Responsible Antibiotic Prescribing

Responsible Antibiotic Prescribing

The COVID-19 pandemic in Michigan has limited patient access to routine oral health care. This has forced many patients to use antibiotics rather than definitive care for infectious dental problems. Most patients who present to Emergency Departments/Urgent Care are prescribed antibiotics and analgesics and directed to seek treatment with a dentist. Unfortunately, even before COVID, many patients often did not follow thru with care once symptoms resolved.

The Problem of Antibiotic Resistance

Currently there is a world-wide problem with antibiotic resistance and health care providers are being encouraged to reassess their use of antibiotics. Over the years, use of antibiotics without an evidence base has contributed to antibiotic resistance in populations.

The cover story of the November 2019 Journal of the American Dental Association (JADA) addressed this issue and is required reading for responsible dentists. “Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling” by Lockhart et al provides necessary guidance for dentists.

Current Evidence

The ADA Center on Evidence Based Dentistry convened an expert panel which conducted a systematic review of relevant scientific research and formulated the guideline. The panel advised against the use of antibiotics in most clinical scenarios irrespective of the definitive conservative dental treatment provided. The conclusions were that antibiotics may provide negligible patient benefits and probably contribute to large harms. These harms may range from potential allergic reaction/anaphylaxis to C. Difficile infections. Antibiotics are only recommended for patients with systemic involvement manifested by fever and malaise/illness or in immunocompromised patients with less severe symptoms.

Modern Practice

From a practical standpoint, we at the Center for Oral Surgery & Dental Implants have been following these principles for some time. Routine use of antibiotics for third molar patients was abandoned in our practice more than 5 years ago. Over that time, we have seen no increase in the overall infection rate. We have modified our surgical protocol to use topical Chlorhexidine rinse during the surgical procedure. When antibiotics are used for a diagnosed post-op infection, we strive for a minimal duration such as 3 days or until symptoms resolve.

Preventing Problems

Inappropriate antibiotic prescribing for patients, especially for protracted courses or multiple episodes, creates 2 problems. First the patient’s intestinal microflora can be permanently altered leading to systemic complications. Secondly, repeated antibiotic courses often compromise dental implant rehabilitation.

A typical case is one where a patient has had past endodontic therapy on a tooth that suddenly becomes symptomatic. Antibiotics are prescribed and the problem “goes away” but the underlying cause of the infection is not addressed by endodontic retreatment or tooth extraction. Chronic bacterial colonization of the tooth and alveolus leads to progressive advancing bone loss. With every “flare-up” and round of antibiotic treatment, more and more bone is lost. This often prevents the possibility of future implant placement without extensive grafting. These episodes also undermine the bone support of adjacent teeth.

Early Referral

We discourage use of antibiotics as the first choice in treating patients with pain or infection.  Endodontic therapy or extraction should be initiated as soon as possible. The ADA Guideline shows no advantage of using antibiotics for most patients. The surgeons at the Center for Oral Surgery & Dental Implants are available every weekday for emergency referral of patients who need immediate evaluation and treatment. Our doctors are also on call after hours and weekends. Don’t hesitate to call us if you have a patient with infection and/or pain who needs surgical therapy. We are here to help.

Sources

The ADA provides a CE activity linked to the November 2019 cover story accessible via https://ebusiness.ada.org/Education/viewcourse.aspx?id=367.

To learn more about antibiotic resistance reduction go to https://mi-marr.org.

For a more in-depth exploration of the human microbiome, we recommend the following review: https://wwwnc.cdc.gov/eid/article/20/11/14-1052_article