Revisiting the Role of Dentists in Prescribing Antibiotics

The use and misuse of antibiotics in dentistry: A scoping review

BACKGROUND

To describe antibiotic prescribing behaviors in dentistry, including clinical and nonclinical indications for their use, the type and regimen of antibiotics prescribed, and factors influencing their prescription, the authors conducted a scoping review.

TYPES OF STUDIES REVIEWED

The authors conducted a scoping review of published literature by searching multiple databases. Key search terms included dentist, antibiotic, antimicrobial, antibacterial, prophylaxis, prescription, pattern, habit, knowledge, and practice. Two authors independently reviewed titles and abstracts by using detailed eligibility criteria. The authors placed no restrictions on study design or publication year. The authors qualitatively assessed studies by using a modified version of the Center for Evidence-Based Management's critical appraisal of a survey checklist.

RESULTS

The authors identified 1,912 studies but considered only 118 studies eligible for review. Most included studies were either cross-sectional surveys (81 studies) or prescription audits (25 studies) from various geographic locations. Publication dates ranged from 1982 through 2017. The authors examined prophylactic and therapeutic antibiotic use in 48 and 29 studies, respectively. Another 29 studies examined the use of both prophylactic and therapeutic antibiotics in dentistry. Overall, dentists prescribed a wide variety of antibiotic regimens for various clinical and nonclinical indications. Dentists have acquired their prescribing knowledge from a variety of sources and have changed their antibiotic prescribing practices throughout their careers for various reasons.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Considering the seriousness of antibiotic resistance, the authors highlight trends in antibiotic prescribing practices, characterize factors contributing to the use and misuse of antibiotics in dentistry, provide insight into the importance of antibiotic stewardship in the oral health setting, and encourage dentists to reflect on their antibiotic prescription practices.

Antibiotic use for irreversible pulpitis

BACKGROUND

Irreversible pulpitis, which is characterised by acute and intense pain, is one of the most frequent reasons that patients attend for emergency dental care. Apart from removal of the tooth, the customary way of relieving the pain of irreversible pulpitis is by drilling into the tooth, removing the inflamed pulp (nerve) and cleaning the root canal. However, a significant number of dentists continue to prescribe antibiotics to stop the pain of irreversible pulpitis.This review updates the previous version published in 2016.

OBJECTIVES

To assess the effects of systemic antibiotics for irreversible pulpitis.

SEARCH METHODS

We searched Cochrane Oral Health's Trials Register (to 18 February 2019); the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1) in the Cochrane Library (searched 18 February 2019); MEDLINE Ovid (1946 to 18 February 2019); Embase Ovid (1980 to 18 February 2019); US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (searched 18 February 2019); and the World Health Organization International Clinical Trials Registry Platform (searched 18 February 2019). There were no language restrictions in the searches of the electronic databases.

SELECTION CRITERIA

Randomised controlled trials which compared pain relief with systemic antibiotics and analgesics, against placebo and analgesics in the acute preoperative phase of irreversible pulpitis.

DATA COLLECTION AND ANALYSIS

Three review authors screened studies and extracted data independently. We assessed the certainty of the evidence of included studies using GRADE. Pooling of data was not possible and a descriptive summary is presented.

MAIN RESULTS

No additional trials could be included in this update. One trial at low risk of bias evaluating oral penicillin in combination with analgesics versus placebo with analgesics, involving 40 participants was included in a former update of the review. The certainty of the evidence was rated low for the different outcomes. Our primary outcome was patient-reported pain (intensity/duration) and pain relief. There was a close parallel distribution of the pain ratings in both the intervention (median 6.0, interquartile range (IQR) 10.5), and for placebo (median 6.0, IQR 9.5) over the seven-day study period. There was insufficient evidence to claim or refute a benefit for penicillin for pain intensity. There was no significant difference in the mean total number of ibuprofen tablets over the study period: 9.20 (standard deviation (SD) 6.02) in the penicillin group versus 9.60 (SD 6.34) in the placebo group; mean difference -0.40 (95% confidence interval (CI) -4.23 to 3.43; P = 0.84). This applied equally for the mean total number of Tylenol tablets: 6.90 (SD 6.87) used in the penicillin group versus 4.45 (SD 4.82) in the placebo group; mean difference 2.45 (95% CI -1.23 to 6.13; P = 0.19). Our secondary outcome on reporting of adverse events was not addressed in this study.

