Advances in medical and pharmacological science have been nothing short of miraculous in the past two decades, unlocking the secrets of the human genome and opening vast new territory in biologic and immunotherapeutic interventions. But it’s occasionally useful to take a step back and look at the most basic of our treatment protocols, conventions, and guidelines.
That’s precisely what a team of researchers at the University of Illinois at Chicago did recently when they retroactively evaluated the data from more than 90,000 patients who had been prescribed antibiotic prophylaxis before a dental procedure in the years between 2011 and 2015.1 The team’s findings were as surprising as they were compelling. They revealed that we still have work to do within the dental practice community when it comes to spreading the word about appropriate antibiotic prescribing guidelines, as well as the individual and public health risks versus the potential benefits of antibiotic prescribing in our patient population.
What’s the bottom line? Evaluated against the evidence-based prescribing guidelines for antibiotic prophylaxis, 80% of the patients in a four-year study were prescribed antibiotics deemed “unnecessary.” That’s roughly 72,000 American patients.1
Let’s take a closer look at the problem, the guidelines, and what the dental profession can do about this.
The American Dental Association’s message on this topic has been clear: antibiotic stewardship is the goal.2 Guidelines on preprocedural antibiotic prophylaxis are constantly evolving based on emerging evidence. Changes in these guidelines may account for the current rate of prophylactic antibiotic overprescription prior to dental procedures.
The current 2007 guidelines from the American Heart Association recommend one dose of antibiotics before procedures for patients at the highest level of risk for negative outcomes from infective endocarditis.3 To date, that guideline remains in effect. But a recommendation from the American Academy of Orthopaedic Surgeons that had recommended prophylaxis for patients with prosthetic joints was significantly revised in 2016.4
The University of Illinois study uncovered prescribing patterns with troubling inconsistencies that may offer additional insights to assist with provider education.1 The authors took the time to evaluate which specific drugs were being prescribed before dental procedures. And while amoxicillin accounted for the majority of prescriptions at 69%, the next most frequently prescribed antibiotic, clindamycin, generated concern for three reasons1:
- Dentists are the highest-frequency prescribers of clindamycin.
- Clindamycin is strongly associated with a high risk of Clostridium difficile infection.
- Patients who were prescribed clindamycin for prophylaxis were more likely to have received an unnecessary prescription than patients who were prescribed amoxicillin.
As health-care practitioners, at the very least we want to ensure that we do no harm. While quarterly conferences and continuing education can help to keep dental professionals in the loop on the latest technology, staying abreast of best practices for patient treatment is a day-to-day responsibility.
The American Dental Association aggregates, reviews, and updates clinical practice guidelines regularly, taking the latest evidence into account. Its Center for Evidence-Based Dentistry collects all of the validated Clinical Practice Guidelines into one centralized resource.5 Add it to your office’s computer bookmarks; consider assigning a guideline-of-the-month for clinical lunch-and-learns; and discuss a guideline monthly at clinical huddles and meetings. There are endless ways to continue to bring your practice into alignment with the safest prescribing and treatment practices.
1. Suda KJ, Calip GS, Zhou J, et al. Assessment of the appropriateness of antibiotic prescriptions for infection prophylaxis before dental procedures, 2011 to 2015. JAMA Network Open. 2019;2(5):e193909. doi:10.1001/jamanetworkopen.2019.3909. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2734798. Published May 31, 2019.
2. Oral health topics: Antibiotic stewardship—key points. Department on Scientific Information. ADA Science Institute. American Dental Association website. https://www.ada.org/en/member-center/oral-health-topics/antibiotic-stewardship
3. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: Guidelines from the American Heart Association: A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2017;116(15):1736-1754. doi:10.1161/CIRCULATIONAHA.106.183095.
4. Quinn RH, Murray JN, Pezold R, Sevarino KS. American Academy of Orthopaedic Surgeons appropriate use criteria for the management of patients with orthopaedic implants undergoing dental procedures. J Bone Joint Surg Am. 2017;99(2):161-163. doi:10.2106/JBJS.16.01107. https://aaos.webauthor.com/go/auc/terms.cfm?auc_id=224995&actionxm=Terms. Published January 18, 2017. Accessed August 1, 2019.
5. ADA Center for Evidence-Based Dentistry: Clinical Practice Guidelines. American Dental Association website. https://ebd.ada.org/en/evidence/guidelines?utm_medium=VanityUrl. Accessed August 1, 2019.
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Editor's note: This article originally appeared in Breakthrough Clinical, a clinical specialties newsletter from Dental Economics and DentistryIQ.