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By Ashraf F. Fouad, D.D.S, M.S.

In the November issue of JADA, an Evidence-based Clinical Practice Guideline was published to assist clinicians and patients in determining the appropriate use of systemic antibiotics for the urgent management of endodontic emergencies (1). The following target conditions were addressed: Symptomatic irreversible pulpitis (SIP) with or without symptomatic apical periodontitis (SAP), pulp necrosis (PN)-SAP, and PN with localized acute apical abscess (PNLAAA) or AAA with systemic involvement. The guidelines further explored the antibiotic role in managing these conditions with or without access to immediate definitive, conservative (tooth-preserving) dental treatment (DCDT) (such as pulpotomy, pulpectomy, nonsurgical root canal treatment, and/or incision for drainage). These guidelines were developed using the Appraisal of Guidelines for Research and Evaluation Reporting II Checklist (2) and Guidelines International Network-McMaster Guideline Development Checklist (3). In addition, a comprehensive systematic review and meta-analysis on the subject was published in the December issue of JADA (4). Of note, the AAE had published guidelines on the same topic two years ago (5).

The expert panel of the Council of Scientific Affairs of the ADA which undertook this effort had interdisciplinary and interprofessional representations. In addition to experts on evidence-based dentistry and bibliographic informatics, the panel had general dentists, two endodontists, an oral surgeon, oral medicine specialists, an infectious disease physician, emergency room physician, a pharmacist and other experts. This group worked for about a year, meeting in person twice and online several times to produce these documents.

The panelists not only examined the published randomized clinical trials and previous systematic reviews, including two Cochrane reviews, they also examined the information available on the risk of harm from antibiotic prescriptions, in order to provide a balanced risk/benefit analysis. The guidelines are intended for all dentists treating these cases as well as others, such as emergency room physicians, who occasionally see these patients and do not have access to a dentist or an oral surgeon. Therefore, the guidelines describe some details that allow the dentists and non-dentists to recognize the emergency condition and assess the need for antibiotic prescription.

First, and foremost, the guidelines stress the importance of prompt dental management of the condition, or referral for endodontic management of the patient, as the most important step in the treatment. In addition, and consistent with the AAE guidelines, these new guidelines stress that for immunocompetent patients with pulpitis, or pulp necrosis with SAP or LAAA, who have no evidence of lymphadenopathy, fever, malaise, fascial space involvement, localized treatment does not need to be accompanied by an antibiotic prescription. The guidelines further stress the following areas, that complement and expand previous guidelines:

  • In addition to patients with AAA and systemic involvement, or systemic disease compromising the immune response, antibiotic prescription is probably indicated for the patient with LAAA who will not receive immediate treatment but will be referred to other practitioners or a future appointment for management.
  • Beta-lactam- based antibiotics (primarily amoxicillin 500 mg three times per day for three to seven days) remain the first line of effective antibiotics for patients in whom antibiotics are indicated. These regimens can be complimented with metronidazole 500 mg three times per day in resistant infections.
  • For the patient who is allergic to penicillin, the patient needs to be asked about the type of reaction that they received. True allergy is identified only for patients with history of anaphylaxis, angioedema or hives. If the patient did not have these reactions, oral cephalexin (500 mg, four times per day, three to seven days) would be indicated.
  • For patient with true allergy to penicillin, the primary alternative antibiotic recommendation has changed. It is now azithromycin with a loading dose of 500 mg, and then 250 mg for four additional days. Clindamycin now has a U.S. Food and Drug Administration black box warning for Clostridioides difficile infection, which can be fatal. Therefore, it is only indicated if the patient cannot take azithromycin.
  • For all patients on antibiotics, the antibiotic treatment is discontinued as soon as definitive treatment and improvement of the condition occurs (as short as three days), rather than to the full course of the prescription.

These guidelines further stress that the original randomized studies that were used to develop these recommendations were generated several decades ago, and that new adequately designed studies addressing various clinical variables and medications are needed to identify the optimal management of immunocompetent and immunocompromised patients.

References:

  1. Lockhart PB, Tampi MP, Abt E, Aminoshariae A, Durkin D, Fouad AF, Gopal P, Hatten BW, Kennedy E, Lang M, Patton LL, Thomas T, Suda KJ, Pilcher L, Urquhart O, O’Brien KK, Carrasco-Labra A. 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. JADA; November 2019 Volume 150, Issue 11, Pages 906–921.e12.
  2. Brouwers MC, Kerkvliet K, Spithoff K. The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines. BMJ. 2016;352:i1152. 920
  3. Schunemann HJ, Wiercioch W, Etxeandia I, et al. Guidelines 2.0: systematic development of a comprehensive checklist for a successful guideline enterprise. CMAJ. 2014;186(3):E123-E142.
  4. Tampi MI, Pilcher L, Urquhart O, Kennedy E, O’Brien KK, Lockhart PB, Abt E, Aminoshariae A, Durkin MJ, Fouad AF, Gopal P, Hatten BW, Lang M, Patton LL, Paumier T, Suda KJ, Cho H, Carrasco-Labra A. Antibiotics for the urgent management of symptomatic irreversible pulpitis, symptomatic apical periodontitis, and localized acute apical abscess. Systematic review and meta-analysis – a report of the American Dental Association. JADA; December 2019 Volume
  5. Fouad AF, Byrne BE, Diogenes AR, Sedgley CM, Cha BY. American Association of Endodontists Position Statement: AAE Guidance on the Use of Systemic Antibiotics in Endodontics, Sept 2017; https://www.aae.org/specialty/wp-content/uploads/sites/2/2017/06/aae_systemic-antibiotics.pdf

Dr. Ashraf F. Fouad is the chair of the Department of Endodontics at the University of North Carolina School of Dentistry. He earned his master’s degree, certificate of endodontics and D.D.S. from the University of Iowa. Dr. Fouad is a Diplomate and past president of the American Board of Endodontics and an associate editor of the Journal of Endodontics. He served as chair of the AAE Special Committee on Antibiotic Use in Endodontics. Dr. Fouad can be reached at afouad@unc.edu.