ANTIBIOTIC PRESCRIBING IN GENERAL DENTAL PRACTICE N O A PALMER1
ABSTRACT The purpose of this paper is to review the principles of antibiotic prescribing in light of the increasing worldwide problem of antibiotic resistance and the evidence of inappropriate use of antibiotics in dentistry. Guidance based on a review of the scientific evidence and recommended good practice for prescribing antibiotics in dental practice will be given. Prim Dent J. 2013; 3(1) 52-57
Introduction Dentists prescribe antibiotics to manage oral and dental infections. The benefits of prescribing antibiotics are, however, limited by a number of problems associated with their use, eg side effects, allergic reactions, toxicity and the development of resistant strains of microbes. 1
FIGURE 1
GENERAL DENTAL PRACTITIONER PRESCRIBING Health & Social Care information centre – prescribing support unit
Dentists working in NHS primary care prescribe nearly 10% of all the oral antimicrobials prescribed in primary care in England.4 Evidence of the inappropriate use of antibiotics in dentistry is well documented and this contributes to the problem of antimicrobial resistance.5-8 With this evidence and the increasing number of prescriptions for antibiotics written by primary care dentists each year (Figure 1) it is imperative to re-examine the role of dentists in prescribing antibiotics in everyday practice.
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Within the last few decades antimicrobial resistance has become a worldwide problem and constitutes a major threat to public health. The Chief Medical Officer recently highlighted the level of this threat by describing it as a “ticking time bomb” that should be put on the government’s national risk register along with terrorism.2 Antimicrobial resistance has increased as a result of widespread use, providing greater opportunity for bacteria to exchange genetic material, allowing resistant genes to spread between bacterial populations. The indiscriminate prescribing of antibiotics by healthcare professions continues to be targeted as a major factor to be addressed,2 especially as fewer and fewer new antibiotics are being developed. Although there are new agents in development, no new class of antibiotic has been brought into clinical use since the 1980s. Dr Margaret Chan, Director General of the World Health Organization, stated that in terms of new antibiotics the “pipeline is virtually dry”.3
1
Nikolaus O A Palmer
Research Associate, Health Education North West and Honorary Lecturer, University of Liverpool
P R I M A R Y D E N TA L J O U R N A L
What influences dentists’ prescribing of antibiotics? Is it applying what was learnt as a student, an individual’s clinical judgement, peer pressure, or is it based on scientific evidence and expert opinion? Whatever the influences, dentists have an ethical, legal and moral responsibility to prescribe antibiotics appropriately.9-11 What are the indications for prescribing antibiotics? Antibiotics can be of benefit and may even be lifesaving in medical and dental treatment, eg Ludwig’s angina, brain abscess. The decision to use antibiotics, however, must be based on a thorough medical history, physical examination and a diagnosis. The indications for prescribing antibiotics in dental practice are listed below: • As an adjunct to surgical treatment of an acute or chronic infection • To treat active infective disease, eg necrotising ulcerative gingivitis • Where definitive treatment may be delayed due to referral to specialist services, eg inability to establish drainage in an uncooperative patient requiring sedation or general anaesthetic12 Therapeutic antibiotic prescribing The indications for the therapeutic use of antibiotics are well documented and defined, namely, where there are signs of spreading infection, the patient feels unwell, is pyrexic (temperature over 38˚C) and tachycardic (pulse over 100) and where there is marked regional lymphadenitis.13,14 The majority of uncomplicated infected swellings of dental origin can be successfully treated by removal of the source of the infection by drainage of the associated abscess, removal of infected pulp contents or by extraction of the tooth. Unless the source of the
VOL 3 NO 1 FEBRUARY 2014
infection is eradicated, any other mode of treatment will ultimately fail. Prescribing antibiotics as a temporary substitute for eradication of the cause of an infection also cannot be justified, except on rare occasions when it is impossible to remove the cause or establish drainage immediately.12
Where there is an absence of infection there is no justification for the therapeutic prescribing of antibiotics
Where there is an absence of infection there is no justification for the therapeutic prescribing of antibiotics. Antibiotics, for example, are not effective in the management of pain associated with irreversible pulpitis.15 The therapeutic prescribing of antibiotics ‘just in case’ problems may arise from recent treatment can lead to serious problems in delaying diagnosis and subjecting patients to side effects or toxicity.13 It has been suggested that inappropriate prescribing of antibiotics could amount to negligence or impairment of fitness to practise, particularly if there were no indications for antibiotics and a serious clinical outcome ensued.16 It is important that clinicians consider carefully the rationale for antibiotic use and balance
53
Caption here?
