Introduction
The word "pharmacology" is derived from Greek φάρμακον, pharmakon, "drug, poison, (paranormal)|-λογία, -logia "study of", "knowledge of". Pharmacology is a branch of medicine and pharmaceutical sciences which is concerned with the study of drug or medication action, where a drug can be broadly or narrowly defined as any man-made, natural, or endogenous (from within the body) molecule which exerts a biochemical or physiological effect on the cell, tissue, organ, or organism (sometimes the word pharmacon is used as a term to encompass these endogenous and exogenous bioactive species). More specifically, it is the study of the interactions that occur between a living organism and chemicals that affect normal or abnormal biochemical function. If substances have medicinal properties, they are considered pharmaceuticals.1
Pharmacotherapeutics is the achievement of the desired therapeutic goal from the drug therapy. It is the clinical purpose and indication of giving a drug.
The two most cited oral health related reasons for a patient contacting an emergency department (ED) or the dental providers are dental pain and intraoral swelling. 2, 3 These signs and symptoms are associated with pulpal and periapical conditions, which usually result from caries. Bacteria associated with caries can cause symptomatic irreversible pulpitis (SIP), an inflammation of the pulpal tissue. This condition may manifest as occasional sharp pain, usually stimulated by temperature change, and can worsen to spontaneous, constant, and dull or severe pain. Progressive pulp inflammation in the apical region (that is, symptomatic apical periodontitis [SAP]) may result in necrotic pulp (that is, pulp necrosis and symptomatic apical periodontitis [PN-SAP]). The infection can continue to move into and through the alveolar bone to the soft tissues surrounding the jaw (that is, localized acute apical abscess).
Depending on location and patient status, this can further develop into systemic infection (Table 1).4, 5 Dentists and physicians often prescribe antibiotics to relieve dental pain and intraoral swelling. General and specialty dentists are the third highest prescribers of antibiotics in all outpatient settings in the United States.6 In addition, reports from 2017 through 2019 suggest that 30% through 85% of dental antibiotic prescriptions are “suboptimal or not indicated.” 7, 8, 9.
Two major concerns with the medications are Drug resistance and over the counter medications.
Drug Resistance
Drug resistance is the reduction in effectiveness of a medication such as an antimicrobial or an antineoplastic in treating a disease or condition.
Over the counter medication (OTC)
It refers to the medicines sold directly to a consumer without a requirement for a prescription from a healthcare professional, as opposed to prescription drugs, which may be supplied only to consumers possessing a valid prescription.
To overcome these issues with the medications, the World Health Organization (WHO) implemented a global action plan to tackle the growing problem of resistance to antibiotics and other antimicrobial medicines at the Sixty-eighth World Health Assembly in May 2015. The theme of the campaign, “Antibiotics: Handle with Care,” reflected the overarching message that antibiotics are a precious resource and physicians should exercise caution with their use.10 Inappropriate and over prescription of antibiotics among dental practitioners is a major concern and have been identified as chief factors in the emergence of antibiotic-resistant microbial strains. Judicious use of antimicrobials by choosing the right drug, the standard dosage, and regimen for the appropriate duration should be a priority besides requesting for a culture and sensitivity test.
Evidence suggests that antibiotics for the target conditions may provide negligible benefits and probably contribute to large harms. The expert panel suggests that antibiotics for target conditions be used only when systemic involvement is present and that immediate DCDT should be prioritized in all cases.
As clinicians, it is also imperative for us to understand the concept of polypharmacy and its implications on oral and systemic health. Polypharmacy, the use of four or more medications by a patient, with co-existing diseases is most common in the elderly. It is often associated with a decreased quality of life, as a consequence of drug effects, interactions, and prescription cascade. Prescription cascade refers to the process whereby the side-effects of drugs are misdiagnosed as symptoms of another problem resulting in further prescriptions and further side-effects.
Elderly dental patients may present with complaints such as dry mouth, loss of taste, pigmentation or drug induced lichenoid lesions, and hyperplasias of the oral cavity. A thorough medical history and knowledge of the prescription they are following as well as regular reviews are recommended to determine the appropriateness of all medications.
