The FDI World Dental Federation strongly supports and recommends coordinated efforts to promote antimicrobial stewardship (AMS) in dental practice. Globally, it is reported that dentists prescribe approximately 10% of antibiotic prescriptions for human use. Overuse of antibiotics by dentists is widely reported with a study from the UK reporting that 80% of antibiotic use for treating acute dental infections was unnecessary. Barriers to evidence-based prescribing reported include time pressure, fear of medico-legal liability, patient pressure on dentists to prescribe antibiotics, lack of awareness of guidelines and limitations in access to timely dental services.

Currently, data on the quantity or quality of antibiotic prescribing by dentists in Ireland is not readily available. A study was conducted investigating dentists’ views and experiences of antimicrobial prescribing and stewardship in Ireland, the key findings of which are outlined in Box 1 at the end of this article.

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Dental procedures are usually the quickest and safest solutions for dental pain and infection. Most dental infections are amenable to treatment by a dental procedure (such as extraction of the tooth) to remove the source of the infection without the need for antibiotics.  An important aspect of dental AMS is to ensure dental procedures are delivered whenever possible and antimicrobial drugs are only used when necessary.

 

Risks of antibiotic use

The risk of adverse outcomes must also be considered when prescribing antibiotics. These include:

• Adverse effects including allergic reactions and antibiotic-induced colitis which can cause significant harm;
• Alteration of the gut microbiome with negative health consequences; and
• The emergence of antimicrobial resistance (AMR).

Exposing a patient to antibiotics when not necessary (for example ‘just in case’, as a substitute for dental procedures, or to meet patient demands) increases the likelihood of AMR and has the potential to limit future antibiotic treatment options for when antibiotics are truly needed.  

Antibiotic use for dental infections

Dental conditions for which antibiotics are not indicated:

• Most oral diseases presented to the dentist are primarily inflammatory conditions that are associated with pain and can be treated without antibiotic treatment by removal of the cause and drainage of the infection using a dental procedure (for example, extraction of the tooth);
• Many common dental infections require only operative measures and antibiotics do not prevent severe complications and cannot replace local surgical treatment;
• Some scenarios where antibiotics are not indicated in dentistry include:
• Before a dental procedure to decrease inflammation or to cure toothache;
• Before most dental procedures to prevent surgical site infections;
• Acute pulpitis where operative dental treatment or treatment with analgesia is more appropriate;
• Dry socket (see antibioticprescribing.ie > community guidelines > dental infections > dry socket guidelines); and
• Endodontic treatment unless there is evidence of significant local spread of infection or systemic infection.

 

Dental conditions for which antibiotics may be indicated

• For people with a severe spreading dental infection, with systemic signs (for example, facial swelling, inability to open the mouth, fever ≥ 38.0 °C, tachycardia, lymphadenopathy and trismus) effective antibiotics and surgical management are vital. Sepsis and the spread of infection may block the upper airway or move to the brain and are life-threatening so should be managed promptly as a medical emergency;
• Clinical situations that require antibiotic therapy on empirical basis are limited:
• – Antibiotics may be indicated for apical or periodontal abscess and necrotising periodontal disease if there is evidence of spreading infection, systemic involvement and/or trismus (see  antibioticprescribing.ie > community guidelines > dental infections > periodontal abscess/necrotising ulcerative gingivitis);
• – Pericoronitis (see antibioticprescribing.ie > community guidelines > dental infections > pericoronitis) is inflammation and sometimes infection of the gum around a partially erupted tooth, often a lower wisdom tooth. It usually occurs in late adolescence and early adult life and can be treated by professional cleaning, saline (hot salty water) mouthwash and, if necessary, by draining the infection. Antibiotics are rarely indicated for pericoronitis unless there is evidence of spreading infection, systemic involvement and/or trismus;
• – There is a lower threshold for prescribing antibiotics in immunocompromised patients with these conditions;
• – Facial cellulitis that may or may not be associated with dysphagia, is a serious disease that should be treated by antibiotics promptly because of the possibility of infection spread via lymph and blood circulation; and
• – Endocarditis prophylaxis for patients undergoing dental procedures is only recommended for a limited number of indications in patients with specific cardiac conditions. For further details, please refer to the Antibiotic prophylaxis of infective endocarditis for dental procedures guideline on antibioticprescribing.ie. (antibioticprescribing.ie > community guidelines > dental infections > antibiotic prophylaxis of infective endocarditis for dental procedures).

