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Dentistry and the use of antibiotics

Dentistry and the use of antibiotics

This article explores the latest evidence regarding antibiotic use and resistance, and offer practical ways to avoid patients’ requests for such prescriptions when their use is unnecessary.

This article is equivalent to one hour of Enhanced CPD

To provide feedback on this article, please contact [email protected]

Learning Outcomes: A | B | C | D

Aims & Objectives

The aim of this article is to explore the latest evidence regarding antibiotic use and resistance, and offer practical ways to avoid patients’ requests for such prescriptions when their use is unnecessary.

On completing this CPD session, the reader will:

  1. Understand why and how antibiotics are losing their effectiveness
  2. Understand the global challenges of antibiotic resistance
  3. Understand the role of dental professionals in ensuring future generations can rely on the efficacy of existing antibiotics
  4. Understand the relevant guidelines in relation to dentistry and antibiotics
  5. Understand how to raise awareness amongst patients about the problem and the realities of what antibiotics can achieve.

This article explores the current situation regarding antibiotic use in dentistry and antimicrobial resistance

Intro page image

Public Health England states that, ‘Antibiotics are losing their effectiveness at an increasing rate.’1

The mechanism by which this occurs can be explained as follows: ‘Bacteria can adapt and find ways to survive the effects of an antibiotic. They become ‘antibiotic resistant’ so that the antibiotic no longer works. The more you use an antibiotic, the more bacteria become resistant to it.’1

Adding to the picture, few new antibiotics are being developed, which is why they need to be used wisely, to ensure future generations can rely on the efficacy of the antibiotics we already have.1

In terms of relevant data, an independent review commissioned by the Government in 2014 suggested that if there is a failure to address the problem of antibiotic resistance, it could result in an estimated 10 million deaths world-wide by 2050 and a cost of £66 trillion to the global economy.1

Dentistry in the UK

Sanderson (2019) wrote: ‘Antimicrobial resistance is arguably the gravest threat to public health both here in the UK and worldwide.2

She continued: ‘…UK dental practices have made huge strides in reducing antibiotic prescribing – dentists dispensed around a quarter fewer prescriptions for antibiotics in 2017 compared to 2013 – but with 5.2% of all antibiotics still prescribed in dentistry, much more remains to be done.’2

Supporting this ethos, the Faculty of General Dental Practice (FGDP) stated: ‘Dentists have a vital role to play in keeping antibiotics working by prescribing them only when necessary, and by educating patients to take and dispose of them responsibly…’.3

In line with all of this, the dental profession has been proactive in addressing the challenges posed by antibiotic resistance.

For example, in 2014, the British Dental Association (BDA) hosted a summit on antimicrobial resistance in dentistry, helping to raise awareness of the issues.2

The BDA is also campaigning for appropriately funded urgent treatment appointments and calling for a removal of the pressures that push dental patients to see their GPs, in the hope that this will reduce potentially unnecessary antibiotic prescribing.4

In addition, a dental antimicrobial stewardship toolkit has been developed by the Dental Subgroup of the English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) in collaboration with the FGDP and the BDA.1

Appropriate antibiotic use

The dental antimicrobial stewardship toolkit comprises a number of important documents including, for instance, the FGDP’s guidelines for prescribing antimicrobials, where it is recommended that they are indicated only in the following circumstances:5

  1. As an adjunct to the management of acute or chronic infection
  2. For the definitive management of active infective disease such as necrotising ulcerative gingivitis
  3. Where definitive treatment has to be delayed due to referral to a specialist service.

 

The guidance also states, ‘There is no indication for the prescribing of antimicrobials for acute pulpitis, where definitive treatment of the cause along with analgesics is more appropriate.’5

The General Dental Council (GDC) offers further advice in its ‘Guidance on prescribing medicines’, stating: ‘Prescribing medicines is an integral aspect of many treatment plans. You must make an appropriate assessment of your patient’s condition, prescribe within your competence and keep accurate records.’6

Patient communication

The UK’s dental antimicrobial stewardship toolkit is clear in its message that antibiotics do not cure a toothache, and have produced patient-friendly leaflets and posters to help raise awareness of this fact.7

One such leaflet that dental professionals may find helpful when discussing the use of antibiotics in dentistry with patients can be found at https://bit.ly/2tQ7nD7, which offers advice such as:8

  1. Antibiotics on their own do not remove the infection or stop pain. Dental treatment is usually needed as well
  2. Antibiotics, like other medicines, can also have side-effects so won’t be prescribed unless absolutely necessary.
  3. Where definitive treatment has to be delayed due to referral to a specialist service.

