Risk of Adverse Reactions to Oral Antibiotics Prescribed by Dentists

Appropriate use of antibiotics for oral/dental conditions in older adults: a narrative review

OBJECTIVES

Considering the high rates in the use of antibiotics for oral/dental conditions in older patients and the rise in antimicrobial resistance, appropriate antibiotic prescription is important. This narrative review aimed to discuss the challenges and special considerations when prescribing antibiotics to older patients for oral/dental conditions.

METHODS

PubMed/MEDLINE, Scopus, Web of Science, and articles' reference lists were searched for antibiotics use for oral conditions by older patients. Moreover, scientific and professional organisations' official websites were searched for guidelines on antibiotic use in dentistry.

RESULTS

Despite several guidelines about the use of antibiotics in dentistry, specific information on their administration to older patients is missing. Relevant challenges include age-related changes in pharmacokinetics and pharmacodynamics, comorbidities and polypharmacy associated with low adherence, contraindications, adverse reactions, and drug-drug interactions. In unfit and frail older patients some antibiotics should be avoided, or doses should be adjusted, according to medical conditions or medications received. Amoxicillin, with doses adapted to renal function, is one of the safest options, while other antibiotics should be chosen with caution upon indications and individual patient characteristics.

CONCLUSIONS

Healthcare providers should prescribe antibiotics to unfit and frail older adults with caution, given the multitude of comorbidities and potential interactions with medications received. Further research is needed on the safe and effective use of antibiotics in older patients.

Pharmacovigilance Strategies to Address Resistance to Antibiotics and Inappropriate Use-A Narrative Review

The spread of antimicrobial resistance (AMR) is a global challenge. Close and continuous surveillance for quick detection of AMR can be difficult, especially in remote places. This narrative review focuses on the contributions of pharmacovigilance (PV) as an auxiliary tool for identifying and monitoring the ineffectiveness, resistance, and inappropriate use of antibiotics (ABs). The terms "drug ineffective", "therapeutic failure", "drug resistance", "pathogen resistance", and "multidrug resistance" were found in PV databases and dictionaries, denoting ineffectiveness. These terms cover a range of problems that should be better investigated because they are useful in warning about possible causes of AMR. "Medication errors", especially those related to dose and indication, and "Off-label use" are highlighted in the literature, suggesting inappropriate use of ABs. Hence, the included studies show that the terms of interest related to AMR and use are not only present but frequent in PV surveillance programs. This review illustrates the feasibility of using PV as a complementary tool for antimicrobial stewardship activities, especially in scenarios where other resources are scarce.

Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults

BACKGROUND

Dental pain can have a detrimental effect on quality of life. Symptomatic apical periodontitis and acute apical abscess are common causes of dental pain and arise from an inflamed or necrotic dental pulp, or infection of the pulpless root canal system. Clinical guidelines recommend that the first-line treatment for these conditions should be removal of the source of inflammation or infection by local operative measures, and that systemic antibiotics are currently only recommended for situations where there is evidence of spreading infection (cellulitis, lymph node involvement, diffuse swelling) or systemic involvement (fever, malaise). Despite this, there is evidence that dentists frequently prescribe antibiotics in the absence of these signs. There is concern that this could contribute to the development of antibiotic-resistant bacteria. This review is the second update of the original version first published in 2014.

OBJECTIVES

To evaluate the effects of systemic antibiotics provided with or without surgical intervention (such as extraction, incision and drainage of a swelling, or endodontic treatment), with or without analgesics, for symptomatic apical periodontitis and acute apical abscess in adults.

SEARCH METHODS

We searched Cochrane Oral Health's Trials Register (26 February 2018 (discontinued)), CENTRAL (2022, Issue 10), MEDLINE Ovid (23 November 2022), Embase Ovid (23 November 2022), CINAHL EBSCO (25 November 2022) and two trials registries, and performed a grey literature search. There were no restrictions on language or date of publication.

