The clinical question asked in this review is an important one. Intuitively, the answer is “no”, since irreversible pulpitis is not an infection. Nevertheless, numerous studies have shown that there is widespread inappropriate use of antibiotics: up to 74% of people who have pulpitis are given a prescription for antibiotics.1

This report, an excellent example of a high quality rigorous systematic review2 examined early stage pulpal disease and found that systemic antibiotics are not effective in relieving pain in these patients. Although only one RCT was located, despite a comprehensive search strategy, the review concurs with the results of two meta-analyses which studied various interventions in acute apical periodontitis3 and acute apical abscess,4 both of which concluded that there is no evidence to support the use of prophylactic antibiotics in the management of localised endodontic disease in healthy patients.

With the increase in multidrug-resistant infections such as methicillin-resistant staphylococcus aureus (MRSA), a major and very serious nosocomial pathogen which is also emerging in the community, most, if not all, dentists would disapprove of inappropriate use of antibiotics in the abstract situation. While antibiotics are appropriate for patients with serious systemic infection, when confronted with a suffering patient and armed with personal or anecdotal experience of the rare patient whose condition has progressed from pulpitis to serious systemic infection, many clinicians are tempted to prescribe antibiotics despite the evidence of ineffectiveness, believing that this will provide more benefit than harm for their individual patient.

This erroneous belief can be disastrous. Adverse drug reactions (ADR) to antibiotics are not uncommon, ranging from nuisance side effects to severely debilitating and fatal outcomes, such as toxic epidermal necrolysis (TEN).5 In our hospital-based practice, we have been asked to consult on two patients in the past few years who developed near-fatal TEN, but recovered with severe sequelae. Both had been treated with amoxicillin for localised endodontic problems.

The fact that severe ADR are not uppermost in the minds of many clinicians when prescribing drugs can be attributed to a number of factors. Clinical trial designs in dentistry usually exclude people, including the elderly, who have comorbid conditions and would be more likely to develop significant ADR. Many clinical trials have inadequate power to detect uncommon but serious adverse events and meta-analysis primarily examines treatment efficacy, not safety.6 Voluntary reporting of ADR to government programmes or pharmaceutical companies is inadequate on a global scale, with reporting rates as low as 4–10% for life-threatening ADR such as TEN.7

Practice points

  • There is no evidence to support the use of prophylactic antibiotics in the management of localised endodontic disease in healthy patients.

  • Adverse drug reactions, while under-reported, are very common and can be life threatening.