The progression in pharmacological and medical sciences has been nothing short of miraculous over the past few decades, from uncovering the secrets of the human genome to discovering eye-opening immunotherapeutic and biological interventions. However, one should not overlook the necessity to investigate some basic treatment protocols, conventions and guidelines.
The question of interest to be examined is “Are prophylactic antibiotics appropriately prescribed to prevent future complications prior to dental procedures?” This question is often widely debated within the field of dental medicine and yet there is currently no clear answer available.
More than 80% of Prophylactic Antibiotics are Unnecessary in Dentistry
In 2007 and 2013, the infective endocarditis and prosthetic joint infections guidelines which illustrated the use of antibiotics as a prophylactic were revised. To determine whether antibiotic prescribing complied with these changes, a team of researchers at University of Illinois in Chicago performed a retrospective cohort study. The study evaluated the clinical histories of 91,438 patients who had been given prophylactic antibiotic treatments between 2 to 7 days before any dental procedures between 2011 and 2015. When following the old guideline, around 81% of patients would require the prophylactic treatments. When following the revised guidelines, only patients with cardiac conditions at the highest risk of adverse outcome from infective endocarditis would require prophylactic treatment. Note that this finding accounted for approximately 21% of the patients in the study. Evidently, by evaluating against the evidence-based prescribing guidelines for prophylactic antibiotic treatments, the study has shown that more than 80% of antibiotics prescribed by dentists were deemed unnecessary. Interestingly, around 70% of the dentists in the study were still prescribing prophylactic antibiotics when the drugs were not required during the study period between 2011 and 2015. They argued that prophylactic antibiotics should be administered due to an increase in the use of dental implants, aging population, and a feasible substitution for oral surgery for patients with underinsurance.
The Dangers of Antibiotic Overdose
This finding is alarming since dentists are responsible for prescribing a significant proportion of antibiotics. Antibiotic prescription, when not warranted, can expose patients to some concerning issues. An example of a frequently prescribed prophylactic antibiotic is clindamycin. The unnecessary prescription of clindamycin as a prophylactic antibiotic by dentists can lead to risk of side effects from a Clostridioides difficile infection and antibiotic resistance. Evidently, the use of clindamycin as a prophylactic antibiotic treatment causes adverse effects that outweigh its potential benefits. There are, however, signs of improvement on the rate of antibiotics being prescribed, which is likely due to the newly revised guidelines established in 2013 and the new antibiotic stewardship strategies.
It should raise awareness to all dental professionals of the importance of improving prescription of antibiotics prophylaxis. Since dentists are the primary prescribers of antibiotics, a reduction in unnecessary antibiotic prophylaxis will greatly reduce overall antibiotic prescription. Although the prescription of prophylactic antibiotics is gradually improving, implementation of antimicrobial stewardship in dental practices is strongly recommended and thus serves as an opportunity to improve antibiotic prescribing for infection prophylactic.
One reason prophylaxis antibiotics are prescribed is to prevent the infection of plaque removed from patients who, for instance, have had an aortic valve replaced and thus cannot risk infections.
Currently, concerns remain to be addressed within the dental practice community regarding the appropriate antibiotic prescribing guidelines, in addition to the individual and public health risks versus the potential benefits of antibiotic prescription in the patient population.
This blog entry was written by Kim-Hau Lui, Edward Lin, Tzu-Ching Lin, students of 2nd-year of Dentistry in Pharmacology at University CEU Cardenal Herrera
Suda KJ, Calip GS, Zhou J, et al. Assessment of the appropriateness of antibiotic prescriptions for infection prophylaxis before dental procedures, 2011 to 2015. JAMA Network Open. 2019;2(5):e193909.