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J Am Dent Assoc, Vol 131, No 11, 1600-1609.
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CLINICAL PHARMACOLOGY

JADA Continuing Education

A SURVEY OF ANTIBIOTIC USE IN DENTISTRY



JOEL B. EPSTEIN, D.M.D., M.S.D., F.R.C.D.(C), SANDRA CHONG, D.D.S. and NHU D. LE, Ph.D.


   ABSTRACT
TOP
 ABSTRACT
METHODS AND MATERIALS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. Antibiotics are important in the management and prophylaxis of infection in patients at risk of experiencing microbial disease. As a result of the increase in antimicrobial resistance, the authors conducted a survey to assess current antibiotic use in dental practice.

Methods. The authors mailed a two-page, pretested survey to all licensed dental practitioners in British Columbia, Canada. A total of 2,542 surveys were mailed; 19.9 percent were returned by fax or mail. The authors examined an association between factors analyzed using a {chi}2 test.

Results. Respondents were demographically consistent with all registered dentists in British Columbia. They reported writing an average of 4.45 prescriptions per week. Antibiotics prescribed after treatment primarily were penicillin and its derivatives. Recommended adult doses of penicillin were prescribed by 59.2 percent of respondents; recommended daily doses of amoxicillin were prescribed by 72.2 percent of respondents. The average prescription duration was 6.92 days. Respondents prescribed prophylactic antibiotics an average of 1.15 times per week for prophylaxis of bacterial endocarditis; 17.5 percent reported postoperative dosing for prophylaxis, ranging from a one- to seven-day prescription with an average of 6.91 postoperative doses. Preoperative antibiotics were prescribed for patients with a history of rheumatic fever or any heart murmur or prosthetic hip. Antibiotics were prescribed more frequently for surgical procedures and patients with acquired immunodeficiency syndrome than for other circumstances.

Conclusions. More than 80 percent of respondents reported that they followed current American Heart Association prophylaxis guidelines. The authors, however, noted discrepancies in prophylactic use of antibiotics for bacterial endocarditis and for patients with large joint prostheses, as well as in prescribing antibiotics in the presence of clinical infection. In therapeutic use, approximately 85 percent of respondents followed appropriate prescription guidelines for dosing and duration of therapy.

Clinical Implications. Appropriate and correct use of antibiotics is essential to ensure that effective and safe treatment is available and that practices that may enhance microbial resistance are avoided. To improve standards of care, dentists need up-to-date pharmacology in dental education, as well as continuing education, further outcome studies and continuous assessment of dental practices.

Antibiotics are invaluable adjuncts in the management of orofacial infections. Although they are not a substitute for definitive treatment, their judicious use can shorten infection periods and minimize associated risks, such as the spread of infection to adjacent anatomical spaces or systemic involvement.1

Increasing microbial resistance to antibiotics, however, is a well-documented and serious global health concern.2–21 First observed in 1940, penicillin-resistant bacteria were overcome with the development of new antibiotics.22,23 The emergence of new multidrug–resistant bacteria, however, has escalated at an alarming rate. One factor that may contribute is inappropriate use of antibiotics in veterinary medicine, agriculture, medicine and, possibly, dentistry.2,22,23

Dentistry’s contribution to the development of antimicrobial resistance is unknown.22 Therefore, we conducted a survey to assess the therapeutic and prophylactic prescription of antibiotics in dental practice.


   METHODS AND MATERIALS
TOP
 ABSTRACT
 METHODS AND MATERIALS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
We pretested, modified, retested and mailed a two-page survey to all licensed practitioners—general dentists and certified specialists working within or outside British Columbia, Canada; nonpracticing and retired dentists; and recently graduated dentists—in British Columbia, in June 1998. Responses were returned by mail or fax. The confidential survey asked for sociodemographic details and included queries and charts that elicited responses regarding antimicrobial use by the practitioner. We entered the data into Microsoft Access 97 (Microsoft Corp.) and analyzed it using a statistical software package (SPSS 9.0, SPSS Inc.). We then examined associations between factors using a {chi}2 test.24


   RESULTS
TOP
 ABSTRACT
 METHODS AND MATERIALS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Of the 2,542 surveys mailed, 505 (19.9 percent) were returned from 20.4 percent of general practitioners surveyed and 18.7 percent of certified specialists surveyed. The respondents were demographically consistent with all registered dentists in British Columbia with respect to age (survey mean 44.2 years, registered dentist mean 44.4 years) and sex (survey mean for males 78.8 percent, for females 21.2 percent; registered mean for males 81.5 percent, for females 18.5 percent). We analyzed the results from the complete response pool and assessed them by years since graduation and between certified specialists and general practitioners.

