Dental pain and antibiotics

Editor – As a dental surgeon, I was so pleased to read this informative article¹ aimed at GPs. I have had too many patients over the years who have been prescribed antibiotics by their GP when this was contraindicated. Patients presenting to a general practice with dental pain should be immediately referred to a dental surgeon. GPs should be reminded that oral and maxillofacial surgeons are available to treat severe cases.

Patients might refrain from seeking appropriate dental treatment once they have been prescribed antibiotics by their GP. This delay in seeing a dentist often leads to greater damage and loss of dentition. Ultimately this can have a big impact on the patient later in life because of reduced dental function and often reduced socialisation.

Gerard Little
Dental surgeon, Toowoomba, Qld

Editor – I listened to the podcast reviewing the latest Therapeutic Guidelines: Oral and dental. I was particularly interested in the patient with dull toothache with no trigger stimulus, provisionally diagnosed as a suspected infected root canal in the absence of both systemic features and facial swelling but unable to see a dentist within 24 hours. The guidelines advise that it is reasonable to prescribe antibiotics in these circumstances along with urgent referral to a dentist. I would comment that this is possibly not within the dental guidelines of antimicrobial stewardship. Your article on the management of dental pain in primary care¹ clearly states the contrary and recommends analgesics would be more appropriate. It states that ‘antibiotics are only indicated as an adjunct to dental treatment when there are signs of systemic involvement, progressive and rapid spread of infection, or when the patient is immunocompromised’.

Beng Lee
General dentist, Private general dental practice, Epping, Sydney

Aovana Timmerman and Peter Parashos, the authors of the article, comment:

We completely agree with Dr Little’s comments. In a medical setting, if the antibiotic prescription is perceived as necessary to help resolve the dental problem (usually due to a spreading infection), then patients should be clearly advised that they need to urgently attend their dentist for definitive treatment. In these circumstances, patients should not wait until they have completed the course of antibiotics before going to their dentist.

In regards to Dr Lee’s comments, if a patient presents with dental pain and the cause is suspected to be root canal infection in the absence of systemic involvement and facial swelling, we would recommend the GP only prescribe analgesics appropriate to the level of pain being experienced,² and refer the patient promptly to a dentist for diagnosis and management.

As mentioned in our article, antibiotics may be recommended as an adjunct to dental treatment, but only in specific situations. Although the Therapeutic Guidelines specify that antibiotics may be considered in some circumstances if the patient cannot see a dentist within 24 hours, there is no evidence to support this timeframe. Also, there is a risk that the patient will rely on the antibiotic prescription rather than seeking urgent dental care.