Critical dental infections might be excruciating, particularly when ache spreads from the mouth to the jaw, ear, and neck, or causes throat and facial swelling.
When dentists aren’t obtainable, many individuals with dental ache search care from major care suppliers, pressing care facilities, or emergency departments (EDs), which deal with practically 2 million circumstances of dental ache a 12 months in america.
Many of those individuals depart with a prescription for antibiotics and over-the-counter ache relievers. Though antibiotics can’t remedy a deep-rooted tooth an infection, they will present a “Band-Help” till individuals can see a dentist for definitive remedy, Lisa Dumkow, PharmD, a medical pharmacist at Trinity Well being Grand Rapids in Michigan, advised CIDRAP Information.
However antibiotics have to be chosen with care, in order that sufferers take the simplest treatment with the bottom danger of hurt. In a examine revealed late final week in Open Discussion board Infectious Illnesses, Dumkow and her colleagues discovered room for enchancment.
On the optimistic aspect, 75% of individuals with tooth ache obtained an antibiotic within the penicillin class, as really useful by the American Dental Affiliation (ADA), in accordance with the examine.
But practically 20% of individuals within the examine obtained clindamycin, an antibiotic that’s well-known for inflicting life-threatening infections from a pathogen known as Clostridioides difficile. The bacterium, also called C difficile, releases toxins that trigger extreme diarrhea and can destroy the liner of the gut.
A CIDRAP Information investigation revealed in February featured the story of Delores Hernandez Owens, 92, who died from a bowel an infection after her dentist prescribed clindamycin.
Clindamycin has carried a “black field” warning, the Meals and Drug Administration’s strongest warning, for no less than 4 a long time. ADA tips revealed in 2019 advocate different, safer antibiotics for individuals with critical dental infections. And in August, the ADA suggested clinicians to “keep away from clindamycin at any time when a safer different is accessible.”
Earlier than prescribing clindamycin, “it’s important to actually be in a scenario the place you possibly can’t use the rest,” Dumkow, the examine’s senior creator, stated.
Dumkow, whose examine included greater than 12,000 individuals throughout Michigan, stated she was upset to see clindamycin used so typically.
“Nearly all of sufferers didn’t want clindamycin,” Dumkow stated. “They may have gotten an alternate antibiotic.”
Penicillin allergic reactions can complicate care
Affected person medical data present that greater than 80% of individuals within the examine have been inspired to observe up with a dentist. Simply over half of examine contributors have been handled in pressing care clinics, with 40% handled within the ED and eight% seen by major care medical doctors.
In some circumstances, clinicians within the examine prescribed clindamycin as a result of sufferers had a reported allergy to penicillin.
But amongst sufferers who obtained an antibiotic aside from penicillin, 21% had no documented allergy or intolerance to penicillin, and 27% had solely a “gentle allergy or intolerance,” in accordance with the examine, which included individuals seen within the Trinity Well being Michigan Community from January 2020 via the top of August 2025.
Nearly all of sufferers didn’t want clindamycin.
Penicillin allergic reactions are much less frequent than individuals suppose.
Though 10% of individuals in america have a penicillin allergy listed on their medical chart, much less than 1% are literally allergic to the drug, in accordance with the Facilities for Illness Management and Prevention. Many individuals develop out of the allergy after just a few years. Others by no means had penicillin allergic reactions to start with.
Within the examine, the authors observe that 35% of sufferers handled with clindamycin had reported very minor reactions to penicillin or comparable antibiotics, akin to a light to average rash.
Dumkow encourages clinicians to attempt to perceive extra a few affected person’s potential allergic reactions earlier than prescribing clindamycin. Whereas formal allergy testing might be time-consuming, she stated clinicians can rapidly estimate an individual’s danger of an allergic response by asking 4 easy questions, akin to whether or not sufferers wanted medical remedy after experiencing a response to penicillin.
