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Upping the ante on antibiotics

Johnson & Johnson is delighted to bring you this article, with the aim of supporting the ongoing CPD needs of dental healthcare professionals in improving and maintaining the oral health of their patients

This article is equivalent to one hour of Enhanced CPD. To provide feedback on this article, please contact dentalcpd@its.jnj.com

Learning outcomes

A,C,D

Aims and objectives

The aim of this article is to explore the current situation with regard to antibiotic use in dentistry and antimicrobial resistance, as well as offering practical advice to clinicians faced with patients requesting antibiotics irrespective of whether their use is indicated.

On completing this Enhanced CPD session, the reader will:

• Understand the current situation in terms of antibiotic use and antimicrobial resistance

• Understand why antimicrobial resistance is a serious global health problem

• Understand why ensuring antibiotics are prescribed appropriately is key to slowing antimicrobial resistance

• Understand the role of the UK Dental Antimicrobial Stewardship Toolkit

• Understand how to communicate the issue to patients who ask for antibiotics when their use is not indicated.

Upping the ‘anti’ on antibiotics

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

Antimicrobials have been used for far longer than some may realise, with tetracycline traces found in human remains dating back to 350-550 CE. What is more familiar for many of us is the work of Paul Ehrlich and Alexander Fleming. Pre-penicillin, there was the discovery of sulfa drugs (sulfonamidochrysoidine), which worked in many situations but are now subject to antimicrobial resistance.1

However, sulfa derivative drugs are still available because, as Aminov (2010) wrote: ‘… many continuously modified derivatives of this oldest class of synthetic antibiotics are still a viable option for therapy, and the action of and resistance to sulfanilamide is one of the best examples for the arms race between man and microbes.’1

Antimicrobial resistance

The World Health Organization (WHO) defines antimicrobial resistance as happening, ‘…when microorganisms (such as bacteria, fungi, viruses, and parasites) change when they are exposed to antimicrobial drugs (such as antibiotics, antifungals, antivirals, antimalarials, and anthelmintics). Microorganisms that develop antimicrobial resistance are sometimes referred to as “superbugs”.’2

WHO continues: ‘As a result, the medicines become ineffective and infections persist in the body, increasing the risk of spread to others.’2

While antimicrobial resistance also occurs naturally over time, often as a result of genetic changes, it is this misuse and overuse of antimicrobials that is speeding up the problem and becoming a serious health concern world-wide.2

WHO has created a list of bacteria that have become resistant to a significant number of antibiotics, divided into critical, high and medium priority to categorise the need for new antibiotics as follows:3

Priority 1: critical

• Acinetobacter baumannii, carbapenem-resistant

• Pseudomonas aeruginosa, carbapenem-resistant

• Enterobacteriaceae, carbapenem-resistant, ESBL-producing

Priority 2: high

• Enterococcus faecium, vancomycin-resistant

• Staphylococcus aureus, methicillin-resistant, vancomycin-intermediate and resistant

• Helicobacter pylori, clarithromycin-resistant

• Campylobacter spp., fluoroquinolone-resistant

• Salmonellae, fluoroquinolone-resistant

• Neisseria gonorrhoeae, cephalosporin-resistant, fluoroquinolone-resistant

Priority 3: medium

• Streptococcus pneumoniae, penicillin-non-susceptible

• Haemophilus influenzae, ampicillin-resistant

• Shigella spp., fluoroquinolone-resistant.

Although this need has been identified, the problem remains that no new classes of antibiotics have been discovered since the 1980s.4

The challenge in dentistry

It has been suggested that one key action to slow antimicrobial resistance lies in ensuring all antibiotics are prescribed appropriately and these prescriptions reviewed regularly.5

Figures indicate that, in 2015, primary care dentists were responsible for 5% of all NHS England antibiotic prescriptions, which equates to 3.4 million prescriptions. The good news is that this is down from 2011, when dentists wrote 3.9 million prescriptions for antibiotics. Nonetheless, work is needed to reduce these figures even further.6

Offering a practical perspective on this issue, Sturrock and colleagues (2018) wrote, ‘…commissioners, providers and individual practitioners should embrace antimicrobial stewardship with the view to improving practice. When prescribing antimicrobials, prescribers should follow local antimicrobial guidelines, where available, or national guidelines, such as the UK Faculty of General Dental Practitioners (FGDP) guidelines on prescribing the shortest effective course, the most appropriate dose and the route of administration for appropriate clinical indications.’7

In response to the antimicrobial resistance challenge, the UK Dental Antimicrobial Stewardship Toolkit was created to help dental primary care practitioners promote the appropriate use of antibiotics in dental care. It offers support to dental professionals and patient-facing resources, for example in the form of posters and leaflets emphasising that antibiotics do not cure toothache.8,9

The toolkit itself comprises a number of documents to help dental professionals manage antibiotic use, created by the FGDP, the British Dental Association (BDA) and the Dental Sub-Group of Public Health England's English surveillance programme for antimicrobial utilisation and resistance (ESPAUR).9

For example, the FGDP’s guidelines for prescribing antimicrobials recommend that they are indicated only in the following circumstances:10

• As an adjunct to the management of acute or chronic infection

• For the definitive management of active infective disease such as necrotising ulcerative gingivitis

• 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 appoproate.’10

The General Dental Council also offers guidance on prescribing medicines, with Standard 7.1 of Standards for the Dental Team requiring dental professionals to, ‘…provide good quality care based on current evidence and authoritative guidance.’11