AUTHORS' CONCLUSIONS

This Cochrane Review which was based on one low-powered small sample trial assessed as at low risk of bias, illustrates that there is insufficient evidence to determine whether antibiotics reduce pain or not compared to not having antibiotics. The results of this review confirm the necessity for further larger sample and methodologically sound trials that can provide additional evidence as to whether antibiotics, prescribed in the preoperative phase, can affect treatment outcomes for irreversible pulpitis.

Antibiotic Prescription Knowledge of Dentists in Kingdom of Saudi Arabia: An Online, Country-wide Survey

AIM

Dentists are probably contributing to the development of bacterial resistance to certain antibiotics. Campaigns to promote prudent use of antibiotics in dentistry are, thus, needed but require proper identification of dentists' knowledge gaps. The objective here was to comprehensively evaluate antibiotic prescription knowledge of dentists in Saudi Arabia.

MATERIAL AND METHODS

A link to an online, previously validated questionnaire was emailed to 5199 dentists registered with the Saudi Dental Society. The questionnaire comprised 42 scorable items measuring antibiotics prescription knowledge in five different domains in addition to nonscorable questions regarding first-choice antibiotics and previous attendance of a course/workshop about antibiotic prescription. Each correct answer was given one mark. Mean scores were calculated as percentages and categorized as good (> 80%), intermediate (60-80%), or poor (< 60%).

RESULTS

The response rate was 9.4%; however, only 373 (7.2%) fully completed the questionnaire. Around half of the participants (52%) reported prescribing amoxicillin/clavulanate as the first-choice antibiotic; 62% reported attending a course/workshop in the last 5 years. The average knowledge score was 69%, being highest for nonclinical indications (79%) and lowest for prophylactic use (56%). The worst per-item scores were noted for rheumatic heart disease (19%), trismus (28%), surgical extraction (30%), apicectomy (31%), and periodontal abscess (33%). Female dentists, dentists in governmental sector, and those with higher qualifications had significantly better knowledge.

CONCLUSION

The level of knowledge was hardly intermediate and several deficits were identified, indicating an urgent need for educational campaigns and provision of guidelines promoting rational use of antibiotics by dentists.

CLINICAL SIGNIFICANCE

Irrational use of antibiotics by dentists can contribute to the problem of antibacterial resistance.

Antibiotic use for irreversible pulpitis

BACKGROUND

Irreversible pulpitis, which is characterised by acute and intense pain, is one of the most frequent reasons that patients attend for emergency dental care. Apart from removal of the tooth, the customary way of relieving the pain of irreversible pulpitis is by drilling into the tooth, removing the inflamed pulp (nerve) and cleaning the root canal. However, a significant number of dentists continue to prescribe antibiotics to stop the pain of irreversible pulpitis.This review updates the previous version published in 2013.

OBJECTIVES

To assess the effects of systemic antibiotics for irreversible pulpitis.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 27 January 2016); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 12); MEDLINE via Ovid (1946 to 27 January 2016); EMBASE via Ovid (1980 to 27 January 2016), ClinicalTrials.gov (to 27 January 2016) and the WHO International Clinical Trials Registry Platform (to 27 January 2016). There were no language restrictions in the searches of the electronic databases.

SELECTION CRITERIA

Randomised controlled trials which compared pain relief with systemic antibiotics and analgesics, against placebo and analgesics in the acute preoperative phase of irreversible pulpitis.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies and extracted data independently. We assessed the quality of the evidence of included studies using GRADEpro software. Pooling of data was not possible and a descriptive summary is presented.

MAIN RESULTS

One trial assessed at low risk of bias, involving 40 participants was included in this update of the review. The quality of the body of evidence was rated low for the different outcomes. There was a close parallel distribution of the pain ratings in both the intervention and placebo groups over the seven-day study period. There was insufficient evidence to claim or refute a benefit for penicillin for pain intensity. There was no significant difference in the mean total number of ibuprofen tablets over the study period: 9.2 (standard deviation (SD) 6.02) in the penicillin group versus 9.6 (SD 6.34) in the placebo group; mean difference -0.40 (95% confidence interval (CI) -4.23 to 3.43; P value = 0.84). This applied equally for the mean total number of Tylenol tablets: 6.9 (SD 6.87) used in the penicillin group versus 4.45 (SD 4.82) in the placebo group; mean difference 2.45 (95% CI -1.23 to 6.13; P value = 0.19). Our secondary outcome on reporting of adverse events was not addressed in this study.