ANTIBIOTIC PRESCRIBING IN GENERAL DENTAL PRACTICE
TA B L E 1
THERAPEUTIC ANTIBIOTIC REGIMENS FIRST CHOICE Amoxicillin 500mg three times daily for up to 5 days OR Phenoxymethylpenicillin 500mg four times daily for up to 5 days. If a predominately anaerobic infection is suspected then: Metronidazole 200mg three times daily for three days SECOND CHOICE Metronidazole 200mg three times daily for three days THIRD CHOICE Clarithromycin 250mg twice daily up to five days or Azithromycin 500mg once daily for 2-3days Paediatric dosages should be based on the age and or body weight of the patient- consult the British National Formulary 45
this against any alternative treatment approach based on evidence, guidelines and best practice.9,12,17 Chronic dentoalveolar infections rarely require antibiotics unless there is evidence of gross local spread; extraction or root canal therapy are the definitive treatment options.18 The routine use of antibiotics for acute pericoronitis is not advocated, with the majority of these patients effectively treated with local measures. These include irrigation of the pericoronal space, removal of the opposing tooth, or easing the occlusion if there is trauma to the pericoronal tissues and the use of appropriate analgesics. Following resolution of the acute phase, soft-tissue surgery or removal of the associated tooth should be considered. Antibiotics should only be prescribed for pericoronitis when there is evidence of a spreading infection or systemic involvement is present.17 Evidence suggests that local measures also suffice in the treatment of dry socket.19,20 It is inappropriate for dentists to prescribe antibiotics routinely for dry
54
socket as the benefit to risk ratio is unfavourable. There is also little indication for dentists to prescribe for uncomplicated sinusitis. Research has shown that antibiotics do not affect the clinical course of this condition.21 The use of systemic antibiotics in the treatment of periodontal disease remains controversial. The use of antibiotics for necrotic ulcerative gingivitis is recommended as part of the initial therapy only in the presence of systemic involvement.22 Chronic marginal gingivitis responds well to good plaque control and periodontal therapy. By its very nature it is not an acute or spreading infection and does not require antibiotics. The majority of uncomplicated swellings of periodontal origin can be successfully treated by drainage of the associated abscess by root surface debridement or extraction of the tooth.23,24 A review of current evidence shows that the routine use of systemic or local antimicrobials,29 as an adjunct to root surface debridement and good plaque control, in the treatment of chronic periodontitis produce no clinical benefit . There is, however, evidence that systemic antibiotics may be of use in aggressive periodontitis in improving pocket depth reductions and gains in clinical attachment,26,30 although these improvements may only be short term.31 Host modulation therapy, in the form of sub-antimicrobial doses of tetracycline, has been suggested as an adjunct to root surface debridement in the management of periodontal disease. There is little evidence of an improvement in clinical outcomes when this therapy is used in primary care.32,33 Where there is an indication for therapeutic use of antibiotics the regimens to be employed are shown in Table 1. The first choice is a penicillin, such as amoxicillin. Phenoxymethylpenicillin is as effective but less reliably absorbed and needs to be taken on an empty stomach.
P R I M A R Y D E N TA L J O U R N A L
susceptible to infection because of a pre-existing disease and for the prevention of postoperative infection for procedures that carry a high risk of infection.
Metronidazole is an excellent first-line treatment for patients who are allergic to penicillin, have recently completed a course of penicillin or if a predominantly anaerobic infection is suspected. A macrolide, such as azithromycin or clarithromycin, can be used as an alternative to penicillin. These are better tolerated than erythromycin, which causes nausea, vomiting and diarrhoea in some patients (and many organisms are resistant to it).
The use of antibiotics to prevent postoperative infection in healthy patients is not supported by experimental evidence and is inconsistent with established principles of surgical antibiotic prophylaxis. It has been recommended that prophylaxis should only be for surgical procedures with a high infection rate.35 Fortunately within dentistry, in the presence of good infection prevention, there are no procedures recorded as having high rates of postoperative infection. Uncomplicated surgical removal of teeth and apicectomies rarely give rise to postoperative infections. Evidence exists that the prophylactic use of antimicrobials has no effect on postoperative pain, swelling, infection or wound healing.36-38
Whenever managing an infection it is important to review after 2-3 days to assess whether the patient is responding to treatment. If antibiotics have been prescribed with definitive management, the swelling should be resolving and the temperature of the patient should have returned to normal. If this is the case, antibiotics can be discontinued.34 Prophylactic prescribing of antibiotics Prophylactic antibiotics have been recommended for patients who are
REFERENCES 1
2
3
4
Finch RG. Adverse reactions to antibiotics. In: Greenwood D, editor. Antimicrobial Chemotherapy. 4th ed. Oxford: Oxford University Press; 2000. p. 200-11. Department of Health. Annual Report of the Chief Medical Officer, Volume Two, 2011. Infections and the Rise of Antimicrobial Resistance. London: DH; 2013. World Health Organization. Launching a new WHO publication on Antimicrobial Resistance, 2013. Geneva: WHO; 2013. Accessed (2013 Nov 25) at: www.who.int/patientsafety/imple mentation/amr/en/index.html Prescribing and Primary Care Services Health and Social Care Information Service. Prescribing by Dentists: England 2012. Accessed (2013 Nov 25) at: https://catalogue.ic.nhs.uk/publi
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cations/primary-care/dentistry/ pres-dent-eng-2012/pres-denteng- 2012-rpt.pdf Palmer NO, Pealing R, Ireland RS, Martin MV. A study of therapeutic antibiotic prescribing in National Health Service general dental practice in England. Br Dent J. 2000;10:554-8. Palmer NO, Martin MV, Pealing R, Ireland RS. Paediatric antibiotic prescribing by general dental practitioners in England. Int J Paediatr Dent. 2001;11:242-8. Palmer NO, Martin MV, Pealing R, Ireland RS. An analysis of antibiotic prescriptions from general dental practitioners in England. J Antimicrob Chemother. 2000;46:1033-5. Tulip DE, Palmer NO. A retrospective investigation of the clinical management of patients attending an out of hours dental clinic in Merseyside under the new NHS dental contract. Br Dent J. 2008;205:659-64. General Dental Council.
