Would you recommend additional antibiotics for a patient with a cracked tooth who had initial improvement with penicillin and return of pain after completion of the course?

From the Guidelines

I would not recommend additional antibiotics for a patient with a cracked tooth who had initial improvement with penicillin but experienced return of pain after completing the course. The patient's symptoms, such as inability to bite down, chew food on the right side, and pain radiating to the bottom jaw, suggest that the underlying structural issue with the tooth remains unresolved. According to the European Society of Endodontology guidelines 1, surgical drainage is key for acute apical abscesses, and adjunctive antibiotics are only recommended in specific patient groups, such as medically compromised patients or those with systemic involvement. In this case, the patient's improvement with penicillin and subsequent return of pain after completion of the course likely indicates that the infection was initially managed, but the structural problem with the tooth persists. Key points to consider include:

• The patient needs definitive dental treatment to address the underlying structural problem 1.
• Antibiotics are only appropriate for managing active infections, not for pain control alone 1.
• Continued antibiotic use without addressing the cracked tooth could lead to antibiotic resistance while failing to resolve the problem 1. The patient should be referred to a dentist urgently for proper evaluation and treatment, which may include root canal therapy, crown placement, or extraction depending on the extent of the crack. For pain management until dental treatment, over-the-counter analgesics like ibuprofen (400-600mg every 6 hours) or acetaminophen (500-1000mg every 6 hours) would be more appropriate than additional antibiotics 1.

From the Research

Patient Presentation and History

• The patient presents with dental pain on the right upper side, which started after a cracked tooth.
• The patient had visited the ER 2 weeks ago and was prescribed penicillin, which led to initial improvement in pain.
• However, the pain returned after completing the antibiotic course.
• The patient reports inability to bite down, chew food on the right side, and pain radiating to the bottom jaw.
• The patient has been using NSAIDs and Orajel for approximately 2 weeks, with no fevers reported.

Antibiotic Prophylaxis in Dental Procedures

• A study published in 2021 2 found that prophylactic antibiotics may reduce the risk of postsurgical infectious complications and dry socket in patients undergoing third molar extractions.
• However, the study noted that the evidence is limited to healthy patients undergoing extraction of impacted third molars, and the results may not be generalizable to all patients undergoing tooth extractions.
• Another study published in 2007 3 found that the use of preoperative antibiotic prophylaxis in dental extraction or implant placement is limited and of poor quality, with small sample sizes and insufficient statistical power.

Antibiotic Prescription Patterns

• A retrospective cohort study published in 2022 4 found that dentists did not discriminate prophylactic antibiotic prescription with regard to endocarditis risk status, and the number of extracted teeth was a factor influencing prescribing behavior.
• A systematic review published in 2017 5 found no relevant randomized controlled trials to determine the effectiveness of systemic antibiotic prophylaxis in preventing local complications after tooth extraction, excluding third molars.

Considerations for Additional Antibiotics

• Given the patient's initial improvement with penicillin and return of pain after completion of the course, it is unclear whether additional antibiotics would be beneficial.
• The patient's symptoms, such as inability to bite down and chew food on the right side, and pain radiating to the bottom jaw, suggest a possible infection or other complication that may require further evaluation and treatment.
• However, the limited evidence on antibiotic prophylaxis in dental procedures and the potential risks of antibiotic overuse must be considered when deciding whether to prescribe additional antibiotics 2, 3, 4, 5.