Vol. 110 No.
1 July 2010
EDITORIAL
Decisions and antibiotics use: more questions and some answers
We, as dentists, are confronted every day with deci-
sions, and I am fascinated by how we make proper
decisions and by what shapes these decisions. An area
of particular interest is how we make treatment deci-
sions and the evidence we use for making those deci-
sions. The overarching question in my mind is: Are we
making appropriate decisions regarding the use of an-
tibiotics? Let’s look at a few example, and ask ques-
tions about how our decisions are being made.
For a nonlife-threatening acute dental infection in a
patient with normal immune and metabolic status, an
antibiotic (i.e., penicillin) is typically prescribed for a
course of 7-10 days. However, what is so magical about
this time frame? The usual oral infection of bacterial
origin requires an average of 4-7 days to resolve with
antibiotics.1,2 This raises the question, “Could our
patients take an antibiotic for fewer days and still
benefit from the antibiotic regimen?” Clearly, studies
have shown that many individuals are not totally
compliant with the prescribed antibiotic regimen and
often have pills left over to take at a later date.3-5
Furthermore, the indication that many patients sur-
vive the infection so that they could take the pills at
a later date or share them with a relative or loved one
suggests that the full course of antibiotic therapy was
not required originally.
It is also generally accepted that an antibiotic must
reach the site of infection in amounts above the mini-
mum inhibitory concentration (MIC) or minimum le-
thal concentration (MLC) for the infecting microorgan-
isms. However, what about the immune response of a
healthy individual? Could a concentration that is near
the MLC be bacteriostatic and shift the balance enough
so that the infection is controlled, particularly in an
otherwise healthy patient? Alternatively, could the
plasma concentration of the antibiotic be above the
MIC for a minimum duration (e.g., just long enough,
perhaps a few days) such that the immune system is
capable of controlling the infection without taking a
7-day course of antibiotics?
In dentistry we have the luxury often not afforded in
medicine that we can reduce the bacterial load or re-
move the source of infection which can limit the need
for antibiotics. For odontogenic infections, we can re-
move/reduce the source of infection by several means,
including extraction, incision and drainage, or root ca-
nal therapy. In these circumstances, antibiotics can be
discontinued after 2-3 days or may not even be needed
provided that proper drainage has been established.6-8
The need for many antibiotic prescriptions in dentistry
is generally lacking, with one study reporting that only
⬃5% of patients who received a prescription for anti-
biotics had an acute infection.9 Yet, many dentists write
prescriptions for penicillins and do so using empirical
7-10 day dosing. This empirical approach could be
optimized by studies that provide scientific evidence
and by asking important questions before deciding to
prescribe an antibiotic, questions such as: Is an antibi-
otic needed? Are the signs and symptoms consistent
with an infection? Does the patient’s health or current
situation place them at risk for the infection spreading?
If an antibiotic is needed, what duration of therapy is
appropriate? By reevaluating the patient at 24, 48, and
72 hours after initial presentation for alleviation of
signs and symptoms, the clinician could assess whether
the proper drug was selected, whether the dose is ef-
fective/ineffective, and whether more days are needed.
This approach could reduce exposure to the antibiotic.
Now, some may say that giving a shorter course of
high-dose antibiotics could lead to antibiotic resistance.
But how does antibiotic resistance develop? Evidence
indicates that long-term and repetitive use of antibiotics
is what promotes antibiotic resistance.10,11 Also, an
adequate concentration needs to be maintained for a
long enough period of time to promote selectivity for
the development of resistant strains.12 Furthermore,
several lines of evidence support the concept that a
short-course high-dose antibiotic regimen can be effec-
tive and should be considered for discontinuation after
1

2 Miller
3 days when proper drainage has been established
and/or signs of the infection are resolving.7,8,13-15
So, let’s take this intellectual debate a step further.
Recently, the need for antibiotic prophylaxis for dental
procedures for patients with joint prosthesis has reap-
peared in the news. In February 2009, the American
Academy and American Association of Orthopedic
Surgeons (AAOS) recommended that clinicians “con-
sider antibiotic prophylaxis for all total joint replace-
ment patients prior to any invasive [dental] procedure
that may cause bacteremia” [http://www.aaos.org/
research/committee/ptsafety/ptsafety.asp (accessed Feb.
11, 2010)].
Several things are interesting about this new recom-
mendation. First, it more expansive than the American
Dental Association (ADA) and AAOS advisory state-
ment on the dental management of patients with pros-
thetic joints published in 1997 and revised in 2003.16,17
This new recommendation includes “any invasive pro-
cedure that may cause bacteremia.” The main premise
for this recommendation is that: 1) bacteremia from
oral flora arising from dental procedures causes late
prosthetic joint infections (LPJIs); 2) there is a temporal
relationship between dental procedures and LPJIs; 3)
antibiotic prophylaxis would prevent bacterial seeding
and subsequent LPJIs; and 4) treatment of LPJIs is
expensive, involving hospitalization, pain, immobility,
and possible implant removal.