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Standards for the Dental Team. London: GDC; 2013. Accessed (2013 Nov 25) at: www.gdcuk.org/ Dentalprofessionals /Standards/Documents/Standard s%20for%20the%20Dental%20 Team.pdf 10 General Dental Council. Guidance on Prescribing Medicines. London: GDC; 2013. Accessed (2013 Nov 25) at: www.gdc-uk.org/Dentalprofess ionals/Standards/Documents/ Guidance%20Sheet%20Guidance %20on%20Prescribing%20 Medicines%20September% 202013%20v2.pdf 11 Department of Health. Health and Social Care Act 2008. Code of Practice on the Prevention and Control of Infections and Related Guidance. London: DH; 2010. Accessed (2013 Nov 25) at: www.gov.uk/government/upload s/system/uploads/attachment_da ta/file/216227/dh_123923.pdf 12 Faculty of General Dental Practice (UK). Antimicrobial Prescribing
13
14
15
16
17
for General Dental Practitioners. 2nd ed. London: FGDP(UK); 2012. Cawson RA, Spector GR. Clinical Pharmacology in Dentistry. 5th ed. London: Churchill Livingstone; 1989. Scottish Dental Clinical Effectiveness Programme (SDCEP). Drug Prescribing for Dentistry. Dental Clinical Guidance. 2nd ed. Dundee: SDCEP; 2011. Nagle D, Reader A, Beck M, Weaver J. Effect of systemic penicillin on pain in untreated irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;90:636-40. Forde MP. Antibiotic overuse in general dental practice: clinical, ethical and legal implications [MA law dissertation]. Manchester: Manchester Metropolitan University; 2000. Faculty of Dental Surgery. National Clinical Guidelines. London: The Royal College of Surgeons of England; 1997.
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Caption here?
ANTIBIOTIC PRESCRIBING IN GENERAL DENTAL PRACTICE
Prescribing prophylactic antimicrobials for implant placement remains controversial and recent research has shown a plethora of regimens used in the absence of guidelines.39 It has been shown that antimicrobials do not provide any significant advantage with regard to postoperative infections in the presence of good asepsis.40,41 A meta-analysis including only four randomised controlled trials has suggested that that prophylactic antimicrobials at implant placement may reduce implant failure.42 In the past, prophylactic antimicrobials have been prescribed to prevent bacteraemias and metastatic infection in medically compromised patients. Review of the research evidence has shown that the frequency of bacteraemias from normal oral function is greater than from dental procedures.43 Prior to the publication of NICE guidelines, patients with acquired or congenital endocardial disease were required to have antimicrobial
18 Pogrel MA. Antibiotics in general practice. Dent Update. 1994;21:274-80. 19 Blum IR. Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization, aetiopathogenesis and management: a critical review. Int J Oral Maxillofac Surg. 2002;31:309-17. 20 Noroozi AR, Philbert RF. Modern concepts in understanding and management of the “dry socket” syndrome: comprehensive review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107:30-5. 21 National Institute for Health and Clinical Excellence. Prescribing of Antibiotics for Self-Limiting Respiratory Infections in Adults and Children in Primary Care. CG69. London: NICE; 2009. 22 Johnson BD, Engel D. Acute necrotizing ulcerative gingivitis. A review of diagnosis, etiology and treatment. J Periodontol. 1986;57:141-50. 23 Matthews DC, Sutherland S, Basrani
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24
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26
27
prophylaxis before a number of dental procedures. NICE guidelines advise antimicrobial prophylaxis is no longer required for these patients.44 Medically compromised patients fall into a number of other groups: patients who have prosthetic implants, patients who are immunocompromised, patients who have had radiotherapy to the jaws or who are receiving bisphosphonates. The Working Party of the British Society of Antimicrobial Chemotherapy advises that patients who have total joint implants do not require antibiotic prophylaxis prior to dental treatment.45 A recent case controlled study confirmed that dental treatment is not a risk factor for subsequent joint replacement infections.46 Patients with cardiac pacemakers, penile, breast or intraocular implants and prosthetic grafts also do not need antimicrobial prophylaxis prior to dental treatment.45 Immune function of patients may be impaired by a range of conditions
B. Emergency management of acute apical abscesses in the permanent dentition: a systematic review of the literature. J Can Dent Assoc. 2003;69:660. Matthews DC, Sutherland S. Clinical practice guidelines on emergency management of acute apical periodontitis and acute apical abscess. Evid Based Dent. 2004;5:7-11. [letter: Evid Based Dent. 2004;5:84.] Herrera D, Sanz M, Jepsen S, Needleman I, Roldán S. A systematic review on the effect of systemic antimicrobials as an adjunct to scaling and root planing in periodontitis patients. J Clin Periodontol. 2002;29 Suppl 3: 136-59; discussion 60-2. Herrera D, Alonso B, León R, Roldán S, Sanz M. Antimicrobial therapy in periodontitis: the use of systemic antimicrobials against the subgingival biofilm. J Clin Periodontol. 2008;35(8 Suppl):45-66. Sgolastra F, Gatto R, Petrucci A, Monaco A. Effectiveness of systemic
28
29
30
31
such as leukaemia, immunosuppressive drugs following transplants, lymphomas, chemotherapy, poorly controlled diabetes and HIV. The importance of good dental health and treating odontogenic infections aggressively for these patients cannot be overemphasised. There is no clear evidence that these patients are at risk of infection as a result of routine dental procedures and as such antimicrobial prophylaxis is not required.45,47 It is important that all emergency treatment for immunocompromised patients should be carried out in conjunction with advice from the patient’s specialist. Osteoradionecrosis is a serious outcome of extractions in patients who have undergone radiotherapy to the head and neck region. It is known that this risk increases with time. Patients on bisphosphonate medication, particularly intravenous zoledronic acid, are also at risk of osteonecrosis.48 The efficacy of prophylactic antimicrobials for dental
