Unnecessary antibiotic use contributes to preventable harms such as antibiotic resistance, Clostridioides difficile (C. diff) infections, and allergic reactions. In the United States, dentists rank fourth in overall antibiotic prescribing, after family practice providers, physician assistants, and nurse practitioners. (1,2) In 2013, dentists prescribed more than 24 million courses of antibiotics (3,4) and published research found that 30-85 percent of dental antibiotic prescriptions are “suboptimal or not indicated.” (4-6) A study in Minnesota found that 15 percent of all community onset C. diff cases were associated with antibiotic courses prescribed by a dentist, demonstrating patient harms associated with dental prescribing. (7) As professionals, dentists can be leaders in antibiotic stewardship by 1) reviewing their own prescribing habits to ensure they align with current national guidance, and 2) educating themselves, colleagues, and patients about right and wrong uses of antibiotics.

Prophylactic Antibiotics in Dentistry

In 2015, the American Dental Association (ADA) published evidence-based guidance stating that, “in general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.” (5) In 2017, the American Heart Association and American College of Cardiology updated their guidance supporting infective endocarditis premedication for a relatively small subset of patients. (8) In your own practice, think about how many prosthetic joint and heart patients receive routine antibiotic premedication who, based on new, better scientific knowledge, don’t need it. It’s time to start the conversation with your patients, colleagues, and referring physicians about using antibiotics only when benefits outweigh the harms.

Antibiotic Treatment in Dentistry

Until very recently, there were no national practice guidelines for odontogenic infections. Dentists practiced according to their training, historical practice, and self-directed education, with resulting variation in practice. (9) In November, 2019, the ADA published a clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intra-oral swelling.(10) They recommend against use of antibiotics for most of these conditions and recommend instead the use of definitive dental treatment and, if needed, over-the-counter pain relievers such as acetaminophen and ibuprofen.

Antibiotic Stewardship in Dentistry

Antibiotic stewardship is a set of coordinated actions to improve antibiotic use in order to maximize benefits and minimize harms. All prescribers, including dentists, should incorporate antibiotic stewardship principles and make use of resources for antibiotic stewardship in their practice. U.S. Centers for Disease Control and Prevention developed core elements of antibiotic stewardship for outpatient settings that can be adapted to dental practices (11). The core elements include commitment, action, tracking and reporting, and education and expertise. See Box for other useful stewardship tools for dentistry. Consider proposing a discussion of antibiotic premedication practices at an upcoming county dental society meeting. Plan with your colleagues how to introduce dental antibiotic stewardship education and practices into your local community.

The Washington State Department of Health Healthcare Associated Infections Program can provide speakers on antibiotic stewardship and infection prevention in dental practice to dental society meetings. We all have a role to play in antibiotic stewardship. We hope Washington dentists will help lead the way.

Stewardship Resources for Dentistry from U.S. Centers for Disease Control

References

1. Hicks LA et al. Clin Infect Dis. 2015 May 1; 60(9):1308-16
2. Suda KJ et al. J Am Pharm Assoc (2003) 2016; 56:621–6 e1.
3. Roberts, et al. Antibiotic prescribing by general dentists in the United States, 2013. J Am Dent Assoc. 2017 Mar;148(3):172-178
4. Suda KJ et al. Use of antibiotic prophylaxis for tooth extractions, dental implants, and periodontal surgical procedures. Open Forum Infect Dis 2018; 5(X):XXX–XX.
5. Gross AE et al. Successful implementation of an antibiotic stewardship program in an academic dental practice. Open Forum Infect Dis, 6 (3) (2019), pp. 1-6
6. Löffler C, Böhmer F. The effect of interventions aiming to optimise the prescription of antibiotics in dental care—a systematic review. PLoS One 2017; 12:e0188061.
7. Bye M, et al. et al. Antibiotic Prescribing for Dental Procedures in Community-Associated Clostridium difficile cases, Minnesota, 2009–2015 Open Forum Infect Dis 4(suppl_1):S1-S1.October 2017
8. Nishimura RA et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the
9. Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017.
10. Durkin MJ et al. An evaluation of dental antibiotic prescribing practices in the United States. J Am Dent Assoc. 2017 Dec;148(12):878-886.e1. doi: 10.1016/j.adaj.2017.07.019. Epub 2017 Sep 20.
11. Lockhart PB, et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. The Journal of the American Dental Association 2019;150(11):906-921.e12.
12. U.S. Centers for Disease Control and Prevention. Core elements of outpatient antibiotic stewardship for healthcare providers. Available at: https://www.cdc.gov/antibiotic-use/core-elements/outpatient.html, accessed on March 11, 2020.