The guidance continues: ‘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.’11

Offering further support are the British Association of Oral Surgeons’ Antimicrobial Stewardship e-Learning Modules, which are free to use and relevant for all general dental practitioners (see https://www.baos.org.uk/elearning/). Upon completion of the three modules, the aim is that, ‘…participants will be able to demonstrate application of the principles of sound antimicrobial stewardship to common clinical scenarios.’12

Patient compliance

As already briefly touched upon, ‘Antibiotics do not cure toothache’ is the main message of the UK Dental Antimicrobial Stewardship Toolkit for patients.6 Still, patients may ask for antibiotics when they are not indicated and dental professionals may be influenced by patient expectations when it comes to prescribing them.’13

Declining a patient’s request for antibiotics is not easy but is essential for the long-term health of the population.’14 On this, 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.’14

In terms of communicating these concerns to patients, Public Health England suggests that patients should be told that antibiotic resistance is a threat to their overall health and the more they are used, the greater the likelihood they will cease working on infections.16

If prescribing antibiotics is appropriate, for them be effective patients must take the medication as directed. There are a variety of reasons why patients might not recall the dental professional’s instructions about their dosage, for example if they feel stressed or are in pain.16

To counteract this, it may be a good idea to provide written instructions alongside those given verbally. As dentists prescribe a small number of drugs, it should be possible to prepare information sheets in advance. It may be sensible to include not just dose and frequency but also common side effects, in what circumstances they should stop taking the medicine, and a telephone number if they have any questions after leaving the practice.16

Looking to the future

Offering an overview of the situation, Johnson and Hawkes (2014) wrote: ‘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.’14

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.’14

Summary of Patrick and Kandiah’s (2018) recommendations for prescribing antibiotics17
Regular training for all prescribing practitioners, particularly when changes to guidance are put into effect
Regular training for all prescribing practitioners, particularly when changes to guidance are put into effect
Use of audit tools (e.g. from FGDP[UK]) for all primary and secondary care facilities
Following current guidelines:
– Documenting extent of swelling, severity of pain and diagnosis in clinical notes
– Pyrexia – the temperature should be recorded of any patient being treated for infection
– Local measures – treat the source of bacteria
– Prescribing the correct drug, dose and duration
– Correct protocol for prophylactic antibiotics
Implementing templates or tick-box proformas in clinical notes (digital or paper) to encourage compliance with guidelines
Quick reference guides or posters for general dental practitioners displayed wherever prescriptions are written
QUESTIONS: 

References

  1. <p>Aminov RI. A brief history of the antibiotic era: lessons learned and challenges for the future. Frontiers in Microbiology 2010; 1(134): 1-7. doi: 10.3389/fmicb.2010.00134</p>

  2. <p>Antimicrobial resistance. WHO 2018; https://www.who.int/en/news-room/fact-sheets/detail/antimicrobial-resist.... Accessed 24 June 2019</p>

  3. <p>WHO publishes list of bacteria for which new antibiotics are urgently needed. WHO 2107; https://www.who.int/news-room/detail/27-02-2017-who-publishes-list-of-ba.... Accessed 24 June 2019</p>

  4. <p>Tackling antimicrobial resistance 2019-2024. The UK’s five-year national action plan. HM Government 2019</p>

  5. <p>Bird L et al. Higher antibiotic prescribing propensity of dentists in deprived areas and those with greater access to care in the North East and Cumbria: A population-based exploration of prescribing variations. BDJ 2018; 225(6): 517-524</p>

  6. <p>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</p>

  7. <p>Sturrock A et al. An audit of antimicrobial prescribing by dental practitioners in the north east of England and Cumbria. BMC Oral Health 2018; 18: 206-213</p>

  8. <p>Resources toolkit for healthcare professionals in England for World Antibiotic Awareness Week and European Antibiotic Awareness Day. Public Health England 2014 (updated 2018).</p>

  9. <p>Dental antimicrobial stewardship: toolkit. Public Health England 2016. https://www.gov.uk/guidance/dental-antimicrobial-stewardship-toolkit. Accessed 26 June 2019</p>

  10. <p>Antimicrobial Prescribing for General Dental Practitioners. Editor: Palmer NO; 2nd Ed, revised 2014. https://www.fgdp.org.uk/antimicrobial-prescribing-standards. Accessed 24 June 2019 11. Guidance on prescribing medicines. GDC 2013. https://www.gov.uk/.../uploads/.../EAAD-AG_Campaign_Resources_Toolkit_20.... Accessed 24 June 2019</p>

  11. <p>Antimicrobial prescribing. https://www.fgdp.org.uk/antimicrobial-prescribing. Accessed 24 June 2019</p>

  12. <p>Sweeney LC et al. Antibiotic resistance in general dental practice − a cause for concern? Journal of Antimicrobial Chemotherapy 2004 53: 567-576</p>

  13. <p>Johnson TM, Hawkes J. Awareness of antibiotic prescribing and resistance in primary dental care. Prim Dent J 2014; 3(4): 44-47</p>

  14. <p>Antibiotic guardian and antibiotic awareness key messages. Public Health England 2015</p>

  15. <p>Crighton A. Prescribing in dental care: primary principles. Prim Dent J 2014; 3(4): 65-69</p>

  16. Patrick A, Kandiah T. Resistance to change: how much longer will our antibiotics work? Faculty Dental Journal 2018; 9(3): 104-111