An outcome audit of three day antimicrobial prescribing for the acute dentoalveolar abscess

The inception of a hospital-based dental emergency department in a precarious region decreases the incidence of severe cellulitis of odontogenic origin

INTRODUCTION

Although most localized odontogenic infections can be managed successfully without complications, some can cause extensive morbidity through the onset of cervicofacial cellulitis. The management of these more severe infections generally requires emergency treatment, including surgical treatment under general anesthesia, and prolonged length of hospital stay.

MATERIAL & METHODS

In this work, we assessed the impact of the provision of a hospital-based dental emergency department on the regional incidence of severe odontogenic cellulitis in a socioeconomically precarious region. Monthly case rates of odontogenic cellulitis treated between January 2010 and December 2019 at the hospital-based dental emergency department of Lille Medical University Hospital were collected.

RESULTS

The mean number of monthly severe odontogenic cellulitis cases treated under general anesthesia was significantly higher before than after the inception of the hospital-based dental emergency service [14.07 (5.83) vs 8.79 (4.42); p<0.0001]. Conversely, the monthly mean number of collected odontogenic cellulitis cases treated under local anesthesia was significantly lower before the emergency service was set up [22.42 (12.73) vs 43.32 (23.41); p<0.0001].

CONCLUSION

The provision of a hospital-based dental emergency department resulted in a decrease in severe dental infections in a region with high indices of socioeconomic precarity, morbidity and mortality. Greater accessibility to dental care allows for the rationalization of care through more precocious and fewer burdensome procedures.

Optimum length of treatment with systemic antibiotics in adults with dental infections: a systematic review

Introduction Guidelines on the length of treatment of dental infections with systemic antibiotics vary across different countries. We aimed to determine if short-duration (3-5 days) courses of systemic antibiotics were as effective as longer-duration courses (≥7 days) for the treatment of dental infections in adults in outpatient settings.Methods We searched Ovid Medline, Ovid Embase, Cochrane, trials registries, Google Scholar and forward and backward citations for studies published between database inception and 30 March 2021. All randomised clinical trials (RCT) and non-randomised trials which compared length of treatment with systemic antibiotics for dental infections in adults in outpatient settings published in English were included.Results One small RCT met our defined inclusion criteria. The trial compared three-day versus seven-day courses of amoxicillin in adults with odontogenic infection requiring tooth extraction. There was no significant difference between groups in terms of participant-reported pain or clinical assessment of wound healing.Discussion While a number of observational studies were supportive of shorter-course therapy, only one small RCT concluded that a three-day course of amoxicillin was clinically non-inferior versus seven days for the treatment of odontogenic infection requiring tooth extraction. Limited conclusions on shorter-course therapy can be drawn from this study as all participants commenced amoxicillin two days before tooth extraction which is not common clinical practice. The variability in guidelines for use of antimicrobials in dental infections suggests that guidelines are based on local or national historical practice and indicates the need for further research to determine the optimum length of treatment. RCTs are required to investigate if short-duration courses of antibiotics are effective and to provide evidence to support consistent guidance for dental professionals.

Status of Microbiota in Odontogenic Inflammatory Lesions and Dental Surgery Procedures Performed on an Outpatient Basis

Inflammations of the facial part of the skull are most commonly caused by a bacterial infection. They are a frequently occurring pathological process, which results from a rich bacterial flora of the oral cavity, as well as diseased teeth and periodontal tissues. These inflammations have a primarily mixed character with the prevalence of anaerobic bacteria. Gangrene of the dental pulp is the most common odontogenic cause. In the case of inflammations of oral tissues an early and corrective treatment results in quick recovery. The purpose of this work was to assess the efficiency of empirical antibiotic therapy applied in patients with inflammations of oral tissues on the basis of a drug susceptibility profile of bacteria isolated from material extracted from inflammatory lesions. The research material consisted of smears collected from patients with existing acute inflammations in the oral cavity. The smear was collected from the bottom of the lesion after its prior surgical treatment and pus evacuation, and again, 7 days after surgery. In patients with acute odontogenic inflammations the recommended first-line therapy are extended-spectrum penicillins, characterized by a low risk of side effects and strong antimicrobial activity. In the study group, both clindamycin and amoxicillin exhibited high efficiency in treating acute odontogenic inflammatory lesions in the oral cavity.

