The Power of Endo to Save Teeth Is IncredibleAugust 31, 2023
Case Study: Hands-On Endo Training for DentistsSeptember 15, 2023
I have a hypothesis: we commonly overprescribe antibiotics in dentistry. Before you protest, I want to reassure you that I’m not against antibiotics at all, and I know that they have powerful benefits. However, they also come with drawbacks we need to consider.
So the next time your patient asks you, “Do I need antibiotics for my tooth infection?” I want you to think about this article.
Let’s explore a quick tooth story that illustrates what I mean.
This case is unfortunately all too common, but I wanted to share an example from a recent conversation I had with my friend.
She let me know that her dad had gone to see his general dentist. He took some quick radiographs and CBCT scans and let him know that two of his teeth (#30 and #3) needed to be extracted.
Here are some of the images he provided (apologies for the fuzzy quality these are not my images). Let’s start with tooth #30.
I’m seeing some dark shadows under the roots on #30. I’m also seeing internal resorption. As far as I know, the general dentist didn’t look into tooth #31, which was a big missed opportunity. Once we dentists see one area of resorption in the mouth, we need to be checking every area.
Let’s move on to tooth #3.
It’s actually hard for me to tell if this is an image of the distobuccal root or the mesiobuccal root. Unfortunately, there was no axial view provided for tooth #3.
Side Note on CBCT Technology
There’s a lot of information we simply can’t get from these images. For instance, I can’t really make a diagnosis from the images provided here, but I can get an idea.
You can see, particularly in the axial view of #30, that just having the screenshots from a CBCT doesn’t help all of the time. I would need to go through the whole volume of images for it to help in my diagnosis. This is much of why I’m always so reluctant to diagnose someone over the phone or via email; it’s important to manipulate the whole volume to get accurate information.
Unfortunately, we as dentists aren’t getting adequate training with respect to reading scans. While the CBCT tech will provide training, it is more focused on acquiring the scan, and less in reading it.
As a result, so many dentists don’t know how to use their fancy cone beams. If you are feeling some stress about CBCT, know that it’s the entire focus of Module 6 in E-School, my online endo CE course.
Were Antibiotics in Dentistry Really Needed Here?
Back to this patient. My friend’s dad reported that his dentist said, “Here’s your treatment plan: Extractions and implants for both teeth. And here are some antibiotics to take while we get you scheduled.”
There’s a lot I want to say about this case, and it’s not all about prescriptions. I promise I’ll circle back to pain management and antibiotics in a second.
I didn’t talk personally with this dentist, but the patient said that there was no cold test. Given the information I have, I don’t have a high degree of confidence that the dentist conducted a true endodontic diagnosis. If this is the case, I find it irresponsible that they decided to doom these teeth to extraction. How can you know if a tooth is savable without diagnosing it?
The next little tidbit of info I got was that the general dentist brands themself as an implant specialist. There is nothing wrong with niching, risk assessment, knowing your limits, or implants. In fact, all of those are good things!
But this particular situation seemed fishy to my friend who told me what was going on with her dad. She couldn’t help but shake the feeling that the dentist was not comfortable with endo, so they were just trying to keep her dad (and his money) in-house with treatments they knew well. I am not in a position to speculate about this, and I’m not accusing the dentist of anything at all. These feelings were expressed to me by the patient and his daughter. I do think it’s an interesting insight into how our patients can sometimes emotionally respond to our decisions in ways that might surprise us.
What’s actually in the patient’s best interest? This is a question we constantly have to ask ourselves.
The truth is, when we do what’s in the patient’s best interest, that’s in our best interest, too. Because the patient will recognize that we have their backs, and they’ll give us their loyalty in return.
Regarding the antibiotic prescription: this is an extremely common approach, and sometimes antibiotics can be an enormous help. But in this situation, there was no pain or swelling, so I didn’t understand the need for antibiotics. I do think it’s important for us to ask ourselves why we are prescribing the antibiotic.
And we have to be mindful that sometimes, antibiotics can make the situation tougher than it was before.
What do I mean by that?
The Truth about Antibiotics in Dentistry
When it comes to antibiotics, treatment always trumps drugs. Antibiotics aren’t going to make the problem go away. The symptoms might go away (for a little while), but that endodontic problem is still there. Antibiotics just delays treatment of the real issue, which might doom a formerly saveable tooth to extraction.
Think about it this way: generally, when a tooth is infected, that tooth’s blood supply is already gone, which means the body can’t get the antibiotic into the canals where the bacteria is. So, while the antibiotic might help reduce the flareup of infection or an abscess, it’s not going to resolve the issue. In fact, when a pulpal infection is early, antibiotics won’t even impact your patient’s symptoms at all!
Plus, there’s a diagnostic danger to antibiotics: They have a tendency to mask symptoms and the source of the problem, making it hard for us doctors to find the correct diagnosis. I always ask my patients not to start any antibiotics prior to seeing me for the first time and not to take any pain meds on the day of that appointment. It’s not that I’m not a glutton for punishment—it’s that I want to be able to see and understand everything in order to make an accurate diagnosis quickly.
If I can’t find the pain, I can’t treat it, and it will delay solving the problem. To be honest, I actually prefer to see my patients on a bad day. That way, I have total clarity about how to help them, and we can get it done.
Here’s another consideration for you. Antibiotics, like any medication, have the possibility of causing adverse reactions. For example, a patient could have an allergic reaction or could develop dysbiosis, which can wreak havoc on their gut. Remember, antibiotics aren’t localized; they impact the whole body. Plus, our bodies could start to develop antibiotic resistance, making their usefulness diminish over time.
How to Think about Antibiotics in Dentistry
Instead of using antibiotics as pain management, try a two-fold approach: treatment + pain medication.
Sure, antibiotics can be very helpful when an infection is totally out of hand. But remember that antibiotics treat infections, and pain medications treat pain. Antibiotics aren’t a cure-all.
When your patient asks you for antibiotics, you can explain why that is or isn’t the wisest course of action. Your patients are advocates for their own bodies, but you are the doctor, so it’s up to you to be the subject matter expert, while they are the experts on their bodies and experiences. It takes both of you to find the right solution.
In the story of my friend’s dad, he ended up seeking a second opinion from a wonderful, trusted endodontist that I referred him to. Because he knew how to use his CBCT, did proper endodontic testing, and saw the patient on a “bad” day with no antibiotic or pain medication, the endodontist was able to confirm what I suspected: that both teeth were totally saveable. Fortunately, the teeth have been saved, and no implants were needed. Here are some images from the endodontist.
Here’s tooth #30…
And tooth #3.
So let’s go back to antibiotics. Does what I’m saying about this topic make sense to you? Are you planning on using a different approach to antibiotics going forward? How about endodontic diagnosis and treatment planning? I hope this story has inspired you to save more teeth!
I encourage you to take my What’s Your Endodontic Know-How Quiz, so you can pinpoint areas of opportunity for your continuing education and continue to become a better dentist.