 

The leaflet also emphasises that there are better ways to manage toothache than to prescribe antibiotics,8 framing the reasons why in an easy-to-understand format.

There is no doubt that it is not easy to persuade a patient who asks for antibiotics that is it not best for them or for the long-term health of the population.9

Offering further insight, Johnson and Hawkes (2014) wrote: ‘Strategies aimed at educating patients and reducing their demand for unnecessary antibiotics should be implemented in dentistry. Studies in general medical practice show that patient satisfaction in primary care settings depends more on effective communication than on receiving an antibiotic prescription.’9

Intro page image

Preparing to overcome resistance

Offering an overview of the challenge dental professionals face, Jeske (2019) wrote: ‘Antibiotics continue to play an important, albeit adjunctive, role in the management of routine odontogenic infections. They are safe and effective when prescribed at recommended doses and based on the patient’s presenting signs, symptoms, and coexisting medical conditions. The number of patients who are candidates for antibiotic prophylaxis is relatively small, and prophylactic use should be guided by the current recommendations of professional organizations, as based on scientific studies. Dentists should continue to consider emerging evidence for the use of low-dosage antibiotics in cases of refractory periodontitis and other inflammatory diseases.’10

Adding to the practical implications in a dental surgery setting, Johnson and Hawkes (2014) stated: ‘Prudent use of antibiotics is essential to counter the significant threat of antibiotic resistance, which is already having a serious impact on patient care. In dentistry, there are usually interventions that can be used as first-line treatments rather than the prescription of antibiotics.’9

They continued: ‘As dental professionals, we have a duty to use the best evidence-based practice available, and to educate our patients about the choices we make and the reasons for doing so. It is vitally important that public behavioural changes around antibiotic usage are undertaken and that we safeguard antibiotic use for when it is really needed and avoid contributing to the rise of resistant bacterial strains.’9

World Health Organization checklist11 Antibiotic resistance – what can dentists do?

  1. Do you always follow infection prevention and control protocols?
  2. Do you only prescribe antibiotics when they are needed and according to current guidelines?
  3. When prescribing antibiotics, do you talk to patients about how to take them correctly, antibiotic resistance and the dangers of misuse?
  4. Do you ask your patient about their previous and present antibiotic use?
  5. Do you talk to patients about preventing infections (e.g. good oral hygiene)?
Questions: 

References

  1. Antibiotic Awareness: Key messages. World Antibiotic Awareness Week. European Antibiotic Awareness Day. Antibiotic Guardian. Public Health England 2019

  2. Sanderson S. Can we reduce antibiotic prescribing in dentistry? May 2019. https://bda.org/news-centre/blog/can-we-reduce-antibiotic-prescribing-in.... Accessed 10 February 2020

  3. Antimicrobial prescribing. https://www.fgdp.org.uk/antimicrobial-prescribing. Accessed 12 February 2020

  4. Antibiotic resistance in dentistry. https://bda.org/amr. Accessed 10 February 2020

  5. Antimicrobial Prescribing for General Dental Practitioners. Editor: Palmer NO; 2nd Ed, revised 2014. https://www.fgdp.org.uk/antimicrobial-prescribing-standards/prescribing-.... Accessed 10 February 2020

  6. Guidance on prescribing medicines. General Dental Council 2013. https://www.gdc-uk.org/docs/default-source/guidance-documents/guidance-o.... Accessed 12 February 2020

  7. Thompson W et al. I’ve got toothache, I need antibiotics: a UK perspective on rational antibiotic prescribing by dentists. Brazilian Dental Journal 2018; 29(4): 395-399

  8. https://assets.publishing.service.gov.uk/government/uploads/system/uploa.... Accessed 12 February 2020

  9. Johnson TM, Hawkes J. Awareness of antibiotic prescribing and resistance in primary dental care. Primary Dental Journal 2014; 3(4): 44-47

  10. Jeske AH. Antibiotics and antibiotic prophylaxis. In: Contemporary Dental Pharmacology. Springer Nature Switzerland AG 2019

  11. Antibiotic resistance. What can dentists do? https://www.who.int/campaigns/world-antibiotic-awareness-week/dentists.p.... Accessed 10 February 2020