Are antibiotics prescribed after dental extraction?

From the Guidelines

Antibiotics are only recommended before and after invasive dental procedures, such as dental extraction, in patients considered to be at higher risk for osteoradionecrosis (ORN) due to prior radiation therapy encompassing the mandible and/or maxilla at the site(s) of planned dental intervention. This is based on the most recent evidence from the Journal of Clinical Oncology 1.

Key Considerations

• The use of antibiotics in patients at risk for ORN is supported by an informal consensus with low weak evidence 1.
• Patients at risk for ORN should receive oral antibiotics before and after invasive dental procedures 1.
• The specific antibiotic regimen is not specified in the guidelines, but common options for dental procedures include amoxicillin or clindamycin for patients allergic to penicillin.
• It is essential to weigh the benefits of antibiotic use against the risks of antibiotic resistance and potential side effects.

Prevention of ORN

• Prior to finalizing dental treatment plans in patients with a history of head and neck radiation therapy, a review of the radiation therapy plan should be performed 1.
• Alternatives to dental extraction, such as root canal or crown, should be offered unless the patient has recurrent infections, intractable pain, or other symptoms that cannot be alleviated without extraction 1.
• Patients at risk for ORN should be instructed to use prescription-strength topical fluoride applied to the teeth daily to reduce the risk of postradiation caries 1.

Management of ORN

• Pentoxifylline and tocopherol may be prescribed for at least 1 week before and 4 weeks after invasive dental procedures in cancer-free patients at elevated risk for ORN 1.
• Routine use of prophylactic hyperbaric oxygen therapy prior to dental extractions in patients who received prior head and neck radiation therapy is not recommended 1.

From the Research

Antibiotics after Dental Extraction

• The use of antibiotics after dental extraction is a common practice to prevent complications due to infection 2.
• A study published in 2021 found that antibiotics may reduce the risk of postsurgical infectious complications in patients undergoing third molar extractions by approximately 66% 2.
• The same study found that antibiotics may also reduce the risk of dry socket by 34% 2.
• However, the evidence for other outcomes such as pain, fever, and adverse effects is uncertain 2.

Types of Antibiotics

• Penicillin V is considered the antimicrobial of choice for the initial empirical treatment of odontogenic infections 3.
• Amoxicillin is recommended for endocarditis prophylaxis, but has little indication for the routine treatment of odontogenic infections 3.
• Clindamycin is effective against all odontogenic pathogens, but its potential gastrointestinal toxicity limits its use to third- or fourth-line therapy 3.
• Metronidazole is effective against anaerobic gram-negative bacilli, but should not be used alone in the treatment of acute odontogenic infections 3.

Antibiotic Prophylaxis

• A review of the literature found that the use of preoperative antibiotic prophylaxis among children and adults undergoing dental extraction or implant placement is limited and of poor quality 4.
• The review found that sample sizes were small and provided insufficient statistical power to avoid type II errors 4.
• Another study found that clindamycin alone and combination of penicillin with metronidazole are both effective pharmaceutical regimens for severe odontogenic infections 5.

Considerations

• The increasing prevalence of bacteria resistant to antibiotic treatment requires clinicians to evaluate the need for prophylactic antibiotic therapy before a dental extraction for each patient on the basis of their clinical conditions and level of risk from infective complications 2.
• Immunocompromised patients require an individualized approach in consultation with their treating medical specialist 2.