amoxicillin/metronidazole as adjunctive therapy to scaling and root planing in the treatment of chronic periodontitis: a systematic review and meta-analysis. J Periodontol. 2012;83:1257-69. Zandbergen D, Slot DE, Cobb CM, van der Weijden FA. The clinical effect of scaling and root planing and the concomitant administration of systemic amoxicillin and metronidazole: a systematic review. J Periodontol. 2013;84:332-51. Bonito AJ, Lux L, Lohr KN. Impact of local adjuncts to scaling and root planing in periodontal disease therapy: a systematic review. J Periodontol. 2005;76:1227-36. Guerrero A, Griffiths GS, Nibali L, Suvan J, Moles DR, Laurell L, et al. Adjunctive benefits of systemic amoxicillin and metronidazole in non-surgical treatment of generalized aggressive periodontitis: a randomized placebo-controlled clinical trial. J Clin Periodontol. 2005;32:1096-107. Varela VM, Heller D, Silva-Senem
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33
34
35
MX, Torres MC, Colombo AP, Feres-Filho EJ. Systemic antimicrobials adjunctive to a repeated mechanical and antiseptic therapy for aggressive periodontitis: a 6-month randomized controlled trial. J Periodontol. 2011;82:1121-30. Preshaw PM, Hefti AF, Bradshaw MH. Adjunctive subantimicrobial dose doxycycline in smokers and non-smokers with chronic periodontitis. J Clin Periodontol. 2005;32:610-6. Sgolastra F, Petrucci A, Gatto R, Giannoni M, Monaco A. Long-term efficacy of subantimicrobial-dose doxycycline as an adjunctive treatment to scaling and root planing: a systematic review and meta-analysis. J Periodontol. 2011;82:1570-81. Martin MV, Longman LP, Hill JB, Hardy P. Acute dentoalveolar infections: an investigation of the duration of antibiotic therapy. Br Dent J. 1997;183:135-7. Slots J, Pallasch TJ. Dentists’ role in halting antimicrobial resistance
P R I M A R Y D E N TA L J O U R N A L
treatment is questionable due to poor blood flow and tissue penetration in both these groups of patients. Nevertheless, antimicrobial prophylaxis has been recommended by some authorities and these patients are best managed in a hospital environment. Patients on oral bisphosphonates do not require antimicrobial prophylaxis for routine dental treatment and can be managed in primary care.49
Conclusion Dental practitioners need to be aware of the increasing problem of antimicrobial resistance and be prudent in their prescribing of antibiotics. Wherever possible dental practitioners should surgically manage dental infections and antibiotics should only be prescribed when necessary based on patient symptoms, diagnosis and current guidelines.
Example of bisphosphonate induced osteonecrosis
36
37
38
39
[editorial] [erratum J Dent Res. 1996;75:1811]. J Dent Res. 1996;75:1338-41. Happonen RP, Backstrom AC, Ylipaavalniemi P. Prophylactic use of phenoxymethylpenicillin and tinidazole in mandibular third molar surgery, a comparative placebo controlled clinical trial. Br J Oral Maxillofac Surg. 1990;28:12-5. Siddiqi A, Morkel JA, Zafar S. Antibiotic prophylaxis in third molar surgery: A randomized double-blind placebo-controlled clinical trial using split-mouth technique. Int J Oral Maxillofac Surg. 2010;39:107-14. Lindeboom JA, Frenken JW, Valkenburg P, van den Akker HP. The role of preoperative prophylactic antibiotic administration in periapical endodontic surgery: a randomized, prospective double-blind placebocontrolled study. Int Endod J. 2005;38:877-81. Ireland RS, Palmer NO,
Lindenmeyer A, Mills N. An investigation of antibiotic prophylaxis in implant practice in the UK. Br Dent J. 2012;213:E14. 40 Abu-Ta’a M, Quirynen M, Teughels W, van Steenberghe D. Asepsis during periodontal surgery involving oral implants and the usefulness of peri-operative antibiotics: a prospective, randomized, controlled clinical trial. J Clin Periodontol. 2008;35:58-63. 41 Esposito M, Cannizzaro G, Bozzoli P, Checchi L, Ferri V, Landriani S, et al. Effectiveness of prophylactic antibiotics at placement of dental implants: a pragmatic multicentre placebo-controlled randomised clinical trial. Eur J Oral Implantol. 2010;3:135-43. 42 Esposito M, Grusovin MG, Loli V, Coulthard P, Worthington HV. Does antibiotic prophylaxis at implant placement decrease early implant failures? A Cochrane systematic review. Eur J Oral Implantol.
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2010;3:101-10. 43 Gould FK, Elliott TS, Foweraker J, Fulford, M, Perry JD, Roberts GJ, et al. Guidelines for the prevention of endocarditis: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother. 2006;57:1035-42. 44 National Institute for Health and Clinical Excellence. Antimicrobial Prophylaxis Against Infective Endocarditis in Adults and Children Undergoing Interventional Procedures. CG64. London: NICE; 2008. Accessed (2013 Nov 25) at: http://guidance.nice.org.uk/CG6 4 45 Joint Formulary Committee. British National Formulary. BNF 66. London: British Medical Association and the Royal Pharmaceutical Society of Great Britain; 2013. Accessed (2013 Nov 25) at: www.BNF.org 46 Berbari EF, Osmon DR, Carr A, Hanssen AD, Baddour LM, Greene
D, et al. Dental procedures as risk factors for prosthetic hip or knee infection: a hospital-based prospective case-control study. Clin Infect Dis. 2010;50:8-16. 47 Lockhart PB, Loven B, Brennan MT, Fox PC. The evidence base for the efficacy of antibiotic prophylaxis in dental practice. J Am Dent Assoc. 2007;138:458-74; quiz 534-5, 437. 48 Bamias A, Kastritis E, Bamia C, Moulopoulos LA, Melakopoulos I, Bozas G, et al. Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: incidence and risk factors. J Clin Oncol. 2005;23:85807. 49 Edwards BJ, Hellstein JW, Jacobsen PL, Kaltman S, Marlotti A, Migliorati CA, et al. Updated recommendations for managing the care of patients receiving oral bisphosphonate therapy: an advisory statement from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2008;139:1674-7.
