Are antibiotics an effective way to prevent infection following tooth removal?

Teeth that are affected by decay or gum disease or painful wisdom teeth are often removed by dentists. Tooth extraction is a surgical procedure that leaves a wound in the mouth that can become infected. Infection can lead to swelling, pain, development of pus, fever, as well as ‘dry socket’. Dry socket is where the tooth socket is not filled by a blood clot, and there is severe pain and bad odour. These complications are unpleasant for patients and may cause difficulty with chewing, speaking, and teeth cleaning, and may even result in days off work or study. Treatment of infection is generally simple and involves drainage of the infection from the wound and patients receiving antibiotics.

Antibiotics work by killing the bacteria that cause infections, or by slowing their growth. However, some infections clear up by themselves. Taking antibiotics unnecessarily may stop them working effectively in future. This ‘antimicrobial resistance’ is a growing problem throughout the world. Antibiotics may also cause unwanted effects such as diarrhoea and nausea. Some patients may be allergic to antibiotics, and antibiotics may not mix well with other medicines. Dentists frequently give patients antibiotics at the time of the extraction as a precaution in order to prevent infection occurring in the first place. This may be unnecessary and may lead to unwanted effects.

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What are the benefits and risks of using antibiotics as well as cleaning by a dental care professional to treat gum disease?

Gum disease is a common condition in which the gums become swollen, sore, or infected. It is caused by bacteria that accumulate on gums and teeth. Diseased gums may bleed when people brush their teeth and may cause bad breath. If gum disease is not treated, teeth can become loose and eventually fall out. This can affect a person’s ability to chew and speak. It can also make people feel self‐conscious about their appearance. Dental‐care professionals can clean teeth and gums to remove excess bacteria from the mouth. They use special instruments – typically, an ultrasound scraper followed by specialised hand‐held instruments – to scrape bacteria from the teeth and stop these from affecting the gums.

Antibiotics (medicines that kill bacteria) taken by mouth (orally) can be used alongside professional cleaning, to remove bacteria from the area between the teeth and gums. However, there are potential risks associated with antibiotics, such as allergic reactions and antibiotic resistance (changes in bacteria after exposure to antibiotics, that allow the bacteria to survive future antibiotic treatment). Continue reading

Toothache caused by inflammation or infection at the root of the tooth: do antibiotics help?

Dental pain is a common problem and can arise when the nerve within a tooth dies due to progressing decay or injury. Without treatment, bacteria can infect the dead tooth and cause a dental abscess, which can lead to swelling and spreading infection, which can occasionally be life threatening.

The recommended treatment for these forms of toothache is removal of the dead nerve and associated bacteria. This is usually done by extraction of the tooth or root canal treatment (a procedure where the nerve and pulp are removed and the inside of the tooth cleaned and sealed). Antibiotics are only recommended when there is severe infection that has spread from the tooth into the surrounding tissues. However, some dentists still routinely prescribe oral antibiotics to patients with acute dental conditions who have no signs of spreading infection, or without dental treatment to remove the infected material.

Use of antibiotics contributes to the development of antibiotic‐resistant bacteria. It is therefore important that antibiotics are only used when they are likely to result in benefit for the patient. Dentists prescribe approximately 8% to 10% of all primary care antibiotics in high‐income countries, and therefore it is important to ensure that dentists have good information about when antibiotics are likely to be beneficial for patients. Continue reading

Do the drugs work? Cochrane evidence on antibiotics in dentistry

799px-Medication_amoxycillin_capsule13-17 November is World Antibiotic Awareness Week. The World Health Organization (WHO) has said that antibiotic resistance is:  “one of the biggest threats to global health, food security, and development today”. Antibiotics are used to prevent and treat bacterial infections, but if over-used they can cause bacteria to change and become resistant. This makes infections more difficult to treat, and results in longer hospital stays, higher medical costs and increased mortality (World Health Organization, 2017).

Antibiotics are still commonly used in dentistry, Cope et al (2014) estimate that 8-10% of antibiotics used in primary care are prescribed by dentists in some parts of the world. Their effectiveness has been explored by several Cochrane Oral Health reviews over the years, looking at some of the scenarios where they might be prescribed. Today we have a look back over the evidence… Continue reading

Treatments for osteonecrosis of the jaw bones associated with bisphosphonate drugs

Woman face with visible jaws and teeths

Bisphosphonates are drugs very similar to pyrophosphate (a normal substance found in bone). They are used to lessen symptoms and complications due to the spread of cancer to the bones, and to prevent and treat fragile bones in osteoporosis (a conditon where tiny holes in the bones makes them brittle). These drugs can cause a rare but serious condition called bisphosphonate-related osteonecrosis of the jaw or ‘BRONJ’. BRONJ affects the healing of bone damage by interrupting the process of removing dead bone and laying down new bone. When this happens, parts or all of the jaw bone becomes friable (a bit like chalk), and eventually this dead bone can be exposed. This makes it difficult for people to eat, speak or brush their teeth, and it often causes severe pain. Many different treatments are currently used for BRONJ. They can be categorised as non-invasive treatments (such as antibiotics and mouth rinses), surgical approaches or “add-on” treatments used to enhance usual care (for example, ozone therapy or use of blood plasma that has been enriched with platelets). Different treatments may be combined. Continue reading

Antibiotic use for severe toothache

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Teeth Problem, young man suffering from tooth pain, cariesIrreversible 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. Continue reading

Should antibiotics be prescribed for toothache caused by infection of the tooth root?

