Antibiotic resistance is recognized as a global threat and the misuse of antibiotics in dentistry partly contributes to it.
As the general public, we often concern about the antibiotic prescription by a physician. But are we even aware of the magnitude of antibiotic usage in dentistry?
Dr. Tina Anto is a diligent dental professional with intelligent discernment for the right choice of treatment. Dr. Tina explains the prescribing practices of antibiotics and its judicious use in dentistry and how the antibiotics eclipse dental intervention procedures.
Question: How does the prescription of antibiotics differ from a dentist and a physician?
Both the dentist and physician prescribe antibiotics for the treatment of bacterial infection. However, there exist two differences in the antibiotic prescription by a dentist and a physician.
A broad range of microorganisms exist in the mouth and not all of them cause infection. The exact microorganism responsible for the infection remains unknown because bacterial culturing is not routinely done in the dentistry. The microorganism responsible for the infection is assumed based on the clinical and bacterial epidemiological data and treatment is decided on probabilistic reasoning.
Therefore, in effect, the prescription of antibiotics in dentistry are
1. The empirical prescription of antibiotics
2. The broad-spectrum antibiotics
Question: Could you please explain what do you mean by “empirical prescription of antibiotics”?
The word empirical is derived from the Greek word empeiria which means experience. It has moved from individual experience to collective experience combined with scientific evidence. The dentists have to select antibiotics based on their observations of the patient (history, physical examination, and laboratory test results) along with the dentist’s past clinical experiences and the current medical literature guidelines.
The dentist usually prescribes antibiotics on a presumptive basis without going for culturing. But certain clinical scenario with signs of infection spreading the whole body including blood even after a short course of broad-spectrum antibiotics requires lab testing.
Question: Mostly the toothaches and other dental conditions are uncomfortable and unbearable. Do patients with acute pain consider antibiotics as an alternative to dental procedures such as root canal?
Daily, I come along with cases that seek immediate relief of symptoms with minimum or no intervention, which itself is a very bad choice. As a dentist, I try, motivate the patient to continue treatment. The patient is informed about antibiotic resistance and the chances of antibioma (a hard swelling caused by the long term use of antibiotics).
If the dentist determines that the patient does not have any systemic infection, other ways to help relieve the symptoms can be suggested. It is not recommended to pressurize the dentist to prescribe an antibiotic. Only prompt and immediate intervention is the key factor for efficient bacterial eradication.
Question: What deleterious effect it could bring by prescribing antibiotics to cover the defects in asepsis and improperly sterilized instruments in dental clinics?
Antibiotic prescription to overrule inadequate sterilization and disinfection protocol in the dental operatory is never justifiable and a serious crime. Studies have shown that chances of cross-contamination are relatively high in dental clinics. A strict sterilization routine must be followed.
Question: What percent of your patients complete the course of antibiotics and comes for follow up consultation?
In my opinion, only 50 – 60% of patients complete the antibiotic course and come for review.
Sometimes they save some of their antibiotics for the next time they get sick. Always Discard any leftover medication once you have completed your prescribed course of treatment.
Some patients tend to skip doses. Patients should administer the antibiotics exactly as the healthcare provider prescribes and should complete the prescribed course of treatment even if the patients are feeling better. Breaking the course of antibiotics may cause the survival of some bacteria and subsequent re-infection. Delay in the correct treatment could allow the bacteria to multiply.
Question: Does the dental fraternity recognize that they have a sizeable contribution towards antimicrobial resistance?
Every health care provider has a sizeable contribution to antimicrobial resistance. Never prescribe antibiotics due to time pressure, patient request/ expectation/ satisfaction, potential return visit cost, drug promotion, prevent complications, and treatment uncertainty.
Always give a second thought, whether the antibiotics are justifiable in the given clinical scenarios or not.
Appropriate guidelines for antibiotic use and it’s abuse must be stipulated to combat drug resistance and regular Continuing Dental Education programs should be conducted to update the use of antibiotics and on newer generations of antimicrobials. National Policy For Containment Of Antimicrobial Resistance India has developed surveillance systems to monitor and audit antibiotic prescriptions.