In a recent commentary, Dr. Arthur Friedlander sup-
ported the AAOS recommendation by presenting a case
for the presence of staphylococci in the oral cavity,
especially in the elderly and those with rheumatoid
arthritis, as well as around implants, root canals, and
odontogenic infections.18-26 He reviews the rates of
bacterial infections of prosthetic joints temporally and
bacteriologically associated with dental procedures and
reiterates the findings from 2 large studies by Laporte et
al.27 and Waldman et al.,28 where 12 “dentally-related”
joint infections were identified from more than 6,400
patients with prosthetic joints. His commentary states
that “the oral microbial environment are more diverse
than originally believed and . . . [thus], it logically
follows that invasive dental procedures (oral and peri-
odontal surgery, scaling, root planing, probing, dental
implant placement, endodontic instrumentation beyond
root apex, placement of subgingival fibers or strips,
intraligamentary injections, and prophylactic cleaning
of teeth or implants where bleeding is anticipated) may
cause both staphylococcus and streptococcus bactere-
mias which have been implicated in late joint prosthe-
ses infections.” Dr. Friedlander then presents an anti-
biotic regimen supported by orthopedic societies that he
and they recommend for use.
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July 2010
Here is where our decision-making skills are put to
the test. No one will disagree that bacteria in the oral
cavity may be associated with bacteremias, and few
will disagree that these organisms have a temporal
relationship with a small number of LJPIs. However,
closer scrutiny of the evidence is required. Bacteremias
associated with daily activities are common, yet no one
recommends (yet) the need for daily prophylactic anti-
biotics when these patients chew gum or brush their
teeth.29 Second, no one has cultured the organisms in
the mouth before and then during the LJPI, so there-
fore the relationship between the 2 sites is only
predicted and not proven. Third, analyses of repor-
ted cases of LJPIs demonstrate that these infections
are rarely caused by bacterial species common to the
mouth.27,28,30 Fourth, a recent well designed, case-
control study performed at the Mayo Clinic in response
to the AAOS posting demonstrated that dental proce-
dures were not risk factors for subsequent total hip or
knee infections.31 Finally, no study exists that has
shown that prophylactic antibiotics reduce the risk of
distant site infections in humans.32-34 In fact, one of the
9 “dentally related” joint infections documented in the
Waldman et al.28 report received prophylactic antibiot-
ics, but the antibiotics failed to be protective. So, one
could extrapolate from these data that the risk of LJPI
is small with or without dental treatment, and antibiotic
prophylaxis is at best 89% efficient in preventing LJPIs.
Let’s consider additional factors that could help in
the decision process. Pertinent questions include: First,
what is the bacterial load in the oral cavity at the time
of the procedure, and how does the load relate to risk of
prosthetic joint infections? Second, which procedures
involve significant risk of bacteremia (e.g., incision into
infected tissues vs. placement of subgingival fibers or
strips)? Third, how does the duration of the procedure
influence the outcome? In the original reports provided
by LaPorte et al. and Waldman et al., the duration of the
invasive dental procedures associated with the infec-
tions were 45-90 minutes and 75-205 minutes, respec-
tively. One could speculate that the duration of the
invasive procedure being ⱖ45 minutes was an impor-
tant risk factor, because in theory bacteria could have
had an increased opportunity to enter the blood stream
if the invasion was longer. Also potentially contribu-
tory is the patient’s immune and metabolic status. In the
LaPorte et al. and Waldman et al. reports, ⬃50% of the
patients who developed LJPIs were immune- or meta-
bolically compromised, and these systemic alterations
have been identified as potentially higher risk since the
1997 ADA/AAOS advisory statement.
In conclusion, much data and controversy exist re-
garding the proper use of antibiotics for infections and
prophylactically. However, clinicians are encouraged
OOOOE
Volume 110, Number 1
to weigh the evidence from weakest (empirical ap-
proaches and expert opinions) to strongest (carefully
controlled clinical trials) for guiding their clinical judg-
ment. After all, that is how practice guidelines should
be established. Rest assured that in the future, these
guidelines will be strengthened based on studies that
address the effects of antibiotics at the site of interest,
adverse effects associated with antibiotic use, develop-
ment of antibiotic resistance, cost implications (prophy-
laxis vs. joint replacement surgery), and quality of life
issues.
Craig Miller, DMD, MS
Section Editor, Oral Medicine Section
doi:10.1016/j.tripleo.2010.03.022
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