Are we still prescribing too many antibiotics in the dental office?

January 1, 2023
By Lisa Germain, DDS, MScD

The discovery of penicillin was, in truth, a happy accident.  Returning from a vacation on September 3, 1928, Alexander Fleming Professor of Bacteriology at St. Mary’s Hospital in London, began to sort through petri dishes containing colonies of Staphylococcus. He noticed something unusual on one dish. It was dotted with colonies, save for one area where a blob of mold was growing. The zone immediately around the mold—later identified as a rare strain of Penicillium notatum—was clear, as if the mold had secreted something that inhibited bacterial growth.1  

Since then, the entire world has benefited from one of the greatest medical advancements in history. The discovery of safe, systemic antibiotics has been a major factor in the control of infectious diseases and, as such, has increased life expectancy and the quality of life for millions of people. However, along with the unquestionable benefits of systemic antibiotics, there has also been an explosion in the number of bacteria that have become resistant to a variety of these drugs. The problem is not the antibiotics themselves. They remain one of our most potent weapons against diseases. Instead, the problem is in the way the drugs are used. The inappropriate overuse of antibiotics has resulted in a crisis situation due to bacterial mutations developing resistant strains.

Many worldwide strains of Staphylococcus aureus exhibit resistance to all medically important antibacterial drugs, including vancomycin. Methicillin-resistant S. aureus (aka  MERSA) has become one of the most frequent nosocomial, or hospital-acquired, pathogens. The rate at which bacteria develop resistance to antibacterial drugs is alarming, demonstrating resistance soon after new drugs have been introduced. This rapid development of resistance has contributed significantly to the morbidity and mortality of infectious diseases, especially nosocomial infections.2

In truth, dangerous and contagious staph infections kill thousands of patients in the most sophisticated hospitals in Europe, North America and Asia.  But incredible as it may sound, there is virtually no sign of this “killer superbug” in the country of Norway. The reason? Norway stopped taking so many antibiotics. A report from Aker University in Oslo, Norway, strongly suggests that bacterial resistance to antibacterial agents can be reversed.3 “We don’t throw antibiotics at every person with a fever. We tell them to hang on, wait and see, and we give them a Tylenol to feel better,” reports Dr. John Haug, infectious disease specialist at Aker University Hospital.

The British Society for Antimicrobial Chemotherapy published a review in the Journal of Antimicrobial Chemotherapy that examined the contributions antibiotic prescribing by general dentists in the United Kingdom has made to the selection of antibiotic resistance in bacteria of the oral flora.4 The review concluded that inappropriate antibacterial drug prescribing by dental practitioners is a significant contributing factor in the selection of drug-resistant bacterial strains. In 1997 the ADA Council on Scientific Affairs published a statement warning that: “Microbial resistance to antibiotics is increasing at an alarming rate. The major cause of this public health problem is the use of antibiotics in an inappropriate manner, leading to the selection of dominance of resistant microorganisms and/or the increased transfer of resistance genes from antibiotic-resistant to antibiotic-susceptible microorganisms.” 5 

The American Dental Association reported the results of another survey of antibiotic use in dentistry in the November 2000 Journal of the American Dental Association.6 The authors found that confusion about prescribing antibiotics and inappropriate prescribing practices was evident, and that inappropriate antibiotic use, such as improper dosing, duration of therapy and prophylaxis are all factors that may affect development of antibiotic resistant microorganisms. The biggest problem is that this data is over 20 years old and the problem persists. General and specialty dentists are currently the third highest outpatient prescribers for antibiotics, and data from 2017 to 2019 suggest 35% to 80% of these antibiotic prescriptions are either not indicated or suboptimal.6

In a healthy host, antibiotics are not curative, but instead function to assist in the re-establishment of the proper balance between the host’s defenses (immune and inflammatory) and the invasive agent(s). Antibiotics do not cure patients; patients cure themselves. It has been estimated that up to 60% of human infections resolve by host defenses alone following removal of the cause of the infection without antibiotic intervention.

Microorganisms cause virtually all pathoses of the pulp and periapical tissues in endodontic disease.  There is ample evidence to support that opportunistic normal oral microbiata colonize in a symbiotic relationship with the host, resulting in endodontic infections.7 However, most endodontic infections do not require systemic antibiotic therapy when the cause of the infection has been properly managed by complete cleaning, shaping and sealing off the root canal system from the oral environment.   Apical periodontitis lesions of pulpal origin are generated by the immune system and are the result of peri-radicular infections. In most situations, this inflammatory process successfully eliminates the bacteria emerging from the apical foramena and prevents their spread to the periapical tissues. This process is primarily facilitated by the polymorphonuclear leukocytes that eventually phagocytize and kill the bacteria.8 Asymptomatic apical periodontitis of pulpal origin does not routinely require systemic antibiotic therapy for satisfactory resolution and healing. Proper endodontic therapy alone is usually sufficient.

