This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2005, Issue 2
http://www.thecochranelibrary.com
Status: New
ABSTRACT
Background
Irreversible pulpitis, which is characterised by acute and intense pain, is one of the most frequent reasons that patients attend for
emergency dental care. Apart from removal of the tooth the customary way of relieving the pain of irreversible pulpitis is by drilling
into the tooth, removing the inflamed pulp (nerve) and cleaning the root canal. However, a significant minority of dentists continue
to prescribe antibiotics to stop the pain of irreversible pulpitis.
Objectives
The objective of this review was to provide reliable evidence regarding the effectiveness of prescribing systemic antibiotics for irreversible
pulpitis by comparing clinical outcomes expressed as pain relief.
Search strategy
We searched the following databases: Cochrane Oral Health Group Trials Register and Pain, Palliative Care and Supportive (PaPaS)
Care Group Trials Register to 6th September 2004; the Cochrane Central Register of Controlled Trials (CENTRAL) The Cochrane
Library Issue 3 2004; MEDLINE (1966 to 6th September 2004); EMBASE (1980 to week 36 2004).
Selection criteria
This review includes one randomised controlled trial which compared pain relief with systemic antibiotics and analgesics, against
placebo and analgesics in the acute preoperative phase of irreversible pulpitis.
Main results
One trial involving 40 participants was included in this review. There was a close parallel distribution of the pain ratings in both the
intervention and placebo groups over the 7 day study period. The between-group differences in sum pain intensity differences (SPID)
for the penicillin group were (6.0±10.5), and for placebo (6.0±9.5) P = 0.776. The sum pain percussion intensity differences (SPPID)
for the penicillin group were (3.5±7.5) and placebo (2.0±7.0) P = 0.290, with differences as assessed by the Mann-Whitney-Wilcoxon
test considered to be statistically significant at P < 0.05. There was no significant difference in the mean total number of ibuprofen
tablets (P = 0.839) and Tylenol tablets (P = 0.325), in either group over the study period. The administration of penicillin over placebo
did not appear to significantly reduce the quantity of analgesic medication taken (P > 0.05) for irreversible pulpitis.
Authors’ conclusions
This review which was based on one methodologically sound but low powered small sample trial provided some evidence that there is
no significant difference in pain relief for patients with untreated irreversible pulpitis who did or did not receive antibiotics in addition
to analgesics.
Antibiotic use for irreversible pulpitis (Review) 1
Copyright ©2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
SYNOPSIS
Antibiotics do not appear to significantly reduce toothache caused by irreversible pulpitis.
Irreversible pulpitis, where the dental pulp (nerve) has been damaged beyond repair is characterised by intense pain and considered to
be one of the most frequent reasons that patients attend for emergency dental care.
This review, which included 1 trial (40 participants), found that there is a small amount of evidence to suggest that the administration
of penicillin does not significantly reduce the pain perception, the percussion perception or the quantity of pain medication required
by patients with irreversible pulpitis.
REFERENCES
Carrotte 2003
References to studies included in this review Carrotte P. A clinical guide to endodontics. London: British Dental
Nagle 2000 {published data only} Association, 2003.
Nagle D, Reader A, Beck M, Weaver J. Effect of systemic penicillin CDC 1999
on pain in untreated irreversible pulpitis. Oral Surgery, Oral Medicine, Naimi T. Four pediatric deaths from community-acquired methi-
Oral Pathology, Oral Radiology & Endodontics 2000;90(5):636–40. cillin-resistant staphylococcus aureus - Minnesota and North Dakota,
1997-1999. CDC Morbidity and Mortality Weekly Report. Depart-
ment of Health and Human Resources. Centers for Disease Control
References to studies excluded from this review and Prevention August 20th 1999.
Fouad 1996
CDC 2003
Fouad AF, Rivera EM, Walton RE. Penicillin as a supplement in re-
Centers for Disease Control. CDC background on antibiotic resis-
solving the localized acute apical abscess. Oral Surgery, Oral Medicine,
tance. http://www.cdc.gov/drugresistance/community/
Oral Pathology, Oral Radiology & Endodontics 1996;81(5):590–5.