Therapeutic antibiotics. Respondents reported that they wrote an average of 4.45 prescriptions per week, ranging from zero to 75. The antibiotics they predominantly prescribed for use after treatment were amoxicillin (64.0 percent); penicillin V potassium (49.9 percent); erythromycin (9.1 percent); clindamycin (8.5 percent); metronidazole (5.0 percent); tetracycline (3.0 percent); ampicillin (1.4 percent; and cloxacillin (1.4 percent).

Respondents prescribed an average penicillin V daily dose of 1.48 grams, ranging from 0.25 to 4.0 g. An adult dose of 1.2 g/day was prescribed by 59.2 percent of respondents; 21.9 percent prescribed twice that dose, 0.8 percent prescribed more than 3.0 g/day, and 15.8 percent prescribed suboptimal doses (< 1.0 g/day). The average daily dose of amoxicillin was 1.41 g, ranging from 0.25 to 4.5 g; 72.2 percent of respondents prescribed 1 to 1.2 g/day, and 4.2 percent prescribed less than .75 g/day.

Respondents prescribed antibiotics for an average of 6.92 days, ranging from one to 21 days. The majority of respondents (57.4 percent) prescribed antibiotics for six to seven days, while 16.7 percent prescribed antibiotics for more than seven days.

Prophylactic antibiotics. Respondents wrote an average of 1.15 prescriptions per week for bacterial endocarditis prophylaxis, ranging from zero to 10. Amoxicillin was the antibiotic of choice among respondents; it was prescribed by 89.3 percent of respondents. The remaining respondents prescribed antibiotics such as ampicillin, penicillin G, clindamycin or vancomycin. Twelve respondents (2.4 percent) prescribed penicillin V; 11 of these dentists had graduated more than 10 years earlier.

A total of 17.5 percent of dentists reported prescribing postoperative doses of antibiotics for prophylaxis; they prescribed an average of 6.91 doses, ranging from one dose to a seven-day prescription. This practice was reported by dentists at approximately the same rate, regardless of the years since graduation.

Antibiotic use before procedures. A greater use of preoperative antibiotics was evident among all respondents for all procedures involving patients with a history of rheumatic fever, any heart murmur or an artificial hip prosthesis. For more invasive procedures such as periodontal surgery, extractions, endodontic surgery and implant placements, patients with acquired immunodeficiency virus, or AIDS, received antibiotics before treatment more often than did patients without HIV or AIDS (Figure 1Go).



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  		Figure 1. Routine use of antibiotics before treatment.

 
In the survey, patients with prosthetic heart valves were the only high-risk patients we listed who required prophylaxis for bacterial endocarditis. While these patients were prescribed more preoperative antibiotics than patients with any other listed condition, they also received medication before treatment that would not cause significant bleeding. The prevalence of antibiotic use for patients with prosthetic heart valves is shown in Figure 2Go. From 50.8 percent to 94.9 percent of respondents prescribed antibiotics before extraction of an impacted tooth with acute infection or treatment of a dental infection with fever (Figure 3Go).



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  		Figure 2. Antibiotics prescribed before treatment for patients with prosthetic heart valves.

 


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  		Figure 3. Antibiotics prescribed before treatment for patients with infections.

