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Are Antibiotics Beneficial for the Treatment of Symptomatic Dental Infections?
ANNALS OF EMERGENCY MEDICINE
MARCH 2015
Systematic Review Snapshot TAKE-HOME MESSAGE There is insufficient evidence to draw a conclusion about the benefit or harm associated with prescribing antibiotics for symptomatic dental infections. METHODS DATA SOURCES The Cochrane Oral Health Group’s Trial Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, WHO International Trials Registry Platform, clinicaltrials.gov, OpenGrey, and Zetoc Conference Proceedings were searched from inception to October 2013. References lists were reviewed for additional studies, and investigators were contacted for unpublished data. STUDY SELECTION The authors included randomized trials comparing systemic antibiotics with placebo for the treatment of apical periodontitis or abscess, with or without accompanying analgesics or procedural intervention. Outcomes included patient-reported pain and swelling, along with clinicianreported infection. DATA EXTRACTION AND SYNTHESIS Two authors independently screened references and abstracted data. Quality of evidence was determined with domain-based and Grading of Recommendations Assessment, Development and Evaluation (GRADE) approaches.1,2 Heterogeneity was expressed with
332 Annals of Emergency Medicine
Are Antibiotics Beneficial for the Treatment of Symptomatic Dental Infections? EBEM Commentators
Aleksandr M. Tichter, MD, MS Kenneth J. Perry, MD Emergency Medicine Residency New York–Presbyterian Hospital Columbia University Medical Center New York, NY
Results Comparison of antibiotic versus placebo for primary outcomes. No. of Studies (No. of Participants)
Outcome Patient reported
Clinician reported
Quality of Evidence
Pain
2 (61)
Very low
Swelling
2 (61)
Very low
Infection
1 (20)
Very low
Time, Hours
Effect Size (95% CI)
24 72 24 72 72
MD –0.03 (–0.53 to 0.47) MD 0.08 (–0.38 to 0.54) SMD 0.27 (–0.23 to 0.78) SMD 0.02 (–0.49 to 0.52) RR 0.27 (0.01 to 4.90)
CI, Confidence interval; MD, mean difference; SMD, standardized mean difference; RR, risk ratio.
Two randomized, placebo-controlled trials studying the effect of oral penicillin VK (in combination with oral analgesics and surgical pulpectomy) on the primary outcomes met inclusion criteria for this meta-analysis. Although antibiotic and analgesic dosing varied between studies, the antibiotic type and outcomes measures were similar and the individual study summary estimates were determined to be sufficiently homogenous to combine (range for I2¼0% to 61%). No significant differences were observed between the antibiotic and placebo groups with respect to selfreported pain or swelling at 24, 48,
or 72 hours, or clinician-reported infection at 72 hours. Adverse effects were reported by only 1 study, in which 1 patient in the antibiotic group reported fatigue and 1 patient in the placebo group reported diarrhea.
Commentary Odontogenic infections result from the extension of decay or damage to the central pulp of a tooth, and, if left untreated, initially localized abscesses have the potential to develop into lifethreatening deep-space neck infections.3 Although office-based dental procedures are the therapeutic mainstay, uninsured and Medicaid patients Volume 65, no. 3 : March 2015
Systematic Review Snapshot the I2 statistic. Mean differences and standard mean differences were calculated with a fixed-effects model.
rely disproportionately on emergency departments (EDs) as a primary source of dental care.4,5 Available data suggest that nontraumatic dental complaints account for 1.4% of ED visits and more than $200 million in hospital costs and are increasing at a rate of 4% annually.3,6,7 Apart from dental referral, antibiotics are among the few adjunctive therapies available to emergency physicians for the interim management of symptomatic patients.8 Existing guidelines recommend their use only for patients with evidence of spreading infection but fail to cite corroborating data.9 ED treatment remains variable, with up to 50% of patients receiving antibiotic therapy, which may result from the conflict between anecdotal evidence juxtaposed with a general mindfulness about antibiotic stewardship.10 This systematic review sought to determine the effect of systemic antibiotics on symptomatic apical periodontitis or acute apical abscess. Although both of the studies included in this review recruited patients from university dental schools, the participants were healthy young adults similar to those presenting with tooth pain in many ED settings. Unlike the ED population, however, study
patients were treated with both antibiotics and simultaneous surgical pulpectomy, a procedural intervention commonly delayed by hours to days after an index ED visit. The quality of evidence was limited by the failure of one study to report missing data and an imbalanced attrition rate exceeding 20% in the other. Although investigators collected information about rescue analgesic use, the latter study failed to report these data, raising the possibility of selective outcome reporting bias. Conclusions about therapeutic benefit or potential harm are further limited by the small number of participants. Overall, the results provide insufficient evidence to draw a conclusion about the benefit of prescribing antibiotics for symptomatic dental infections in the ED. Editor’s Note: This is a clinical synopsis, a regular feature of the Annals’ Systematic Review Snapshot (SRS) series. The source for this systematic review snapshot is: Cope A, Francis N, Wood F, et al. Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults. Cochrane Database Syst Rev. 2014;(6):CD010136. http://dx.doi.org/10. 1002/14651858.CD010136.pub2. (Assessed as up to date: October 1, 2013.) 1. Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.
2. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336: 924-926. 3. Eisler L, Wearda K, Romatoski K, et al. Morbidity and cost of odontogenic infections. Otolaryngol Head Neck Surg. 2013;149:84-88. 4. Nalliah RP, Allareddy V, Elangovan S, et al. Hospital emergency department visits attributed to pulpal and periapical disease in the United States in 2006. J Endod. 2011;37:6-9. 5. Lewis C, Lynch H, Johnston B. Dental complaints in emergency departments: a national perspective. Ann Emerg Med. 2003;42:93-99. 6. Okunseri C, Okunseri E, Thorpe JM, et al. Patient characteristics and trends in nontraumatic dental condition visits to emergency departments in the United States. Clin Cosmet Investig Dent. 2012;4:1-7. 7. Lee HH, Lewis CW, Saltzman B, et al. Visiting the emergency department for dental problems: trends in utilization, 2001 to 2008. Am J Public Health. 2012;102:e77-e83. 8. Dailey YM, Martin MV. Are antibiotics being used appropriately for emergency dental treatment? Br Dent J. 2001;191:391-393. 9. SDCEP. Drug Prescribing for Dentistry: Dental Clinical Guidance. 2nd ed. Dundee, Scotland: Scottish Dental Clinical Effectiveness Programme; 2011. 10. Okunseri C, Okunseri E, Thorpe JM, et al. Medications prescribed in emergency departments for nontraumatic dental condition visits in the United States. Med Care. 2012;50:508-512.
Michael Brown, MD, MSc, Alan Jones, MD, and David Newman, MD, serve as editors of the SRS series.
Did you know? Podcasts are available for almost every article in Annals.
Visit http://www.annemergmed.com/content/podcast to find out more.
Volume 65, no. 3 : March 2015
Annals of Emergency Medicine 333
MARCH 2015
Systematic Review Snapshot TAKE-HOME MESSAGE There is insufficient evidence to draw a conclusion about the benefit or harm associated with prescribing antibiotics for symptomatic dental infections. METHODS DATA SOURCES The Cochrane Oral Health Group’s Trial Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, WHO International Trials Registry Platform, clinicaltrials.gov, OpenGrey, and Zetoc Conference Proceedings were searched from inception to October 2013. References lists were reviewed for additional studies, and investigators were contacted for unpublished data. STUDY SELECTION The authors included randomized trials comparing systemic antibiotics with placebo for the treatment of apical periodontitis or abscess, with or without accompanying analgesics or procedural intervention. Outcomes included patient-reported pain and swelling, along with clinicianreported infection. DATA EXTRACTION AND SYNTHESIS Two authors independently screened references and abstracted data. Quality of evidence was determined with domain-based and Grading of Recommendations Assessment, Development and Evaluation (GRADE) approaches.1,2 Heterogeneity was expressed with
332 Annals of Emergency Medicine
Are Antibiotics Beneficial for the Treatment of Symptomatic Dental Infections? EBEM Commentators
Aleksandr M. Tichter, MD, MS Kenneth J. Perry, MD Emergency Medicine Residency New York–Presbyterian Hospital Columbia University Medical Center New York, NY
Results Comparison of antibiotic versus placebo for primary outcomes. No. of Studies (No. of Participants)
Outcome Patient reported
Clinician reported
Quality of Evidence
Pain
2 (61)
Very low
Swelling
2 (61)
Very low
Infection
1 (20)
Very low
Time, Hours
Effect Size (95% CI)
24 72 24 72 72
MD –0.03 (–0.53 to 0.47) MD 0.08 (–0.38 to 0.54) SMD 0.27 (–0.23 to 0.78) SMD 0.02 (–0.49 to 0.52) RR 0.27 (0.01 to 4.90)
CI, Confidence interval; MD, mean difference; SMD, standardized mean difference; RR, risk ratio.
