More Good Than Harm

The antibiotic class of drug has had a profound impact on the treatment and prevention of dental infections.  They have been so effective, cheap and readily available that last year there were five prescriptions written for every six people in the United States.  Canada ranked even higher in our disbursement with 23 million prescriptions in 2014, the 12th highest in the developed world according to the Canadian Antimicrobial Resistance Surveillance System Report 2016.

While prescription levels have held steady since public awareness campaigns began (“Not all bugs need drugs” etc.), antibiotic resistance infections have continued to climb at ever alarming rates.  This is due, in part, that up to an estimated 50% of antibiotics are either prescribed or used incorrectly. In the United States, roughly 2 million multi-drug resistant infections occur each year resulting in 23,000 deaths.

Few of us reading this will have had a patient die as a result of these types of infections, but increasingly we will have seen dental infections not respond to our first choice drug.  Additional risks, beyond promoting drug resistance, with antibiotic use, include disturbance of the intestinal micro flora biodiversity.  This can result in mild side effects including cramping, nausea, and diarrhea to more severe complications such as Clostridium difficile infections.  According to the United States Center for Disease Control, 1 in 11 patients over the age of 65 died of C. difficile infections last year totaling 29,000.

Last month the American Association of Endodontists published a position statement on the use of systemic antibiotics in endodontics.  While the statement did not contain any new knowledge, it did serve as a concise reminder of the conditions where antibiotics will have maximum benefit.  The statement also reiterated that there is no evidence that adjunctive treatment of an inflammatory process (pulpitis) with systemic antibiotics will have any effect on pain, the progression towards necrosis or on the prevention of acute periapical pathology.

Successful management and treatment of endodontic infections primarily involve the debridement of the root canal system and, in cases of swelling, establishment of a drainage pathway in the soft tissue.  The AAE points out that there is evidence from systematic reviews and randomized clinical trials that adding antibiotics therapy will not have a benefit if debridement and drainage have been achieved unless there is evidence of a spreading infection.  Where controversy arises is when complete debridement is not possible.  There are no studies, nor would ethical ones be possible, which could analyze the indications, efficacy or duration of antibiotic use in cases where the primary etiology of the infection remains.  In cases such as these, weighing the harm risks with the potential benefits falls to individual cases and should involve discussion with the patient.  The use of “stand-by” prescriptions can be helpful in these cases for use when signs of spreading infection present.

The AAE’s position continues, pointing out that use of beta-lactam antibiotics such as PenVK and amoxicillin have been shown to be highly effective against isolates of endodontic infections.  Amoxicillin has been shown to be the most effective given its rapid absorption (even in the presence of food), low protein binding, broad spectrum, and longer half-life which allows for better patient compliance.  There are studies showing shorter courses (2-3 days) are more effective than traditional courses (7-10 days) which were based on unknown etiologies or hospital studies.  In cases where there is a hypersensitivity to beta-lactam drugs, clindamycin shows a 75% effectiveness against endodontic organisms.  There is also an 8-fold increase in the incidence of C. difficile infections with this drug so using a short course will assist in preventing this as well as combating the rise of resistance.

Rapid, if not immediate, resolution of a patient’s pain and/or infection is the desire of any practitioner.  Reminding ourselves that accurate diagnosis and treatment of the etiology can be the fastest route to that goal.  Knowing that healing can take time, can be a comfort to patients and relieve some of the responsibility that we may feel. Appropriate use of antibiotics during this time will help to ensure that we are delivering care that includes more benefit with less harm.

Dr. Jason ConnAbout Dr. Jason Conn, DMD, CAGS, FRCD(C)
Langley EndodonticsDr. Conn was born and raised in Langley. He completed a Bachelors in Chemistry at Simon Fraser University before receiving his DMD and Certificate of Advanced Graduate Study in Endodontics at Boston University where he wrote a thesis in clinical decision making and another in odontogenic stem cell differentiation.

Dr. Conn has maintained an active practice alongside Dr. Bittner since 2012 while teaching as a part-time clinical assistant professor at the University of British Columbia.

In his free time, Dr. Conn is a Cub Scout leader, long-distance runner, back-country hiker, snowboarder, and yogi-in-training.

On October 23, 2017, posted in: News for Doctors by

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