Clear as mud: Antibiotic stewardship in dentistry

As the marvels of antibiotics became known and their use grew, our understanding of their limitations did as well. Through decades of antibiotic overuse we are now seeing the rise of super bacteria, organisms that have evolved means to evade traditional antibiotics. These “super bugs” are now causing serious, life-threatening infections. The situation is so serious in fact that in 2015 the World Health Organization called for global action to combat antibiotic resistance.

The American Dental Association, the American Heart Association, American Academy of Orthopedic Surgeons and other medical organizations have re-evaluated their previous guidelines regarding antibiotic use. All have significantly reduced antibiotic use in dental treatment. The profession of dentistry is reducing antibiotic prescribing practices and it is our ethical obligation to educate and bring the new guidelines into our clinics. So what are those guidelines?

Generally speaking there are two ways antibiotics are used in dentistry: therapeutic and prophylactic.

In the therapeutic setting, the antibiotic is used to control the spread of an acute dental abscess. In the prophylactic scenario, a one-time dose of antibiotic is used to reduce the risk of a short-lived burst of bacteria in the blood stream that could potentially cause complications for very specific types of patients. 

Guidelines for the therapeutic scenario are straightforward. Antibiotics are NOT appropriate for most toothaches unless the person shows signs of systemic involvement. Systemic involvement would manifest as swelling, hot clammy tissue, fever or swollen lymph nodes. Your dentist can help determine which antibiotic and for what dose and duration are appropriate for you after thorough evaluation.

What most people don’t understand about dental infections is that the antibiotic alone won’t solve the infection. The sources of the many types of bacteria are the surfaces of the oral tissues surrounding the teeth which are ever-present. Definitive therapy is required for the infection to go away: either deep cleaning, root canal or extraction. If antibiotics are used repeatedly without removing the home for the bacteria (the infected tooth structure), the bacteria in the tooth infection evolve and become resistant to the antibiotic. Eventually the antibiotic will have no effect on the abscess and the patient has greater risk for severe complications from the antibiotic itself.

Guidelines for the second type, the prophylactic scenario, are less straightforward. Three groups of patients were assessed: cardiac patients, orthopedic joint replacement patients and transplant patients. Generally speaking, antibiotics are now not required routinely except for very specific types of cardiac patients and only for more invasive procedures. Multiple factors will dictate if prophylactic antibiotics are needed such as transplant stability, immune function, the presence of infection, diabetic control, history of previous joint or transplant infections and patient stability post- surgery. 

Antibiotics work when it is appropriate. In dentistry it isn’t appropriate most of the time, with some exceptions.

If you are a transplant, cardiac or orthopedic patient be sure to have the conversation regarding oral health care before starting surgery and during routine follow up. If you are immunocompromised and the surgeon requests antibiotic prophylaxis, have them prescribe the proper type and dose.

If you end up at the dentist after surgery, be sure to contact your surgeon before going to the dentist to verify and bring any recent blood lab work that would demonstrate your immune function. With everything there can be exceptions, having an open conversation with your health care team will lead to the best care we can all feel confident about.

References:

Clinical Practice Guidelines of the Clinical Affairs Committee, American Academy of Pediatric Dentistry. “Guidelines on Antibiotic Prophylaxis for Dental Patients at Risk for Infection.” 2014 Revision. Reference Manual V37 No. 6.

Stein, Kelli. Et.al. Oct. 2018. “The use and misuse of antibiotics in dentistry: a scoping review.” JADA 149(10) p 869-884.

Sollecito, Thomas P. et.al. 2015. “The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guidelines for dental practitioners-a report of the American Dental Association Council on Scientific Affairs.” JADA 146(1). P11-16.

Stooper et.al. 2012. “Do Patients with Solid Organ Transplants or Breast Implants Require Antibiotic Prophylaxis before dental treatment?” J Can Dent Association 2012; 78:c5.

The American Association of Endodontists. 2017. “Antibiotic Prophylaxis 2017 Update”. AAE Quick Reference Guide.