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Nikolaus O A Palmer

Antimicrobial Resistance and

Antibiotic Prescribing in Dental
Abstract: The purpose of this paper is to review the principles of antibiotic prescribing in light of the increasing worldwide problem
of antimicrobial resistance and the evidence of inappropriate use of antibiotics in dentistry. Guidance on the management of dental
infections and antibiotic prophylaxis based on a review of the scientific evidence will be given to ensure good patient care.
CPD/Clinical Relevance: To discuss the relevance of legislation around antimicrobial prescribing and antimicrobial stewardship for
Dent Update 2016; 43: 954960

Dentists prescribe antibiotics to manage use providing greater opportunity for Although there is evidence of reduced
oral and dental infections. The benefits of bacteria to exchange genetic material, so antibiotic prescribing over the last few
prescribing antibiotics are, however, limited that resistant genes can spread between years in NHS primary care, evidence of the
by a number of problems associated with bacterial populations. The indiscriminate inappropriate use of antibiotics in dentistry
their use, eg side-effects, allergic reactions, prescribing of antibiotics by healthcare is well documented and this contributes to
toxicity and the development of resistant professions continues to be targeted as a the problem of increasing AMR.5-9 With this
strains of microbes.1 major factor to be addressed,2 especially as evidence and the clear link between the
Within the last few decades fewer and fewer new antibiotics are being consumption of antibiotics in both primary
antimicrobial resistance (AMR) has become developed. Although there are new agents and secondary care and the higher rates
a worldwide problem and constitutes a in development, no new class of antibiotic of resistance,10 it is imperative to ensure
major threat to public health. The Chief has been brought into clinical use since the appropriate prescribing of antibiotics in
Medical Officer recently highlighted 1980s. As antibiotics become less effective, dental practice.
the level of this threat by describing the healthcare gains such as organ/ What influences dentists
it as a ticking time bomb that should stem cell transplants, major surgery and prescribing of antibiotics? Is it applying
be put on the governments national chemotherapy, will be lost, leaving these what was learnt as a student, an individuals
risk register along with terrorism.2 AMR patients with a higher risk of mortality. It clinical judgement, peer pressure, or
has increased as a result of widespread is estimated that 700,000 people die of is it based on scientific evidence and
antibiotic resistant infections each year and expert opinion? Whatever the influences,
that, by 2050, the cumulative global cost dentists have an ethical, legal and moral
will be 30 million lives and between $60 responsibility to prescribe antibiotics
Nikolaus O A Palmer, BDS, MFGDP(UK),
and $100 trillion.3 appropriately.11-13
PhD, FDS RCSEng, FFGDP(UK), Research
Dentists working in NHS primary
Fellow and Clinical Adviser in Dental
care prescribe nearly 9% of all the oral
Education Health Education England
antimicrobials prescribed in primary care What are the indications for
North West, Honorary Lecturer, School
in England.4 The antibiotics prescribed prescribing antibiotics?
of Dentistry, University of Liverpool,
by NHS dental practitioners are shown in Antibiotics can be of benefit
Pembroke Place, Liverpool L3 5PS, UK
Table 1. There is little robust data of dental and may even be life-saving in medical and
antibiotic prescribing in secondary care. dental treatment, eg Ludwigs angina, brain
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abscess. The decision to use antibiotics, antibiotics could amount to negligence of this condition.23
however, must be based on a thorough or impairment of fitness to practise, The use of systemic antibiotics
medical history, physical examination and particularly if there were no indications for in the treatment of periodontal disease
a diagnosis. The indications for prescribing antibiotics and a serious clinical outcome remains controversial. The use of
antibiotics in dental practice are listed ensued.18 It is important that clinicians antibiotics for necrotic ulcerative gingivitis
below: consider carefully the rationale for antibiotic is recommended as part of the initial
As an adjunct to surgical treatment of an use and balance this against alternative therapy only in the presence of systemic
acute or chronic infection; treatment approaches based on evidence, involvement.24 Chronic marginal gingivitis
To treat active infective disease, eg guidelines and best practice.11,14,19 responds well to good plaque control and
necrotizing ulcerative gingivitis; Chronic dento-alveolar periodontal therapy and by its very nature
Where definitive treatment may be infections rarely require antibiotics unless is not an acute or spreading infection and