SELECTION CRITERIA

Randomised controlled trials of systemic antibiotics in adults with a clinical diagnosis of symptomatic apical periodontitis or acute apical abscess, with or without surgical intervention (considered in this situation to be extraction, incision and drainage, or endodontic treatment) and with or without analgesics.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the results of the searches against inclusion criteria, extracted data and assessed risk of bias. We used a fixed-effect model in the meta-analysis as there were fewer than four studies. We contacted study authors to request missing information. We used GRADE criteria to assess the certainty of the evidence.

MAIN RESULTS

There was one new completed trial on this topic since the last update in 2018. In total, we included three trials with 134 participants. Systemic antibiotics versus placebo with surgical intervention and analgesics for symptomatic apical periodontitis or acute apical abscess One trial (72 participants) compared the effects of a single preoperative dose of clindamycin versus a matched placebo when provided with a surgical intervention (endodontic chemo-mechanical debridement and filling) and analgesics to adults with symptomatic apical periodontitis. We assessed this study at low risk of bias. There were no differences in participant-reported pain or swelling across trial arms at any time point assessed. The median values for pain (numerical rating scale 0 to 10) were 3.0 in both groups at 24 hours (P = 0.219); 1.0 in the antibiotic group versus 2.0 in the control group at 48 hours (P = 0.242); and 0 in both groups at 72 hours and seven days (P = 0.116 and 0.673, respectively). The risk ratio of swelling when comparing preoperative antibiotic to placebo was 0.50 (95% confidence interval (CI) 0.10 to 2.56; P = 0.41). The certainty of evidence for all outcomes in this comparison was low. Two trials (62 participants) compared the effects of a seven-day course of oral phenoxymethylpenicillin (penicillin VK) versus a matched placebo when provided with a surgical intervention (total or partial endodontic chemo-mechanical debridement) and analgesics to adults with acute apical abscess or symptomatic necrotic tooth. Participants in both trials also received oral analgesics. We assessed one study at high risk of bias and the other at unclear risk of bias. There were no differences in participant-reported pain or swelling at any time point assessed. The mean difference for pain (short ordinal numerical scale 0 to 3, where 0 was no pain) was -0.03 (95% CI -0.53 to 0.47) at 24 hours; 0.32 (95% CI -0.22 to 0.86) at 48 hours; and 0.08 (95% CI -0.38 to 0.54) at 72 hours. The standardised mean difference for swelling was 0.27 (95% CI -0.23 to 0.78) at 24 hours; 0.04 (95% CI -0.47 to 0.55) at 48 hours; and 0.02 (95% CI -0.49 to 0.52) at 72 hours. The certainty of evidence for all the outcomes in this comparison was very low. Adverse effects, as reported in two studies, were diarrhoea (one participant in the placebo group), fatigue and reduced energy postoperatively (one participant in the antibiotic group) and dizziness preoperatively (one participant in the antibiotic group). Systemic antibiotics without surgical intervention for adults with symptomatic apical periodontitis or acute apical abscess We found no studies that compared the effects of systemic antibiotics with a matched placebo delivered without a surgical intervention for symptomatic apical periodontitis or acute apical abscess in adults.

AUTHORS' CONCLUSIONS

The evidence suggests that preoperative clindamycin for adults with symptomatic apical periodontitis results in little to no difference in participant-reported pain or swelling at any of the time points included in this review when provided with chemo-mechanical endodontic debridement and filling under local anaesthesia. The evidence is very uncertain about the effect of postoperative phenoxymethylpenicillin for adults with localised apical abscess or a symptomatic necrotic tooth when provided with chemo-mechanical debridement and oral analgesics. We found no studies which compared the effects of systemic antibiotics with a matched placebo delivered without a surgical intervention for symptomatic apical periodontitis or acute apical abscess in adults.

Evaluation of patients labeled with a penicillin allergy to promote antimicrobial stewardship in dental practice

BACKGROUND

Approximately 10% of the US population self-reports a penicillin allergy history or are labeled as penicillin allergic. However, from 90% through 99% of these patients are not allergic on formal evaluation.