For further details refer to Guidance for antibiotic use for dental infections on the HSE website antibioticprescribing.ie (antibioticprescribing.ie > community guidelines > dental infections).  

Antibiotic considerations for dental infections

• Pharmacists should review antibiotic prescriptions for dental indications;
• If an antibiotic is indicated, one of the following ‘Green (preferred) antibiotics’ (see antibioticprescribing.ie > community guidelines > preferred antibiotic use in community Green Red table) are recommended, the choice being dependent on the indication: phenoxymethylpenicillin, amoxicillin or metronidazole. These Green antibiotics are likely to be effective, have fewer adverse effects and less potential for AMR than ‘Red antibiotics’;
• In particular, the following ‘Red antibiotics’ are not recommended for the empiric treatment of dental infections as they do not offer any additional clinical benefit and are more likely to cause adverse effects and AMR: clindamycin, co-amoxiclav, ciprofloxacin and cephalosporins. To note, although use for all antibiotics carries a risk for Clostridioides difficile infection, these antibiotics carry a much higher risk;
• For the treatment of dental abscess, phenoxymethylpenicillin is the preferred option. It has a narrower spectrum of antimicrobial activity than amoxicillin but has equivalent efficacy for this indication. Amoxicillin should be reserved for patients where frequency of dosing proves adherence to be more challenging (for example in children);
• Refer to the relevant guideline in the ‘Dental infections’ section of ie (antibioticprescribing.ie > community guidelines > dental infections) for specific recommendations regarding antibiotics including choice, dose and duration and whether an antibiotic is indicated. A summary of guidance for antimicrobial prescribing for common dental conditions can be viewed at antibioticprescribing.ie > community guidelines > dental infections > antimicrobial prescribing in dentistry — summary guidance for common conditions in adults;
• Other considerations for pharmacists when presented with antibiotic prescriptions are allergy status, age and weight for children, drug-drug interactions, whether patient is pregnant or breastfeeding, has liver or renal impairment and previous antibiotic treatment; and
• Pharmacists should inform patients of potential side effects of the prescribed antibiotic and give clear information on dose, frequency, duration of course and how best to take antibiotics.

 

Managing dental pain

• Acute dental pain with facial or gingival swelling requires an urgent dental referral;
• Antibiotics are not needed for dental pain, which can be treated with analgesics or a dental procedure if appropriate;
• Pharmacists have an important role in advising on the general management of dental pain. Ibuprofen and paracetamol, once clinically appropriate for the patient, are first choice analgesics for dental pain. In the case of severe pain, ibuprofen and paracetamol may work better when taken in combination; and
• Weight-based dosing guidelines for paracetamol and ibuprofen are available for healthcare professionals in the ‘Prescribing for children’ section of ie (antibioticprescribing.ie > community guidelines > prescribing for children).

 

The role of oral antiseptics

• Regular use of mouthwashes with an antiseptic product (for example, chlorhexidine) may be considered in case of acute exacerbations of periodontal disease;
• Chlorhexidine mouthwash is recommended for short-term use only due to tooth-staining. Caution should be exercised with the use of chlorhexidine mouthwash in patients following extractions or treatment of alveolar osteitis (dry socket following dental extraction) as it has been associated with anaphylaxis;
• The use of mouthwashes should only be an adjunct to regular toothbrushing and interdental flossing; and
• Rinsing with saline (salty water) can help to maintain good oral hygiene.

 

Prevention is better than cure

Untreated tooth decay is the most common global health condition. Dental caries and periodontal disease are largely preventable. As the progression of dental caries and periodontal disease may continue slowly from childhood to adulthood, the negative health effects of oral disease are cumulative. Even a small reduction in risk factors early in life confers significant benefits in later life, decreasing the likelihood of the need for antibiotics for dental infections in the future. Certain groups of patients are more susceptible to dental problems: for example, people living with diabetes, immune compromise, xerostomia (dry mouth), physical or cognitive disabilities, older adults and pregnant women. Pharmacists have an important role in promoting good oral health. This includes promoting:

• Reduced sugar consumption: Dental caries do not occur without sugar, therefore minimising dietary free sugars is key to avoiding dental pain and infections caused by dental caries;
• Regular toothbrushing and interdental flossing: To prevent the accumulation of dental plaque which is important for preventing dental caries or periodontal disease. Flouride-containing toothpaste strengthens the tooth enamel making it more resistant to caries. Regular professional dental cleaning may be necessary to maintain oral health; and
• Smoking cessation: Stopping tobacco use, whether smoked or smokeless, should also be promoted for the prevention of periodontal disease and oral cancer.

