Dentists Overuse Antibiotics in Children

Laird Harrison

January 20, 2012

January 20, 2012 — A survey has suggested that most dentists tend to overprescribe antibiotics in children, researchers report in an article published in the January issue of the Journal of the American Dental Association.

The study, in which 154 North Carolina dentists indicated how they would treat hypothetical cases, found that adherence to professional prescribing guidelines ranged from 10% to 42%.

"I was surprised at how low it was, frankly," the article's corresponding author, Jessica Y. Lee, DDS, MPH, told Medscape Medical News.

The dentists tended to prescribe antibiotics when the guidelines say they are not needed, said Dr. Lee, an associate professor of pediatric dentistry at the University of North Carolina in Chapel Hill.

"What can go wrong is that we can develop antibiotic-resistant organisms," she warned. "And people can have an allergic reaction that can be pretty severe."

US dentists write between 200 million and 300 million antibiotic prescriptions each year, accounting for about 10% of all such prescriptions in the United States, Dr. Lee and colleagues write.

To understand how well these drugs are being used, the researchers wrote a set of scenarios describing patients and their symptoms and asking under what circumstances the respondents would prescribe antibiotics.

Of the almost 300 dentists to whom the surveys were sent, 154 dentists responded, of whom 48 (31%) were pediatric dentists and 106 (69%) were general dentists.

The researchers compared these responses with guidelines from the American Academy of Pediatric Dentistry (AAPD) and the American Dental Association (ADA). Although the guidelines were in agreement with each other, the AAPD guidelines were more specific.

The patient in the first hypothetical case presented with a deep carious lesion on the mandibular right primary second molar. Dentists were asked which symptoms would prompt them to prescribe antibiotics: pain and local swelling with no radiographic evidence of pathology, symptoms of pain and local swelling with radiographic evidence of pathology, and symptoms of pain and facial swelling with radiographic evidence of pathology.

According to the AAPD professional guidelines, dentists should consider prescribing antibiotics when a patient has facial swelling, either with or without pain, or radiographic evidence of pathology, or a combination of the 3 symptoms.

Only 26% of the respondents gave the correct answer according to these criteria. Among the pediatric dentists, 31% adhered to the guidelines, whereas 24% of the general dentists did so.

Adding fever to the list of collective signs and symptoms, the researchers found that overall adherence dropped to 12%. When they added local swelling and removed fever from the list, overall adherence increased to 32%.

Dentists also departed from the guidelines in showing a willingness to prescribe antibiotics over the telephone, the researchers say. The ADA guidelines state that to prescribe antibacterial drugs, the dentist must "make an accurate diagnosis." However, less than a quarter of the dentists said they would prescribe antibiotics only after seeing the patient.

In some of the scenarios, dentists who had completed advanced education, such as residency, were more likely to adhere to the guidelines (P < .05). Rural dentists were less likely to adhere to them, and dentists who see more than 15 children per week were also more likely to hand out the prescriptions.

Dr. Lee said professional groups need to work harder to make sure dentists know about the guidelines, and to devise more specific guidelines.

Asked to comment on the study, American Academy of Pediatric Dentistry Spokesperson Paul S. Casamassimo, DDS, pointed out to Medscape Medical News that most of the dentists in the study had graduated from a single dental school, the University of North Carolina, Chapel Hill, so the findings may not apply to all dentists.

He added that he was not surprised by the finding, as he had seen similar results in studies of medical physicians.

"There's a lot of defensive dentistry practiced by people who see kids," said Dr. Casamassimo, a professor at Ohio State University in Columbus, who was not associated with the study. "And a lot of pediatricians are forced into giving antibiotics to satisfy the parents rather than to treat the patient. In the scheme of things, I don't think it's a major issue."

He pointed out that there has been very little research on the effectiveness of antibiotics in dentistry, and he likened overuse of antibiotics to the overuse of fossil fuels, because in both cases the harm is hidden from the abuser. "The typical dentist doesn't see the effect of this," he said. "They can go through a lifetime of abusing antibiotics."

Dr. Casamassimo and Dr. Lee have disclosed no relevant financial relationships.

J Am Dent Assoc. 2012;143:31-38. Abstract

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