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Are antibiotics being used appropriately for emergency dental treatment?

Antibiotics use and misuse - a prospective clinical study

Source: British Dental Journal OCTOBER 13 2001, VOLUME 191, NO. 7, PAGES 391-393

Are antibiotics being used appropriately for emergency dental treatment? 
  Y. M. Dailey1 and M. V. Martin2 
Lecturer, Department of Clinical Dental Sciences, University
  of Liverpool, Liverpool L69 3BX; 2Senior Lecturer, Department of Clinical Dental
  Sciences, University of Liverpool, Liverpool L69 3BX 
Correspondence to: Y. M. Dailey
Aim To investigate the therapeutic prescribing of antibiotics
  to patients presenting for emergency dental treatment.
Design A prospective clinical study.
Method: Information was collected via
a questionnaire concerning the patient's reason for attendance and treatment
  undertaken at emergency dental clinics in North and South Cheshire. 
Results: Over an 11-week period 1,069
patients attended the five clinics, 1,011 questionnaires were analyzed. The
majority of the attendees had pain (879/1011). 35% (311/879) of these patient
had pulpitis and 74% (230/311) had been issued a prescription for antibiotics,
without any active surgical intervention. The principal antibiotic prescribed
  for both adult and child patients was amoxicillin.
Conclusion: The majority of patients attending
the emergency dental clinics had pain, with a large proportion having localised
infections either as pulpitis or localised dental abscess. Three quarters of
these patients had no surgical intervention and were inappropriately prescribed

The General Dental Council states that 'the dentist has
a professional responsibility for emergency dental care'. They recognise the
difficulties in defining an emergency but state that a sympathetic response
to patients with pain is expected. If a patient has acute spread of infection,
haemorrhage, or trauma, it is the dentist's duty to make arrangements for the
 patient to receive advice or treatment in a reasonable time.1

 Management of acute dental conditions is primarily based
 upon extraction of teeth or extirpation of the pulp.2 The use of antibiotics
 as an adjunct in the management of orofacial infections is an important treatment
 option and when clinically indicated is of therapeutic benefit to the patient.3
 However systemic antibiotics should be used with restraint because of the possibility
 of allergic reactions, toxicity, side effects and the development of resistant
 strains of microbes.4
In 1996 Thomas et al., investigated the prescribing of
antibiotics to emergency dental patients by primary healthcare workers.5 They
concluded that both general medical and general dental practitioners had prescribed
antibiotics inappropriately to patients with dental emergencies. Evidence from
further studies further suggests that antibiotics are being prescribed inappropriately
within general dental practice.6-9 However these studies are based upon hypothetical
case scenario questionnaires. They are unable to predict the effect that the
dentist-patient relationship may have upon the practitioners' prescribing behaviour.
The aims of this study were to investigate the appropriateness of antibiotic
prescribing to patients presenting for emergency dental treatment. 

Materials and methods
The study was undertaken prospectively over an 11-week period, between January
1999 and April 1999, at five out-of-hours emergency dental clinics provided
by North and South Cheshire Health Authorities. The timing of the study was
set to avoid any bank holidays, when it was known that the number of patients
attending the clinics increased. The dentists providing the emergency treatment
collected information for each patient who attended the clinic. 

Data Collection 
Information about the patient's reason for attending the emergency clinic and
the treatment provided was collected using a questionnaire. The dental nurse
completed the first part of the questionnaire; which recorded patient's demographic
details including gender, date of birth and whether the patient claimed to be
registered with a dentist. The dentist completed the rest of the questionnaire,
which recorded the nature of the patient's complaint. The complaints were classified
as pain, localized swelling, diffuse swelling, swelling that caused closure
of the eye or difficulty in swallowing, lost restorations, cavities, trauma,
and bleeding, A space was left for the dentist to record their clinical diagnosis
of the patient's complaint and the treatment provided. If the treatment involved
the prescribing of antibiotics the dentist was asked to indicate the type of
antibiotic prescribed. 

Statistical analysis
The questionnaires received were coded and entered into the Statistical Package
for Social Sciences (SPSS) Version 9 for windows TM.10 Summary statistics were
calculated to include frequencies, percentages, and means and standard deviations
where indicated.

During the study period 55 dentists worked in the emergency
dental clinics, from 10.00 am until 12.00 midday, on both Saturdays and Sundays.
There were 34 male and 21 female dentists. Their mean age was 41 years (range
27-56). A total of 1,069 patients attended the five emergency dental clinics
over the 11-week period. Fifty-eight questionnaires were incomplete and the
remaining 1,011 were analysed. 

The mean number of patients attending the clinics per session
was 10.2 (range 6-31). There were 522 males (52%) and 489 females (48%), of
which 895 (89%) were adults and 116 (11%) children (i.e. below the age of 18
years). A total of 91 (9%) patients attending the clinics were thought by the
dentists to be non-genuine emergencies: those with lost crowns/bridges and one
patient requesting a new pair of dentures.