CASE DESCRIPTION

Patients labeled as penicillin allergic receive broader-spectrum and sometimes less-effective antibiotics, thereby contributing to increased treatment failures, antibiotic resistance, and adverse drug reactions. Self-reported penicillin allergy can be eliminated or classified as low-, medium-, or high-risk after a careful review of patient history. This allows these patients to be delabeled; that is, having any reference to their penicillin allergy history or of having an allergy to penicillin eliminated from their health records.

PRACTICAL IMPLICATIONS

Oral health care professionals are ideally placed to partner in both antibiotic stewardship interventions by means of recognizing pervasive mislabeling and aiding in the process of delabeling.

Frequency and Risk Factor Analysis for Metronidazole-Associated Neurologic Adverse Events

BACKGROUND

Little is known about the risk factors and frequency of metronidazole-associated neurological adverse events.

OBJECTIVE

To investigate the risk factors and frequency of metronidazole-associated neurological adverse events.

DESIGN

This retrospective study contained two parts. First, we investigated metronidazole treatment-associated neurologic adverse events by performing a population-based cohort study using the Korea Adverse Event Reporting System (KAERS) database from January 2011 to December 2020. Second, we conducted a matched case-control study based on a retrospective cohort of patients treated with metronidazole between January 2006 and July 2021 at a tertiary hospital in South Korea. The data analysis was performed from August 2021 to April 2022.

PARTICIPANTS

In the case-control study, case patients were defined as those diagnosed with metronidazole-associated encephalopathy or peripheral neuropathy during the study period with causal assessment based on the clinical diagnoses and findings from associated tests. In a ratio of 1:3, case patients were compared to a control group of patients prescribed metronidazole without neurologic adverse events matched for age and cumulative dose of metronidazole.

MAIN MEASURES

Frequency and risk factors for metronidazole-associated neurological adverse events.

KEY RESULTS

Overall, 2,309 cases of neurologic adverse events were reported to the KAERS from 2011 to 2020, and the number of reported neurological adverse events showed an increasing trend. Further, 92,838 patients were prescribed metronidazole during the study period at the Severance Hospital; 54 patients were diagnosed with metronidazole-associated encephalopathy or peripheral neuropathy, 40 with central and 28 with peripheral nervous system adverse events. Liver cirrhosis, chronic kidney disease, intravenous administration, and lower body weight were identified as risk factors for these adverse events.

CONCLUSIONS

The number of reported metronidazole-associated neurological adverse events are increasing. Prolonged metronidazole treatment in patients with the aforementioned factors requires careful examination for neurological adverse events.

Targeted Clindamycin Delivery Systems: Promising Options for Preventing and Treating Bacterial Infections Using Biomaterials

Targeted therapy represents a real opportunity to improve the health and lives of patients. Developments in this field are confirmed by the fact that the global market for drug carriers was worth nearly $40 million in 2022. For this reason, materials engineering and the development of new drug carrier compositions for targeted therapy has become a key area of research in pharmaceutical drug delivery in recent years. Ceramics, polymers, and metals, as well as composites, are of great interest, as when they are appropriately processed or combined with each other, it is possible to obtain biomaterials for hard tissues, soft tissues, and skin applications. After appropriate modification, these materials can release the drug directly at the site requiring a therapeutic effect. This brief literature review characterizes routes of drug delivery into the body and discusses biomaterials from different groups, options for their modification with clindamycin, an antibiotic used for infections caused by aerobic and anaerobic Gram-positive bacteria, and different methods for the final processing of carriers. Examples of coating materials for skin wound healing, acne therapy, and bone tissue fillers are given. Furthermore, the reasons why the use of antibiotic therapy is crucial for a smooth and successful recovery and the risks of bacterial infections are explained. It was demonstrated that there is no single proven delivery scheme, and that the drug can be successfully released from different carriers depending on the destination.