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ABSTRACT The purpose of this paper is to review the principles of antibiotic prescribing in light of the increasing worldwide problem of antibiotic resistance and the evidence of inappropriate use of antibiotics in dentistry. Guidance based on a review of the scientific evidence and recommended good practice for prescribing antibiotics in dental practice will be given. Prim Dent J. 2013; 3(1) 52-57
Introduction Dentists prescribe antibiotics to manage oral and dental infections. The benefits of prescribing antibiotics are, however, limited by a number of problems associated with their use, eg side effects, allergic reactions, toxicity and the development of resistant strains of microbes. 1
FIGURE 1
GENERAL DENTAL PRACTITIONER PRESCRIBING Health & Social Care information centre – prescribing support unit
Dentists working in NHS primary care prescribe nearly 10% of all the oral antimicrobials prescribed in primary care in England.4 Evidence of the inappropriate use of antibiotics in dentistry is well documented and this contributes to the problem of antimicrobial resistance.5-8 With this evidence and the increasing number of prescriptions for antibiotics written by primary care dentists each year (Figure 1) it is imperative to re-examine the role of dentists in prescribing antibiotics in everyday practice.
40 00
38 00 37 00 36 00 35 00 34 00 33 00 32 00
Year
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
31 00
1996
Antibiotic prescribing in thousands
39 00
52
Within the last few decades antimicrobial resistance has become a worldwide problem and constitutes a major threat to public health. The Chief Medical Officer recently highlighted the level of this threat by describing it as a “ticking time bomb” that should be put on the government’s national risk register along with terrorism.2 Antimicrobial resistance has increased as a result of widespread use, providing greater opportunity for bacteria to exchange genetic material, allowing resistant genes to spread between bacterial populations. The indiscriminate prescribing of antibiotics by healthcare professions continues to be targeted as a major factor to be addressed,2 especially as fewer and fewer new antibiotics are being developed. Although there are new agents in development, no new class of antibiotic has been brought into clinical use since the 1980s. Dr Margaret Chan, Director General of the World Health Organization, stated that in terms of new antibiotics the “pipeline is virtually dry”.3
1
Nikolaus O A Palmer
Research Associate, Health Education North West and Honorary Lecturer, University of Liverpool
P R I M A R Y D E N TA L J O U R N A L
What influences dentists’ prescribing of antibiotics? Is it applying what was learnt as a student, an individual’s clinical judgement, peer pressure, or is it based on scientific evidence and expert opinion? Whatever the influences, dentists have an ethical, legal and moral responsibility to prescribe antibiotics appropriately.9-11 What are the indications for prescribing antibiotics? Antibiotics can be of benefit and may even be lifesaving in medical and dental treatment, eg Ludwig’s angina, brain abscess. The decision to use antibiotics, however, must be based on a thorough medical history, physical examination and a diagnosis. The indications for prescribing antibiotics in dental practice are listed below: • As an adjunct to surgical treatment of an acute or chronic infection • To treat active infective disease, eg necrotising ulcerative gingivitis • Where definitive treatment may be delayed due to referral to specialist services, eg inability to establish drainage in an uncooperative patient requiring sedation or general anaesthetic12 Therapeutic antibiotic prescribing The indications for the therapeutic use of antibiotics are well documented and defined, namely, where there are signs of spreading infection, the patient feels unwell, is pyrexic (temperature over 38˚C) and tachycardic (pulse over 100) and where there is marked regional lymphadenitis.13,14 The majority of uncomplicated infected swellings of dental origin can be successfully treated by removal of the source of the infection by drainage of the associated abscess, removal of infected pulp contents or by extraction of the tooth. Unless the source of the
VOL 3 NO 1 FEBRUARY 2014
infection is eradicated, any other mode of treatment will ultimately fail. Prescribing antibiotics as a temporary substitute for eradication of the cause of an infection also cannot be justified, except on rare occasions when it is impossible to remove the cause or establish drainage immediately.12
Where there is an absence of infection there is no justification for the therapeutic prescribing of antibiotics
Where there is an absence of infection there is no justification for the therapeutic prescribing of antibiotics. Antibiotics, for example, are not effective in the management of pain associated with irreversible pulpitis.15 The therapeutic prescribing of antibiotics ‘just in case’ problems may arise from recent treatment can lead to serious problems in delaying diagnosis and subjecting patients to side effects or toxicity.13 It has been suggested that inappropriate prescribing of antibiotics could amount to negligence or impairment of fitness to practise, particularly if there were no indications for antibiotics and a serious clinical outcome ensued.16 It is important that clinicians consider carefully the rationale for antibiotic use and balance
53
Caption here?