AUTHORS' CONCLUSIONS

This systematic review which was based on one low powered small sample trial assessed as at low risk of bias, illustrates that there is insufficient evidence to determine whether antibiotics reduce pain or not compared to not having antibiotics. The results of this review confirm the necessity for further larger sample and methodologically sound trials that can provide additional evidence as to whether antibiotics, prescribed in the preoperative phase, can affect treatment outcomes for irreversible pulpitis.

Antibiotic use for irreversible pulpitis

BACKGROUND

Irreversible pulpitis, which is characterised by acute and intense pain, is one of the most frequent reasons that patients attend for emergency dental care. Apart from removal of the tooth, the customary way of relieving the pain of irreversible pulpitis is by drilling into the tooth, removing the inflamed pulp (nerve) and cleaning the root canal. However, a significant number of dentists continue to prescribe antibiotics to stop the pain of irreversible pulpitis.

OBJECTIVES

To assess the effects of systemic antibiotics for irreversible pulpitis.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 5 September 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 9); MEDLINE via OVID (1946 to 5 September 2013); EMBASE via OVID (1980 to 5 September 2013) and the US National Institutes of Health Trials Register (http://clinicaltrials.gov). There were no language restrictions in the searches of the electronic databases.

SELECTION CRITERIA

Randomised controlled trials which compared pain relief with systemic antibiotics and analgesics, against placebo and analgesics in the acute preoperative phase of irreversible pulpitis.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies and extracted data independently. We assessed the quality of the evidence of included studies using GRADEPro software. Pooling of data was not possible and a descriptive summary is presented.

MAIN RESULTS

One trial assessed at low risk of bias, involving 40 participants was included in this update of the review. The quality of the body of evidence was rated low for the different outcomes. There was a close parallel distribution of the pain ratings in both the intervention and placebo groups over the seven-day study period. There was insufficient evidence to claim or refute a benefit for penicillin for pain intensity. There was no significant difference in the mean total number of ibuprofen tablets over the study period: 9.2 (standard deviation (SD) 6.02) in the penicillin group versus 9.6 (SD 6.34) in the placebo group; mean difference -0.40 (95% confidence interval (CI) -4.23 to 3.43; P value = 0.84). This applied equally for the mean total number of Tylenol tablets: 6.9 (SD 6.87) used in the penicillin group versus 4.45 (SD 4.82) in the placebo group; mean difference 2.45 (95% CI -1.23 to 6.13; P value = 0.19). Our secondary outcome on reporting of adverse events was not addressed in this study.

AUTHORS' CONCLUSIONS

This systematic review which was based on one low powered small sample trial assessed as a low risk of bias, illustrates that there is insufficient evidence to determine whether antibiotics reduce pain or not compared to not having antibiotics. The results of this review confirm the necessity for further larger sample and methodologically sound trials that can provide additional evidence as to whether antibiotics, prescribed in the preoperative phase, can affect treatment outcomes for irreversible pulpitis.

Randomized study of surgical prophylaxis in immunocompromised hosts

Although prophylaxis is current practice, there are no randomized controlled studies evaluating preoperative antimicrobial prophylaxis in dental procedures in patients immunocompromised by chemotherapy or organ transplants. To evaluate prophylaxis in dental-invasive procedures in patients with cancer or solid organ transplants, 414 patients were randomized to receive one oral 500-mg dose 2 hours before the procedure (1-dose group) or a 500-mg dose 2 hours before the procedure and an additional dose 8 hours later (2-dose group). Procedures were exodontia or periodontal scaling/root planing. Follow-up was 4 weeks. No deaths or surgical site infections occurred. Six patients (1.4%) presented with use of pain medication > 3 days or hospitalization during follow-up: 4 of 207 (2%) in the 1-dose group and 2 of 207 (1%) in the 2-dose group (relative risk, 2.02; 95% confidence interval, 0.37-11.15). In conclusion, no statistically significant difference occurred in outcome using 1 or 2 doses of prophylactic amoxicillin for invasive dental procedures in immunocompromised patients.