Essential considerations towards development of effective nasal antibiotic formulation: features, strategies, and future directions

INTRODUCTION

Intranasal antibiotic products are gaining popularity as a promising method of administering antibiotics, which provide numerous benefits, e.g. enhancing drug bioavailability, reducing adverse effects, and potentially minimizing resistance threats. However, some issues related to the antibiotic substances and nasal route challenges must be addressed to prepare effective formulations.

AREAS COVERED

This review focuses on the valuable points of nasal delivery as an alternative route for administering antibiotics, coupled with the challenges in the nasal cavity that might affect the formulations. Moreover, this review also highlights the application of nasal delivery to introduce antibiotics for local therapy, brain targeting, and systemic effects that have been conducted. In addition, this viewpoint provides strategies to maintain antibiotic stability and several crucial aspects to be considered for enabling effective nasal formulation.

EXPERT OPINION

In-depth knowledge and understanding regarding various key considerations with respect to the antibiotic substances and nasal route delivery requirement in preparing effective nasal antibiotic formulation would greatly improve the development of nasally administered antibiotic products, enabling better therapeutic outcomes of antibiotic treatment and establishing appropriate use of antibiotics, which in turn might reduce the chance of antibiotic resistance and enhance patient comfort.

Is Antibiotic Prophylaxis Needed for the Extraction of Premolars for Orthodontic Purposes?

Introduction Antibiotic prophylaxis for tooth extractions is a common practice in dentistry to prevent postoperative infections. However, the routine use of antibiotics has been questioned due to concerns about bacterial resistance and potential side effects. This study aimed to evaluate the necessity of postoperative antibiotics in patients undergoing orthodontic tooth extraction. Materials and methods This prospective study involved 100 patients requiring orthodontic tooth extraction, divided into two groups. The patients were recruited from Saveetha Dental College and Hospital, Chennai, India, after obtaining approval from the Institutional Human Ethics Committee, Saveetha Dental College (approval number: IHEC/SDC/OMFS-2103/23/293). Group 1 (n = 50) received antibiotics (amoxicillin 500 mg, three times a day for three days) after extraction, while Group 2 (n = 50) did not receive antibiotics. Postoperative infection was assessed on postoperative days (POD) 3 and 7. Data analysis was conducted using IBM SPSS Statistics for Windows, version 26.0 (released 2019, IBM Corp., Armonk, NY). Categorical variables were presented as frequencies and percentages, and differences between groups were assessed using chi-square or Fisher's exact tests. A p-value of <0.05 was considered statistically significant. Results The incidence of postoperative infection was recorded in both groups. In group 1 at POD 3 and POD 7, there were two patients and one patient with infection, respectively. In group 2 at POD 3 and POD 7, there were four patients and two patients with infection, respectively. Conclusion The findings of this study suggest that the routine administration of antibiotics for the non-traumatic extraction of teeth in healthy patients might not be necessary. The absence of postoperative infections in patients who did not receive antibiotics indicates that antibiotics may be avoidable in many cases of orthodontic tooth extraction. These results emphasize the importance of reconsidering the widespread use of antibiotics to combat the growing concern of bacterial resistance. Antibiotics should be prescribed judiciously, only for patients with specific medical conditions who are prone to infection. One of the limitations of this study is the limited sample size; hence, studies with larger and heterogeneous groups should be done to validate the same.

Assessment of Knowledge, Attitude, and Practice of Pharmacovigilance and Materiovigilance among Oral Health Practitioners in India

Aim

This electronic survey was carried out to assess the knowledge, attitude, and practices among the oral health practitioners.

Methods

A questionnaire survey was conducted among undergraduates, graduated practitioners, and specialist practitioners. A Google Form that included a specified instruction format, informed consent with a clear description of the purpose of the study, and questions in different categories were sent through Whatsapp and email. Descriptive statistics were used to analyze responses. The association of knowledge and attitude with respect to oral health professionals was analyzed with the Chi-square test.