 
Certified specialists reported prescribing preoperative antibiotics for patients with prosthetic heart valves less often than did general dentists in virtually all cases, including extraction of an impacted tooth with acute infection or treatment of a dental infection with fever (Table 1Go). Although it is not statistically significant, we found that certified specialists prescribed more preoperative antibiotics for patients with insulin-dependent diabetes mellitus, or IDDM; noninsulin–dependent diabetes mellitus, or NIDDM; human immunodeficiency virus, or HIV; or AIDS before periodontal surgery and dental extraction. We found no significant differences in prescribing antibiotics between certified specialists and general dentists before treating patients who had hip prostheses, IDDM, HIV or AIDS or had had cancer therapy. Similarly, we found no differences between certified specialists and general dentists in prescribing antibiotics after treating patients who had had a heart attack or cancer therapy or in patients with hip prostheses, IDDM, HIV or AIDS (Figure 4Go).


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  		TABLE 1 ANTIBIOTICS PRESCRIBED TO PATIENTS WITH PROSTHETIC HEART VALVES BEFORE TREATMENT BY GENERAL DENTISTS AND CERTIFIED SPECIALISTS.

 


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  		Figure 4. Antibiotic use after treatment of various dental procedures.

 
We assessed practitioners’ year of graduation by decade and found that approximately equal numbers of dentists who were graduated before and after 1980. Dentists who graduated after 1980 prescribed prophylactic antibiotics less often than did earlier graduates for patients with IDDM (6.7 percent vs. 12.9 percent; P = .02). We noted a trend of less frequent prescribing of antibiotics among more recent graduates compared with earlier graduates when treating patients with prosthetic valves after scaling and root planing (23.0 percent vs. 30.0 percent; P = .08) and after periodontal surgery (30.5 percent vs. 38.8 percent; P = .07). We saw a statistically significant trend toward more frequent prescribing of antibiotics among recent graduates compared with earlier graduates in patients with HIV (82.1 percent vs. 71.1 percent; P = .005), patients with AIDS (82.7 percent vs. 73.3 percent; P = .016) and patients who had undergone cancer therapy (80.6 percent vs. 72.0 percent; P = .028). Trends toward more frequent prescribing of antibiotics were reported by more recent graduates compared with earlier graduates for patients who had had heart attacks (78.6 percent vs. 71.7 percent; P = .08), those with hip prostheses (81.2 percent vs. 74.2 percent; P = .07) and those with IDDM (82.0 percent vs. 75.1 percent; P = .06).

Antibiotic use after procedures. Dentists commonly prescribed antibiotics after surgical treatment for patients with clinical infections. They prescribed antibiotics after treatment for approximately one-third of patients; the greatest frequency was for patients with prosthetic heart valves, prosthetic hips, AIDS or a history of rheumatic fever (Figure 5Go).



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  		Figure 5. Antibiotic use after treatment of medically compromised patients.

 
From 58.0 to 88.5 percent of dentists prescribed antibiotics after extraction of an impacted tooth with an acute infection or dental infection with fever. Recent graduates appeared to prescribe at a lower rate than earlier graduates after treatment in general. Dentists prescribed antibiotics for patients with HIV and AIDS after most procedures, especially after periodontal surgery, extractions (particularly for impacted teeth) with and without infection, and treatment of dental infections with fever.

Certified specialists prescribed antibiotics less frequently than did general dentists for patients with prosthetic heart valves after some surgical procedures, except for patients with a history of rheumatic fever (Table 2Go).


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  		TABLE 2 ANTIBIOTICS PRESCRIBED TO PATIENTS WITH PROSTHETIC HEART VALVES AFTER TREATMENT BY GENERAL DENTISTS AND CERTIFIED SPECIALISTS.

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS AND MATERIALS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Antibiotic resistance is increasing at an alarming rate.2–21 Antibiotic use and misuse may contribute to this problem. The concern about antibiotic-resistant organisms only recently has become emphasized and reached the attention of the health care professions and the public. Previous studies have examined antibiotic use in dentistry from various perspectives—including examining a random selection of antibiotic prescriptions written by dentists1; comparing practices of medical and dental practitioners for acute dentoalveolar infections25; monitoring patterns of acute cases in a dental hospital26,27; assessing use in a dental teaching hospital28; and conducting a clinical audit.29 While these studies elicited critical data regarding antibiotic use in dentistry, the current study is the first to evaluate a large dental community in Canada with respect to antibiotic use as interpreted by practicing dentists. The results may have relevance throughout Canada and United States because of the comparability between Canadian and U.S. dental education as reflected in the accreditation standards for undergraduate and graduate dental programs.

