Antibiotics: friend or foe?
Reena Patel explains why it’s so important to prescribe antibiotics only in the correct situations.
The media has inundated the news lately with the misuse and overuse of antimicrobials around the world.
Dentists tend to issue 5-7% of NHS antibiotic prescriptions in the UK. Sadly, poor prescribing techniques and misuse of antimicrobials has caused an exponential increase in multi drug-resistance infections. This has resulted in 700,000 deaths worldwide and the Government estimates this will increase to 10 million by 2050 (www.nice.org, 2015)
NHS England has stated that: ‘Antibiotic resistance is one of the biggest threats facing us today.’ The overuse of antibiotics now will affect their potency in treating diseases in the future.
Misuse of antibiotics in dentistry is mainly from prescribing in ‘inappropriate situations’ or for too long (Peedikayil, 2011). Sometimes our desire as clinicians to make our patients well and prevent unpleasant complications, with the belief that many oral problems are infectious, spark us to prescribe antibiotics.
The signs and symptoms our patients undergo are usually cyclical. In most circumstances they would improve automatically with time. The temporary improvement seen with antibiotics would have likely occurred in spite of a prescription (Peedikayil, 2011).
So when are antimicrobials not justified?
Here’s some guidance taken from the Faculty of General Dental Practice (FGDP):
- There is no evidence to show that antibiotics are useful in treating irreversible pulpitis (Nagle et al, 2000; Agnihotry et al, 2016)
- Necrotic pulps and related pain are better managed with irrigation of the root canal system (Cope et al, 2014)
- Local acute dental abscesses are managed more efficiently with drainage, extraction or endodontic therapy (Matthews et al, 2003)
- Pericorinitis is managed best with local measures such as irrigation, operculectomy, removal of opposing wisdom tooth, chlorhexidiene mouthwash and analgesics (www.nice.org, 2015)
- Failed root canal treatments require apicectomy or orthograde retreatment (Cope et al, 2014). Dry socket will heal without antibiotics once debridement of the socket has occurred and temporary bacteria static or bactericidal dressing is placed (Lindeboom et al, 2005; Jesudasan, Wahab and Sekhar, 2015)
- Chronic adult periodontitis will not respond to antimicrobials and is almost totally responsive to mechanical therapy (Peedikayil, 2011).
The FGDP has also stated that antibiotics should only be used in primary care (www.fgdp.org.uk, 2016):
Prophylactic antibiotic prescribing
The administration of antimicrobials for the prevention of infectious diseases is still a controversial topic.
In the past, prophylaxis in the UK was indicated for patients at risk of infective endocarditis before undergoing invasive dental procedures. The idea of this was to prevent bacteraemia and metastatic infections as a result of dental treatment.
In 2008, NICE published new guidance to cease the need for antibiotic prophylaxis in the UK. It concluded the severity and frequency of bacteraemias is no greater than that from normal chewing or tooth brushing. It was also stated that the severity of adverse drug reactions caused by prophylaxis outweighed the few cases in which infective endocarditis could be prevented (nice.org.uk, 2016).
In conclusion, the use of antibiotics in healthcare is a crucial step to decrease the rate and development of antibiotic resistance. We as dentists should play our part to reduce prescriptions and should stay up to date with prescribing recommendations.
So, before you pick up the prescription pad, think! Someone’s life could be at stake here.
Agnihotry A, Fedorowicz Z, Van Zuuren EJ, Farman A and Al-Langawi J (2016) Antibiotic use for severe toothache (irreversible pulpitis) Cochrane Database Syst Rev
Cope AL, Francis N, Wood F and Chestnutt IG (2014) The effects of antibiotics on toothache caused by inflammation or infection at the root of the tooth in adults. Cochrane Database Syst Rev
Daly B, Sharif MO, Newton T, Jones K and Worthington HV (2012) What treatment can be used to prevent and treat alveolar osteitis (dry socket)? Cochrane Database Syst Rev
http://nice.org.uk/guidance/cg64 (2016) accessed 7/2/2019
Jesudasan JS, Wahab PU and Sekhar MR (2015) Effectiveness of 0.2% chlorhexidine gel and a eugenol based paste on postoperative alveolar osteitis in patients having third molars extracted; a randomized controlled clinic trial. Br J Oral Maxillofac Surg 53(9): 826-30
Lindeboom JA, Frenken JW, Valkenburg P and van den Akker HP (2005) The role of preoperative prophylactic antiobiotic administration in periapical endodontic surgery; a randomized prospective double-blind placebo-controlled study. Int Endod J 38(12): 877-81
Matthews DC, Sutherland S and Basrani B (2003) Emergency management of acute apical abscess in the permanent dentition: a systematic review of the literature. J Can Dent Assoc 69(10): 660