Oral Antibiotic for Empirical Management of Acute Dentoalveolar Infections-A Systematic Review

Concerns regarding increasing antibiotic resistance raise the question of the most appropriate oral antibiotic for empirical therapy in dentistry. The aim of this systematic review was to investigate the antibiotic choices and regimens used to manage acute dentoalveolar infections and their clinical outcomes. A systematic review was undertaken across three databases. Two authors independently screened and quality-assessed the included studies and extracted the antibiotic regimens used and the clinical outcomes. Searches identified 2994 studies, and after screening and quality assessment, 8 studies were included. In addition to incision and drainage, the antibiotics used to manage dentoalveolar infections included amoxicillin, amoxicillin/clavulanic acid, cefalexin, clindamycin, erythromycin, metronidazole, moxifloxacin, ornidazole and phenoxymethylpenicillin. Regimens varied in dose, frequency and duration. The vast majority of regimens showed clinical success. One study showed that patients who did not receive any antibiotics had the same clinical outcomes as patients who received broad-spectrum antibiotics. The ideal choice, regimen and spectrum of empirical oral antibiotics as adjunctive management of acute dentoalveolar infections are unclear. Given that all regimens showed clinical success, broad-spectrum antibiotics as first-line empirical therapy are unnecessary. Narrow-spectrum agents appear to be as effective in an otherwise healthy individual. This review highlights the effectiveness of dental treatment to address the source of infection as being the primary factor in the successful management of dentoalveolar abscesses. Furthermore, the role of antibiotics is questioned in primary space odontogenic infections, if drainage can be established.

Knowledge and attitudes of recently qualified dentists working in Wales towards antimicrobial prescribing and resistance

AIMS

To discover newly qualified dentists' confidence towards prescribing antimicrobials and explore their attitudes concerning the emergence of antimicrobial resistance (AMR).

MATERIALS AND METHODS

This was a cross-sectional study; questionnaires exploring attitudes towards issues related to antimicrobial use and resistance were distributed to dentists undergoing Dental Foundation (DF), Dental Core (DC) or Longitudinal Dental Foundation Training in Wales.

RESULTS

A total of 71 of 90 questionnaires were returned, giving a response rate of 78.9%. Most respondents (90.0%) agreed that antimicrobial resistance poses a serious threat to public health in the UK and 78.9% reported that they considered the impact of dental prescribing to the emergence of resistance to be moderate or greater. The greatest influences on prescribing behaviour were the use of guidelines and teaching received as an undergraduate. Although the majority of participants agreed that they had sufficient training in antimicrobial prescribing, some were not confident when issuing a prescription or undertaking operative treatment for patients with acute dental conditions. Many reported that their prescribing behaviours were influenced by additional pressures, such as if operative treatment had to be delayed. The majority (77.5%) agreed that changes should be implemented to optimise dentists' antimicrobial prescribing practices, such as increasing the availability of clinical guidelines or further teaching at undergraduate level.

DISCUSSION AND CONCLUSIONS

Undergraduate dental curricula should include specific competencies relating to antimicrobial use and factors contributing to the development of antimicrobial resistance.

Antimicrobial prescribing by dentists in Wales, UK: findings of the first cycle of a clinical audit

Objective To describe the findings of the first cycle of a clinical audit of antimicrobial use by general dental practitioners (GDPs).Setting General dental practices in Wales, UK.Subjects and methods Between April 2012 and March 2015, 279 GDPs completed the audit. Anonymous information about patients prescribed antimicrobials was recorded. Clinical information about the presentation and management of patients was compared to clinical guidelines published by the Scottish Dental Clinical Effectiveness Programme (SDCEP).Results During the data collection period, 5,782 antimicrobials were prescribed in clinical encounters with 5,460 patients. Of these 95.3% were antibiotic preparations, 2.7% were antifungal agents, and 0.6% were antivirals. Of all patients prescribed antibiotics, only 37.2% had signs of spreading infection or systemic involvement recorded, and 31.2% received no dental treatment. In total, 79.2% of antibiotic, 69.4% of antifungal, and 57.6% of antiviral preparations met audit standards for dose, frequency, and duration. GDPs identified that failure of previous local measures, patient unwillingness or inability to receive treatment, patient demand, time pressures, and patients' medical history may influence their prescribing behaviours.Conclusions The findings of the audit indicate a need for interventions to support GDPs so that they may make sustainable improvements to their antimicrobial prescribing practices.

The Pattern of Antibiotic Prescribing by Dental Practitioners in Zagreb, Croatia

BACKGROUND

Bacterial resistance is considered a consequence of misuse or overuse of antibiotics. Dentistry significantly contributes to this increasing public health problem. The aim of this cross-sectional study was to examine the pattern of antibiotics prescribed by Croatian dentists in Zagreb area.

METHODS

Out of 220 Doctors of Dental Medicine (DMDs) from Zagreb 110 responded to survey. Prior to the research an ethical approval was obtained. Participants were directly contacted. The questionnaire consisted of two parts: general data on DMDs and the part concerning indications, duration, type and dosage of antibiotic therapy. Data were processed using MS Excel and SPSS for Windows, Version 17.0. Statistical significance was tested by Fisher's exact test, chi-square test, Mann-Whitney U test and Spearman's rank correlation at the level of statistical significance p<0.05.

