Irreversible pulpitis occurs where the dental pulp (tissue inside the tooth which contains the nerve) has been damaged beyond repair. It is characterised by intense pain (toothache), sufficient to wake someone up at night and is considered to be one of the most frequent reasons that patients attend for emergency dental care. Any tooth may be affected, it is not restricted to particular age groups, and it usually occurs as a direct result of dental decay, a cracked tooth or trauma. The ‘standard of care’ for irreversible pulpitis – immediate removal of the pulp from the affected tooth – is now widely accepted and yet in certain parts of the world antibiotics continue to be prescribed.
What was the research?
A systematic review of the evidence to find out whether oral antibiotics are effective and safe for treating pain in irreversible pulpitis (inflammation of the nerve inside the tooth/nerve damage).
Who conducted the research?
The research was conducted by a team led by Anirudha Agnihotry from the Family Healthcare Network, Porterville, USA, on behalf of Cochrane Oral Health. Wendy Thompson, Zbys Fedorowicz, Esther J. Van Zuuren and Julie Sprakel were also on the team.
What evidence was included in the review?
The evidence on which this review is based was current as of 18 February 2019. One study involving 40 people with irreversible pulpitis (nerve damage) was included. There were two groups of 20 people, one group was treated with penicillin 500 mg, the other with placebo (no active ingredient) every six hours over a seven-day period. In addition, all of the participants received painkillers (ibuprofen and paracetamol (acetaminophen) combined with codeine).
What did the evidence say?
Antibiotics do not appear to significantly reduce toothache caused by irreversible pulpitis. Furthermore, there was no difference in the total number of ibuprofen or Tylenol tablets used over the study period between both groups. The administration of penicillin does not significantly reduce the pain perception, the percussion (tapping on the tooth) perception or the quantity of pain medication required by people with irreversible pulpitis. There was no reporting on adverse events or reactions.
How good was the evidence?
This was a study with a small number of participants and the certainty of the evidence for the different outcomes was rated as low. There is currently insufficient evidence to be able to decide if antibiotics help for this condition. This review highlights the need for more and better quality studies on the use of antibiotics for irreversible pulpitis.
What are the implications for dentists and the general public?
This review illustrates that there is insufficient evidence to determine whether antibiotics reduce pain or not when compared to not having antibiotics. The certainty of the evidence for the different outcomes was low, mainly due to imprecision of the data. Although there was a paucity of high‐certainty evidence to guide clinical practice, the prescribing of antibiotics for irreversible pulpitis should not be seen as a substitute for immediate pulpectomy which is now widely accepted as the ‘standard of care.’
What should researchers look at in the future?
The results of this systematic review confirm the necessity for further larger sample and methodologically sound trials that can help provide additional evidence as to whether antibiotics can affect treatment outcomes for irreversible pulpitis.
Any future randomised controlled trials must be well-designed, well-conducted, and adequately delivered with subsequent reporting, including high-quality descriptions of all aspects of methodology. Reporting should conform to the Consolidated Standards of Reporting Trials (CONSORT) statement (http://www.consort-statement.org/) which will enable appraisal and interpretation of results, and accurate judgements to be made about the risk of bias, and the overall quality of the evidence. However, it may be more appropriate for future research to concentrate on pain control rather than prescription of antibiotics.
Agnihotry A, Thompson W, Fedorowicz Z, van Zuuren EJ, Sprakel J. Antibiotic use for irreversible pulpitis. Cochrane Database of Systematic Reviews 2019, Issue 5. Art. No.: CD004969. DOI: 10.1002/14651858.CD004969.pub5.
You can read the authors’ declarations of interest here.
This post is an extended version of the review’s plain language summary, compiled by Anne Littlewood at Cochrane Oral Health’s Editorial Base.