Question: Are children the major consumers of antibiotics for dental problems?
The treatment of children mainly depends on two factors
– cooperation of the patient
– the attitude of the parents
Generally, the dental examination of children is unmanageable. Most of the children are difficult to handle for any dental intervention procedures. Coupled with patient contention, if the parents would not want to see their child crying, the dentists are forced to prescribe antibiotics to subside the infection and pain without any dental procedures.
Therefore, in that way, children mostly end up consuming more antibiotics though it might not be the right choice of treatment.
However, in some instances, though the patient does not cooperate, the parent opts for the right choice of treatment.
Question: CDC states that dentists prescribe approximately 10 % of outpatient antibiotics and studies suggest that 30 % to 50 % of antibiotics prescribed are unnecessary or not optimally prescribed. As a practicing dentist in India, what is your opinion on this? And what is the scenario in India?
Antibiotics account for the vast majority of medicines prescribed by dentists because antibiotics are routinely prescribed in dental practice for either prophylactic or therapeutic purpose.
Prophylactic medicine is intended to prevent disease. So the administration of antibiotics in dentistry is meant to prevent bacterial infection before a dental procedure or surgery. Antibiotics prevent diseases due to the introduction of the oral bacteria to distant or to a local site in an immunocompromised host (for example, patients with diabetes, rheumatoid arthritis, cancer, chemotherapy, and cardiovascular diseases) at risk.
Therapeutic medications are prescribed for the treatment of diseases or infections. Antibiotics can manage orofacial (related to the mouth and face) infections in the dentistry. Since most of the human orofacial infections originate from odontogenic (originates in the tooth) infections, the prescription of antibiotics by dental practitioners have become an important aspect of dental practice.
However, the over-prescription of antimicrobials is never justifiable.
The sad reality in India is that some of the dental practitioners are not always aware of the current clinical guidelines regarding antibiotic prophylaxis or therapeutic dosage. This coupled with increasing patient demand and reluctance to dental treatment has to lead to the over-prescription of antibiotics.
Question: As you have mentioned, the prophylactic prescription of antibiotics in dentistry is unnecessary unless for high-risk patients or immunocompromised patients. Besides that, prophylactic use of antibiotics is common in dentistry, what is your opinion on that?
In dentistry, Prophylactic antibiotic has been advocated
(i) to reduce the chances of local complications after a dental procedure (such as infections after the extraction of permanent adult tooth) or any serious systemic complications (like infective endocarditis)
(ii) in surgical removal of tumors
(iii) in immunocompromised patients
However, most often dentists provide antibiotics as a prophylactic measure before a majority of the dental procedures due to patient apprehension, immediate relief of acute symptoms even before the intervention, and on patient demand.
According to the recent guidelines of the American Dental Association (ADA), the clinician should always go for judicious prescription of prophylactic antimicrobials and more emphasis should be placed on improving oral health.
The views and opinions expressed in this interview are exclusive to the interviewee.
The article does not express views and opinions of livingwithmicrobes and the organization to which the interviewee belongs.
About Dr. Tina Anto
Dr. Tina Anto pursued her post-graduation in Conservative Dentistry and Endodontics from Annoor Dental College and Hospital, Kerala, KUHS university. During her post-graduation, she was engaged in undergraduate dental student teaching including practical sessions and various other research activities. She had published her work in various regional journals related to her specialization in dentistry.
Dr. Tina runs her own dental clinic named Saras Super Specialty Dental Clinic in Kerala. She provides her service to various other private dental clinics as a visiting dental consultant.
Dr. Tina is a dedicated dentist who aims to provide the right choice of treatment to her patients. She is also very good at communicating with her patients by explaining and creating awareness among the patients regarding the various dental treatments, abuse of antibiotics to overpower the dental procedures, etc.
Dr. Tina is a member of the Indian Association of Conservative Dentistry and Endodontics (IACDE) and Conservative and Endodontic Society of Kerala (CAESOK). She is committed to lifelong learning to deepen her knowledge of endodontics.
Outside her dental apron, Dr. Tina enjoys reading, driving around, and spending quality time with her family.