Cecic 1983
Henry 2001
Cecic PA, Hartwell GR, Belizzi R. Cold as a diagnostic aid in cases of
Henry M, Reader A, Beck M. Effect of penicillin on postoperative
irreversible pulpitis. Report of two cases. Oral Surgery, Oral Medicine,
endodontic pain and swelling in symptomatic necrotic teeth. Journal
Oral Pathology 1983;56(6):647–50.
of Endodontics 2001;27(2):117–23.
Clarke 2003
Nusstein 2003 Clarke M, Oxman AD, editors. Cochrane Reviewers’ Handbook
Nusstein JM, Beck M. Comparison of preoperative pain and medica- 4.2.0 [updated March 2003]. In: The Cochrane Database of Systematic
tion use in emergency patients presenting with irreversible pulpitis or Reviews, 2, 2003.
teeth with necrotic pulps. Oral Surgery, Oral Medicine, Oral Pathology,
Oral Radiology, & Endodontics 2003;96(2):207–14. Cohen 1998
Cohen S, Burns RC. Pathways of the pulp. 7th Edition. St Louis:
Mosby, 1998.
Additional references Colgan 2001
Bergenholtz 1990 Colgan R, Powers JH. Appropriate antimicrobial prescribing: ap-
Bergenholtz G. Pathogenic mechanisms in pulpal disease. Journal of proaches that limit antibiotic resistance. American Family Physician
Endodontics 1990;16(2):98–101. 2001;64(6):999–1004.
Antibiotic use for irreversible pulpitis (Review) 8
Copyright ©2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Cox 1995 of the literature. Journal of the Canadian Dental Association 2003;69
Cox RA, Conquest C, Mallaghan C, Marples RR. A major outbreak (10):660.
of methicillin-resistant Staphylococcus aureus caused by new phage- Nagle 2000
type (EMRSA-16). Journal of Hospital Infection 1995;29(2):87–106. Nagle D, Reader A, Beck M, Weaver J. Effect of systemic penicillin
Fouad 1996 on pain in untreated irreversible pulpitis. Oral Surgery, Oral Medicine,
Fouad AF, Rivera EM, Walton RE. Penicillin as a supplement in re- Oral Pathology, Oral Radiology & Endodontics 2000;90(5):636–40.
solving the localized acute apical abscess. Oral Surgery, Oral Medicine, Oguntebi 1992
Oral Pathology, Oral Radiology & Endodontics 1996;81(5):590–5. Oguntebi BR, DeSchepper EJ, Taylor TS, White CL, Pink FE. Post-
operative pain incidence related to the type of emergency treatment
Hahn 1991
of symptomatic pulpitis. Oral Surgery, Oral Medicine, Oral Pathology
Hahn CL, Falkler WA, Minah GE. Microbiological studies of carious
1992;73(4):479–83.
dentine from human teeth with irreversible pulpitis. Archives of Oral
Biology 1991;36(2):147–53. Palmer 2000
Palmer NA, Pealing R, Ireland RS, Martin MV. A study of prophy-
Heft 1984 lactic antibiotic prescribing in National Health Service general dental
Heft MW, Parker SR. An experimental basis for revising the graphic practice in England. British Dental Journal 2000;189(1):43–6.
rating scale for pain. Pain 1984;19(2):153–61.
SMAC 1997
Henry 2001 Standing Medical Advisory Committee. The path of least resistence.
Henry M, Reader A, Beck M. Effect of penicillin on postoperative Standing Medical Advisory Committee Sub-Group on Antimicrobial
endodontic pain and swelling in symptomatic necrotic teeth. Journal Resistance. London: Department of Health, 1997.
of Endodontics 2001;27(2):117–23.
Soames 1998
John 1997 Soames JV, Southam JC. Oral pathology. 3rd Edition. Oxford: Oxford
John JF, Fishman NO. Programmatic role of the infectious diseases University Press, 1998.
physician in controlling antimicrobial costs in the hospital. Clinical Tronstad 1991
Infectious Diseases 1997;24(3):471–85. Tronstad L. The endodontium. Clinical Endodontics. New York:
Lipton 1993 Thieme, 1991:1–31.