Reasons for attendance 
Table 1 shows the reasons for attendance at the emergency dental clinics. The
majority of patients 887 (adult: 788/895, 88%, child: 99/116, 85%) presenting
at the emergency clinics complained of pain. In some cases other signs and symptoms
were also present. One hundred and five (adult: 82/895, 9%, child: 23/116, 20%)
had a localized swelling, whilst 51 (adult: 49/895, 5%, child: 2/116, 1.5%,)
had a diffuse swelling, 3 adults had swelling causing difficulty in swallowing
and 2 had swelling which closed the eye. The proportion of patients who were
recorded as having a cavity (adult: 72/895, 8%, child: 26%, 31/116) or dental
trauma (adult: 2/895, 0.2%, child: 5/895, 4%) was higher in children than adults.
However one adult had presented with facial trauma and another with a bleeding
socket, following a tooth extraction 36 hours earlier. 

Treatment Provided
Figures 1 and 2 show the treatment received by adult and child patients attending
the emergency dental clinics. The issuing of a prescription was the only treatment
that 495 (49%) of adult and 77 (62%) of child patients received, at the emergency
dental clinics. A higher proportion of adults (86/895, 10%) than children (5/116,
4%) received active surgical treatment together with the antibiotic prescription.

The proportion of patients undergoing extraction without
the issue of a prescription was similar for both adults and children (adults:
101/895, 11%, child: 13/116 10%). Only adults however, had their swelling incised
or underwent endodontic treatment. Dressings were provided for lost restorations,
tooth fractures and dry sockets. Sixty-five adults received a variety of treatments,
which included recementing of crowns/bridges; curettage around partially erupted
eight's and advice only. Three of these patients were referred to the local
hospital oral surgery department. This included a patient with a suspected condyle
fracture, and two patients who had difficulty in swallowing because their swelling
was crossing the midline.

Prescribing of antibiotics for pain (Table 2)

Dentoalveolar abscess and pulpitis was attributed to the cause of pain in nearly
all child patients (94/99, 95%), three quarters of these children received an
antibiotic prescription (76/99, 76%). The same diagnosis was attributed to over
half of the adult patients with pain (464/788, 59%), of whom nearly half received
an antibiotic prescription (355/788, 45%). 

Sixty-nine (7.8%) adult patients, who complained of pain
had a periapical infection related to ongoing or completed root canal treatment,
16 of them received a prescription for antibiotics. A definitive diagnosis could
not be made for 64 (7.3%) of the patients who attended the clinic complaining
of pain, just over one third (24/64) received a prescription for antibiotics.
Antibiotics prescribed

Table 3 shows the frequency of the antibiotics prescribed. For both adults and
children amoxicillin was the most frequently prescribed antibiotic (422/509,
72%). Only adult patients were prescribed a combination of metronidazole and
amoxicillin: 78 (13.3%). A total of 45 (7.7%), adults were prescribed metronidazole
only . The prescribing of penicillin and erythromycin was infrequent; only one
adult patient received a combination of erythromycin and metronidazole.


Ninety five per cent of the questionnaires returned were
completed. To encourage cooperation with data collection, the questionnaire
was designed to be brief and easy to complete. 

The study investigated the prescribing of antibiotics during
emergency dental treatment in North and South Cheshire. The authors acknowledge
that the results may not be a representative sample of the UK. The levels of
prescribing could be affected by differences in service provision and the type
of dental emergency presenting. Nevertheless the results confirm the main findings
of recent questionnaire studies, in general dental practice the fundamental
principles in antibiotic prescribing are being ignored and antibiotics are being
inappropriately prescribed 

The majority of the patients attending the emergency clinics
were complaining of pain. For nearly all the child patients and three quarters
of the adult patients, pain was attributed to a localised infection either as
pulpitis or localised dental abscess. Three quarters of the patients (both adult
and child) had antibiotics prescribed for pulpitis. Pulpitis is inflammatory
in nature and local treatment only could have removed and relieved the pain
and infection.11 In fact the majority of the children were suffering from a
local infection and the use of antibiotics as a treatment option was not entirely

Seventeen adult patients had a cellulitic infection. This
is usually indicated by the presence of a diffuse swelling, increased temperature,
malaise and lymphadenitis and at the very least requires systemic antibiotics.
However if the antibiotics are administered without drainage then the patient
must be carefully monitored.12This in itself would prove difficult for practitioners
working on the emergency dental clinic rota. 

The most common antibiotic prescribed was amoxicillin,
either alone or for adults only, in combination with metronidazole. Both have
been supported for their use in treating a dental abscess by microbiological
and clinical findings.13-14 These antibiotics should however, only be used as
an adjunct to the management of acute dentoalveolar abscess and not treatment.

Why the practitioners prescribed inappropriately is not
known. However, some explanations can be put forward. Firstly, the practitioners
may have a poor understanding of the pathological processes involved in pulp
and periapical diseases.15 Furthermore, there could be a lack of knowledge of
the indications for effective antibiotic use. 

