Elaine M. Bailey, Pharm.D., Executive Director, Michigan Antibiotic Resistance Reduction Coalition
Antibiotic resistance is a serious public health threat requiring a multifaceted approach. Approximately 10 percent of outpatient antibiotics in the U.S. are prescribed by dentists, amounting to nearly 25 million courses each year.1 Approximately 1.5 million additional antibiotic courses are prescribed to patients presenting in emergency departments with dental pain.2. There are increasing reports of inappropriate antibiotic prescribing in dental patients as well as dental patients experiencing Clostridiodes (formerly Clostridium) difficile diarrhea. 3,4. Given these findings, the American Dental Association (ADA) committed to the U.S. Antimicrobial Resistance Challenge by creating and disseminating guidance to help clinicians appropriately prescribe antibiotics. 5 The American Academy of Orthopedic Surgeons (AAOS) also committed to increase awareness of when antibiotics should and should not be used for patients with hip and knee implants who are undergoing dental procedures. (https://www.cdc.gov/drugresistance/intl-activities/amr-challenge.html
The ADA guideline for treatment of oral infections addresses many stewardship principles. The guideline encourages a paradigm shift in the use of antibiotics in dentistry from a “just in case” approach to using only when absolutely necessary. For example, when the patient is able to obtain interventional treatment (e.g. pulpotomy, pulpectomy, nonsurgical root canal treatment, or incision and drainage) within 24 hours, antibiotics are generally not recommended. The ADA suggests practicing “Delayed Prescribing/Watchful Waiting” in situations where antibiotic treatment is unlikely to be of benefit. If a decision is made to prescribe antibiotics, then the maximum duration is seven days and the patient should discontinue antibiotics after they have been symptom-free for 24 hours. The ADA has also attempted to curb the use of clindamycin, which has been shown to be highly associated with Clostridiodes Difficile Infection (CDI)6, by following the guidance of the CDC in terms of evaluating penicillin allergy and suggesting the use of azithromycin as an alternative to prescribing clindamycin in the face of a true (anaphylactic) penicillin allergy.
For infective endocarditis prophylaxis in patients undergoing dental procedures, current guidelines support premedication for only a small subset of patients.7 Unfortunately, in the case of patients with prosthetic joint replacements who are undergoing dental procedures, the guidelines developed by the ADA and AAOS have changed over the past 17 years, at times being incongruent particularly related to how long after the implant the patient should continue to receive prophylaxis before a dental procedure. The AAOS Appropriate Use Criteria (AUC) online tool indicates that it is rarely appropriate to prophylax patients who have undergone joint replacement more than one year before the dental procedure. The antibiotics prescribed are generally aligned with the American Hospital Association (AHA) guidelines with the exception of the removal of clindamycin as a choice (Table 2). Unfortunately, several dental providers in Michigan have shared that their orthopedic colleagues are often not in compliance with the AAOS guidance.
Comprehensive guidelines exist for the development of stewardship programs in inpatient settings but despite the majority of antibiotics being prescribed in the outpatient setting, stewardship guidelines are generally lacking. The CDC include dentists in their list of intended audiences in the Core Elements of Antibiotic Stewardship for outpatient settings. 8 However, guidance is not provided on how to implement the Antimicrobial Stewardship Program (ASP) in the unique setting of dental offices.
Dentists have little opportunity to observe firsthand the adverse events associated with antibiotic prescribing, such as CDI, so they are generally unaware of the impact of their prescribing habits. The majority of dentists are solo practitioners with variably trained support staff and collectively the dental office has limited knowledge of antibiotic pharmacology. 9 Here are just a few suggestions of how our profession can support dentists, their staff and patients, to be better antibiotic stewards:
- Talk to all the staff in your dentist’s office about their important role in antibiotic stewardship. Advise them about the resources available through the Michigan Antibiotic Resistance Reduction (MARR) Coalition and other organizations (Table 3).
- When filling an outpatient prescription for treatment of an oral infection, insure that it is consistent with the ADA guideline.5 In particular, focus on the duration of therapy and the prescribing of clindamycin. Provide patients with information on how to dispose of unused antibiotics in the event that their symptoms resolve before completing seven days of therapy.
- Advise patients with prosthetic devices that in many cases the risk of antibiotics outweigh the benefits of taking them before dental manipulation and therefore they should consider discussing the need for antibiotics not only with their dentists but with their other healthcare providers. In some cases, their general practitioner (GP) may have assumed the responsibility for writing the prescription if the patient is over a year out of their implant and the GP may not be aware of the change in the guidelines. Dentists have shared that referring their medical colleagues to the AAOS AUC tool has been a helpful communication tactic.
- Incorporate dental stewardship principles, particularly regarding prophylaxis, in systemwide ASPs. Focus on educating orthopedic surgeons on the increasing incidence of community-associated CDI and the association with dental antibiotics. Policies should be implemented in emergency departments and urgent care centers consistent with the ADA treatment guidelines.
- Critically evaluate cases of penicillin allergy since the majority of dental patients with a penicillin allergy are prescribed clindamycin. If the patient’s allergy history is dated, recommend that they discuss with their regular physician.
Given the numerous stakeholders involved, implementing antibiotic stewardship in dentistry is going to be challenging. Pharmacy has an opportunity to positively influence dental stewardship by educating all the stakeholders, particularly the patients. Please review these helpful resources.
- Roberts RM, Bartoces M, Thompson SE, Hicks LA, Antibiotic prescribing by general dentists in the United States, 2013. J Am Dent Assoc 2017;148(3) :172-178
- Roberts RM, Hersh AL, Shapiro DJ, Fleming- Dutra KE, Hicks LA. Antibiotic prescriptions associated with dental-related emergency department visits. Ann Emerg Med. 2019;74(1):45-49.
- Suda KJ, Calip GS, Zhou J, Rowan S, Gross AE, Hershow RC, Perez RI, McGregor JC, Evans CT. Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015. JAMA Netw Open. 2019 May 3;2(5):e193909
- Bye M, Whitten T, Holzbauer S. Antibiotic Prescribing for Dental Procedures in Community-Associated Clostridium difficile cases, Minnesota, 2009–2015. Open Forum Infect Dis. 2017;4(Suppl 1):S1. Published 2017 Oct 4. doi:10.1093/ofid/ofx162.001
- Lockhart PB, Tampi MP, Abt E et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling. J Am Dent Assoc.2019;150:906-921.
- Guh AY, Adkins SH, Li O, et al. Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study. Open Forum Infect Dis. 2017 Oct 26;4(4):ofx171
- Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc 2008;139 Suppl:3S-24S.
- Center for Disease Control and Prevention. Core Elements of Outpatient Antibiotic Stewardship. Available at: https://www.cdc.gov/antibiotic-use/community/pdfs/16_268900-A_CoreElementsOutpatient_508.pdf Accessed 3/28/20.
- American Dental Association, Survey Center. 2012 Distribution of Dentists survey. Chicago: American Dental Association, 2011.