Lipton JA, Ship JA, Larach-Robinson D. Estimated prevalence and Yingling 2002
distribution of reported orofacial pain in the United States. Journal Yingling NM, Byrne BE, Hartwell GR. Antibiotic use by members
of the American Dental Association 1993;124(10):115–21. of the american association of endodontists in the year 2000: report
of a national survey. Journal of Endodontics 2002;28(5):396–404.
Matthews 2003
Matthews DC, Sutherland S, Basrani B. Emergency management of
acute apical abscesses in the permanent dentition: a systematic review ∗
Indicates the major publication for the study
TABLES
Fouad 1996 This study combined antibiotic or placebo or neither as an adjunct to operative endodontic treatment in resolving
the acute apical abscess.
Henry 2001 This study combined antibiotic as an adjunct to endodontic treatment.
Nusstein 2003 This study was a retrospective non-experimental study.
ADDITIONAL TABLES
Table 01 Baseline pain and percussion values for penicillin and placebo groups
Penicillin Placebo
Initial pain (median & interquartile range) 2.00+/- 0.00 2.00+/- 1.00
Initial percussion pain (median & interquartile range) 2.00+/- 0.50 2.00+/- 1.00
Pain ratings: moderate 65% 80%
Pain ratings: severe 35% 20%
Percussion pain ratings: mild 20% 25%
Percussion pain ratings: moderate 50% 65%
Percussion pain ratings: severe 30% 10%
Sum pain intensity difference (median and interquartile range) 6.0 +/- 10.5 6.0 +/- 9.5 .776
Sum percussion pain intensity difference (median and interquartile range) 3.5+/-7.5 2.0 +/- 7.0 .290
Total number of Ibuprofen (mean & SD) 9.2 ± 6.02 9.6 ± 6.34 .839
Total number of Tylenol (mean & SD) 6.9 ± 6.87 4.45 ± 4.82 .325
DAY 1
Penicillin 17 (85%) 10 (50%) 1 (5%)
No of tablets 33 21 0
No of tablets 28 11 0
DAY 2
Penicillin 17 (85%) 10 (50%) 0
No of tablets 30 28 0
No of tablets 31 18 0
DAY 3
Penicillin 13 (65%) 9 (45%) 4 (20%)
No of tablets 27 20 0
No of tablets 28 14 0
DAY 4
Penicillin 12 (60%) 9(45%) 6 (30%)
No of tablets 24 23 0
No of tablets 28 8 0
DAY 5
Penicillin 12 (60%) 8 (40%) 7 (35%)
No of tablets 21 15 0
No of tablets 32 11 0
DAY 6
Penicillin 13 (65%) 8 (40%) 5 (25%)
No of tablets 24 15 0
No of tablets 24 13 0
DAY 7
Penicillin 14 (70%) 10 (50%) 4 (20%)
No of tablets 25 16 0
No of tablets 20 14 0
COVER SHEET
Title Antibiotic use for irreversible pulpitis
Contribution of author(s) James Keenan (JVK), Zbys Fedorowicz (ZF) and Tim Newton (TN) were responsible for:
Data collection for the review
Screening search results
Screening retrieved papers against inclusion criteria
Appraising quality of papers
Abstracting data from papers
Obtaining and screening data on unpublished studies
Entering data into RevMan
Analysis of data
Interpretation of data
Writing the review.
ZF was responsible for:
Organising retrieval of papers
Writing to authors of papers for additional information
Providing additional data about papers.
JVK and ZF were responsible for:
Designing the review
Co-ordinating the review
Data management for the review
Performing previous work that was the foundation of current study.
ZF conceived the idea for the review and will also be the guarantor for the review.
Date new studies found but not Information not supplied by author
yet included/excluded
Antibiotic use for irreversible pulpitis (Review) 12
Copyright ©2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Date new studies found and Information not supplied by author
included/excluded