What are the guidelines for analgesic, antibiotic, antifungal, and antimicrobial prescriptions for dentists in Canada?

Guidelines for Analgesic, Antibiotic, Antifungal, and Antimicrobial Prescriptions for Dentists in Canada

Antibiotic Prescribing: Surgery First, Antibiotics Second

Surgical intervention (root canal therapy, extraction, or incision and drainage) is the primary treatment for dental infections, and antibiotics should NOT be prescribed as a substitute for proper surgical management. 1, 2

When Antibiotics Are NOT Indicated

• Do not prescribe antibiotics for acute apical periodontitis or acute apical abscesses when surgical drainage is feasible 1
• Do not prescribe antibiotics for irreversible pulpitis 1
• Do not prescribe antibiotics for chronic periodontitis or peri-implantitis 1
• Do not prescribe antibiotics for acute dental abscesses—treatment is surgical only (root canal therapy or extraction) 1

When Antibiotics ARE Indicated

Prescribe antibiotics only when:

• Systemic involvement is present: fever, malaise, lymphadenopathy, or cellulitis 1, 2
• Patient is medically compromised (immunocompromised, diabetes, cardiac conditions requiring prophylaxis) 1, 2
• Diffuse swelling that cannot be adequately drained 1, 2
• Progressive infection extending into cervicofacial tissues or facial spaces 1, 2
• Failure to respond to surgical treatment alone 1

Antibiotic Selection for Dental Infections

First-line choice:

• Amoxicillin for 5 days following incision and drainage for acute dentoalveolar abscesses 1
• Phenoxymethylpenicillin (Penicillin V) for medically compromised patients or those with systemic involvement 1

Important caveat: The Canadian Collaboration on Clinical Practice Guidelines in Dentistry (2004) states that no specific antibiotic can be recommended over another when antibiotics are indicated 1. However, the WHO guidelines and Médecins Sans Frontières support amoxicillin as first-line 1.

Special Consideration: Chronic Periodontitis

• Sub-antimicrobial dose doxycycline (20 mg twice daily for 3-9 months) may be used as an adjunct to scaling and root planning for chronic periodontitis 1
• This is the ONLY indication where antimicrobials have demonstrated benefit in chronic periodontal disease 1

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Analgesic Prescribing: NSAIDs Are Superior

NSAIDs (particularly ibuprofen) provide superior pain relief for moderate to severe dental pain compared to acetaminophen-opioid combinations and should be the first-line analgesic. 3, 4

First-Line Analgesic Strategy

• Ibuprofen is the preferred first-line analgesic for dental pain due to its anti-inflammatory and analgesic properties 3, 4
• Prescribe on a fixed schedule (not "as needed") to maintain therapeutic levels and prevent breakthrough pain 4
• Standard dosing: 400-600 mg every 6 hours 3, 4

Second-Line and Combination Strategies

• Acetaminophen 500-1000 mg can be used if NSAIDs are contraindicated (provides analgesia but minimal anti-inflammatory effect) 3, 4
• Combination therapy: Acetaminophen + ibuprofen provides superior pain relief compared to either agent alone 5
  • Acetaminophen 500 mg + ibuprofen 150 mg every 6 hours demonstrated significantly lower pain scores (P<0.01) 5
• Acetaminophen-opioid combinations (codeine, hydrocodone, oxycodone with 600-1000 mg acetaminophen) should be reserved for patients who cannot tolerate NSAIDs 4

Opioid Prescribing

• Reserve opioids for severe pain only due to significant side effects 3
• Most commonly used: codeine in combination with acetaminophen 3
• Opioids should be prescribed on a fixed schedule, not "as needed" 4

Temporomandibular Disorder (TMD) Pain

• NSAIDs are recommended as first-line pharmacotherapy 1
• Neuromodulatory medications (amitriptyline, gabapentin) may be considered for chronic TMD pain 1
• Paracetamol (acetaminophen) is listed as an option but NSAIDs are preferred 1

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Antifungal Prescribing: Limited Dental Indications

Antifungal prescriptions in dentistry are primarily for oral candidiasis and should follow standard systemic antifungal guidelines.

Fluconazole Considerations

• Fluconazole is a commonly used systemic antifungal for oral candidiasis 6
• Drug interactions: Fluconazole is a moderate CYP3A4 inhibitor and has significant interactions with multiple medications including statins, oral contraceptives, warfarin, and many others 6
• Ibuprofen interaction: Fluconazole combined with ibuprofen has demonstrated synergistic antifungal activity in vitro against some Candida species, though clinical significance is unclear 7

Azithromycin Note

• While azithromycin is an antibiotic, it showed better pain reduction than amoxicillin/clavulanic acid in one study of apical abscesses, though no difference in infection resolution 1
• Azithromycin has multiple drug interactions and should be used cautiously 8

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Infection Control Practices

All dental procedures must follow strict infection control protocols to prevent cross-contamination and healthcare-associated infections. 1

Essential Infection Control Measures

• Gloves must be worn for all procedures with potential blood or saliva contact; change between patients 1
• Hand washing before and after each patient (before glove placement and after removal) 1
• Surgical masks and protective eyewear when splashing or spattering is likely 1
• Protective clothing changed daily or when visibly soiled 1
• Never recap needles using both hands; use one-handed scoop technique or mechanical device 1
• Antimicrobial surgical handscrub for surgical procedures (plain soap adequate for routine procedures) 1

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Common Pitfalls to Avoid

• Never prescribe antibiotics without surgical intervention—this is ineffective and contributes to antimicrobial resistance 1, 2
• Never prescribe analgesics "as needed"—fixed dosing schedules prevent breakthrough pain 4
• Never use opioids as first-line—NSAIDs provide superior pain relief for dental pain 3, 4
• Never prescribe antibiotics for irreversible pulpitis—definitive dental treatment is required 1
• Never ignore drug interactions when prescribing fluconazole or azithromycin—review patient medications carefully 8, 6