A second explanation is that attitudes to prescribing could
be modified by the effects of the local environment. It is known that at the
emergency clinics there is no appointment system and a large numbers of patients
are seen in succession. This may restrict the dentist's ability to make a diagnosis,
or limit the amount of time for surgical treatment that can be attempted. It
is possible that facilities were not available in the emergency dental centres
for the provision of surgical treatment. In a recent study by Palmer et al,7
lack of time and uncertainties of diagnosis were cited as reasons for antibiotic
prescribing. Appropriate treatment decisions may therefore have been influenced
by pressures within the system and antibiotics inappropriately prescribed to
both adult and child patients as the first line of treatment.

What then is the way forward? Qualitative research is required
to see if we can find out directly from practitioners why this problem of inappropriate
antibiotic prescribing is so intractable. Methods also need to be developed
to enable practitioners to change their prescribing behaviour. One such method
is audit. Within medical practice antibiotic prescribing has been the subject
of many audits.16, 17One of the few dental audits on antibiotic prescribing
was reported in 1997 by Steed and colleagues.18 The audit looked at dental practitioners
antibiotic prescribing regimes. Subsequently, a consensus was achieved on the
rationale for antibiotic prescribing and the number of prescriptions issued
fell by 50%. In addition, since the completion of the study, the Faculty of
General Dental Practitioners, Royal College of Surgeons have published guidelines
for antibiotic prescribing.19 There is a need to investigate the effects of
the guidelines upon practitioner's antibiotic prescribing regimes.

The majority of the patients attending the emergency dental
clinics had pain (879/1011), associated with a localised infection either as
a pulpitis (311/879) or a localised dental abscess (248/879) with only a minority
(56/1011) showing signs/symptoms of a possible spreading infection. Three-quarters
of patients (adult and child) with pulpitis were prescribed antibiotics with
no surgical intervention. This study lends support to the hypothesis that antibiotics
are being inappropriately prescribed by the dental profession.

   1 General Dental Council (Maintaining Standards) November
     1997: Providing for dental emergencies and out of hour's care, paragraph 3.11.  
   2 Olson A K, MacEdington E, Kulid J C, Weller R N. Update on antibiotics for
     endodontic practice. Compend Continuing Educ Dent 1995; 11: 328-332. 
   3 Pogrel M A. Antibiotics in general practice. Dent Update 1994; 21: 274-270.
   4 Mata E, Koren L Z, Morse D R, Sinai I H. Prophylatic use of penicillin V in
     teeth with necrotic pulps and asymptomatic periapical radiolucencies. Oral Surg
     Oral Med Oral Pathol 1985; 60: 201-207. 
   5 Thomas D W, Satterthwaite J, Absi E G, Lewis M A O, Shepard J P. Antibiotic
     prescription for acute dental conditions in the primary care setting. Br Dent
     J 1996; 181: 401-404. 
   6 Palmer N A O, Pealing R, Ireland R S, Martin M V. A study of prophylatic antibiotic
     prescribing in National Health Service general dental practice in England. Br
     Dent J 2000; 189: 43-46. 
   7 Palmer N A O, Pealing R, Ireland R S, Martin M V. A study of therapeutic antibiotic
     prescribing in National Health Service general dental practice in England. Br
     Dent J 2000; 188: 554-558. 
   8 Palmer N A O, Ireland R, Palmer S. Antibiotic prescribing patterns of a group
     of general dental practitioners: results of a pilot study. Prim Dent Care 1998;
     4: 137-141. 
   9 Baker G R, Qualtrough A J E. An investigation into antibiotic prescribing
     at a dental teaching hospital. Br Dent J 1987; 162: 303-306. 
  10 SPSS for Windows Base Version 9.0.0. SPSS Inc, Chicago. 1998
  11 Matthews R W, Peak J D, Scully C. The efficacy of management
     of acute dental pain. Br Dent J 1994; 176: 413-416.
  12 Martin M V, Longman L P, Hill J B, Hardy P. Acute dentoalveolar
     infections: an investigation of the duration of antibiotic therapy. Br Dent
     J 1997; 183: 135-137.
  13 Lewis M A O, McGowan D A, MacFarlane T W. Short-course
     high dosage Amoxicillin in the treatment of acute dentoalveolar abscess.
     Dent J 1986; 161: 299-302.
  14 Fazakerley M W, McGowan P, Hardy P, Martin M V. A comparative
     study of cephadrine, amoxicillin and phenoxymethylpenicillin in the treatment
       of acute dentoalveolar infection. Br Dent J 1993; 174: 359-363.
  15 Abbott P V. Selective and intelligent use of antibiotics
     in endodontics. Aust Endo J 2000; 26: 30-39.
  16 De Santis G, Harvey K J, Howard D, Mashford M L, Moulds
     R F. Improving the quality of antibiotic prescription patterns in general practice.
     The role of educational intervention. Med J Aust 1994; 160: 502-505.
  17 Swann R A, Clark J. Antibiotic policies - relevance
     to general practitioner prescribing. Family Health Services Authority, Great
     Britain. J Antimicrob Chemother 1994; 33: 131-135.
  18 Steed M, Gibson J. An audit of antibiotic prescribing
     in general dental practice. Prim Dent Care 1997; 4: 66-70.
  19 Faculty of General Dental Practitioners (UK) Royal
     College of Surgeons, England. Adult antimicrobial prescribing in primary dental
     care for general dental practitioners, 2000. 
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