ANTIBIOTIC PRESCRIBING IN GENERAL DENTAL PRACTICE
TA B L E 1
THERAPEUTIC ANTIBIOTIC REGIMENS FIRST CHOICE Amoxicillin 500mg three times daily for up to 5 days OR Phenoxymethylpenicillin 500mg four times daily for up to 5 days. If a predominately anaerobic infection is suspected then: Metronidazole 200mg three times daily for three days SECOND CHOICE Metronidazole 200mg three times daily for three days THIRD CHOICE Clarithromycin 250mg twice daily up to five days or Azithromycin 500mg once daily for 2-3days Paediatric dosages should be based on the age and or body weight of the patient- consult the British National Formulary 45
this against any alternative treatment approach based on evidence, guidelines and best practice.9,12,17 Chronic dentoalveolar infections rarely require antibiotics unless there is evidence of gross local spread; extraction or root canal therapy are the definitive treatment options.18 The routine use of antibiotics for acute pericoronitis is not advocated, with the majority of these patients effectively treated with local measures. These include irrigation of the pericoronal space, removal of the opposing tooth, or easing the occlusion if there is trauma to the pericoronal tissues and the use of appropriate analgesics. Following resolution of the acute phase, soft-tissue surgery or removal of the associated tooth should be considered. Antibiotics should only be prescribed for pericoronitis when there is evidence of a spreading infection or systemic involvement is present.17 Evidence suggests that local measures also suffice in the treatment of dry socket.19,20 It is inappropriate for dentists to prescribe antibiotics routinely for dry
54
socket as the benefit to risk ratio is unfavourable. There is also little indication for dentists to prescribe for uncomplicated sinusitis. Research has shown that antibiotics do not affect the clinical course of this condition.21 The use of systemic antibiotics in the treatment of periodontal disease remains controversial. The use of antibiotics for necrotic ulcerative gingivitis is recommended as part of the initial therapy only in the presence of systemic involvement.22 Chronic marginal gingivitis responds well to good plaque control and periodontal therapy. By its very nature it is not an acute or spreading infection and does not require antibiotics. The majority of uncomplicated swellings of periodontal origin can be successfully treated by drainage of the associated abscess by root surface debridement or extraction of the tooth.23,24 A review of current evidence shows that the routine use of systemic or local antimicrobials,29 as an adjunct to root surface debridement and good plaque control, in the treatment of chronic periodontitis produce no clinical benefit . There is, however, evidence that systemic antibiotics may be of use in aggressive periodontitis in improving pocket depth reductions and gains in clinical attachment,26,30 although these improvements may only be short term.31 Host modulation therapy, in the form of sub-antimicrobial doses of tetracycline, has been suggested as an adjunct to root surface debridement in the management of periodontal disease. There is little evidence of an improvement in clinical outcomes when this therapy is used in primary care.32,33 Where there is an indication for therapeutic use of antibiotics the regimens to be employed are shown in Table 1. The first choice is a penicillin, such as amoxicillin. Phenoxymethylpenicillin is as effective but less reliably absorbed and needs to be taken on an empty stomach.
P R I M A R Y D E N TA L J O U R N A L
susceptible to infection because of a pre-existing disease and for the prevention of postoperative infection for procedures that carry a high risk of infection.
Metronidazole is an excellent first-line treatment for patients who are allergic to penicillin, have recently completed a course of penicillin or if a predominantly anaerobic infection is suspected. A macrolide, such as azithromycin or clarithromycin, can be used as an alternative to penicillin. These are better tolerated than erythromycin, which causes nausea, vomiting and diarrhoea in some patients (and many organisms are resistant to it).
The use of antibiotics to prevent postoperative infection in healthy patients is not supported by experimental evidence and is inconsistent with established principles of surgical antibiotic prophylaxis. It has been recommended that prophylaxis should only be for surgical procedures with a high infection rate.35 Fortunately within dentistry, in the presence of good infection prevention, there are no procedures recorded as having high rates of postoperative infection. Uncomplicated surgical removal of teeth and apicectomies rarely give rise to postoperative infections. Evidence exists that the prophylactic use of antimicrobials has no effect on postoperative pain, swelling, infection or wound healing.36-38
Whenever managing an infection it is important to review after 2-3 days to assess whether the patient is responding to treatment. If antibiotics have been prescribed with definitive management, the swelling should be resolving and the temperature of the patient should have returned to normal. If this is the case, antibiotics can be discontinued.34 Prophylactic prescribing of antibiotics Prophylactic antibiotics have been recommended for patients who are
REFERENCES 1
2
3
4
Finch RG. Adverse reactions to antibiotics. In: Greenwood D, editor. Antimicrobial Chemotherapy. 4th ed. Oxford: Oxford University Press; 2000. p. 200-11. Department of Health. Annual Report of the Chief Medical Officer, Volume Two, 2011. Infections and the Rise of Antimicrobial Resistance. London: DH; 2013. World Health Organization. Launching a new WHO publication on Antimicrobial Resistance, 2013. Geneva: WHO; 2013. Accessed (2013 Nov 25) at: www.who.int/patientsafety/imple mentation/amr/en/index.html Prescribing and Primary Care Services Health and Social Care Information Service. Prescribing by Dentists: England 2012. Accessed (2013 Nov 25) at: https://catalogue.ic.nhs.uk/publi
5
6
7
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cations/primary-care/dentistry/ pres-dent-eng-2012/pres-denteng- 2012-rpt.pdf Palmer NO, Pealing R, Ireland RS, Martin MV. A study of therapeutic antibiotic prescribing in National Health Service general dental practice in England. Br Dent J. 2000;10:554-8. Palmer NO, Martin MV, Pealing R, Ireland RS. Paediatric antibiotic prescribing by general dental practitioners in England. Int J Paediatr Dent. 2001;11:242-8. Palmer NO, Martin MV, Pealing R, Ireland RS. An analysis of antibiotic prescriptions from general dental practitioners in England. J Antimicrob Chemother. 2000;46:1033-5. Tulip DE, Palmer NO. A retrospective investigation of the clinical management of patients attending an out of hours dental clinic in Merseyside under the new NHS dental contract. Br Dent J. 2008;205:659-64. General Dental Council.
