Are dentists contributing to an antibiotic overuse?

Before early 20^th century, folk or traditional medicine was widely practiced all over the world to treat infections. The advent of antibiotic Penicillin in 1928 by Scottish Bacteriologist Sir Alexander Fleming revolutionized medical practice. He noticed inhibitory action of a stray mold on a plate culture of staphylococcus bacteria in his laboratory at St. Mary’s Hospital, London. The mold was a strain of Penicillium, P.notatum which gave its name to the famous drug Penicillin. The term antibiotic derives from Greek anti which means “against”+ biōtikos, “fit for life, lively”, which comes from biōsis, “way of life”, and that from bios, “life”. Antibiotics are a class of antimicrobial drugs used to treat and prevent bacterial infections.

Majority of the orofacial infections encountered in dental practice are of odontogenic origin. Most of the odontogenic infections are caused by aerobic and anaerobic bacteria. Viridans streptococci are the most frequently isolated bacteria among the aerobes, whereas Peptostreptococcus, Bacteroides and Prevotella are the most common bacterial species among anaerobes. Therefore, the use of antibiotics in dentistry for therapeutic as well as the prophylactic purpose is quite common. Amoxicillin which belongs to the Penicillin family is the first drug of choice to treat dental infections and to prevent other medical complications. But with 34% of Prevotella species resistant to amoxicillin, alternatives such as amoxicillin/clavulanate, clindamycin and metronidazole are also considered in dentistry.

Patients allergic to penicillin are treated with clindamycin which is the second drug followed by azithromycin and metronidazole. Azithromycin has enhanced pharmacokinetics in encountering the anaerobes involved in endodontic infections. Metronidazole is a synthetic antimicrobial agent, which is bactericidal and most effective against anaerobes. Ciprofloxacin is one of the common drugs used for endodontic infections due to its effective action against oral anaerobes, gram-positive aerobic organisms (Staphylococcus aureus, Enterobacter species and Pseudomonas). The first generation cephalosporins like cefadroxil, cephradine provide a broad spectrum antibiotic when gram-positive organisms are suspected to be the causative factor of the infection. Cephalosporin is advisable for delayed-type allergic reactions to penicillin and when erythromycin cannot be used. It is indicated in endodontic practice as they exhibit good bone penetration. Tetracyclines are bacteriostatic antibiotics that may be used alone or in combination with surgical intervention in periodontal conditions.

As per The ICU Book, “The first rule of antibiotics is trying not to use them, and the second rule is trying not to use too many of them.” Antibiotic prescribing may be associated with unfavourable side effects ranging from gastrointestinal disturbances to fatal anaphylactic shock and development of resistance. Antibiotics should be prescribed at correct frequency, dose and duration so that minimal inhibitory concentration is exceeded, in order to prevent the side effects and selection of resistant bacteria. The ideal duration of antibiotic treatment is the shortest cycle capable of preventing both clinical and microbiological relapse. Repeated antibiotic prescriptions and prolonged courses of antibiotics destroy the commensal flora of oral cavity. In addition, longer durations up to 21 days may result in the selection of resistant strains and a reduction in the ability of the oral flora to resist the colonization by harmful microorganisms that are not normal residents, leading to superimposed infections by multi-resistant bacteria and yeasts. The alteration in GIT microflora also adversely affects gastrointestinal health.

Over the period of year’s misuse of antibiotics has led to Antibiotic Resistance (AR or ABR). Antibiotic resistance is the ability of a microorganism to withstand the effects of an antibiotic. It is a specific type of drug resistance. Antibiotic resistance evolves naturally via natural selection through random mutation, but it could also be engineered by applying an evolutionary stress on a population. In simple terms, there is emergence of bacterial strains that become resistant and continue to multiply even in the presence of therapeutic levels of antibiotic that it normally should have been susceptible to. Hence, they no longer respond to treatment with the most common antibiotics. The inappropriate use and overuse of antibiotics like penicillin and erythromycin have been associated with emerging antibiotic resistance since 1950s. We have entered an era where some bacterial species are resistant to the full range of antibiotics available with the methicillin-resistant Staphylococcus aureus. It is the most widely known example of extensive resistance.