The role of phenoxymethylpenicillin, amoxicillin, metronidazole and clindamycin in the management of acute dentoalveolar abscesses--a review

Antibiotics are the most widely prescribed category of drugs issued on prescription by general dental practitioners. Despite this there remains little evidence-based literature on what should be prescribed for any given clinical situation, at what dosage and for how long. Given the current climate of evidence-based research, the need to keep antibiotic prescribing to an acceptable minimum, increasing levels of resistance of micro-organisms and widespread hospital infections with 'superbugs', there is a distinct need for appropriate prescribing guidelines. Considering best practice, an extensive review of the literature and a thorough understanding of current empirical treatment regimes, an attempt has been made to recommend suitable antibiotic prescribing for the adult patient suffering from acute dentoalveolar infections based on evidence.

Incidence of antibiotic prescribing in dental practice in Norway and its contribution to national consumption

OBJECTIVES

To assess dentistry-based utilization of the 11 antibiotics prescribed by dentists in Norway and its relative contribution to national outpatient consumption and to determine the relationship between numbers of prescriptions and the consumption of these antibiotics.

METHODS

Data on national antibiotic prescriptions by dentists in 2004 and 2005 were used. Consumption of the antibiotics was expressed using WHO defined daily doses (DDDs), DDDs per 1000 inhabitants per day (DIDs) and numbers of prescriptions per 1000 inhabitants (PIDs).

RESULTS

Analysis of 268,834 prescriptions issued by 4765 dentists showed that the dentists' prescriptions contributed 8% of the total national consumption of the 11 antibiotics and 13.5%, 2.8% and 1.2% of the national beta-lactam penicillins, macrolides and lincosamides and tetracyclines utilization, respectively. The dentists' contributions to the national phenoxymethylpenicillin, spiramycin and metronidazole consumptions were considerably higher (> or =13.2%) than for the other prescribed antibiotics (< or =8.6%). There was a strong positive correlation between numbers of DDDs and numbers of prescriptions and between DIDs and numbers of PIDs.

CONCLUSIONS

Reliance of Norwegian dentists on phenoxymethylpenicillin as their first choice suggests a low prevalence of antibiotic resistance among oral bacteria in Norway. Norwegian dentists prefer to prescribe narrow-spectrum antibiotics; their prescribing is conservative and relatively low compared with that of physicians.

Case report: teeth and tonsils: the use of culture and sensitivity testing for antibiotic prescribing in dental infection

This case report highlights the usefulness of bacterial culture and sensitivity testing in the prescribing of antibiotics for dental infections, demonstrated by the management of a 10-year-old child with a non-vital upper central incisor and, reportedly, associated recurrent tonsillitis.

Knowledge of prescribing antimicrobials among Yemeni general dentists

OBJECTIVE

Overuse of antimicrobial agents is closely related to an increase in bacterial resistance. A sound knowledge of appropriate prescribing of antimicrobials among health professionals is thus critical in combating the resistance. The objectives of this study were to assess the rationale for and patterns of antimicrobial prescriptions by general dental practitioners in Yemen.

MATERIAL AND METHODS

A questionnaire containing 65 closed questions was used for this cross-sectional study and distributed to 280 dentists in the three major governorates in Yemen. The anonymously completed questionnaires sought answers to demographic questions and to questions on the therapeutic and prophylactic use of antimicrobial agents in dentistry. Correct and incorrect answers were defined according to information available in the current authoritative literature. Each correct answer was given a score of 1 while an incorrect answer scored 0. Thus, the total score had an attainable range from 0 to 65. Frequencies, means, and associations were assessed statistically.

RESULTS

Out of 181 collected forms (response rate 64.6%), 150 were appropriately completed and used for data analyses. Penicillins were the most frequently prescribed drugs (72%), followed by spiramycin (10%). It was found that up to 84% of practitioners were likely to prescribe an antimicrobial agent when there was no clinical indication for such a medication. Many respondents (70%) would consider antibiotics for at least one of the given non-clinical factors.

CONCLUSIONS

The results suggest that dental practitioners in Yemen lack uniformity in the rationale for appropriate prescribing of antimicrobials to their patients. Consequently, to reduce overuse, there is an urgent need for the dental community in the country to be informed about evidence-based guidelines and the appropriate use of antimicrobial agents in clinical dental practice.