The HSE has some useful information for looking after childrens’ teeth (www2.hse.ie/babies-children/parenting-advice/caring-for-a-child/looking-after-your-childs-teeth/).  

How pharmacists can promote AMS in dentistry

• Check antimicrobial prescriptions, paying particular attention to the indication for antibiotic need and choice of drug, dose and duration of treatment and drug-drug interactions;
• Support dentists to integrate and consider AMS in their day-to-day practice, including weighing up the risks and benefits of antibiotics for the patient;
• Promote use of the recommended guidance on ie;
• Support patients with optimal use of analgesics;
• Promote good oral hygiene;
• Manage patients’ perceptions, concerns, beliefs and expectations about antibiotics. A useful phrase is ‘Antibiotics do not cure toothache’; and
• Encourage patients to attend their dentist for dental problems and regular dental checks, including children.

 

Box 1: Findings from a study exploring Irish dentists’ views and experiences of antibiotic use and stewardship.

Authors: Cailín Napier¹, Charlotte Jennings¹, Aoife Fleming¹, Cristiane Da Mata², Mala Shah^1,3, Callum Ryan³, Teresa M. Barbosa¹

Affiliations: ¹School of Pharmacy, University College Cork; ²Cork University Dental School and Hospital, University College Cork; and ³HSE.

Summary:

• A mixed methods study was conducted in 2024, with an initial survey (79 responses) followed by qualitative interviews (n=12 dentists);
• The main reason for antibiotic use was abscess (42.3%, 33/78 always/often), and 14.9% would prescribe for dry socket (11/74 always/often). Occasional ‘Just in case’ prescribing was reported by 9.7% (7/72) and was also noted in the interview findings;
• Despite concerns about antimicrobial resistance, most felt antibiotics are overprescribed in dentistry (62/79, 78.4% agree/strongly agree), were more likely to prescribe under time pressure (70.9%, 56/79 agree/strongly agree);
• Amoxicillin was the most commonly prescribed antibiotic (86.1%, 68/79);
• While over half of the dentists had positive views on the antibiotic prescribing guidelines for dental infections on antibioticprescribing.ie (56.4%, 44/78 excellent and good), more than a quarter of the participants admitted never using these guidelines (28.2%, 22/78);
• Over 40% (32/78, 41%) of respondents reported they never calculate a weight-based antibiotic dose for a child;
• Many participants believe patients often expect antibiotics (74.7%, 59/79, agree/strongly agree);
• While dentists endorsed antibiotic use only when intervention is not feasible, factors impacting prescribing decisions included educational needs, guidelines, clinical complexity, limited general anaesthesia and patient expectations; and
• Dentists reported challenges with time pressure can impact on dental and antibiotic treatment decisions. Treatment decisions were also impacted by challenges in dental interventions and antibiotic compliance in children or those with special needs.

 

Implications for pharmacists:

• This study highlights the need for pharmacists to be familiar with the antibiotic treatment guidelines and raise awareness of guidelines with dental colleagues; and
• Addressing patient expectations for antibiotics for dental ailments and supporting reductions in just-in-case antibiotics are important ways pharmacists can support AMS.

 

Glossary of terminology

• Periodontal disease: Conditions that involve inflammation and infection of the tissues (gum and bone) that surround and support the teeth.
• Pulpitis: Inflammation of the dental pulp causing pain which often occurs as a result of the progression of dental caries.
• Dry socket (alveolar osteitis): An inflammatory complication of tooth extraction which may develop a few days after extraction, last for more than a week and is extremely painful.
• Pericoronitis: Inflammation of the gum tissue surrounding the crown of a partially erupted tooth.
• Trismus: Commonly known as lockjaw, a condition that causes painful spasms in your jaw muscles and restricts the ability to open the mouth fully.
• Abscess: Localised collection of pus caused by a bacterial infection in the tooth, gingivae (gums) or alveolar bone supporting the tooth.
• Apical abscess: Infection at the apex of the dental root originating from within the dental pulp. The most common form of dental abscess and usually results from untreated dental caries.
• Periodontal abscess: Where there is a collection of pus between the root and alveolar bone usually resulting from serious gum diseases.
• Necrotising periodontal disease (also known as necrotising ulcerative gingivitis): A severe gum infection characterised by necrosis and ulcerations caused by a bacterial infection and often accompanied by severe pain and a strongly unpleasant smell.
• Gingivitis: Inflammation of the gingivae (gums).