Common forms of antibiotic misuse include excessive use of prophylactic antibiotics in travellers and failure to prescribe correct dosage of antibiotics on the basis of the patient’s weight and medical history. Other forms of misuse include failure to take entire prescribed course of the antibiotic, incorrect dosage and administration or failure to rest for sufficient recovery. Many antibiotics are frequently prescribed to treat symptoms or diseases that do not even respond to antibiotics or that are likely to resolve without treatment. Also, incorrect or suboptimal antibiotics are prescribed for certain bacterial infections.

Self-prescription of antibiotics is another example of misuse. A large chunk of the Indian population prefers going to a pharmacist rather than a doctor in order to self-prescribe antibiotics. These pharmacists inappropriately prescribe antibiotics even for viral infections such as common cold. The appropriate guidelines for prescribing antibiotics are not followed in most of the cases. The compulsory 3 to 7 day course for acute infections isn’t even mentioned to the patient. This leads to missed antibiotic dosages which contribute significantly to antibiotic resistance.

I personally witnessed an incident at a pharmacy right beside a hospital where a gentleman asked the pharmacist to prescribe a tablet for relieving cough & cold. The pharmacist politely asked him to take an appointment with the doctor in the hospital.The gentleman replied that he didn’t have time to consult a doctor. It made me wonder what made him to do so. Did he think that he would save time as well as few bucks which he would have had to spend as consultation? Also isn’t it obvious that he wouldn’t mind referring to a pharmacist again for a toothache, just to save money?

Is it a smart move? What about antibiotic misuse? Who is then responsible for the burden of Antimicrobial Resistance (AMR)? Are people even aware that it as an urgent threat to mankind? The increasing ineffectiveness of antimicrobial drugs to treat common and life-threatening infections would take a serious toll on healthcare. In developed countries, stringent rules and regulations do not allow patients to self-administer antibiotics without a doctor’s prescription. Is it high time that even we need to incorporate such rules in order to avoid indiscriminate use of antibiotics?

I’m sure as practising dentists; majority of you must have come across a lot of patients who just ask for tablets to relieve pain and infection. They have no interest whatsoever to get the tooth treated. To some extent, patient counselling does help to make them understand that pulp extirpation or tooth extraction is the treatment for the offending tooth. However, there is a group of treatment-averse patients who turn a deaf ear to our insistence.

In another scenario, lot of people must have experienced unscheduled emergency pain cases and walked into the clinic on a busy day leaving us with just 5-10 min to spare between other scheduled patients. The protocol would be to accurately diagnose the condition and do the needful accordingly. In spite of being aware that dental pain is primarily an inflammatory condition and usually best treated by clinical intervention supported with effective analgesia. But lack of time makes it more convenient for us to prescribe antibiotics and analgesics as we do not want a call from the patient late at night disturbing our peace and sleep.

Often, it happens that patients refer to the best dentist with acute pain symptoms. The dentists prescribe them with antibiotic and analgesic, the patients do not make subsequent appointments further for treatment of the offending tooth. After a week, when their pain shoots up. Severe pain again force them to refer to another dentist who again prescribes them with same routine antibiotics and analgesics. By chance, if the patient again fails to get treated and repeats this with third dentist, the susceptibility to opportunistic infections increase plus it leads to antibiotic resistance.

Can we afford to imagine a world without effective antibiotics? It is not just the responsibility of the medical practitioners but dental practitioners too to curb the menace of antibiotic abuse. Minimizing inappropriate antibiotic prescribing plays a key role in limiting the development of antibiotic-resistant bacteria. Since dentists prescribe approximately 7 to 10% of all primary care antibiotics, dental prescribing may contribute to antibiotic misuse. The National Center for Disease Control and Prevention estimate that approximately one-third of all outpatient antibiotic prescriptions are unnecessary. Antibiotics should be prescribed when there is severe infection spreading in the mouth. Unfortunately, lot of dentists routinely prescribe oral antibiotics in acute dental conditions. They are under the impression that over-antibiotics give better and unpleasant complications to patients.