Our survey’s limitations include a low response rate of 19.9 percent, which may have been increased through a second mailing that we did not undertake. The ages and sex of the respondents, however, are comparable to all licensed dentists in British Columbia. The survey is limited by the nature of all volunteer surveys of this type. Although the survey was about antibiotic use, the query regarding the number of prescriptions written per week could have been specific for antibiotics, removing the potential for respondents to include other prescription medications in their responses. Also, the phrases "history of rheumatic fever" and "any heart murmur" may have caused confusion, as some respondents added conditional notes such as referral to a physician for electrocardiogram, which would not have been helpful in diagnosing and determining the need for antibiotic use. These represent standard questions used in dental health histories.

The choice of dose prescribed and duration of therapeutic and prophylactic antibiotics were appropriate in the majority of responses.1 Confusion about prescribing antibiotics and inappropriate prescribing practices, however, were reported by dentists. The majority of orofacial infections resolve in three to seven days26,30,31; thus, the 16.7 percent of respondents who routinely prescribe antibiotics for more than seven days should reassess how they prescribe antibiotics. The survey also indicated that 17.5 percent of respondents were not using the current guidelines for prophylaxis against infective endocarditis.32–34 Most of these dentists were using the pre-1997 dose recommendations; however, some reported prescribing antibiotics for up to seven days—clearly an overuse of medication.

Antibiotic prophylaxis. Current prophylaxis guidelines state that patients with prosthetic heart valves should receive antibiotics before procedures that may induce oral bleeding.32–35 The guidelines, however, preclude prophylaxis for such treatments as routine dental restorations (although this could be subject to interpretation) and intracanal endodontics. Prophylaxis is required for patients with prosthetic heart valves, a history of rheumatic fever with evidence of valvular dysfunction and pathological heart murmurs, among other cardiac conditions. All other medical conditions listed in this survey—patients with hip prostheses, HIV, AIDS and IDDM, and patients who have had a heart attack or undergone cancer therapy—do not merit routine antibiotic use. In addition, antibiotic prophylaxis currently is recommended for patients with artificial hip prostheses in select cases (patients with inflammatory arthropathies, immunosuppression, IDDM, previous joint infections, malnourishment or hemophilia within the first two years of placement of the prosthesis).36 Routine use of antibiotics for medically compromised or immunocompromised patients has not been shown to be necessary or required unless neutropenia is present.36 Confusion about prophylactic guidelines may explain the large number of antibiotic prescriptions written for patients with a history of rheumatic fever, heart murmur or placement of an artificial hip prosthesis before and after treatment. Erring on the side of safety by prescribing antibiotics for prophylaxis when uncertain also indicates a lack of awareness by health care professionals about the potential impact on antibacterial resistance and the alarming increase in resistant infections.

Respondents prescribed pre-treatment antibiotics for approximately one-half of the patients who had a history of rheumatic fever for procedures that were unlikely to induce bleeding, including routine restorative care and routine cleaning. Approximately 20 percent of patients with any heart murmur and approximately one-third of patients with hip prostheses were prescribed antibiotics for these procedures. For these procedures, less than 10 percent of the respondents prescribed antibiotics for patients with AIDS. For procedures that may cause bleeding, approximately two-thirds of patients with a history of rheumatic fever were prescribed antibiotics; approximately one-fourth of patients with any heart murmur and one-fourth of patients with AIDS were prescribed antibiotics. For dental extractions and dental infections, 91.3 percent of patients with a history of rheumatic fever were prescribed antibiotics, as were 59.9 percent of patients with any heart murmur, 70.0 percent with hip prostheses and 64.8 percent with AIDS. These examples indicate that an overuse of antibiotics is occurring in dental practice. Thus, a more complete understanding of the sequelae of rheumatic fever should be emphasized at the undergraduate level and in continuing education.

Considerable confusion was present in prophylaxis for hip prosthesis. We noted less frequent prescribing of antibiotics for patients with AIDS; however, it is important to note that approximately 40 percent of these patients would be prescribed antibiotics despite the lack of outcome studies indicating that coverage should be provided and at the risk of patients experiencing drug interactions and developing secondary opportunistic (fungal) infections.