Results

The questionnaire was completed by 570 participants. Thirty percent of participants encountered ADR related to the drugs available in the market and 33.2% of participants encountered adverse reaction related to materials used in practice. ADR should be reported as soon as it is detected, according to this study about 12.1% of participants reported the ADRs, and this reporting is primarily for patient safety. Almost 66.8% of participants perceived that dental products can cause ADR owing to a lack of information about ADR and reporting procedures, or due to fear of legal concerns. Only about 9.5% of the participants had previously attended an ADR workshop.

Conclusion

Oral health practitioners have a general understanding of ADR; however, there is substantial evidence of underreporting and a lack of reporting system information. Organizing an orientation program and raising awareness about ADR reporting could help improve spontaneous reporting and better patient care.

To prescribe or not to prescribe? A review of the Prescribing Competencies Framework for dentistry

OBJECTIVES

Dentists in Australia are the second largest prescriber group, and are generally not formally taught how to prescribe. The objective of this review is to describe the Prescribing Competencies Framework and its relevance to dentistry.

DATA

The four-model stage of prescribing by Coombes and colleagues, and the seven competencies within the Prescribing Competencies Framework devised by the Australian National Prescribing Service MedicineWise, are discussed and applied to dentistry.

SOURCES AND STUDY SELECTION

Each of the seven competencies are analysed and detailed in the context of clinical dental practice. Competencies 1-5 describe the skillset and tasks required by dentists to safely prescribe, whereas Competencies 6 and 7 describe the clinical environment and recommended resources to support dentists to prescribe safely and effectively.

CONCLUSIONS

The Prescribing Competencies Framework provides an overview of safe and effective prescribing. Prescribing is a process, and a separate skillset to clinical dentistry. The process involves information gathering, clinical assessment, effective communication and review of the patient. Access to timely and appropriate resources and relevant electronic sources of health information for clinicians are important to provide the support required for better informed prescribing decisions. The framework describes a patient-centered prescribing process, and ultimately prescribing should be a shared decision between the dentist and the patient.

CLINICAL SIGNIFICANCE

Safe and effective prescribing is an integral part of dentistry and dentists are the second largest prescriber group. However, dentists display high rates of inappropriate and unnecessary prescribing, and to minimise errors, the Prescribing Competencies Framework has been established. This article details how the Framework applies to clinical practice dentistry.

The frequency and duration of side-effects associated with the use of oral metronidazole; A prospective study of VITA trial participants

BACKGROUND

The tolerability of metronidazole is often perceived as being poor and in particular as being a cause of gastrointestinal side effects, but the frequency, severity and duration of adverse effects (AE) is not well characterised. This study assessed the frequency and type of metronidazole associated AEs in women treated for bacterial vaginosis.

METHODS

An exploratory study of participants from the lactic acid gel versus metronidazole for treating bacterial vaginosis (VITA) randomised controlled trial. In this sub-study, women aged ≥16 years, diagnosed with bacterial vaginosis and who received oral MTZ (400 mg twice daily, for 7 days) were followed up prospectively over 2 weeks. Baseline demographic and clinical data, and self-reported data on the incidence, time to onset, and duration of AEs were analysed.

RESULTS

155 women were included, of whom 64% (99/155) reported at least one metronidazole AE, including 47% (72/155) who reported gastrointestinal symptoms (nausea and/or vomiting [52/155], abdominal pain [31/154] or diarrhoea [31/154]) mostly within 3 days of starting treatment and resolving within 5 days of onset. Treatment discontinuation occurred in 8% (12/148) overall and AEs were given as the reason for discontinuing in only 3% (4/148).

CONCLUSION

Overall, metronidazole side effects occurred commonly, but resolved within a few days and had a limited impact on treatment completion.

Guidelines for Diagnosis and Management of Infective Endocarditis in Adults: A WikiGuidelines Group Consensus Statement

Importance

Practice guidelines often provide recommendations in which the strength of the recommendation is dissociated from the quality of the evidence.

Objective

To create a clinical guideline for the diagnosis and management of adult bacterial infective endocarditis (IE) that addresses the gap between the evidence and recommendation strength.

