PART ONE IN A TWO-PART SERIES
Emergency clinicians are not rigorously trained in dental medicine, but an increasing number of patients, particularly those without insurance or access to a dentist, often seek dental care in the ED. Many dentists and dental clinics will not accept a patient without insurance or cash payment, so patients flock to the ED for pain relief.
Despite minimal dental experience and expertise, emergency physicians can provide temporary pain relief. They also often prescribe antibiotics and offer referral for follow-up. This is not definitive care for toothaches, but it generally suffices, and it is paramount that the ED have established referrals for patient-friendly dental care.
ED visits for toothache are most often seen in patients aged 20 to 30, and ED visits for toothache increase three to five percent per year in this age group, in which toothache was the fifth most common reason for an ED visit and the third most common for those who were uninsured. (J Am Dent Assoc. 2015;146:295; http://bit.ly/2ZxEw10.) Medicaid accounts for almost 40 percent of payers for dental-related ED visits, with self-pay around the same percentage. The ED is a well-known safety net for those with no direct physician access, so it's not surprising that a painful tooth would send patients to us for relief. Dental visits can be difficult and even contentious with the current prohibition against prescribing opioids for most conditions.
It turns out, however, that the value of antibiotics for any ED dental condition is questionable.
Are Antibiotics Beneficial for the Treatment of Symptomatic Dental Infections?
Tichter AM, Perry KJ
Ann Emerg Med.
This relatively short Cochrane-based review drew conclusions from the minimal data available on antibiotics for treating symptomatic dental infections. The authors reviewed the only two randomized, placebo-controlled trials evaluating the effects of oral penicillin VK (in combination with analgesics and surgical pulpectomy) v. placebo on the primary outcome of patients with toothache. The study population had more than a simple toothache, either apical periodontitis or an abscess.
The authors noted that odontogenic infections result from extensive tooth decay or damage to the central pulp of the tooth. These infections can lead to abscess formation and life-threatening deep space neck infections. Their data suggest that 1.5 percent of all ED visits and more than $200 million in hospital costs are related to patients seeking primary dental care. Guidelines recommend using antibiotics only for patients with evidence of spreading infection, with little corroborating evidence, but antibiotics are commonly prescribed by emergency clinicians even for patients with a simple toothache. The authors stated that almost 50 percent of patients in the ED for tooth pain will receive an antibiotic prescription. The young healthy patients in these studies were treated with antibiotics or placebo and surgical pulpectomy, a procedure often delayed by hours or days after an initial ED visit.
This review provided insufficient evidence of therapeutic benefit or harm from prescribing antibiotics for symptomatic dental infections in patients with obvious signs of clinical infection. No significant differences were observed between antibiotics and placebo in pain, swelling, or persistent infection. Minimal adverse effects were found.
Comment: The data were sparse, but even patients with obvious infection and need for dental intervention do not seem to benefit from antibiotics. This is contrary to most EPs' knowledge and practice. Patients in the study were treated in a dental school, and all had a definitive dental intervention in addition to antibiotics, usually penicillin VK. I doubt if any individual presenting to the ED or dental office with obvious infection or abscess would not be prescribed antibiotics despite no proof that they are beneficial.
Gottlieb and Khishfe studied patients with toothache but no overt infection (more common in the ED), defined as fever, intraoral swelling, purulence, or trismus. (Ann Emerg Med. 2017;69:128; http://bit.ly/2YLOAX6.) A literature search showed that only two studies directly addressed penicillin for dental pain, presumably from irreversible pulpitis without obvious infection. Analgesics were allowed in both studies. About 10 percent of patients in each group developed an obvious infection. Neither study found benefit for pain or subsequent infection when penicillin was prescribed for dental pain in the absence of initial overt infection. The authors noted that only penicillin was prescribed.
Antibiotic Prescriptions Associated with Dental-Related Emergency Department Visits
Roberts RM, et al.
Ann Emerg Med.
This study sought to quantify how often and for which dental diseases antibiotics were prescribed in the ED. The authors noted that the Centers for Disease Control and Prevention estimated that about 30 percent of the antibiotic prescriptions in the outpatient setting are unnecessary. Antibiotics have been prescribed for about 70 percent of ED visits with any dental-related diagnosis, including those with obvious infection. Penicillin was by far the most frequently prescribed antibiotic, followed closely by clindamycin and amoxicillin. A few patients received amoxicillin-clavulanic or a first-generation cephalosporin.
The exact dental problem was not identified, but dental caries and periapical abscess without sinus involvement were the most commonly known conditions for which patients received antibiotics. Some theoretical reasons for using antibiotics are that they may bridge therapy until the patient sees a dentist or the condition may have progressed to a point that the physician believed antibiotics were required. These authors concluded that antibiotics are probably overprescribed for common dental problems.
Comment: Surprisingly few studies of dental problems in the ED have been done. After a brief ED evaluation, most individuals are given an antibiotic and an analgesic and told to find a dentist. The data are minimal, and no benefit of antibiotics was apparent for treating a simple toothache or even an obvious dental infection. It is likely that clinicians will continue to give prescriptions for antibiotics to patients for almost any dental problem. The most commonly prescribed are penicillin and clindamycin. Oral penicillin VK appears to be adequate, even for definitive infection. Clindamycin, more expensive and with more side effects, is not suggested for a good old-fashioned toothache.
It may be a common reflex for even a simple toothache, but antibiotic prescriptions in the ED are not indicated in the absence of infection. It's questionable whether they are of any real value even if a dental infection is obvious. Infection generally presents as swelling of the gingiva or even a definitive periapical abscess. Most EPs would prescribe antibiotics if a patient has an open cavity, again without substantiating data. There is no common dental problem where antibiotics have proven beneficial.
Next month: Addressing pain relief for toothaches.
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Dr. Robertsis a professor of emergency medicine and toxicology at the Drexel University College of Medicine in Philadelphia. Read the Procedural Pause, a blog by Dr. Roberts and his daughter, Martha Roberts, ACNP, PNP, athttp://bit.ly/EMN-ProceduralPause, and read his past columns athttp://bit.ly/EMN-InFocus.