The use and misuse of antibiotics in dentistry: A scoping review

This study was published in the Journal of the American Dental Association in October 2018. This is a summary of its findings. 

Kelli Stein, Julie Farmer, Sonica Singhal, Fawziah Marra, Susan Sutherland, Carlos Quiñonez, The use and misuse of antibiotics in dentistry: A scoping review, The Journal of the American Dental Association, Volume 149, Issue 10, 2018, Pages 869-884.e5

Purpose To describe antibiotic prescribing behaviors in dentistry, including clinical and nonclinical indications for their use, the type and regimen of antibiotics prescribed, and factors influencing their prescription, the authors conducted a scoping review. Clinical Implications Considering the seriousness of antibiotic resistance, the authors highlight trends in antibiotic prescribing practices, characterize factors contributing to the use and misuse of antibiotics in dentistry, provide insight into the importance of antibiotic stewardship in the oral health setting, and encourage dentists to reflect on their antibiotic prescription practices.

Describe the Clinical and Nonclinical Indications for Prescribing Prophylactic and Therapeutic Antibiotics in Dentistry

• The use of primary prophylaxis is common in both patients who are healthy and patients who are medically compromised who are believed to be at risk of developing an infection.
• Dentists also commonly prescribed prophylactic antibiotics when placing implants and during periodontal surgery, irrespective of patient medical history.
• Patients with a systemic disease, periodontitis, poor oral hygiene, or a smoking habit more commonly received prescriptions for prophylactic antibiotics when undergoing implant placement.
• The use of antibiotics for secondary prophylaxis was limited specifically to patients with specific cardiac conditions or a joint prosthesis who were undergoing various oral health procedures.
• For endodontic treatment, tooth preparation with oral impressions, and Class II restorations, dentists were more diverse in their decisions.
• Dentists also prescribed prophylactic antibiotics for nonclinical reasons. Specifically, pressure from patients or their cardiologists or physicians was a reason for prescribing antibiotics.
• it was common for dentists to prescribe antibiotics for acute and chronic periapical infections with or without sinus tracts and systemic involvement.
• Dentists also used antibiotics as an adjunct to mechanical therapy and surgery to treat periodontal disease. Dentists often prescribed patients antibiotics in the absence of signs of spreading infection or systemic involvement. Many dentists prescribed antibiotics to patients when pain was their only symptom.
• Dentists were more likely to prescribe antibiotics to patients who were underinsured rather than completing recommended surgical treatment because of affordability issues.

Clinical Implications

• Dentists often prescribe primary prophylaxis to healthy patients undergoing invasive oral health procedures such as surgical extractions, implant placement, and endodontic procedures, which is worrisome because the evidence in support of
  antibiotic use for these procedures is minimal and inconsistent.
• For endodontic procedures, antibiotic prophylaxis is not effective in eliminating postoperative infection. Similarly, for implant placement, the routine use of systemic antibiotics with implant placement in healthy patients is not supported by results from double-blinded randomized control trials. For tooth extractions, there is some evidence to support the use of prophylactic antibiotics to reduce the risk of experiencing pain, infection, or dry socket after third-molar extractions but no evidence to support its use in preventing fever, swelling, or trismus.
• No conclusive findings are available regarding the effects of prophylactic antibiotics on the extraction of severely carious teeth, periodontally involved teeth, or tooth extractions in patients who are immunocompromised.
• Dentists often prescribed antibiotic prophylaxis to patients medically compromised with rheumatic heart disease, coronary artery bypass graft, mitral valve prolapse, recent myocardial infarction, and TJR; however, guidelines no longer recommend antibiotic prophylaxis for patients with these conditions.

Describe the Type and Regimen of Prophylactic and Therapeutic Antibiotics Prescribed by Dentists

• Prophylactic antibiotics: In general, amoxicillin was the prophylactic antibiotic dentists most commonly prescribed to patients without an allergy to penicillin. Clindamycin was the prophylactic antibiotic dentists most commonly prescribed to patients allergic to penicillin. Other popular prophylactic antibiotics prescribed to patients allergic to penicillin were cephalexin, azithromycin, clarithromycin, and erythromycin.
• Therapeutic antibiotics: In general, amoxicillin was the antibiotic dentists most commonly prescribed to patients without a penicillin allergy, both alone and in combination with clavulanic acid.

Clinical Implications

A large proportion of dentists prescribed antibiotics to patients with a localized fluctuant swelling when there was no evidence of systemic spread.This finding suggests that dentists are prescribing antibiotics when local treatment would have sufficed.

Dentists also commonly prescribed antibiotics as an adjunct to mechanical therapy for the treatment of periodontal disease which is effective only in certain clinical circumstances.

Describe Factors Influencing the Antibiotic Prescription Patterns of Dentists

• For the most part, dentists acquired their knowledge from reputable sources; however, it is worrisome that a substantial number of dentists reported verbal informal, personal communication as their primary source of knowledge because this method is less comprehensive and may lead to the incorrect prescription of antibiotics and serious health outcomes.
• Audits and education and training may help improve dentists’ antibiotic prescription habits.

 

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CDA Oasis Team