Evidence Review

This consensus statement and systematic review applied an approach previously established by the WikiGuidelines Group to construct collaborative clinical guidelines. In April 2022 a call to new and existing members was released electronically (social media and email) for the next WikiGuidelines topic, and subsequently, topics and questions related to the diagnosis and management of adult bacterial IE were crowdsourced and prioritized by vote. For each topic, PubMed literature searches were conducted including all years and languages. Evidence was reported according to the WikiGuidelines charter: clear recommendations were established only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were crafted discussing the risks and benefits of different approaches.

Findings

A total of 51 members from 10 countries reviewed 587 articles and submitted information relevant to 4 sections: establishing the diagnosis of IE (9 questions); multidisciplinary IE teams (1 question); prophylaxis (2 questions); and treatment (5 questions). Of 17 unique questions, a clear recommendation could only be provided for 1 question: 3 randomized clinical trials have established that oral transitional therapy is at least as effective as intravenous (IV)-only therapy for the treatment of IE. Clinical reviews were generated for the remaining questions.

Conclusions and Relevance

In this consensus statement that applied the WikiGuideline method for clinical guideline development, oral transitional therapy was at least as effective as IV-only therapy for the treatment of IE. Several randomized clinical trials are underway to inform other areas of practice, and further research is needed.

The use of antibiotics in acute oral health patients presenting at public dental clinics in the Western Sydney region

BACKGROUND

There is a limited need for antibiotics when treating oral health problems, yet they are often prescribed, increasing risk of antimicrobial resistance (AMR). With AMR a threat to public health, the objectives of this study were to assess the frequency, suitability, and factors associated with antibiotic prescriptions for acute dental problems across Greater Western Sydney public dental clinics.

METHODS

Patients' reason for attending, details of any antibiotics use, and the treating dental practitioner's clinical examination and diagnosis were compared to current prescribing guidelines, and logistic regression was used to identify predictors of antibiotic prescription.

RESULTS

In all, 1,071 patients participated in the study, and 15.9% reported to using antibiotics for their dental problem. Over three-quarters obtained the antibiotics from their general medical practitioner (GMP). A high prevalence of antibiotics were not indicated for the patient's complaint (71.8%) including for those with a history of extraction, pain, or intraoral swelling, who had significantly higher odds of antibiotic prescription (OR > 9). The antibiotic type prescribed was generally suitable.

CONCLUSIONS

In summary, the data suggest that the majority of antibiotics were inappropriately prescribed for the patient's dental complaints and there is a need for interventions to improve compliance with antibiotic prescribing guidelines.

Quantifying the risk of prosthetic joint infections after invasive dental procedures and the effect of antibiotic prophylaxis

BACKGROUND

Dentists face the expectations of orthopedic surgeons and patients with prosthetic joints to provide antibiotic prophylaxis (AP) before invasive dental procedures (IDPs) to reduce the risk of late periprosthetic joint infections (LPJIs), despite the lack of evidence associating IDPs with LPJIs, lack of evidence of AP efficacy, risk of AP-related adverse reactions, and potential for promoting antibiotic resistance. The authors aimed to identify any association between IDPs and LPJIs and whether AP reduces LPJI incidence after IDPs.

METHOD

The authors performed a case-crossover analysis comparing IDP incidence in the 3 months immediately before LPJI hospital admission (case period) with the preceding 12-month control period for all LPJI hospital admissions with commercial or Medicare supplemental or Medicaid health care coverage and linked dental and prescription benefits data.

RESULTS

Overall, 2,344 LPJI hospital admissions with dental and prescription records (n = 1,160 commercial or Medicare supplemental and n = 1,184 Medicaid) were identified. Patients underwent 4,614 dental procedures in the 15 months before LPJI admission, including 1,821 IDPs (of which 18.3% had AP). Our analysis identified no significant positive association between IDPs and subsequent development of LPJIs and no significant effect of AP in reducing LPJIs.

CONCLUSIONS

The authors identified no significant association between IDPs and LPJIs and no effect of AP cover of IDPs in reducing the risk of LPJIs.