When the peri-radicular infection is able to overwhelm the host’s immune response, viable bacteria are able to gain access to the periapical tissues and colonize forming an active infection. This results in the formation of an apical abscess. A chronic apical abscess usually presents with gradual onset, no to mild symptoms and the presence of a sinus tract. The majority of chronic apical abscesses of endodontic origin do not require systemic antibiotic therapy for satisfactory resolution and healing. An acute apical abscess usually presents with rapid onset, spontaneous pain and swelling, both localized and intraoral, sometimes with exudate present, or with diffuse facial cellulitis. When the abscess is intraoral and localized debridement of the pulp space and placement of calcium hydroxide and surgical incision for drainage is usually sufficient to resolve the problem without the use of antibiotics. Antibiotics should not be substituted for root canal debridement and drainage of purulence from a peri-radicular swelling. Additionally, the ADA developed guidelines for the management of dental pain and intra-oral swelling that largely recommended against the use of antibiotics for the treatment of infections without systemic involvement, favoring dental intervention in immunocompetent patients. 9

Antimicrobial use within the realm of dentistry has received growing attention with regards to prophylactic therapy, as well,  as evidenced by recently updated ADA antibiotic stewardship recommendations.9  Following guidance from the American Academy of Orthopedic Surgeons (AAOS) and the American Heart Association (AHA), the ADA has established recommendations for antimicrobial prophylaxis prior to dental procedures in patients with prosthetic joint implants and patients thought to be at increased risk for developing endocarditis.10

The ADA provided updated recommendations for antimicrobial prophylaxis prior to dental procedures in May of 2021.11 These recommendations highlight that there is a relatively small subset of patients that are indicated to receive antibiotic prophylaxis when compared to older versions of guidelines published by AAOS and AHA.  The AHA’s 2021 scientific update reinforced that antibiotic prophylaxis is only indicated for patients at the highest risk of infective endocarditis, citing that risks of adverse effects and development of drug-resistance likely outweighs benefits of prophylaxis in many patients that were historically included in previous guidelines.  Additionally, these recommendations apply only to dental procedures in which there is manipulation of the gingival tissue or the periapical region of teeth, or perforation of the oral mucosa.

All antibiotic use, appropriate or not, “uses up” some of the effectiveness of that antibiotic, diminishing our ability to use it in the future. For current and future generations to have access to effective prevention and treatment of bacterial infections as part of their right to health, all of us need to act now. There was a time when I would ask myself which antibiotic I should prescribe for any given situation.  Now I ask myself a different question.  Should I prescribe one at all?

 

  1. Bennett JW, Chung KT. Alexander Fleming and the discovery of penicillin. Adv Appl Microbiol. 2001;49:163-84. doi: 10.1016/s0065-2164(01)49013-7. PMID: 11757350.
  2. ADA Council on Scientific Affairs. Combating antibiotic resistance. J Am Dent Assoc 2004;135:484.
  3. Associated Press. Killer superbug solution discovered in Norway. msnbc.com, December 2009
  4. Sweeney LC, Jayshree D, Chambers PA, Heritage J. Antibiotic resistance in general dental practice—a cause for concern. J Antimicrobial Chemotherapy 2004;53:567.
  5. ADA Council on Scientific Affairs. Antibiotic use in dentistry. J Am Dent Assoc 1997; 128:648.
  6. Epstein JB, Chong S, Le ND. A survey of antibiotic use in dentistry. J Am Dent Assoc 2000;131:1600.
  7. Baumgartner JC. Microbiology of Endodontic Disease. In: Endodontics. 6th ed. B.C. Decker Inc. Hamilton, Ontario, Canada, 2008
  8. Baumgartner JC, et al. Experimentally induced infection by oral anaerobic microorganisms in a mouse model. Oral Microbiol Immunol 1992;7:253-6.

 

  1. Lockhart PB, Tampi MP, Abt E, et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. J Am Dent Assoc. 2019;150(11):906-21.e12

 

  1. American Dental Association. Oral health topics: Antibiotic stewardship. American Dental Association website. September 29, 2020. Accessed July 20, 2021. https://www.ada.org/en/ member-center/oral-health-topics/antibiotic-stewardship.
  2. American Dental Association. Oral health topics: Antibiotic prophylaxis prior to dental procedures. American Dental Association website. September 29, 2020. Accessed July 20, 2021. https://www.ada.org/en/ member-center/oral-health-topics/antibiotic-stewardship.