore, this study aims to assess the efficacy and level of safety of using antibiotics to treat adult symptomatic apical periodontitis patients.

METHODS

The present protocol study will conduct a search on electronic databases to look for randomized controlled trials (RCTs) that have evaluated the effectiveness and safety of antibiotics when used to treat adult patients with symptomatic apical periodontitis. The databases will be search from their beginning to April 2021. The search is not bound by publication status or language restrictions. The following databases will be searched: Web of Science, PubMed, the Cochrane Library, Chinese National Knowledge Infrastructure, and EMBASE. This study will employ ZETOC Conference Proceedings and OpenGrey to identify potential grey literature. Afterwards, 2 independent authors will select the studies, extract data from the studies, and conduct a risk assessment to check for bias. All discrepancies between the authors will be resolute via discussion involving a third independent author. The data synthesis and statistical analysis of this study will be done with the RevMan software (Version: 5.3).

RESULTS

The present protocol report will provide high-quality evidence related to the efficacy and level of safety when using antibiotics to treat mature symptomatic apical periodontitis patients.

CONCLUSION

The outcomes of the present study will update the evidence available for assessing the efficacy and safeness of using antibiotics to treat mature symptomatic apical periodontitis patients.

ETHICS AND DISSEMINATION

This study does not require an ethical approval since individual patient data is not included in any form.

REGISTRATION NUMBER

DOI 10.17605/OSF.IO/CVP8 M (https://osf.io/cvp8m/).

Dental health care providers' concerns, perceived impact, and preparedness during the COVID-19 pandemic in Saudi Arabia

Background

Dental health care providers (DHCPs)are at high risk of cross-infection during clinical practice therefore, the aim of the study was to evaluate the DHCPs Covid-19 related concerns, its perceived impact, and their preparedness in Saudi Arabia.

Methods

This cross-sectional study on DHCPs was carried out at five dental teaching hospitals/colleges in four provinces of Saudi Arabia from October to December 2020. A 35-item valid and reliable questionnaire was used to assess the concerns, perceived impact, and preparedness of DHCPs in the COVID-19 pandemic. Chi-square tests and logistic regression were used to compare parameters between the clinical and non-clinical staff.

Results

A total of 320 DHCPs participated in this study with proportion of clinical staff (57.5%) surpassing the non-clinical staff (42.5%). The clinical DHCPs felt greater odds of falling ill with COVID-19 than non-clinical workers (OR, 2.61) and willing to look for another job (OR, 3.50). The higher proportion in both groups was worried that people close to them would be at higher exposure risk (96.3%) however, slightly more clinical DHCPs were concerned for their children than a non-clinical worker (OR, 3.57). The clinical DHCPs have greater odds of worrying that people would avoid them and their family members because of their job (OR, 2.75). A higher proportion in both groups (75.0%, 63.2%) felt that they would feel stress at work. More non-clinical DHCPs (94.1%) had received training for infection control than clinical (94.1% vs 63.0%: OR 0.10). Similarly, more DHCPs in the nonclinical group received adequate personal protective equipment training (88.2%; OR, 0.48). Most participants practiced self-preparation such as buying masks and disinfection (94.4%, 96.9%).

Conclusion

The majority of DHCPs felt concerned about their risk of exposure and falling ill from infection and infecting friends/family. These concerns could potentially affect the working of DHCPs during this pandemic. Measures to improve protection for DHCPs, minimize psychological implications, and potential social stigmatization should be identified at the planning phase before any pandemic.