Bacterial infections

Prolonged courses of antibiotic treatment can encourage the development of drug resistance and therefore the prescribing of antibiotics must be kept to a minimum and used only when there is a clear need.

The emergence and spread of antibiotic resistance is a global concern and is a major threat to public health. The indiscriminate use of antimicrobials in primary care, including dentistry, has been identified as one of the drivers of antibiotic resistance. Dental antimicrobial prescribing in Scotland has been increasing year on year and although in 2013/14 there was a 5.5% reduction in items dispensed compared to the previous year, dental prescriptions still accounted for almost 9% of all oral antibacterials dispensed in NHS primary care. It has been estimated from clinical audit that around 50% of dental prescriptions for antibacterials are inappropriate.  Prudent, appropriate use of antibacterials will slow the emergence of bacterial resistance and will preserve the usefulness of existing drugs for future generations.

The use of broad-spectrum antibiotics has also been associated with the rise in Clostridium difficile - associated disease observed in both primary and secondary care. Care should therefore be taken when prescribing these antibiotics to vulnerable groups, such as the elderly and those with a history of gastrointestinal disease, including those using proton pump inhibitor (PPI) drugs for dyspepsia and gastro-oesophageal reflux diseases.

As a first step in the treatment of bacterial infections, use local measures. For example, drain pus if present in dental abscesses by extraction of the tooth or through the root canals, and attempt to drain any soft-tissue pus by incision. However, do not attempt to drain a cellulitis-type swelling.

Antibiotics are only appropriate for oral infections where there is evidence of spreading infection (cellulitis, lymph node involvement, swelling) or systemic involvement (fever, malaise). In addition, other indications for antibiotics are cases of necrotising ulcerative gingivitis or pericoronitis where there is systemic involvement or persistent swelling despite local treatment. Antibiotics are also appropriate for sinusitis where there are persistent symptoms and purulent discharge lasting at least seven days or where symptoms are severe. Use antibiotics in conjunction with, and not as an alternative to, local measures.

Note that patients who have recently taken a course of antibiotics (within the preceding six weeks) have an increased risk of harbouring bacteria resistant to that drug and should therefore be prescribed an alternative. Where there is significant trismus floor-of-mouth swelling or difficulty breathing, transfer patients to hospital as an emergency.

There is no evidence to support the prescription of antibiotics for the treatment of pulpitis or the prevention of dry socket in patients undergoing non-surgical dental extractions. Dental pain arising from these conditions is due primarily to an inflammatory response which should be managed by the appropriate use of analgesics and local measures. Antibiotics should not be used as prophylactic prescriptions to prevent infections after a routine dental surgical procedure.

Before prescribing antibiotics, refer to the BNF and BNFC for drug interactions (available at www.medicinescomplete.com). Advise patients to space out doses as much as possible throughout the day. Review patients with bacterial infections who have been treated with local measures or who have received a course of antibiotic treatment within 2 to 7 days.