PRACTICAL IMPLICATIONS

In the absence of benefit, the continued use of AP poses an unnecessary risk to patients from adverse drug reactions and to society from the potential of AP to promote development of antibiotic resistance. Dental AP use to prevent LPJIs should, therefore, cease.

Assessment of the Prescriptions of Systemic Antibiotics in Primary Dental Care in Germany from 2017 to 2021: A Longitudinal Drug Utilization Study

(1) Background: Due to increasing antibiotic resistance, the frequency of antibiotic use should be questioned in dentistry and attention paid to the choice of the best suited substance according to guidelines. In Germany, overprescribing of clindamycin was noteworthy in the past. Therefore, the aim of our study was to determine the trend of antibiotic prescriptions in primary dental care. (2) Methods: Prescriptions of antibiotics in German primary dental care from 2017 to 2021 were analysed using dispensing data from community pharmacies, claimed to the statutory health insurance (SHI) funds, and compared with all antibiotic prescriptions in primary care. Prescriptions were analysed based on defined daily doses per 1000 SHI-insured persons per day (DID). (3) Results: Amoxicillin was the most frequently prescribed antibiotic (0.505 DID in 2017, 0.627 in 2021, +24.2%) in primary dental care, followed by clindamycin (0.374 DID in 2017, 0.294 in 2021, -21.4%). Dental prescriptions still made up 56% of all clindamycin prescriptions in primary care in 2021. (4) Conclusions: Our study suggests that the problem of overuse of clindamycin in German dentistry has improved, but still persists.

Impact of the COVID-19 Pandemic on Antibiotic Prescribing by Dentists in Galicia, Spain: A Quasi-Experimental Approach

Background: Antibiotic resistance is one of the most pressing public health problems. Health authorities, patients, and health professionals, including dentists, are all involved in its development. COVID-19 pandemic restrictions on dental care may have had repercussions on antibiotic prescribing by dentists. The aim of this study was to assess the impact of the COVID-19 pandemic on antibiotic prescribing by dentists, and to review antibiotic consumption according to the WHO Access, Watch, Reserve classification. We conducted a natural, before-and-after, quasi-experimental study, using antibiotic prescription data covering the period from January 2017 to May 2021. A segmented regression analysis with interrupted time series data was used to analyse the differences between the numbers of defined daily doses (DDD) of antibiotics prescribed monthly. The outcomes showed an immediate significant decrease in overall antibiotic prescribing by primary-care dentists during lockdown, followed by a non-significant upward trend for the next year. This same pattern was, likewise, observed for Access and Watch antibiotics. COVID-19 pandemic restrictions on dental care influenced the prescription of antibiotics. During confinement, an initial decrease was observed, this trend changed when in person consultations were recovered. It might be beneficial to analyse the prescription of antibiotics using the WHO AWaRe classification, in order to monitor their appropriate use.

Private Practice Dentists Improve Antibiotic Use After Dental Antibiotic Stewardship Education from Infectious Diseases Experts

Background

Private practice dentists represent 72% of United States dentists. We conducted a prospective cohort study of private practice dentists comparing antibiotic use before and after dental antibiotic stewardship education by infectious diseases (ID) antibiotic stewardship experts.

Methods

Study phases were as follows: phase 1 (preeducation), 3 months of retrospective antibiotic data and a presurvey assessed baseline antibiotic knowledge; phase 2 (education), dentists attended 3 evening Zoom sessions; phase 3, (posteducation/interventions), 3 months of prospective audits with weekly feedback; phase 4, postsurvey and recommendations to reach more dentists.

