Local dental treatment alone provides effective management for odontogenic infections in general dental practice. Antibiotics should be reserved for use where there are clear signs of systemic infection to help combat antimicrobial resistance (AMR). Studies suggest that there is a high level of inappropriate prescribing in dental practice together with the prescription of longer courses of antibiotics than necessary. Shorter courses may reduce cost, adverse effects, and AMR.
The objective of this review was to identify and evaluate published evidence assessing the effect of short-duration (3–5 days) compared with longer-duration (≥7 days) courses of antibiotics used for the treatment of dental infections in general practice or outpatient clinics.
Methods
The authors registered a protocol for the review on PROSPERO. Searches were undertaken in the Cochrane Library, Medline, Embase, Google Scholar, ClinicalTrials.gov and the WHO International Trials Registry Platform. Randomised controlled trials (RCTs) and non-randomised studies of antibiotic usage and regime in health adults (>18 years) human having outpatient treatments for dental infections and published in English were considered. Two reviewers screened and selected studies and extracted data. Studies were appraised independently by two reviewers using the Joanna Briggs Institute (JBI) tool for assessing risk of bias in RCTs. A narrative synthesis was planned with risk ratios (RR) and 95% confidence intervals (CI) calculated for dichotomous outcomes and mean difference (MD) with 95% CI for continuous outcomes. It was also planned to use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess the quality of evidence.
Results
- One RCT considered to be at low risk of bias and involving a total of 81 patients was included.
- The trail compared a 3-day course of amoxicillin versus 7- days for an odontogenic infection requiring tooth extraction.
- There was no significant difference between groups in terms of participant-reported pain or clinical assessment of wound healing.
Conclusions
The authors concluded: –
a clinical audit of 188 patients with dental infection and signs of systemic involvement treated by abscess drainage and a three-day antibiotic regime demonstrated no adverse effect. No robust evidence in the form of RCTs supporting durations of antibiotic treatment for dental infections within current national guidelines was found. Further research in this area is required to inform guidelines and provide evidence to support more consistent practice. Exploring a move to shorter duration of treatment has potential benefits for patients and for tackling the threat of AMR.
Comments
The authors provided a protocol for the review on PROSPERO and have searched a good range of databases. They have restricted inclusion to publication in English which may have excluded some relevant papers. Only one small RCTs (Chardin et al., 2009) met the inclusion criteria with no significant differences being reported between 3- and 7- day course of amoxicillin during which a tooth was extracted. The trial was considered to be at low risk of bias. In the results section the review authors also discuss 3 other studies which they had previously excluded supportive of shorter courses as well as an audit of 188 patients. While these studies may be of interest, they did not meet the criteria for the review and should only be considered very cautiously as they are likely to be of very low certainty. It should also be pointed out that in their concluding paragraph the review authors reference to the clinical audit of 188 patients which is technically not part of the review so should not be included there. Clearly high quality well conducted and reported RCTs of suitable size would be required to confirm a difference between different length antibiotic courses for dental infections.
Links
Primary Paper
Cooper L, Stankiewicz N, Sneddon J, Smith A, Seaton RA. Optimum length of treatment with systemic antibiotics in adults with dental infections: a systematic review. Evid Based Dent. 2022 Sep 7. doi: 10.1038/s41432-022-0801-6. Epub ahead of print. PMID: 36071280.
Other references
Chardin H, Yasukawa K, Nouacer N, Plainvert C, Aucouturier P, Ergani A, Descroix V, Toledo-Arenas R, Azerad J, Bouvet A. Reduced susceptibility to amoxicillin of oral streptococci following amoxicillin exposure. J Med Microbiol. 2009 Aug;58(Pt 8):1092-1097. doi: 10.1099/jmm.0.010207-0. Epub 2009 Jun 15. PMID: 19528154.
