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Dentoalveolar abscess guidelines
HANDS ON Antibiotic Therapy Dentoalveolar abscess guidelines Background.—The resistance of microorganisms to antibiotics is increasingly noted worldwide. Several bacteria are now resistant to multiple antibiotics. To slow this trend will require radical changes in the prescribing habits of medical and dental practitioners. Evidence-based
guidelines were developed and implemented and patient outcomes were evaluated retrospectively. Methods.—Evidence-based prescribing guidelines were drawn up after a literature search of MEDLINE,
Fig 1.—Guidelines on the usage of antibiotics in the primary care setting. (Courtesy of Ellison SJ: An outcome audit of three-day antimicrobial prescribing for the acute dentoalveolar abscess. Br Dent J 211:591-594, 2011.)
Volume 57
Issue 6
2012
297
EMBASE, and the Cochrane Library concerning the use of antibiotics to manage acute dentoalveolar abscess (Fig 1). Of 6586 adult patients coming to Bristol Dental Hospital for treatment of pain, 188 showed signs of systemic involvement related to a dentoalveolar abscess and were prescribed antibiotics according to these guidelines, for a prescribing rate of 2.9%. The effectiveness of a 3-day course of standard-dose antibiotics following drainage of the abscess was evaluated. Results.—The 22 patients who were evaluated clinically had resolution of their systemic symptoms and a verbal:clinical correlation of 100%. One hundred twenty-nine additional patients were interviewed by telephone (response rate 77.7%). Combining the two groups yielded a response rate of 80.3%. Seven patients had no resolution of their symptoms after the course of antibiotics, for a success rate of 95.3%. Of the seven, four had not achieved successful drainage, two patients failed to wait for their drainage/ extractions to be done, and one patient was diagnosed with dry socket rather than ongoing infection. Based on these findings, all patients who submitted to review and had undergone successful drainage had 100% resolution of their symptoms. Discussion.—Several audits have been performed regarding the prescribing habits of general dental and general medical practitioners. Most show that antimicrobial prescribing habits are high when managing patients with acute dental pain, even if obvious infection is not present. In addition, these audits find considerable variation in the type of antimicrobial prescribed, in dosages, and in duration of treatment. Guidelines regarding the appropriate use of
antimicrobials are lacking, resulting in excessive prescriptions being written. Specific to dentoalveolar abscess, the appropriate course of treatment is surgical drainage of the site to remove the infectious agent, then the use of antibiotics only for patients who exhibit systemic symptoms.
Clinical Significance.—It is appropriate to give patients who have systemic infection related to their dentoalveolar abscess antibiotics, but these agents are needed only until the systemic symptoms resolve. This is generally 2 to 3 days. This study shows that a 3-day course of standard-dose antibiotic according to the guidelines developed will effectively manage dentoalveolar infections. Because of the high costs associated with the use of antibiotics, increased levels of bacterial resistance, resistance of some organisms to multiple antimicrobial agents, and the threat of litigation, practitioners should be extremely careful when prescribing antibiotics for dentoalveolar abscesses, with greater emphasis on providing adequate drainage.
Ellison SJ: An outcome audit of three-day antimicrobial prescribing for the acute dentoalveolar abscess. Br Dent J 211:591-594, 2011 Reprints available from SJ Ellison, Dept of Oral Medicine and Primary Care, Bristol Dental Hosp, Lower Maudlin St, Bristol, BS1 2LY; e-mail: [email protected]
Bisphosphonate Osteonecrosis Osteonecrosis of the jaw Background.—The risk factors for developing osteonecrosis of the jaw (ONJ) include head and neck radiotherapy, chemotherapy, periodontal disease, edentulous regions, dental procedures involving bone surgery, and trauma from poorly fitting dentures. More recently ONJ has been associated with intravenous (IV) and oral bisphosphonate (BP) therapy. BPs are used for bone resorptive bone diseases and metastatic bone lesions from breast cancer, prostate cancer, and multiple myeloma. BPs reduce bone resorption and turnover. When used for osteoporosis, oral BPs are best, whereas for cancer patients more potent IV BPs are chosen. The diagnosis of BP-related osteonecrosis of the jaw (BRONJ) demands the presence of three characteristics: current
298
Dental Abstracts
or previous treatment with a BP, exposed necrotic bone in the maxillofacial region for more than 8 weeks, and not having radiation therapy to the jaws (Fig 1). No specific radiographic features indicate the diagnosis, so its identification can be delayed. The effectiveness of preventive strategies for BRONJ in patients having BP treatment was evaluated. Methods.—The analysis included 282 patients, 162 of whom were women and 120 men. Two hundred seventeen were assigned to the preventive approach (PA) group and 65 to the observation (OB) group. PA patients had not taken BPs previously, but OB patients had already had BP treatments. All patients underwent a complete oral and dental
guidelines were developed and implemented and patient outcomes were evaluated retrospectively. Methods.—Evidence-based prescribing guidelines were drawn up after a literature search of MEDLINE,
Fig 1.—Guidelines on the usage of antibiotics in the primary care setting. (Courtesy of Ellison SJ: An outcome audit of three-day antimicrobial prescribing for the acute dentoalveolar abscess. Br Dent J 211:591-594, 2011.)