delayed due to referral to specialist there is evidence of gross local spread; does not require antibiotics. The majority
services, eg inability to establish extraction or root-canal therapy are the of uncomplicated swellings of periodontal
drainage in an unco-operative definitive treatment options.20 The routine origin can be successfully treated by
patient requiring sedation or general use of antibiotics for acute pericoronitis drainage of the associated abscess, by root
anaesthetic;14 is not required in the majority of these surface debridement or extraction of the
Rarely for prophylaxis. patients who can be treated effectively with tooth.25,26
local measures. These include irrigation A review of current evidence
Therapeutic antibiotic of the pericoronal space, removal of the shows that the routine use of systemic27-30
prescribing opposing tooth, or easing the occlusion, if or local antimicrobials,31 as an adjunct
there is trauma to the pericoronal tissues, to root surface debridement and good
The clinical indications for the
and the use of appropriate analgesics. plaque control in the treatment of chronic
therapeutic use of antibiotics are well
Following resolution of the acute phase, periodontitis, produces no added clinical
documented and defined, namely, where
soft tissue surgery or removal of the benefit. There is, however, evidence that
there are signs of spreading infection, the
associated tooth should be considered. systemic antibiotics may be of use in
patient feels unwell, is pyrexic (temperature
Antibiotics should only be prescribed for aggressive periodontitis in improving
over 38C) and tachycardic (pulse over
pericoronitis when there is evidence of a pocket depth reductions and gains in
100) and where there is marked regional
spreading infection or systemic involvement clinical attachment.28,32 These improvements
is present.19 though may only be short term.33
The majority of uncomplicated
Evidence suggests that local Host modulation therapy, in
infected swellings of dental origin can
measures also suffice in the treatment the form of sub-antimicrobial doses of
be successfully treated by removal of the
of dry socket.21,22 It is inappropriate for tetracycline, has been suggested as an
source of the infection by drainage of the
dentists to prescribe antibiotics routinely adjunct to root surface debridement in the
associated abscess, removal of infected
for dry socket as the benefit to risk ratio is management of periodontal disease. There
pulp contents or by extraction of the
unfavourable. There is also little indication is little evidence of an improvement in
tooth. Unless the source of the infection is
for dentists to prescribe for uncomplicated clinical outcomes when this therapy is used
eradicated, any other mode of treatment
sinusitis. Research has shown that in primary care.34,35
will ultimately fail. The management of
antibiotics do not affect the clinical course Where there is an indication
acute dento-alveolar infections is shown
in Figure 1. Prescribing antibiotics as a
temporary substitute for eradication of
the cause of an infection also cannot be Antibiotic No of items Percentage of all
justified, except on rare occasions when it is antibacterials
impossible to remove the cause or establish Penicillins 2,278,942 66.3
drainage immediately.14
Where there is an absence of Metronidazole 972,869 28.3
infection there is no justification for the
Macrolides 149,996 4.4
therapeutic prescribing of antibiotics.
Antibiotics, for example, are not effective Clindamycin 16,524 0.5
in the management of pain associated
with irreversible pulpitis.17 The therapeutic Cephalosporins 11,202 0.3
prescribing of antibiotics just in case
problems may arise from recent treatment Tetracyclines 10,153 0.2
and can lead to serious problems in
delaying diagnosis and subject patients to Total 3,439,686 100
side-effects or toxicity.15
Table 1. Antibacterial drugs prescribed by dentists 2015. HSCIC 2016.
Inappropriate prescribing of
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for therapeutic use of antibiotics the Prophylactic prescribing of any significant advantage with regard
regimens to be employed are shown in antibiotics to post-operative infections in the
Table 2. The first choice is a penicillin, such Prophylactic antibiotics have presence of good asepsis.44,45 A recent
as amoxicillin.14 Phenoxymethylpenicillin been recommended for patients who are Cochrane review concluded that the
is as effective but less reliably absorbed susceptible to infection because of a pre- oral administration of two grams of
and needs to be taken on an empty existing disease and for the prevention of amoxicillin one hour before placement of
stomach. Metronidazole is an excellent post-operative infection for procedures dental implants to 25 people will prevent
first line treatment for patients allergic to one person experiencing early implant
that carry a high risk of infection.
