Antibiotic Use and Abuse
Antibiotic prescriptions are commonly written in dental offices across the US & Canada every day. We use them to manage infections, reduce pain and prevent possible infections associated with certain surgical procedures. When used properly and where indicated, antibiotics are indispensable in treating infection…when used improperly, antibiotic abuse will contribute to resistance of possible pathogenic organisms to future medical treatment.
The question for dentists and patients alike is often: When to prescribe? This may seem trivial or obvious, but it is critically important to our future well-being. If we, as dentists, prescribe inappropriately, we will not only offer our patients ineffective treatment, but we actually will change the microbial flora (i.e. the bacterial populations) and possibly make future antibiotic use less effective or ineffective. Which brings us back to the question of when to prescribe.
When to prescribe
There are a few clearly defined conditions that warrant antibiotic treatment. These are:
- Facial cellulitis. This is an infection that has invaded muscle and tissue spaces in the face and can be life-threatening.
- Lateral periodontal abscess
- Pericoronitis. This is an infection around a partially erupted tooth (commonly a wisdom tooth) that requires immediate attention and if untreated, may progress to cellulitis
- An infection where the patient is experiencing systemic symptoms (fever, malaise, or feeling of being unwell)
- In conjunction with certain surgical procedures where the risk of infection is high
- Before invasive dental procedures in patients with certain heart conditions, including:
- A prosthetic heart valve
- A history of infective endocarditis
- A heart transplant with abnormal valve function
- Certain congenital heart defects
The conditions in the above list currently warrant antibiotic coverage because the potential reward or upside of using antibiotics outweighs the potential risks. Potential risks of antibiotic use include: bacterial resistance; allergic reaction; drug interactions and GI complications due to C. difficile infection. A recent study reports 33,000 deaths per year from resistant infections in Europe alone.
When not to prescribe
In short, for everything else. We should never prescribe “just in case.” We should never prescribe for a condition that may be an infection. For years, orthopedic surgeons insisted that antibiotics be used by anyone with a prosthetic joint every time the they go to the dentist, in spite of there being no good reason for this practice. That alone is a tremendous abuse of antibiotic prescription writing. A joint statement by The Canadian Orthopedic Association (COA), the Canadian Dental Association (CDA) and the Association of Medical Microbiology and Infectious Disease (AMMI) Canada suggested that antibiotics not be used routinely for people with “total joint replacement, nor for patients with orthopedic pins, plates and screws.” In spite of this recommendation, they are prescribed for these very conditions every day.
In the dental setting, we are often pressured by patients to prescribe in situations that do not warrant antibiotic use. This can be a difficult conversation as many people are adamant that antibiotics should be used. I don’t think there is a dentist who has not been pressured by their patients into prescribing. This fact underscores the need for dentists to understand when to prescribe and to take the time to educate their patients on the risks and rewards of antibiotic use.
What to do?
Education is the first, second and ongoing step. As dentists, we have to remain current with antibiotic prescribing standards, including when to prescribe, what to prescribe and when not to prescribe. We have to pass that information along to our patients. When in doubt, we need to consult with our dental and medical colleagues. As a patient population, we have to understand that our dentist has considered antibiotics and if they are not prescribing, understand there is a reason. It is appropriate to ask about antibiotics, to learn about the advantages, disadvantages, risks and alternatives to antibiotics. It is not appropriate to pressure your prescriber into giving you a prescription because you are certain it will make you feel better. Open, clear, honest conversation is the best way toward the best use of antibiotics.
Sources
https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance
https://www.aae.org/specialty/wp-content/uploads/sites/2/2017/06/aae_systemic-antibiotics.pdf
https://www.cda-adc.ca/en/about/position_statements/jointreplacement/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2909496/