Good knowledge of antibiotics is the need of the hour in prescribing for dental conditions. Recommendations to improve antibiotic prescribing practices are given below in an attempt to curb the increasing incidence of antibiotic resistance and other side effects of antibiotic abuse. Antibiotics should be prescribed only if it is clinically beneficial to the patient. Here are a few conditions commonly encountered in clinical practice that do not require an antibiotic prescription:

1. Pulpitis: Inflammation is confined. Hence, it is not a true infection. Extirpation of inflamed pulp is the ideal treatment.
2. Apical periodontitis: Infectious process has just reached adjacent periodontal tissues without any signs of systemic infection such as fever or facial swelling. Since there is pulpal necrosis involved there is no circulation. Effectiveness of antibiotic in such a situation is questionable as it is unlikely that the antibiotic would reach the bacteria in the necrotic pulp in therapeutic concentrations.
3. Dentinal Hypersensitivity: Differentiate between pulpitis and dental hypersensitivity. Eliminate the cause such as sealing off open dentinal tubules by fillings or desensitizing toothpastes.
4. Apthous ulcers: They are self-limiting. Symptomatic therapy such as hydration and topical analgesics is sufficient.
5. Traumatic ulcers: Ulcers due to traumatic injuries, hot food items, chemical burns etc. heal within 10-14 days. Ulcers due to sharp cusps, ill-fitting dentures; sharp denture edges, Orthodontic wires etc. resolve after the trauma-inducing factor is removed. Provide symptomatic relief using topical analgesics.
6. Viral infections like HSV-1 infections (Primary Herpetic Gingivostomatitis, Herpes labialis): Self- limiting, symptomatic therapy for associated fever and ulcers. Topical and oral antivirals, hydration, oral hygiene maintenance.
7. Chronic Gingivitis: Resolves after removal of local irritant i.e. plaque via mechanical therapy.
8. Chronic periodontal conditions: Resolves after removal of local irritant i.e. plaque & Calculus via mechanical therapy.
9. Dry socket: Gentle irrigation and zinc oxide eugenol packs. NSAIDS for pain relief.
10. Post-endodontic flare ups: Controlled prospective clinical trials have demonstrated that antibiotics are not beneficial in treating symptoms after root canal treatments.

Listed below are a few common conditions requiring antibiotics:

1. Acute periapical abscess
2. Infected periapical cyst
3. Periodontal abscess
4. Facial cellulitis which may or may not be associated with dysphagia
5. Pericoronitis
6. Acute Necrotizing ulcerative gingivitis: For cases of acute necrotizing ulcerative gingivitis requiring systemic antibiotic therapy in which penicillin is precluded, tetracyclines are most beneficial.
7. Acute periodontal conditions where drainage and debridement is not possible and infection is spreading systemically
8. Medically compromised patients, diabetics, organ transplant patients, HIV, Neutropenia, Chronic steroid usage, sickle cell anemia
9. Oral infections accompanied by elevated body temperature, evidence of systemic spread like lymphadenopathy
10. Bacterial sialadenitis
11. Prophylactic antibiotics for Bacterial endocarditis
12. Permanent Tooth avulsion

There is a clear need for the development of prescribing guidelines and educational initiatives to encourage the rational and appropriate use of antibiotics in dentistry. The concerned authorities in India need to start campaigns to create awareness among the dentists as well as general public regarding antibiotic misuse. Multifactorial interventions aimed at both dentists and patients can reduce inappropriate prescription of antibiotics. Knowledge about antibiotic selection, dosage duration of antibiotic therapy is a must. We as dentists must reinforce the phrase “Antibiotics don’t cure toothache” among patients. Therefore, antibiotics should never be considered as an alternative to dental intervention, but rather as an adjunct.

References:

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DISCLAIMER : “Views expressed above are the author’s own.”