penicillin, or who have recently completed loss.46
The use of antibiotics to
a course of penicillin, or if a predominantly In the past, prophylactic
prevent post-operative infection in
anaerobic infection is suspected. A antimicrobials have been prescribed to
healthy patients is not supported by
macrolide, such as azithromycin or prevent bacteraemias and metastatic
experimental evidence and is inconsistent
clarithromycin, can be used as an infection in medically compromised
with the established principles of surgical
alternative to penicillin. These are better patients. Review of the research
antibiotic prophylaxis. It has been
tolerated than erythromycin, which evidence has shown that the frequency
recommended that prophylaxis should
causes nausea, vomiting and diarrhoea of bacteraemias from normal oral
only be for surgical procedures with
in some patients, and many organisms function is greater than from dental
high infection rates, eg open reduction
are resistant to it. It is calculated that NHS procedures.47 Prior to the publication of
dentists prescribe 18% of all clindamycin fractures, orthognathic surgery and NICE guidelines, patients with acquired
prescribed in primary care.4 The prescribing intra-oral bone grafting.38,39 Fortunately, or congenital endocardial disease
of clindamycin, cephalosporins or within routine dentistry, in the presence were required to have antimicrobial
co-amoxiclav offers no advantage in of good infection prevention, there prophylaxis before a number of
the management of dento-alveolar are no procedures recorded as having dental procedures. NICE guidelines
infections and could contribute to the high rates of post-operative infection. advise antimicrobial prophylaxis is no
development of resistance. Prescribing of Uncomplicated surgical removal of longer required for these patients.48
these antibiotics has also been associated teeth and apicectomies rarely give rise The recent publication of evidence of
with the increased clostridium infections in to post-operative infections. Evidence rising numbers of cases of infective
primary and secondary care.36 exists showing that the prophylactic endocarditis since adoption of NICE
Whenever managing a dental use of antimicrobials has little effect on guidelines49 led to a review by NICE. This
infection it is important to review after post-operative pain, swelling, infection or review showed no causal relationship
23 days to assess whether the patient wound healing.40-42 and NICE reaffirmed that antimicrobial
is responding to treatment. If antibiotics Prescribing prophylactic prophylaxis is not routinely required for
have been prescribed with definitive antimicrobials for implant placement dental procedures to prevent infective
management, then the swelling should remains controversial and research has endocarditis.48
be resolving and the temperature of the shown a plethora of regimens used in Medically compromised
patient returned to normal. If this is the the absence of guidelines.43 It has been patients fall into a number of groups:
case, antibiotics can be discontinued.37 shown that antimicrobials do not provide Patients who have prosthetic
Patients who are
First choice immunocompromised;
Amoxicillin 500 mg three times daily for up to 5 days Patients who have had radiotherapy
to the jaws; or
OR Patients who are receiving
Phenoxymethylpenicillin 500 mg four times daily for up to 5 days
The Working Party of
If a predominately anaerobic infection is suspected then:
the British Society of Antimicrobial
Metronidazole 400 mg three times daily for up to 5 days
Chemotherapy advises that patients who
Second choice have total joint implants do not require
Metronidazole 400 mg three times daily for up to 5 days antibiotic prophylaxis prior to dental
treatment.50 A recent case-controlled
Third choice
study confirmed that dental treatment
Clarithromycin 250 mg twice daily up to five days or Azithromycin 500 mg once daily for
is not a risk factor for subsequent joint
23 days
replacement infections.51 Patients with
Paediatric dosages should be based on the age and/or body weight of the patient cardiac pacemakers, penile, breast or
consult the British National Formulary50 intra-ocular implants and prosthetic
grafts also do not need antimicrobial
Table 2. Therapeutic antibiotic regimens.
prophylaxis prior to dental treatment.52
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Immune function of
patients may be impaired by a range Acute
of conditions, such as leukaemia, dento-alveolar
immunosuppressive drugs following abscess
transplants, lymphomas, chemotherapy,
poorly controlled diabetes and HIV.
The importance of good dental health
and treating odontogenic infections Raised axillary
aggressively for these patients cannot Defined swelling
temperature or
be overemphasized. There is no clear diffuse swelling
evidence that these patients are at risk
of infection as a result of routine dental
procedures and, as such, antimicrobial
prophylaxis is not required.50,52 It is
important that all emergency treatment Remove cause, Remove cause,
for immunocompromised patients establish drainage establish drainage.
should be carried out in conjunction with and prescribe NO antibiotics
advice from the patients specialist. antimicrobials required
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
Review Review
with time. Patients on bisphosphonate
23 days 23 days
medication, particularly intravenous
zoledronic acid, are also at risk of
osteonecrosis.53 The efficacy of
prophylactic antimicrobials for dental
treatment is questionable due to poor
blood flow and tissue penetration
Resolution of
in both these groups of patients.
swelling and Resolution
Nevertheless, antimicrobial prophylaxis
has been recommended by some
authorities and these patients are best
managed in a hospital environment.
Patients on oral bisphosphonates do Failure of
not require antimicrobial prophylaxis resolution:
for routine dental treatment and can be check drainage
managed in primary care.54 OR refer
With the increasing problems
of antimicrobial resistance, dentists Figure 1. Management of acute odontogenic infections. Reproduced with kind permission of
should embrace NICE guidance on FGDP(UK).
antimicrobial stewardship.55 Dentists,
when considering prescribing of
antimicrobials, should follow this
must optimize patient outcomes, reduce antibiotics should only be prescribed when
guidance and take account of the risk of
the risk of adverse events, reduce the necessary, based on patient symptoms,
AMR, both for individual patients and the
risks of AMR and have systems in place to diagnosis and current guidelines. Dentists
population as a whole, recording signs,
manage and monitor prescribing to ensure should also ensure that there are systems in
symptoms, diagnosis and, if prescribing
appropriate use, eg clinical audit.13 place to monitor appropriate use.
an antimicrobial, the clear reasons for
All dentists in England have Conclusion References
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