Introduction

Antibiotics, along with analgesics, are the most commonly prescribed medications by dental practitioners. Antibiotics are considered a safe drug as they have no direct effect on the host, only attacking the bacterial microflora. This apparent safety has engendered an attitude of prescribing antibiotics for a wide variety of conditions just in case’ of infection and patients often expect antibiotic prescription. There is increasing evidence that this attitude is totally inappropriate. Adverse reactions, bacterial resistance rendering antibiotics useless and the rise of multiresistant bacteria are increasing problems (1)
Centers for Disease Control and Prevention (CDC) conservatively estimated that 47 million prescriptions for antibiotics (30% of all outpatient antibiotic prescriptions) are unnecessary (2)

 

Inappropriate antibiotic use in dentistry

Dentists prescribe between 7% and 11% of all common antibiotics (beta- lactams, macrolides, tetracyclines, clindamycin, metronidazole), and abuse can be substantial. Inappropriate antibiotic use in dentistry includes:(3)
  1. postsurgical ‘prevention’’ of an infection not likely to occur and not demonstrated clinically to respond to ‘after the fact’’ prophylaxis,
  2. use in endodontics as ‘analgesics,’’
  3. failure to adhere to principles established for use of prophylactic antibiotics,
  4. overuse to prevent metastatic ‘focal’’ infections,
  5. treatment of chronic adult periodontitis, which is almost totally amenable to mechanical therapy,
  6. using antibiotics instead of mechanical periodontal therapy,
  7. chronic long-term antibiotic therapy for periodontal disease,
  8. antibiotic therapy instead of appropriate incision and drainage,
  9. use of antibiotics to prevent negligence claims, and
  10. antibiotics used in inappropriate situations, dosages, and durations of therapy

Antibacterial resistance

The increase in antibacterial resistance has been attributed primarily to two different processes. First, reduced susceptibility may develop via genetic mutations that spontaneously confer a newly resistant phenotype. Alternatively, the exchange of resistant determinants between sensitive and resistant microorganisms (of the same or different species) may occur. Regardless of the genetic basis of resistance, the selective pressure exerted by widespread use of antibacterial drugs is the driving force behind this public health problem. (4)

 

 In a study published in JADA 2017:148(12):878-886, it was found that:(5)
  • Among antibiotic prescriptions according to dental care providers only, the most common antibiotics prescribed were amoxicillin, clindamycin, penicillin, azithromycin, and cephalexin
  • Although general dentists prescribed the highest volume of antibiotics, they had lower prescribing rates than did some other dental specialists. As specialists, oral and maxillofacial pathologists were much more likely to prescribe antibiotics than were other dental specialists.
  • Other high-volume dental prescribing specialists included oral and maxillofacial pathologists, oral and maxillofacial surgeons, periodontists, and endodontists. Orthodontists prescribed the fewest antibiotics per prescriber.
  • Investigators in several studies have demonstrated that antibiotic prescribing among dentists is comparable with that of many medical specialties.
  • General dentists were responsible for 10% of antibiotic prescriptions and were the fourth highest prescriber of antibiotics in the United States by volume.
  • National antibiotic prescribing rates increased by 50% among dental practitioners in Australia between 2001 and 2012

In a study published in Niger J Clin Pract. 2017 Jul;20(7):804-810, authors found:(6)

  • Amoxicillin (73.8%) was the most commonly preferred antibiotic for most of the orofacial infections among the dentists. The overall adherence to the professional guidelines ranged from 9.5 to 45%.
  •  A lack of consistency in the antibiotic prescription pattern among dentists in Jeddah and overall low adherence to the professional guidelines was observed.
  • Most participants (99.2%) used oral route for administration of antibiotics and almost 59.5% of the dentists prescribed antibiotic for an average duration of 5 days.
  •  65.9% of the dentists did not follow any specific guidelines. Similar finding were seen in other studies in the USA.

In a study published in Saudi Med J. 2017 Aug;38(8):852-856, evaluating antibiotic prescription practices during root canal treatments among general dentists in private dental clinics in Al-Madinah Al Munawarah, Saudi Arabia. It was found the following:(7)

  • 60% of the dentists prescribed amoxicillin with clavulanic acid as the first choice treatment for endodontic pathosis
  • Approximately 83.3% of general practitioners prescribed antibiotics for acute apical abscesses
  • This study reveals antibiotic abuse in endodontic treatment practice in private dental clinics in Al-Madinah Al Munawarah, Saudi Arabia
  • General dental practitioners are lacking knowledge regarding the prescription of antibiotics in endodontic  treatment and situations requiring prophylactic antibiotics.

Finally..

Microbes will leave us alone if we leave them alone and stop forcing them to invent new ways to survive (after all, they have had 3.5 billion years of practice). This can be accomplished by reducing our use of antimicrobials to the level where they are necessary for our survival and not merely for doctor and patient comfort.(8)

References:

  1. Australian Dental Journal 2000;45:3
  2. JADA 148(12)
  3. Dent Clin N Am 47 (2003) 623–63
  4. JADA, Vol. 135, April 2004
  5. JADA 2017:148(12):878-886
  6. Niger J Clin Pract. 2017 Jul;20(7):804-810
  7. Saudi Med J. 2017 Aug;38(8):852-856
  8. Dent Clin N Am 47 (2003) 623–639
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Mahmoud H. Al-Johani

Author Mahmoud H. Al-Johani

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