Do emergency departments overprescribe antibiotics?

2016 09 27 16 12 55 970 Woman Pain2 400

Emergency department physicians may be overprescribing antibiotics for dental pain, according to a new review by two emergency physicians. Antibiotics don't help some types of dental pain commonly seen in emergency rooms, the authors found.

Michael Gottlieb, MD, practices in emergency medicine in Chicago.Michael Gottlieb, MD, practices in emergency medicine in Chicago.

Study authors Michael Gottlieb, MD, and Basem Khishfe, MD, work in the emergency department at two Chicago hospitals, Rush University Medical Center and Mount Sinai Hospital. They recognized that medical providers are trained to use antibiotics to treat acute dental pain when other signs of infection are not present. These physicians wanted to know if evidence proved antibiotics were effective in these cases (Annals of Emergency Medicine, October 5, 2016).

"As an emergency physician, I frequently treat patients with acute and chronic atraumatic dental pain. When I was in training, it was common to indiscriminately prescribe antibiotics to all patients presenting with dental pain," Dr. Gottlieb wrote in an email to "However, there was never any evidence provided to justify the practice and prescribing antibiotics does carry risks."

What does the evidence point to?

Antibiotic overuse and misuse are contributing to antibiotic resistance, a "quickly growing, extremely dangerous problem," according the U.S. Centers for Disease Control and Prevention (CDC). The CDC recommends providers prescribe antibiotics in the correct dose and duration, and only when it is likely to benefit a patient. Nevertheless, many patients who visit an emergency department for acute dental pain are prescribed antibiotics without any obvious signs of infection, such as fever, intraoral or extraoral swelling, purulence, or trismus.

"Atraumatic acute dental conditions account for 1.4% of all emergency department visits, with a 4% annual rate of increase between 1997 and 2007," the study authors wrote. "Dental pain without overt infection is common, with irreversible pulpitis being a significant subset of this population."

Therefore, they decided to review existing evidence to see if antibiotics adequately treated acute pain, like that caused by pulpitis.

Drs. Gottlieb and Khishfe searched PubMed for studies related to antibiotic use and dental pain without obvious infection. After limiting their findings to original, primary research articles, they ended up with two studies, one from 2000 (Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, November 2000, Vol. 90:5, pp. 636-640) and another from 2004 (Academic Emergency Medicine, December 2004, Vol. 11:12, pp. 1268-1271).

Both studies were randomized, double-blind, placebo-controlled trials that compared the effectiveness of 500 mg of penicillin to a placebo. However, neither found penicillin reduced patient pain or the amount of analgesic medications patients took.

Comparison of studies
Study Cohort Invention group Control group Finding
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology 2000 40 patients with irreversible pulpitis 20 patients took 500 mg of penicillin four times per day for one week. 20 patients took lactose for one week. Penicillin did not significantly reduce pain or the number of analgesic medications taken.
Academic Emergency Medicine, December 2004 195 patients with acute dental pain but no obvious infection (only 134 patients followed up) 98 patients took 500 mg of penicillin four times per day for one week. 97 patients took a placebo for one week. Penicillin did not significantly reduce pain, the number of analgesic medications taken, or number of adverse effects.

"Neither study demonstrated a clinically or statistically significant difference in pain with the use of antibiotics," the authors wrote. "Additionally, there was no significant reduction in the rate of infection in patients receiving antibiotics compared with placebo in the single study assessing this outcome."

However, because of the limited number of studies on this topic, the authors couldn't make their findings a definite conclusion.

"There is limited evidence in favor of the prescription of antibiotics for acute nonspecific dental pain," Dr. Gottlieb said. "However, it is equally important to realize that there is limited data against this practice and that one must weigh the available evidence and make their own decision based upon the available information."

Why aren't there more studies on this topic?

The most obvious shortcomings of the paper are that only two studies were included in the review, and both studies were more than 10 years old. A special note from the Annals of Emergency Medicine editor that accompanied the study points out that this review is part of a series in which there is a "sufficient literature base to draw a reasonable conclusion but not such a large literature base that a traditional 'evidence-based' review, meta-analysis, or systematic review can be performed."

“There is limited evidence in favor of the prescription of antibiotics for acute nonspecific dental pain”
— Michael Gottlieb, MD

"Unfortunately, these types of studies are rare in the literature for a number of reasons," noted Dr. Gottlieb, citing reasons such as lack of funding, the challenge of getting follow-up data, and not producing the same level of excitement as other topics.

Nevertheless, the two studies included in the review did have merit, including accounting for clinical and patient-centered outcomes, using a common treatment, and having trials with scientific rigor.

While Dr. Gottlieb will not be continuing this research in the future (he'll be returning to his primary academic interest of ultrasound and medical education), he hopes dentists and emergency physicians can work together in the future to determine the best standard of care for patients.

"I would love to see more collaborative studies between emergency physicians and dentists," he stated. "We often see different aspects of the same patient population, and it would be beneficial to combine both aspects of the patient care continuum. This could be particularly valuable for performing larger studies on the efficacy of antibiotics in acute dental pain."

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