While current American Heart Association, or AHA,35 antibiotic prophylaxis guidelines recommend coverage for at-risk patients in whom bleeding may occur, in this survey, we found that respondents prescribed antibiotics for routine restorative procedures for two-thirds of patients, even though bleeding was not expected to occur during these procedures. In other procedures, including surgical treatment in which bleeding was anticipated, respondents prescribed antibiotics for up to 93 percent of patients. Therefore, while antibiotic prophylaxis may be overused in some instances, 100 percent compliance with current guidelines is the goal for patients with prosthetic heart valves in procedures in which bleeding is anticipated.

Current evidence has shown that antibiotic prophylaxis is not 100 percent effective, and a cause-effect relationship between dental visits and subsequent endocarditis has not been proved.33,37–42 In fact, only a very small fraction of endocarditis cases potentially would be prevented by full compliance with antibiotic prophylaxis guidelines before dental treatment.38–42 Hence, educating clinicians, the public and peers in the medical field is necessary to prevent continued misuse of antibiotics in these situations.

Educating clinicians, the public and peers in the medical field is necessary to prevent continued misuse of antibiotics in situations involving potential bacterial endocarditis.

Routine use of antibiotics before and after treatment for both extraction of an impacted tooth with infection and a dental infection with fever is appropriate.33,43 The percentages of respondents prescribing antibiotics ranged from 50.8 to 94.9 percent and were lower than expected in these situations. This was especially true among certified specialists who prescribed antibiotics at a lower frequency than did general dentists for all patient conditions when clinical infection was present.

Antibiotic use by graduates before and after 1980. The general pattern we observed among more recent graduates to prescribe prophylactic antibiotics at a lower rate than earlier graduates before treatment suggests that undergraduate education or continuing education may be successful in educating dentists about current antibiotic practices. The more recent graduates, however, reported prescribing antibiotics more frequently than earlier graduates for medically complex patients who did not require antibiotics. The difference between earlier and more recent graduates in prescribing antibiotics was small but may be due to sample size, an increased awareness of the growing concerns about antibiotic resistance or an increased concern about potential litigation. Of concern, however, was the trend of recent graduates’ prescribing antibiotics more frequently than earlier graduates after periodontal surgery and tooth extraction in patients with diabetes, HIV or AIDS. This may be because they are more anxious about the systemic condition than are earlier graduates.

While the number of certified specialists responding to the survey was less than 10 percent of the number of general dentists who responded, several findings involving them require discussion. Certified specialists prescribed antibiotics at a higher rate than general dentists for pre- and postoperative procedures for immunocompromised patients, patients undergoing periodontal surgery and all patients with implant placements. While one outcome study concluded that five-day antibiotic use after orthognathic surgery reduced the incidence of infection,44 most studies have shown no benefit from routine antibiotic use for most procedures.44–48 Antibiotic use after third-molar extractions45,46 and implant placement47 have not been shown to reduce postoperative infection. One retrospective study reported an increased risk of developing postextraction complications in patients with HIV48; however, others concluded that patients with HIV49 or other immunocompromised patients were not more prone to complications or infections, and antibiotics may not be indicated unless the patient was neutropenic.2,33,36

Certified specialists may justify increased antibiotic use because of an increased complexity of treatment, but this has not been shown to be beneficial. Approximately 20 percent of certified specialists, however, reported not prescribing antibiotics before procedures that cause bleeding in patients with prosthetic valves, which is stated clearly in accepted guidelines as an indication for antibiotic prophylaxis. Surprisingly, certified specialists treating patients with infections that caused fevers were less likely than general dentists to use antibiotics. As a result, clinicians should modify their practices to maximize the potential benefits of prophylaxis, minimize the impact of unnecessary antibiotic use on antimicrobial resistance and prescribe antibiotics when systemic infection indicates the need for antibiotic use.