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Standards for the Dental Team. London: GDC; 2013. Accessed (2013 Nov 25) at: www.gdcuk.org/ Dentalprofessionals /Standards/Documents/Standard s%20for%20the%20Dental%20 Team.pdf 10 General Dental Council. Guidance on Prescribing Medicines. London: GDC; 2013. Accessed (2013 Nov 25) at: www.gdc-uk.org/Dentalprofess ionals/Standards/Documents/ Guidance%20Sheet%20Guidance %20on%20Prescribing%20 Medicines%20September% 202013%20v2.pdf 11 Department of Health. Health and Social Care Act 2008. Code of Practice on the Prevention and Control of Infections and Related Guidance. London: DH; 2010. Accessed (2013 Nov 25) at: www.gov.uk/government/upload s/system/uploads/attachment_da ta/file/216227/dh_123923.pdf 12 Faculty of General Dental Practice (UK). Antimicrobial Prescribing
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for General Dental Practitioners. 2nd ed. London: FGDP(UK); 2012. Cawson RA, Spector GR. Clinical Pharmacology in Dentistry. 5th ed. London: Churchill Livingstone; 1989. Scottish Dental Clinical Effectiveness Programme (SDCEP). Drug Prescribing for Dentistry. Dental Clinical Guidance. 2nd ed. Dundee: SDCEP; 2011. Nagle D, Reader A, Beck M, Weaver J. Effect of systemic penicillin on pain in untreated irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;90:636-40. Forde MP. Antibiotic overuse in general dental practice: clinical, ethical and legal implications [MA law dissertation]. Manchester: Manchester Metropolitan University; 2000. Faculty of Dental Surgery. National Clinical Guidelines. London: The Royal College of Surgeons of England; 1997.
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ANTIBIOTIC PRESCRIBING IN GENERAL DENTAL PRACTICE
Prescribing prophylactic antimicrobials for implant placement remains controversial and recent research has shown a plethora of regimens used in the absence of guidelines.39 It has been shown that antimicrobials do not provide any significant advantage with regard to postoperative infections in the presence of good asepsis.40,41 A meta-analysis including only four randomised controlled trials has suggested that that prophylactic antimicrobials at implant placement may reduce implant failure.42 In the past, prophylactic antimicrobials have been prescribed to prevent bacteraemias and metastatic infection in medically compromised patients. Review of the research evidence has shown that the frequency of bacteraemias from normal oral function is greater than from dental procedures.43 Prior to the publication of NICE guidelines, patients with acquired or congenital endocardial disease were required to have antimicrobial
18 Pogrel MA. Antibiotics in general practice. Dent Update. 1994;21:274-80. 19 Blum IR. Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization, aetiopathogenesis and management: a critical review. Int J Oral Maxillofac Surg. 2002;31:309-17. 20 Noroozi AR, Philbert RF. Modern concepts in understanding and management of the “dry socket” syndrome: comprehensive review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107:30-5. 21 National Institute for Health and Clinical Excellence. Prescribing of Antibiotics for Self-Limiting Respiratory Infections in Adults and Children in Primary Care. CG69. London: NICE; 2009. 22 Johnson BD, Engel D. Acute necrotizing ulcerative gingivitis. A review of diagnosis, etiology and treatment. J Periodontol. 1986;57:141-50. 23 Matthews DC, Sutherland S, Basrani
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prophylaxis before a number of dental procedures. NICE guidelines advise antimicrobial prophylaxis is no longer required for these patients.44 Medically compromised patients fall into a number of other groups: patients who have prosthetic implants, patients who are immunocompromised, patients who have had radiotherapy to the jaws or who are receiving bisphosphonates. The Working Party of the British Society of Antimicrobial Chemotherapy advises that patients who have total joint implants do not require antibiotic prophylaxis prior to dental treatment.45 A recent case controlled study confirmed that dental treatment is not a risk factor for subsequent joint replacement infections.46 Patients with cardiac pacemakers, penile, breast or intraocular implants and prosthetic grafts also do not need antimicrobial prophylaxis prior to dental treatment.45 Immune function of patients may be impaired by a range of conditions
B. Emergency management of acute apical abscesses in the permanent dentition: a systematic review of the literature. J Can Dent Assoc. 2003;69:660. Matthews DC, Sutherland S. Clinical practice guidelines on emergency management of acute apical periodontitis and acute apical abscess. Evid Based Dent. 2004;5:7-11. [letter: Evid Based Dent. 2004;5:84.] Herrera D, Sanz M, Jepsen S, Needleman I, Roldán S. A systematic review on the effect of systemic antimicrobials as an adjunct to scaling and root planing in periodontitis patients. J Clin Periodontol. 2002;29 Suppl 3: 136-59; discussion 60-2. Herrera D, Alonso B, León R, Roldán S, Sanz M. Antimicrobial therapy in periodontitis: the use of systemic antimicrobials against the subgingival biofilm. J Clin Periodontol. 2008;35(8 Suppl):45-66. Sgolastra F, Gatto R, Petrucci A, Monaco A. Effectiveness of systemic
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such as leukaemia, immunosuppressive drugs following transplants, lymphomas, chemotherapy, poorly controlled diabetes and HIV. The importance of good dental health and treating odontogenic infections aggressively for these patients cannot be overemphasised. There is no clear evidence that these patients are at risk of infection as a result of routine dental procedures and as such antimicrobial prophylaxis is not required.45,47 It is important that all emergency treatment for immunocompromised patients should be carried out in conjunction with advice from the patient’s specialist. Osteoradionecrosis is a serious outcome of extractions in patients who have undergone radiotherapy to the head and neck region. It is known that this risk increases with time. Patients on bisphosphonate medication, particularly intravenous zoledronic acid, are also at risk of osteonecrosis.48 The efficacy of prophylactic antimicrobials for dental