Antibiotics

Photo copyright The Global Panorama, under Creative Commons Licence

Dental pain is a common problem and can be caused when the nerve in the tooth dies due to tooth decay or trauma. The tissue around the end of the tooth root then becomes inflamed and this can lead to pain which gets worse on biting. Without treatment, bacteria can infect the dead tooth and cause a dental abscess, which can lead to swelling and infection, and could be life-threatening. The recommended treatment of this form of toothache is the removal of the dead nerve from the tooth and the associated bacteria. This is usually done by dental extraction or root canal treatment. Oral antibiotics are often also prescribed routinely by some dentists, but concerns about antibiotic resistance are growing. Research is needed to demonstrate whether there is evidence that prescribing antibiotics in these circumstances reduces infection. Continue reading

Antibiotic use for severe toothache

Antibiotics - irreIrreversible pulpitis occurs where the tissue inside the tooth which contains the nerve (tooth pulp) has been damaged beyond repair. It is characterised by severe toothache, and is one of the main reasons for emergency dental care. Any tooth can be affected, and it usually occurs because of dental decay, a cracked tooth or trauma to the tooth. The standard care is to remove the pulp from the affected tooth, however in some parts of the world antibiotics continue to be prescribed. Continue reading

Oral Health Group publications in the new issue of the Cochrane Library

Cochrane Review on distalising upper first molars - does an extraoral appliance work better than an intraoral appliance?

Cochrane Review on distalising upper first molars – does an extraoral appliance work better than an intraoral appliance?

October’s edition of the Cochrane Library saw the publication of one new review and one updated review from the Cochrane Oral Health Group. Continue reading

Review of the Month: do antibiotics cause more harm than good?

AntibioticsDentists often have to remove teeth which are affected by decay or gum disease. They also remove wisdom teeth that are poorly aligned or underdeveloped. The risk of infection after extracting wisdom teeth is around 10%, but can be as high as 25% in patients who are already sick. Swelling, pain, fever and dry socket are common complications.

But should dentists try to protect patients from infection by giving them antibiotics just before or just after surgery? Or are the side effects of the antibiotics worse than the infection? There has been concern that too much exposure to antibiotics is a risk to health, as the body becomes less able to fight off infections. What’s the evidence on the use of antibiotics to prevent complications after tooth extraction? Our highlighted Review of the Month for August considers the issues.

What was the research?

A systematic review of the evidence to find out whether taking antibiotics is an effective way to prevent infections after tooth extraction.

Who conducted the research?

The research was conducted by a team led by Giovanni Lodi from the Universita degli Studi di Milano, on behalf of the Cochrane Oral Health Group. Lara Figini, Andrea Sardella, Antonio Carrassi, Massimo Del Fabbro and Susan Furness were also on the team.

What evidence was included in the review?

Data was extracted from 18 randomised controlled trials. A total of 2,456 people having teeth extracted participated in the trials, and were randomly assigned to antibiotics or placebo.

What did the evidence say?

There is evidence that antibiotics reduce the risk of infection by approximately 70%. There is also evidence that people who take antibiotics have less pain a week after the extraction compared with those who do not. However, using antibiotics caused more generally brief and minor side effects for these patients. There was no evidence of a difference between antibiotics and placebo in reduction of fever or swelling.

The review found that approximately 12 people would need to receive antibiotics in this way to prevent one infection, and 38 people would need to be treated with antibiotics to prevent one case of dry socket

The review concludes that antibiotics given to healthy people to prevent infection may cause more harm than benefit to both the individual patients and the population as a whole. There were no trials which looked at antibiotics to prevent infections in people with severely decayed teeth, or those who were sick or had low immunity. It is possible that antibiotics may be more beneficial for these patients.

How good was the evidence?

13 trials were at high risk of bias, and the risk of bias for the other five trials was not clear due to poor reporting of the methods and results. The quality of the evidence was generally moderate for most of the outcomes that were under study.

What are the implications for dentists and the general public?

There is moderate quality evidence that use of antibiotics as a prophylaxis, given to prevent infection, reduces the risk of infection in patients undergoing tooth extraction. There is no clear evidence that the timing of when the drugs are given (just before or just after surgery) is important. The size of the benefit is not enough to recommend routine use of antibiotics, due to the increased risk of mild side effects and the potential for developing resistance to antibiotics.

What should researchers look at in the future?

Future randomized controlled trials should look at whether infection can be prevented by use of antibiotics in patients at high risk of complications, such as people with low immunity. Trials on patients undergoing extractions for severe tooth decay are also needed.

Link

Lodi G, Figini L, Sardella A, Carrassi A, Del Fabbro M, Furness S. Antibiotics to prevent complications following tooth extractions. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD003811. DOI: 10.1002/14651858.CD003811.pub2.