Although a number of countries and clinical practice guideline development groups have produced recommendations on the use of systemic antibiotics to treat pulpal and periapical infections there are no guidelines from the American Dental Association (ADA) for dentists. 11, 12, 13, 14 Based on the WHO directions, many national and international agencies, including the US federal government and Center for Disease Control and Prevention, have joined forces with the ADA to help prevent a postantibiotic era in which antibiotics will no longer be effective in treating bacterial infections. 15, 16, 17, 18, 19 The ADA Council on Scientific Affairs convened an expert panel of academic and clinical experts specializing in dentistry, medicine, and pharmacology to develop this guideline and its accompanying systematic review. 20 The ADA Center for Evidence-Based Dentistry (EBD) provided methodological support, and drafted manuscripts on the same.
Table 1
Pulpal and periapical target conditions and their clinical signs and symptoms
Table 2
Recommendations as per the clinical situation based on availability of DCDT
Scope, Purpose, and Target Audience
These guidelines focus primarily on Immunocompetent adult patients (18 years or older) with the target conditions and without additional comorbidities. Immunocompetent is defined as the ability of the body to mount an appropriate immune response to an infection. Immunocompromised patients do not meet the criteria for this recommendation, and they can include, but are not limited to, patients with HIV with an AIDS-defining opportunistic illness, cancer, organ or stem cell transplants, and autoimmune conditions on immunosuppressive drugs.21, 22, 23
The patients with co morbidities or other systemic illnesses require a different protocol. Although these recommendations are intended primarily for use by general dentists, they also may be used by specialty dentists, dental educators, emergency and primary care physicians, infectious disease specialists, physician assistants, nurse practitioners, pharmacists, and policy makers. These recommendations also might be discussed during chairside conversations with patients (Table 2)
Recommendations
The ADA expert panel suggests prescribing antibiotics for Immunocompetent adult patients (patients with an ability to respond to a bacterial challenge) with PN-LAAA in settings in which DCDT is not available. This recommendation is specific to situations in which the risk of experiencing systemic involvement is high and a patient may lack immediate access to care. The expert panel suggests not prescribing antibiotics for Immunocompetent adult patients with SIP with or without SAP, PN-SAP, or PN-LAAA in settings in which DCDT is available owning to potentially negligible benefits and likely large harms associated with their use.
The type of antibiotic chosen and its dosing regimen are dependent upon the severity of infection and the predominant type of causative bacteria. Amoxicillin is recommended for dental infections in doses ranging from 250 mg to 500 mg, every 8 hours 24. The use of 3 g amoxicillin repeated after 8 hours is also mentioned, as a short course of oral therapy. Another antibiotic that is also recommended by the BNF is co-amoxiclav, which can be used in doses ranging from 375 mg to 625 mg every 8 hours.25 In patients allergic to penicillin, clindamycin can be used in doses ranging from 150 mg to 450 mg every 6 hours.26 Another option for penicillin-allergic patients (as recommended by the BNF) is metronidazole, which can be used in a dose of 200 mg every8 hours for 3–7 days. For severe odontogenic infections, higher doses of a broad-spectrum antibiotic may be required. Clindamycin is prescribed for patients who are allergic to penicillin as it is active against some oral anaerobes and acultative bacteria, and has the advantage of good bone penetration. Infections in which anaerobic bacteria are implicated (such as pericoronitis, periodontal abscess and necrotizing ulcerative gingivitis) are better treated with metronidazole; the best dosage regimen in terms of pharmacodynamic/ pharmacokinetic aspect is 250 mg every 8 hours.
Conclusion
The awareness of the recommended guidelines among dental practitioners can improve the prescribing practices of dentists. The universal guidelines of prescription can be of great benefit to the patients as well as it removes the chance of ambiguity regarding the indication and dosage of the prescription.
As Hippocrates stated “If you wish to become a physician always follow the maxim, first do no harm” let us all in the dental fraternity strive to make the lives of our patients more comfortable and at ease.
Abbreviation
ADA: American Dental Association.
CDC: Center for Disease Control and Prevention.
DCDT: Definitive, conservative dental treatment.
EBD: Evidence-based dentistry.
ED: Emergency department.
GPS: Good practice statements.
GRADE: Grading of Recommendations Assessment, Development and Evaluation.
PNLAAA: Pulp necrosis and localized acute apical abscess.
PNSAP: Pulp necrosis and symptomatic apical periodontitis.
SAP: Symptomatic apical periodontitis.
SIP: Symptomatic irreversible pulpitis.