amoxicillin/metronidazole as adjunctive therapy to scaling and root planing in the treatment of chronic periodontitis: a systematic review and meta-analysis. J Periodontol. 2012;83:1257-69. Zandbergen D, Slot DE, Cobb CM, van der Weijden FA. The clinical effect of scaling and root planing and the concomitant administration of systemic amoxicillin and metronidazole: a systematic review. J Periodontol. 2013;84:332-51. Bonito AJ, Lux L, Lohr KN. Impact of local adjuncts to scaling and root planing in periodontal disease therapy: a systematic review. J Periodontol. 2005;76:1227-36. Guerrero A, Griffiths GS, Nibali L, Suvan J, Moles DR, Laurell L, et al. Adjunctive benefits of systemic amoxicillin and metronidazole in non-surgical treatment of generalized aggressive periodontitis: a randomized placebo-controlled clinical trial. J Clin Periodontol. 2005;32:1096-107. Varela VM, Heller D, Silva-Senem
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MX, Torres MC, Colombo AP, Feres-Filho EJ. Systemic antimicrobials adjunctive to a repeated mechanical and antiseptic therapy for aggressive periodontitis: a 6-month randomized controlled trial. J Periodontol. 2011;82:1121-30. Preshaw PM, Hefti AF, Bradshaw MH. Adjunctive subantimicrobial dose doxycycline in smokers and non-smokers with chronic periodontitis. J Clin Periodontol. 2005;32:610-6. Sgolastra F, Petrucci A, Gatto R, Giannoni M, Monaco A. Long-term efficacy of subantimicrobial-dose doxycycline as an adjunctive treatment to scaling and root planing: a systematic review and meta-analysis. J Periodontol. 2011;82:1570-81. Martin MV, Longman LP, Hill JB, Hardy P. Acute dentoalveolar infections: an investigation of the duration of antibiotic therapy. Br Dent J. 1997;183:135-7. Slots J, Pallasch TJ. Dentists’ role in halting antimicrobial resistance
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treatment is questionable due to poor blood flow and tissue penetration in both these groups of patients. Nevertheless, antimicrobial prophylaxis has been recommended by some authorities and these patients are best managed in a hospital environment. Patients on oral bisphosphonates do not require antimicrobial prophylaxis for routine dental treatment and can be managed in primary care.49
Conclusion Dental practitioners need to be aware of the increasing problem of antimicrobial resistance and be prudent in their prescribing of antibiotics. Wherever possible dental practitioners should surgically manage dental infections and antibiotics should only be prescribed when necessary based on patient symptoms, diagnosis and current guidelines.
Example of bisphosphonate induced osteonecrosis
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[editorial] [erratum J Dent Res. 1996;75:1811]. J Dent Res. 1996;75:1338-41. Happonen RP, Backstrom AC, Ylipaavalniemi P. Prophylactic use of phenoxymethylpenicillin and tinidazole in mandibular third molar surgery, a comparative placebo controlled clinical trial. Br J Oral Maxillofac Surg. 1990;28:12-5. Siddiqi A, Morkel JA, Zafar S. Antibiotic prophylaxis in third molar surgery: A randomized double-blind placebo-controlled clinical trial using split-mouth technique. Int J Oral Maxillofac Surg. 2010;39:107-14. Lindeboom JA, Frenken JW, Valkenburg P, van den Akker HP. The role of preoperative prophylactic antibiotic administration in periapical endodontic surgery: a randomized, prospective double-blind placebocontrolled study. Int Endod J. 2005;38:877-81. Ireland RS, Palmer NO,
Lindenmeyer A, Mills N. An investigation of antibiotic prophylaxis in implant practice in the UK. Br Dent J. 2012;213:E14. 40 Abu-Ta’a M, Quirynen M, Teughels W, van Steenberghe D. Asepsis during periodontal surgery involving oral implants and the usefulness of peri-operative antibiotics: a prospective, randomized, controlled clinical trial. J Clin Periodontol. 2008;35:58-63. 41 Esposito M, Cannizzaro G, Bozzoli P, Checchi L, Ferri V, Landriani S, et al. Effectiveness of prophylactic antibiotics at placement of dental implants: a pragmatic multicentre placebo-controlled randomised clinical trial. Eur J Oral Implantol. 2010;3:135-43. 42 Esposito M, Grusovin MG, Loli V, Coulthard P, Worthington HV. Does antibiotic prophylaxis at implant placement decrease early implant failures? A Cochrane systematic review. Eur J Oral Implantol.
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2010;3:101-10. 43 Gould FK, Elliott TS, Foweraker J, Fulford, M, Perry JD, Roberts GJ, et al. Guidelines for the prevention of endocarditis: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother. 2006;57:1035-42. 44 National Institute for Health and Clinical Excellence. Antimicrobial Prophylaxis Against Infective Endocarditis in Adults and Children Undergoing Interventional Procedures. CG64. London: NICE; 2008. Accessed (2013 Nov 25) at: http://guidance.nice.org.uk/CG6 4 45 Joint Formulary Committee. British National Formulary. BNF 66. London: British Medical Association and the Royal Pharmaceutical Society of Great Britain; 2013. Accessed (2013 Nov 25) at: www.BNF.org 46 Berbari EF, Osmon DR, Carr A, Hanssen AD, Baddour LM, Greene
D, et al. Dental procedures as risk factors for prosthetic hip or knee infection: a hospital-based prospective case-control study. Clin Infect Dis. 2010;50:8-16. 47 Lockhart PB, Loven B, Brennan MT, Fox PC. The evidence base for the efficacy of antibiotic prophylaxis in dental practice. J Am Dent Assoc. 2007;138:458-74; quiz 534-5, 437. 48 Bamias A, Kastritis E, Bamia C, Moulopoulos LA, Melakopoulos I, Bozas G, et al. Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: incidence and risk factors. J Clin Oncol. 2005;23:85807. 49 Edwards BJ, Hellstein JW, Jacobsen PL, Kaltman S, Marlotti A, Migliorati CA, et al. Updated recommendations for managing the care of patients receiving oral bisphosphonate therapy: an advisory statement from the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2008;139:1674-7.
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