What's the story with antibiotics in dentistry?
Sarah is Assistant Programme Manager for the Longitude Prize.
The fight to reduce the spread of antibiotic resistance is now a familiar one, and the potential consequences of failing in this fight are well publicised. The common causes of resistance often centre on inappropriate use, with reducing inappropriate prescriptions often at the forefront of suggestions in how to curb resistance. By ensuring clinicians can correctly diagnose an infection, reducing over-the-counter purchases and improving awareness to reduce patient pressure on clinicians, we can begin to turn the tide.
When most people think about antibiotic prescriptions, and whether or not they are appropriate, they probably think of respiratory illnesses, urinary tract infections, sexually transmitted infections, and preventative measures for surgical procedures such as Caesarean sections and joint replacements. But during a series of talks hosted by the Northern Ireland Antimicrobial Resistance (AMR) Network in Belfast last week, we heard first-hand about overprescribing of antibiotics in dentistry, and how this may be contributing to the overuse and misuse of this dwindling resource.
Should dentists prescribe antibiotics?
Indications for the use of antibiotics in dental patients are few: oral infection accompanied by high body temperature and widespread evidence of infection, and a severe condition called facial cellulitis which can lead to septicaemia, are the main reasons antibiotics should be prescribed.
Yet dentistry accounts for 7 to 10% of all antibiotic prescribing in the UK. How can this be?
A recent study carried out by Dr Kathryn Burnett’s team at Ulster University, Northern Ireland, and the subject of one of the talks at the NI AMR Network’s Focus on Pharmacy event, found antibiotic prescriptions were as high as 2000 in just one month in an area covering around 1000 practitioners. 17% of all prescriptions for amoxicillin and metronidazole given during routine appointment were inappropriate, and on top of this the longer a practitioner had been qualified, the more likely they were to prescribe antibiotics.
The findings of this study are concerning, but not news. A 2010 review also highlighted issues with overprescribing in dental practice, and found this was associated with prescribing antibiotics in non-indicated conditions such as inflammation and localised infections, which are better treated operatively. More specifically, for irreversible pulpitis or acute apical periodontitis, 40 to 70% of patients in India and 86% of patients in Spain are prescribed a course of antibiotics, in direct contradiction of guidelines.
What’s the solution to inappropriate prescriptions?
There is perhaps insufficient guidance at present to inform dental antibiotic prescribing in the UK, a point that was raised at the NI AMR Network event. NICE guidelines focus on specific conditions, such as infective endocarditis and dental abscess, rather than providing overarching prescription guidance. However, robust and useful guidelines do exist: Scottish guidelines from SDCEP were highlighted as a gold standard at the Focus on Pharmacy event. Similar guidelines are desperately needed in the rest of the UK, and likely worldwide, and reinforcement of these must happen in order to reduce overprescribing.
The recent prominence of AMR in the media following the final AMR Review report, and upcoming discussions at G7, G20 and the UN General Assembly, provide a perfect platform to widen the debate even further. The publicity surrounding AMR in general could be used as leverage to put the development of new guidelines on the agenda of governments worldwide, followed up by sufficient auditing to ensure that these are adhered to. Then, perhaps, the apparent trend in overprescribing in dentistry may begin to be reversed.