Nearly 1 in 5 patients with dental infections receive high-risk antibiotic, study shows
Liz Szabo, MAToday at 5:23 p.m.
Antimicrobial Stewardship
Serious dental infections can be excruciating, especially when pain spreads from the mouth to the jaw, ear, and neck, or causes throat and facial swelling.
When dentists aren’t available, many people with dental pain seek care from primary care providers, urgent care centers, or emergency departments (EDs), which treat nearly 2 million cases of dental pain a year in the United States.
Many of these people leave with a prescription for antibiotics and over-the-counter pain relievers. Although antibiotics can’t cure a deep-rooted tooth infection, they can provide a “Band-Aid” until people can see a dentist for definitive treatment, Lisa Dumkow, PharmD, a clinical pharmacist at Trinity Health Grand Rapids in Michigan, told CIDRAP News.
But antibiotics need to be chosen with care, so that patients take the most effective medication with the lowest risk of harm. In a study published late last week in Open Forum Infectious Diseases, Dumkow and her colleagues found room for improvement.
On the positive side, 75% of people with tooth pain received an antibiotic in the penicillin class, as recommended by the American Dental Association (ADA), according to the study.
Yet nearly 20% of people in the study received clindamycin, an antibiotic that’s well known for causing life-threatening infections from a pathogen called Clostridioides difficile. The bacterium, also known as C difficile, releases toxins that cause severe diarrhea and can destroy the lining of the intestine.
A CIDRAP News investigation published in February featured the story of Delores Hernandez Owens, 92, who died from a bowel infection after her dentist prescribed clindamycin.
Clindamycin has carried a “black box” warning, the Food and Drug Administration’s strongest warning, for at least four decades. ADA guidelines published in 2019 recommend other, safer antibiotics for people with serious dental infections. And in August, the ADA advised clinicians to “avoid clindamycin whenever a safer alternative is available.”
Before prescribing clindamycin, “you have to literally be in a situation where you can’t use anything else,” Dumkow, the study’s senior author, said.
Dumkow, whose study included more than 12,000 people across Michigan, said she was disappointed to see clindamycin used so often.
“The majority of patients did not need clindamycin,” Dumkow said. “They could have gotten an alternative antibiotic.”
Penicillin allergies can complicate care
Patient medical records show that more than 80% of people in the study were encouraged to follow up with a dentist. Just over half of study participants were treated in urgent care clinics, with 40% treated in the ED and 8% seen by primary care doctors.In some cases, clinicians in the study prescribed clindamycin because patients had a reported allergy to penicillin.
Yet among patients who received an antibiotic other than penicillin, 21% had no documented allergy or intolerance to penicillin, and 27% had only a “mild allergy or intolerance,” according to the study, which included people seen in the Trinity Health Michigan Network from January 2020 through the end of August 2025.
Penicillin allergies are less common than people think.
Although 10% of people in the United States have a penicillin allergy listed on their medical chart, less than 1% are actually allergic to the drug, according to the Centers for Disease Control and Prevention. Many people grow out of the allergy after a few years. Others never had penicillin allergies to begin with.
In the study, the authors note that 35% of patients treated with clindamycin had reported very minor reactions to penicillin or similar antibiotics, such as a mild to moderate rash.
Dumkow encourages clinicians to try to understand more about a patient’s potential allergies before prescribing clindamycin. While formal allergy testing can be time-consuming, she said clinicians can quickly estimate a person’s risk of an allergic reaction by asking four simple questions, such as whether patients needed medical treatment after experiencing a reaction to penicillin.
If patients answer “no” to all four questions, their risk of an allergic reaction is less than 1%. In that case, clinicians can feel safe giving the patient one pill and monitoring them for an hour, as long as they have medications on hand to quickly control any allergic reactions, she said.
Clindamycin is losing its potency
The study underscores the importance of sharing ADA guidelines with other clinicians who might treat dental pain, said Erinne Kennedy, DDS, MPH, assistant dean for curriculum and learning at Kansas City College of Dental Medicine in Missouri.
“This is a really great article that helps us understand the prescribing patterns that we're seeing in emergency department visits,” said Kennedy, who wasn’t involved in the new study.
In addition to being riskier than penicillin, clindamycin also appears to be less effective, according to the study. About 5% of patients in the study experienced “treatment failure,” in which they needed a different antibiotic or an additional prescription for the same antibiotic within 30 days.
Clindamycin had an 11% risk of treatment failure, the highest of any antibiotic in the study.
Dumkow said she has already shared the study with her health system’s urgent care providers, to help educate them about the best antibiotics to prescribe.
“It's powerful to say, ‘These are your data and your patients are six times more likely to fail therapy if you prescribe clindamycin,’ and ‘Here's how we work through allergies and what we should use instead,’” she said.
The study’s results are similar to a report of antibiotic effectiveness based on bacterial samples from dental patients in Kansas, Kennedy said.
In that analysis, antibiotics in the penicillin class were much more effective at killing oral bacteria than clindamycin. Scientists perform such analyses to gauge whether bacteria are evolving to become impervious to antibiotics.
To reduce the risk that bacteria will become harder to kill, the ADA advises dentists to prescribe antibiotics sparingly, such as when tooth pain is accompanied by a fever, chills, or other signs of a wider inhey live in a rural area or lack transportation, Kennedy said.fection. Dentists can also prescribe antibiotics when patients can’t see a dentist right away, such as because t
Did antibiotics fail? Or did the health system?
Some experts say it’s not fair to conclude that antibiotics “failed” to treat a patient’s dental infection.That’s because dental antibiotics aren’t the primary treatment for tooth pain, said Thomas Paumier, DDS, ADA president. The only way to cure a dental infection is through a procedure in a dentist’s office that removes infected tissue.
“The correct treatment is a dental procedure, such as a root canal, which they aren’t doing in an urgent-care settings,” said Debra Goff PharmD, professor of pharmacy practice at The Ohio State University College of Pharmacy, who wasn’t involved in the new study. “Antibiotics are the Band-Aid until definitive dental care can be given.”
If a patient with tooth pain returns to the ED within a month, the real problem is that the person hasn’t seen a dentist, Paumier said.
Many people included in the research may have faced such obstacles, Dumkow said.
About 38% of people in the study had no health insurance, and 27% were covered by Medicaid, the government health insurance program for people with low incomes or disabilities. Even people with dental insurance may not have coverage for the invasive procedures often needed to treat deep tooth infections, such as extractions or root canals. Some dental specialists don’t accept insurance at all. Dentists charge from $1,500 to $3,500 for a root canal and a crown, which is needed to cover the formerly infected area.
One way to help patients in pain is to make sure that physicians have a list of dentists who are willing to treat patients with dental infections promptly, Erinne Kennedy said.
“We work really closely with our emergency department,” Kennedy said. “We not only accept referrals, but we send patients to them who need emergency care.”