COMMENTARY

Why Has Antibiotic Prescribing by Dentists Increased?

Scott S. De Rossi, DMD

Disclosures

August 04, 2016

Antibiotic Prescribing by Dentists Has Increased: Why?

Marra F, George D, Chong M, Sutherland S, Patrick DM
J Am Dent Assoc. 2016;147:320-327

Antimicrobial Stewardship

According to the Centers for Disease Control and Prevention (CDC), in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections.[1] Antimicrobial stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration.[2] The use and overuse of antibiotics in dentistry has been documented in the scientific literature.[3] A recent study by Marra and colleagues in the Journal of the American Dental Association highlights a concerning trend and sheds light on the possible cause for increased antibiotic use in dentistry.

Study Summary

The study was conducted to investigate the increased rate of prescribing by dentists despite the fact that the overall rate of antibiotic prescribing had been declining in British Columbia, Canada. The investigators obtained anonymous data on outpatient prescriptions from 1996 to 2013 from a centralized, population-based prescription database. From 1996 to 2013, physician prescribing declined by 18.2%. However, at the same time, dental prescribing increased by 62.2%, and its proportionate contribution increased from 6.7% to 11.3% of all antibiotic prescriptions. The rate of prescribing increased most for dental patients aged 60 years or older. Several explanatory themes were offered:

  • Unnecessary prescriptions for periapical abscesses and irreversible pulpitis;

  • Increased prescribing associated with dental implants and their complications;

  • Slow adoption of guidelines calling for less perioperative antibiotic coverage for patients with valvular heart disease and prosthetic joints;

  • Emphasis on cosmetic practices reducing the surgical skill set of average dentists;

  • Underinsurance practices driving antibiotics to be a substitute for surgery;

  • The aging population; and

  • The fact that there are now more dental providers per capita.

Viewpoint

Antibiotic resistance continues to be a major issue confronting healthcare providers and their patients. Changing antibiotic resistance patterns, rising antibiotic costs, and the introduction of new antibiotics have made selecting the optimal antibiotic regimen more difficult now than ever before. We have all heard that if we do not use antibiotics carefully, they will lose their efficacy. Antibiotic prescribing by oral health professionals should be reviewed regularly to make sure that we are compliant with the most recent evidence-based guidelines. It is clear that emerging themes for dental prescribing need to be explored further in future studies; however, the themes already identified by Marra and colleagues may guide priorities in prescribing. Clinicians must champion responsible antibiotic usage and stay up-to-date with the best evidence-based guidelines, including:

  • Guidelines for patients with prosthetic joint implants state that, in general, antibiotics are not recommended before dental procedures [4];

  • Guidelines from the American Heart Association and approved by the American Dental Association's Council on Scientific Affairs about prevention of infective endocarditis[5]; and

  • Insights from the American Dental Association's Council on Scientific Affairs about combating antibiotic resistance, which note that "Any perceived potential benefit of antibiotic prophylaxis must be weighed against the development, selection and transmission of microbial resistance."[6]

Proper antibiotic stewardship by the oral health professional should include never using an antibiotic "just to be on the safe side" or where inflammatory disease such as pulpitis will not benefit from a systemic antimicrobial. To date, dentists have escaped the monitoring of antibiotic use that is typical in hospitals and other areas of healthcare, but we must still adhere to best prescribing practices. It may be a matter of life or death!

Abstract

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