Volume 57
Issue 6
2012
297
EMBASE, and the Cochrane Library concerning the use of antibiotics to manage acute dentoalveolar abscess (Fig 1). Of 6586 adult patients coming to Bristol Dental Hospital for treatment of pain, 188 showed signs of systemic involvement related to a dentoalveolar abscess and were prescribed antibiotics according to these guidelines, for a prescribing rate of 2.9%. The effectiveness of a 3-day course of standard-dose antibiotics following drainage of the abscess was evaluated. Results.—The 22 patients who were evaluated clinically had resolution of their systemic symptoms and a verbal:clinical correlation of 100%. One hundred twenty-nine additional patients were interviewed by telephone (response rate 77.7%). Combining the two groups yielded a response rate of 80.3%. Seven patients had no resolution of their symptoms after the course of antibiotics, for a success rate of 95.3%. Of the seven, four had not achieved successful drainage, two patients failed to wait for their drainage/ extractions to be done, and one patient was diagnosed with dry socket rather than ongoing infection. Based on these findings, all patients who submitted to review and had undergone successful drainage had 100% resolution of their symptoms. Discussion.—Several audits have been performed regarding the prescribing habits of general dental and general medical practitioners. Most show that antimicrobial prescribing habits are high when managing patients with acute dental pain, even if obvious infection is not present. In addition, these audits find considerable variation in the type of antimicrobial prescribed, in dosages, and in duration of treatment. Guidelines regarding the appropriate use of
antimicrobials are lacking, resulting in excessive prescriptions being written. Specific to dentoalveolar abscess, the appropriate course of treatment is surgical drainage of the site to remove the infectious agent, then the use of antibiotics only for patients who exhibit systemic symptoms.
Clinical Significance.—It is appropriate to give patients who have systemic infection related to their dentoalveolar abscess antibiotics, but these agents are needed only until the systemic symptoms resolve. This is generally 2 to 3 days. This study shows that a 3-day course of standard-dose antibiotic according to the guidelines developed will effectively manage dentoalveolar infections. Because of the high costs associated with the use of antibiotics, increased levels of bacterial resistance, resistance of some organisms to multiple antimicrobial agents, and the threat of litigation, practitioners should be extremely careful when prescribing antibiotics for dentoalveolar abscesses, with greater emphasis on providing adequate drainage.
Ellison SJ: An outcome audit of three-day antimicrobial prescribing for the acute dentoalveolar abscess. Br Dent J 211:591-594, 2011 Reprints available from SJ Ellison, Dept of Oral Medicine and Primary Care, Bristol Dental Hosp, Lower Maudlin St, Bristol, BS1 2LY; e-mail: [email protected]
Bisphosphonate Osteonecrosis Osteonecrosis of the jaw Background.—The risk factors for developing osteonecrosis of the jaw (ONJ) include head and neck radiotherapy, chemotherapy, periodontal disease, edentulous regions, dental procedures involving bone surgery, and trauma from poorly fitting dentures. More recently ONJ has been associated with intravenous (IV) and oral bisphosphonate (BP) therapy. BPs are used for bone resorptive bone diseases and metastatic bone lesions from breast cancer, prostate cancer, and multiple myeloma. BPs reduce bone resorption and turnover. When used for osteoporosis, oral BPs are best, whereas for cancer patients more potent IV BPs are chosen. The diagnosis of BP-related osteonecrosis of the jaw (BRONJ) demands the presence of three characteristics: current
298
Dental Abstracts
or previous treatment with a BP, exposed necrotic bone in the maxillofacial region for more than 8 weeks, and not having radiation therapy to the jaws (Fig 1). No specific radiographic features indicate the diagnosis, so its identification can be delayed. The effectiveness of preventive strategies for BRONJ in patients having BP treatment was evaluated. Methods.—The analysis included 282 patients, 162 of whom were women and 120 men. Two hundred seventeen were assigned to the preventive approach (PA) group and 65 to the observation (OB) group. PA patients had not taken BPs previously, but OB patients had already had BP treatments. All patients underwent a complete oral and dental