Two randomized, placebo-controlled trials studying the effect of oral penicillin VK (in combination with oral analgesics and surgical pulpectomy) on the primary outcomes met inclusion criteria for this meta-analysis. Although antibiotic and analgesic dosing varied between studies, the antibiotic type and outcomes measures were similar and the individual study summary estimates were determined to be sufficiently homogenous to combine (range for I2¼0% to 61%). No significant differences were observed between the antibiotic and placebo groups with respect to selfreported pain or swelling at 24, 48,
or 72 hours, or clinician-reported infection at 72 hours. Adverse effects were reported by only 1 study, in which 1 patient in the antibiotic group reported fatigue and 1 patient in the placebo group reported diarrhea.
Commentary Odontogenic infections result from the extension of decay or damage to the central pulp of a tooth, and, if left untreated, initially localized abscesses have the potential to develop into lifethreatening deep-space neck infections.3 Although office-based dental procedures are the therapeutic mainstay, uninsured and Medicaid patients Volume 65, no. 3 : March 2015
Systematic Review Snapshot the I2 statistic. Mean differences and standard mean differences were calculated with a fixed-effects model.
rely disproportionately on emergency departments (EDs) as a primary source of dental care.4,5 Available data suggest that nontraumatic dental complaints account for 1.4% of ED visits and more than $200 million in hospital costs and are increasing at a rate of 4% annually.3,6,7 Apart from dental referral, antibiotics are among the few adjunctive therapies available to emergency physicians for the interim management of symptomatic patients.8 Existing guidelines recommend their use only for patients with evidence of spreading infection but fail to cite corroborating data.9 ED treatment remains variable, with up to 50% of patients receiving antibiotic therapy, which may result from the conflict between anecdotal evidence juxtaposed with a general mindfulness about antibiotic stewardship.10 This systematic review sought to determine the effect of systemic antibiotics on symptomatic apical periodontitis or acute apical abscess. Although both of the studies included in this review recruited patients from university dental schools, the participants were healthy young adults similar to those presenting with tooth pain in many ED settings. Unlike the ED population, however, study
patients were treated with both antibiotics and simultaneous surgical pulpectomy, a procedural intervention commonly delayed by hours to days after an index ED visit. The quality of evidence was limited by the failure of one study to report missing data and an imbalanced attrition rate exceeding 20% in the other. Although investigators collected information about rescue analgesic use, the latter study failed to report these data, raising the possibility of selective outcome reporting bias. Conclusions about therapeutic benefit or potential harm are further limited by the small number of participants. Overall, the results provide insufficient evidence to draw a conclusion about the benefit of prescribing antibiotics for symptomatic dental infections in the ED. Editor’s Note: This is a clinical synopsis, a regular feature of the Annals’ Systematic Review Snapshot (SRS) series. The source for this systematic review snapshot is: Cope A, Francis N, Wood F, et al. Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults. Cochrane Database Syst Rev. 2014;(6):CD010136. http://dx.doi.org/10. 1002/14651858.CD010136.pub2. (Assessed as up to date: October 1, 2013.) 1. Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.
2. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336: 924-926. 3. Eisler L, Wearda K, Romatoski K, et al. Morbidity and cost of odontogenic infections. Otolaryngol Head Neck Surg. 2013;149:84-88. 4. Nalliah RP, Allareddy V, Elangovan S, et al. Hospital emergency department visits attributed to pulpal and periapical disease in the United States in 2006. J Endod. 2011;37:6-9. 5. Lewis C, Lynch H, Johnston B. Dental complaints in emergency departments: a national perspective. Ann Emerg Med. 2003;42:93-99. 6. Okunseri C, Okunseri E, Thorpe JM, et al. Patient characteristics and trends in nontraumatic dental condition visits to emergency departments in the United States. Clin Cosmet Investig Dent. 2012;4:1-7. 7. Lee HH, Lewis CW, Saltzman B, et al. Visiting the emergency department for dental problems: trends in utilization, 2001 to 2008. Am J Public Health. 2012;102:e77-e83. 8. Dailey YM, Martin MV. Are antibiotics being used appropriately for emergency dental treatment? Br Dent J. 2001;191:391-393. 9. SDCEP. Drug Prescribing for Dentistry: Dental Clinical Guidance. 2nd ed. Dundee, Scotland: Scottish Dental Clinical Effectiveness Programme; 2011. 10. Okunseri C, Okunseri E, Thorpe JM, et al. Medications prescribed in emergency departments for nontraumatic dental condition visits in the United States. Med Care. 2012;50:508-512.
Michael Brown, MD, MSc, Alan Jones, MD, and David Newman, MD, serve as editors of the SRS series.
Did you know? Podcasts are available for almost every article in Annals.
Visit http://www.annemergmed.com/content/podcast to find out more.
Volume 65, no. 3 : March 2015
Annals of Emergency Medicine 333