Improving Clinical Dentistry
Antibiotics are a crucial tool in treating bacterial infections in dental clinics. However, excessive and inappropriate use of antibiotics can lead to antibiotic resistance, which has become a significant public health concern. Resistance is a growing problem worldwide and can compromise the effectiveness of antibiotics, making it difficult to treat bacterial infections.
As a dentist, it is essential to understand when to use antibiotics by following the evidence based dental antibiotic guidelines set forth by the American Dental Association (ADA).
The Importance of Proper Antibiotic Use
Resistance occurs when bacteria develop the ability to withstand the effects of antibiotics, making them less effective in treating infections. The overuse or misuse of broad spectrum medications like Clavulin (Amoxicillin/Clavulanate) can lead to the evolution of antibiotic-resistant bacteria. This can cause infections that are more severe, longer hospital stays, increased healthcare costs, and even death.
In my experience working as a clinical pharmacist in the hospital setting I have seen the unfortunate consequences of repeated antibiotic use first hand. The insidious part about resistance is that it is not isolated to infection type, or person.
One example I have seen is a patient that had been treated repeatedly for cellulitis developed a pneumonia that cultured for methicillin resistant staph aureus (MRSA). This patient unfortunately was not isolated soon enough and transmitted MRSA pneumonia to other patients throughout the ward.
This might seem like an isolated occurrence in hospitals, but treating patients with broad spectrum medications like Clavulin can lead to serious consequences in community as well. As a community healthcare provider, it is important for dentists to understand proper antibiotic use and follow the guidelines set forth by the ADA to help prevent bacterial resistance and protect your patients' health.
Overuse in Dental Clinics
Let’s address the elephant in the room: there is growing concern about the overuse of antibiotics in dental clinics. Some dentists prescribe antibiotics as a precautionary measure, even when there is no clear indication of infection. This can lead to unnecessary exposure and an increased risk of resistance.
But, that's why you're here: to learn and adapt your practice towards patient needs, improving dental healthcare!
Careful evaluation of each patient's condition is crucial in determining whether infection control is necessary. Alternative treatments, such as pain management and localized treatment, should be considered before prescribing antibiotics.
In the following section we will explore when and how antibiotics should be used in the dental setting, as described by the ADA.
American Dental Association:
Dental Antibiotic Guidelines
The ADA has established comprehensive antibiotic guidelines for the prevention and treatment of dental infections. These guidelines provide a framework for prescribing antibiotics in a manner that prevents the development of bacterial resistance.
According to the ADA guidelines, antibiotics should only be prescribed for specific conditions, such as acute oral infections, prophylaxis in patients with certain heart conditions, and in cases where there is a risk of infection spreading to other parts of the body. Antibiotics should not be prescribed for routine dental procedures, such as fillings or extractions, unless the patient has a pre-existing condition that puts them at risk of infection.
Unfortunately, the ADA guidelines are a bit dense and don't really have a good summary. So instead of just sending you to read through the full articles, I have compiled the recommendations set out by the ADA for your convenience:
Antibiotic Prophylaxis
Evidence Based Recommendations for the PREVENTION of ENDOCARDITIS
| Indication | Recommendation | Alternatives for Severe Penicillin Allergy |
| Endocarditis Prophylaxis
| Amoxicillin 2g PO 30-60min prior to procedure IF dental procedure involves manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa AND patient fulfills any of the following:
· Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
· Previous infective endocarditis
· Unrepaired cyanotic CHD, including palliative shunts and conduits
· Repaired congenital heart defect with prosthetic material or device
· Cardiac transplantation recipients who develop cardiac valvulopathy
· Case dependent risk factors such as immunosuppression, diabetes, dialysis, and old age | Cephalexin 2g PO
OR
Clindamycin 600mg PO
OR
(The 2021 AHA scientific statement on prevention of infective endocarditis no longer recommends use of Clindamycin due to risk of Clostridium difficile opportunistic infections)
Azithromycin 500mg PO |
Prevention of infective endocarditis: Guidelines from the American Heart Association
Note: There is currently NO evidence supporting antibiotic prophylaxis for PREVENTION of PROSTHETIC JOINT INFECTIONS
This is also a nice decision making tree from UpToDate to help with visualization:
Antibiotic Treatment
Evidence-Based Recommendations for ACTIVE INFECTIONS
| Indication | Recommendation | Alternatives for Severe Penicillin Allergy |
Symptomatic apical periodontitis
OR
Localized acute apical abscesss
WITH
Pulp necrossis
| Amoxicillin 500mg PO TID x 5d IF patient fulfills any of the following:
· Definitive conservative dental treatment is not immediately available
· Any systemic involvement (fever, chills, sweating, shortness of breath, etc.)
· Immunocompromised
IF no improvement by day 3 then:
Change to Amox/clav 500/125mg PO TID x 7d
OR
Add Metronidazole 500mg PO TID x 7d | Cephalexin 500mg PO QID x 5d
OR
Clindamycin 450mg PO TID x 5d
OR
Azithromycin 500mg PO x 1d then Azithromycin 250mg PO daily x 4d
IF no improvement by day 3 then:
•
Add Metronidazole 500mg PO TID x 7d
|
Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling
Feel free to use these resources at your dental clinic, and let me know if they are helpful for you!
The Role of Dentists in Antimicrobial Stewardship
Dentists have a critical role to play in antimicrobial stewardship stewardship, which is the responsible use of these agents to preserve their effectiveness. Dentists can contribute to antibiotic stewardship by following the ADA guidelines, carefully evaluating each patient's condition, and prescribing antibiotics only when necessary.
In order to help in this endeavor, we have created the mobile and web application DentalRx. Dentists Use DentalRx to Research antibiotics so that they may Safely Prescribe, and Ultimately Provide Better Patient Care.
All this without having to scour the internet for updated guidelines or deciphering outdated resources.