Respondents prescribed penicillin or its derivatives for more than seven days to 16.7 percent of their patients. They prescribed antibiotics for endocarditis prophylaxis generally following the current AHA guidelines; however, 17.5 percent of respondents prescribed more than one postoperative dose and some provided seven-day doses of antibiotics for an average of 6.91 postoperative doses. In addition, antibiotic prophylaxis appeared to be provided in more instances than required by the current AHA guidelines35 and the current guidelines for patients with total joint replacements.37 Antibiotics were used as prophylaxis before some surgical procedures, including implant placements and periodontal surgery. Thus, we identified an overuse of antibiotics in the dental practice setting and underuse in some cases in which symptomatic infection was present.

Of concern is the trend of recent graduates’ prescribing antibiotics more frequently than earlier graduates after periodontal surgery and tooth extraction in patients with diabetes, HIV or AIDS.

Posttreatment antibiotics should be prescribed for patients who have clinical infection, particularly when the infections are associated with fever. Indeed, antibiotic use should be related to the presence of signs of regional or systemic infection, regardless of any cardiac or joint considerations. The survey presented a clinical model in which antibiotics should be provided after extraction of impacted teeth associated with infection, and respondents reported prescribing antibiotics to approximately two-thirds of patients in such cases. Approximately 80 percent of patients with a fever were prescribed antibiotics, when 100 percent should have been received a prescription. Antibiotics also were prescribed more often when systemic illness was perceived to heighten risk—for example, in patients with IDDM vs. those with NIDDM and in patients with AIDS vs. patients with HIV. Approximately 10 percent of patients, however, received antibiotics after a heart attack, and 10 to 20 percent were prescribed antibiotics after cancer therapy. Thus, these examples indicate an overuse of antibiotics in patients with underlying medical conditions or significant past medical therapy.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS AND MATERIALS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Our findings suggest that overall, dentists prescribed antibiotics in a responsible manner. Appropriate antibiotic application, however, was not evident in 100 percent of cases, especially in patients with a history of rheumatic fever or functional heart murmurs; patients with large joint prostheses; and patients with systemic diseases such as diabetes, HIV, AIDS or cancer. In addition, antibiotics were prescribed postsurgically in conditions in which there was no compelling evidence of their being effective in promoting healing. Appropriate antibiotics, doses and prescription durations must be used when indicated. Suboptimal dosing, extended duration of antibiotic use and use when not indicated (overuse) are all factors that may affect development of antibiotic-resistant microorganisms.

We suggest the following to improve appropriate use of antimicrobials in the dental community:

– further clarification of and education about the current antibiotic guidelines, and recommendations and indications for use at the undergraduate and graduate levels;
– increased outcomes-based research to document clinical benefits of antibiotic use, thus justifying or eliminating routine prescription patterns, and to establish clinical practice guidelines;
– continuing education to disseminate information to practicing dentists;
– further evaluation and surveys of antibiotic use and reassessment of prescribing practices over time.

Antibiotic therapy is very important in medicine and dentistry; we depend on its efficacy as clinicians and as members of the population. Dentistry should strive to achieve 100 percent compliance with antibiotic prophylaxis recommendations and understanding of the appropriate use of antibiotics in dentistry. Conscientious use of antibiotics is imperative for all practitioners, especially when considering the rapid development of antibacterial resistance and the alarming consequences of this trend.


   FOOTNOTES
 

Dr. Epstein is the head, Department of Dentistry, Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia, Canada; a professor, Faculty of Dentistry, the University of British Columbia, Vancouver; a medical/dental staff member, British Columbia Cancer Agency, Vancouver; and a professor, School of Dentistry, University of Washington, Seattle. Address reprint requests to Dr. Epstein at Vancouver Hospital, Willow Pavilion, 1st Floor, 855 West 12th Ave., Vancouver, British Columbia, Canada V5Z 1M9, e-mail "joelbep{at}u.washington.edu".


Dr. Chong was a general practice dental resident, University of British Columbia, Vancouver, British Columbia, Canada, when this article was written. She now is in general practice, Kamloops, British Columbia, Canada.


Dr. Le is a statistician, Cancer Control Research, BC Cancer Research Centre, Vancouver, British Columbia, Canada.


Readers interested in obtaining a complete copy of the survey used in this study should contact Dr. Epstein.


   REFERENCES
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 ABSTRACT
 METHODS AND MATERIALS
 RESULTS
 DISCUSSION
 CONCLUSIONS
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