RESULTS

During the period of two months, the doctors prescribed antibiotics to 1,500 patients, 690 (46%) were men and 810 (54%) women. The most often prescribed antibiotics were penicillin (72.5% of patients), represented mostly by amoxicillin in combination with clavulanic acid (57.6%). The most common indication for the prescribed antibiotics was periapical or periodontal abscess (44%). Definite clinical indication (71.2%) was stated as the most common reason for antibiotic prescription. Antibiotic therapy usually lasted 7 days (62.9%). The doctors prescribed daily doses of antibiotics according to the instructions for the use of specific drugs.

CONCLUSION

The examined subjects prescribe antibiotics according to the curriculum taught at the School of Dental Medicine for majority of types, doses and duration of the treatments, although antibiotics over-prescription in cases without medical indication was observed. The national guidelines on antibiotic regimens are required in order to reduce unnecessary antibiotic use.

Pain Part 4: Odontogenic Pain

Pain is one of the major reasons that lead patients to seek dental care. For the majority of patients, the pain is of odontogenic origin, as a consequence of dental disease. The timely diagnosis and management of dental pain is an essential component of dental care, and this article reminds readers of the common presenting symptoms of simple dental pain, diagnoses and pragmatic management.

CLINICAL RELEVANCE

Pain of odontogenic origin is common, and distressing. However, the pathology is consistent, as are the symptoms, and an understanding of this underpins the careful history-taking that will lead the clinician to the diagnosis.

Amoxicillin/Clavulanic Acid for the Treatment of Odontogenic Infections: A Randomised Study Comparing Efficacy and Tolerability versus Clindamycin

Background. Treatment of odontogenic infections includes surgical drainage and adjunctive antibiotics. This study was designed to generate efficacy and safety data to support twice daily dosing of amoxicillin/clavulanic acid compared to clindamycin in odontogenic infections. Methods. This was a phase IV, randomised, observer blind study; 472 subjects were randomised to receive amoxicillin/clavulanic acid (875 mg/125 mg BID, n = 235) or clindamycin (150 mg QID, n = 237) for 5 or 7 days based on clinical response. The primary endpoint was percentage of subjects achieving clinical success (composite measure of pain, swelling, fever, and additional antimicrobial therapy required) at the end of treatment. Results. The upper limit of two-sided 95% confidence interval for the treatment difference between the study arms (7.7%) was within protocol specified noninferiority margin of 10%, thus demonstrating noninferiority of amoxicillin/clavulanic acid to clindamycin. Secondary efficacy results showed a higher clinical success rate at Day 5 in the amoxicillin/clavulanic acid arm. Most adverse events (raised liver enzymes, diarrhoea, and headache) were similar across both arms and were of mild to moderate intensity. Conclusion. Amoxicillin/clavulanic acid was comparable to clindamycin in achieving clinical success (88.2% versus 89.7%) in acute odontogenic infections and the safety profile was consistent with the known side effects of both drugs. Trial Registration. This trial is registered with Clinicaltrials.gov identifier: NCT02141217.

Epidemiology and variables involved in dental abscess: survey of dental emergency unit in Trieste

OBJECTIVES

The objective of this epidemiologic study was to estimate the healing time of acute dental abscesses and to evaluate the main variables involved in the healing process itself.

SUBJECTS AND METHODS

Among a sample of over 24 000 patients visited at the emergency dental unit, 688 subjects were diagnosed with dental abscess and enrolled in the study. Case histories of all patients were collected to investigate the clinical course and healing time of dental abscess according to anamnestic and diagnostic data and therapeutic management. A multiple logistic regression model was performed to evaluate the association of each variable with the healing time required for dental abscess.

RESULTS

Variables associated with increased healing time were spring seasonality at admission, pyretic state, trismus, involvement of multiple anatomic spaces, and spontaneous drainage. Moreover, administration of some, but not all, classes of antibiotics was also associated with an increased healing time.

CONCLUSIONS

The knowledge of variables involved in healing time for dental abscess is crucial in the optimization of managing such infections in terms of cost-benefit ratio. This would represent a valuable way to ensure a shortened and more effective healing.

Clinical audit--process and outcome for improved clinical practice

Audit is a key aspect of everyday clinical care and essential for the safe as well as efficient functioning of any clinical environment. This applies to clinical care both within primary practice and secondary care within a hospital environment. The undertaking of an audit allows the clinician to analyse his or her own clinical practice in relation to current guidance or 'gold standard' parameters to enable best practice within all aspects of patient care to be implemented. This paper aims to explore the origins and importance of clinical audit as well as the various processes involved in undertaking it successfully.

CLINICAL RELEVANCE

This article will enable clinicians to understand the importance of audit and how to incorporate it into their everyday practice.

Dental and related infections

Emergency physicians should be comfortable treating most dental and related infections. In this article, we outline recommended techniques to perform a dental examination, explore common pathologies, recommend pain and antibiotic management strategies and review common pitfalls. How to avoid overprescribing opioid analgesics is discussed in depth, along with recent studies to support this strategy.