These guidelines were developed by the Dental Antibiotic Stewardship Working Group, which is a subgroup of the Primary Care Antimicrobial Guideline Expert Advisory Committee associated with the HSE Antimicrobial Resistance and Infection Control Team. The guidelines facilitate antimicrobial prescription in primary dental care to minimise patient adverse events and minimise antimicrobial resistance. The guidelines provided advice, taking account of best available evidence, on dental prescribing including BNF¹, BNFc² and the SDCEP Guidelines on Drug Prescribing in Dentistry³.
The following treatment options are meant as guidelines for prescribers, they do not replace clinical judgement but augment it. These prescribing guidelines have been developed after review of national and international guidelines and current practice, expert opinion, clinical consensus and published evidence where it exists. While the guidelines are primarily for use by dentists they may also be of benefit to GP’s where a patient presents with a dental infection.
Before prescribing antimicrobials clinicians should also consider the following:
- Previous antimicrobial treatment which has been prescribed for the current and previous infections
- The allergy status of the patient
- Concurrent medication that the patient is taking
- Patient’s medical history
There is emerging evidence of significant interactions between antibiotics, antifungals, and statins. Caution is advised when prescribing macrolides such as clarithromycin and erythromycin, metronidazole, fucidic acid and miconazole oral gel. Macrolides, antifungals such as miconazole (incl. Daktarin oral gel) and fucidic acid have shown adverse reactions with statins, such as a risk of myopathy.
- There are also emerging concerns about increased risk of bleeding where miconazole oral gel or metronidazole are prescribed for patients on anticoagulants.
- Co-amoxiclav, is not recommended for use in dentistry and has recently been associated with increased incidence of liver toxicity.
- See table on adverse drug interactions for current best guidance.
- It is important to recognise that antibiotics should be administered at the correct dose ie avoid underdosing or overdosing.
- Underdosing has been shown to be associated with increasing resistance. This is especially true of the Macrolides classes e.g.( erythromycins ).
- Overdosing may lead to toxicity issues.
Principles of Antimicrobial Treatment
- This guidance is based on the best available evidence, but its application must be tailored by professional judgement.
- A dose and duration of treatment is suggested
- Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
- The prescribing of clindamycin, cephalosporins or co-amoxiclav offers no advantage over a penicillin, metronidazole or a macrolide and is not recommended for the routine management of dental infections. The inappropriate use of these drugs can increase the risk of resistant strains and limit the future usefulness of these important agents 4
- Caution in prescribing practices is advised for patients who are pregnant, diabetic, with kidney disease or liver disease, who are on statins, warfarin and for very young children and the elderly or infirm.
- Antimicrobials prescription is only indicated as:
- An adjunct to the management of acute infection
- Where definitive treatment has to be delayed due to referral to a specialist/hospital 5,6
- There is no indication for antimicrobials in acute pulpitis where treatment with analgesics is more appropriate 1, 7, 8
- Antimicrobials are not indicated in endodontics unless there is evidence of significant local spread of infection or systemic infection. Antimicrobials should not be routinely prescribed post-operatively as research indicates that it does not reduce pain, swelling or the need for analgesics in symptomatic root filled teeth 9, 10
Dental Antibiotic Stewardship Working Group Membership
- Dr Sile O’Connor, Antimicrobial Pharmacist, University Hospital Kerry
- Dr P Creedon, Principal Dental Surgeon Wexford/Waterford, CHO Area 5
- Dr R Cunney, Consultant Microbiologist, HPSC (Chair)
- Dr N Galvin ANOHL Quality and Risk
- Ms J O’Brien, Primary Care Pharmacist, HSE DNE
- Dr M Ormsby, ANOHL Primary Care
- Ms M Shah, Antimicrobial Pharmacist, CUH
- Dr. Nuala O’Connor (Chair), ICGP Lead, HCAI AMR
How to write prescriptions: Dentists
Click here to view the page on how to write prescriptions
Visit HPSC Information Leaflets pages for the General Public, (MRSA, CRE, etc)
Reviewed Dec 2019