If sufferers reply “no” to all 4 questions, their danger of an allergic response is lower than 1%. In that case, clinicians can really feel secure giving the affected person one tablet and monitoring them for an hour, so long as they’ve drugs readily available to rapidly management any allergic reactions, she stated.
Clindamycin is shedding its efficiency
The examine underscores the significance of sharing ADA tips with different clinicians who may deal with dental ache, stated Erinne Kennedy, DDS, MPH, assistant dean for curriculum and studying at Kansas Metropolis Faculty of Dental Drugs in Missouri.
“This can be a actually nice article that helps us perceive the prescribing patterns that we’re seeing in emergency division visits,” stated Kennedy, who wasn’t concerned within the new examine.
Along with being riskier than penicillin, clindamycin additionally seems to be much less efficient, in accordance with the examine. About 5% of sufferers within the examine skilled “remedy failure,” through which they wanted a unique antibiotic or a further prescription for a similar antibiotic inside 30 days.
Clindamycin had an 11% danger of remedy failure, the best of any antibiotic within the examine.
Dumkow stated she has already shared the examine together with her well being system’s pressing care suppliers, to assist educate them about the perfect antibiotics to prescribe.
“It is highly effective to say, ‘These are your information and your sufferers are six instances extra prone to fail remedy if you happen to prescribe clindamycin,’ and ‘This is how we work via allergic reactions and what we must always use as a substitute,’” she stated.
The examine’s outcomes are much like a report of antibiotic effectiveness based mostly on bacterial samples from dental sufferers in Kansas, Kennedy stated.
In that evaluation, antibiotics within the penicillin class have been far more efficient at killing oral micro organism than clindamycin. Scientists carry out such analyses to gauge whether or not micro organism are evolving to turn out to be impervious to antibiotics.
These are your information, and your sufferers are six instances extra prone to fail remedy if you happen to prescribe clindamycin.
To cut back the danger that micro organism will turn out to be tougher to kill, the ADA advises dentists to prescribe antibiotics sparingly, akin to when tooth ache is accompanied by a fever, chills, or different indicators of a wider inhey stay in a rural space or lack transportation, Kennedy stated.fection. Dentists can even prescribe antibiotics when sufferers can’t see a dentist immediately, akin to as a result of t
Did antibiotics fail? Or did the well being system?
Some specialists say it’s not truthful to conclude that antibiotics “failed” to deal with a affected person’s dental an infection.
That’s as a result of dental antibiotics aren’t the first remedy for tooth ache, stated Thomas Paumier, DDS, ADA president. The one method to remedy a dental an infection is thru a process in a dentist’s workplace that removes contaminated tissue.
“The proper remedy is a dental process, akin to a root canal, which they aren’t doing in an urgent-care settings,” stated Debra Goff PharmD, professor of pharmacy observe at The Ohio State College Faculty of Pharmacy, who wasn’t concerned within the new examine. “Antibiotics are the Band-Help till definitive dental care might be given.”
If a affected person with tooth ache returns to the ED inside a month, the true drawback is that the particular person hasn’t seen a dentist, Paumier stated.
Many individuals included within the analysis could have confronted such obstacles, Dumkow stated.
About 38% of individuals within the examine had no medical health insurance, and 27% have been lined by Medicaid, the federal government medical health insurance program for individuals with low incomes or disabilities. Even individuals with dental insurance coverage could not have protection for the invasive procedures typically wanted to deal with deep tooth infections, akin to extractions or root canals. Some dental specialists don’t settle for insurance coverage in any respect. Dentists cost from $1,500 to $3,500 for a root canal and a crown, which is required to cowl the previously contaminated space.
A technique to assist sufferers in ache is to make it possible for physicians have an inventory of dentists who’re prepared to deal with sufferers with dental infections promptly, Erinne Kennedy stated.
“We work actually carefully with our emergency division,” Kennedy stated. “We not solely settle for referrals, however we ship sufferers to them who want emergency care.”