Results

Fifteen dentists participated. Ten had practiced >20 years. Presurvey, 14 were unfamiliar with dental stewardship. The number of antibiotic prescriptions pre/post decreased from 2124 to 1816 (P < .00001), whereas procedures increased from 8526 to 9063. Overall, appropriate use (prophylaxis and treatment) increased from 19% pre to 87.9% post (P < .0001). Appropriate prophylaxis was 46.6% pre and 76.7% post (P < .0001). Joint implant prophylaxis decreased from 164 pre to 78 post (P < .0001). Appropriate treatment antibiotics pre/post improved 5-fold from 15% to 90.2% (P = .0001). Antibiotic duration pre/post decreased from 7.7 days (standard deviation [SD], 2.2 days) to 5.1 days (SD, 1.6 days) (P < .0001). Clindamycin use decreased 90% from 183 pre to 18 post (P < .0001). Postsurvey responses recommended making antibiotic stewardship a required annual continuing education. Study participants invited ID antibiotic stewardship experts to teach an additional 2125 dentists via dental study clubs.

Conclusions

After learning dental antibiotic stewardship from ID antibiotic stewardship experts, dentists rapidly optimized antibiotic prescribing. Private practice dental study clubs are expanding dental antibiotic stewardship training to additional dentists, hygienists, and patients across the United States.

Profiles of sugar fermenting bacteria of the oral cavity among children with dental caries attending stomatology services at Ruhengeri referral hospital in Musanze District, Northern Rwanda

BACKGROUND

Dental caries remains a public health threat of concern among children. About 2.3 billion people are affected by dental caries, of which 530 million are children globally.

OBJECTIVE

This study was carried out to identify sugar fermenting bacteria in the oral cavity and their antibiotic susceptibility pattern, assess the association with sugar fermenter bacteria and dental caries and evaluate dental caries outcomes among children.

MATERIALS AND METHODS

This was a cross-sectional study conducted between October 2021 and February 2022 at Ruhengeri Referral Hospital. About 136 oral swab samples were collected from children with and without dental caries at 1:1 ratio. The samples were put in Stuart sterile container and transported to INES-clinical microbiology laboratory for microbial identification. Logistic regression analysis of demographic characteristics was performed to study the relationship between demographic variables and dental caries. Chi-square test was performed for the association between variables.

RESULTS

About 67.6% were male, while children of age 7-9 years (64.7%) dominated the age groups. Lactobacilli spp (15.29%) and Streptococcus mutans (12.94%) were the most predominant microorganisms observed in the oral cavity among children with dental caries. The S. mutans (x² = 27.03, P < 0.00001, 95% confidence interval [CI]=0.2901-0.5785), S. aureus (x² = 34.59, P < 0.00001, 95% CI = 0.3541-0.6292), Enterobacter aerogenes (x² = 13.5, P = 0.000239, 95% CI = 0.151-0.4622), Serratia marcescens (x² = 11.64, P = 0.00645, 95% CI = 0.1275-0.4418) and Klebsiella pneumonia (x² = 13.51, P = 0.000237, 95% CI = 0.1511-0.4623) were significantly associated with dental caries. Teeth loss (x² = 51.04, P < 0.00001, 95% CI = 0.4757-0.7205), teeth pain (x² = 5.05, P = 0.0246, 95% CI = 0.0249-0.33499), and infection (x² = 4.73, P = 0.02964, 95% CI = 0.0186-0.3441) were dental outcomes associated with tooth decay. Ciprofloxacin, clindamycin, and amoxicillin were the most sensitive antibiotics, while vancomycin and chloramphenicol were the most resistant.

CONCLUSION

Sugar consumption favours the growth of sugar fermenter bacteria that cause dental caries among children. Dental caries is associated with adverse oral health outcomes among children. Oral health education is recommended for children. Parents are advised to reduce the consumption of sugary food for their children for oral health safety.

Antibiotic Prophylaxis for Prosthetic Joint Patients Undergoing Invasive Dental Procedures: Time for a Rethink?

BACKGROUND

In the United States, it has been common practice to recommend that dentists provide antibiotic prophylaxis (AP) before invasive dental procedures (IDPs) to prevent late periprosthetic joint infections (LPJIs) in patients who have prosthetic arthroplasties despite lack of evidence for a causal relationship between IDP and LPJI and a lack of evidence for AP efficacy.

METHODS

A recent study quantified the IDP incidence over the 15-month period prior to LPJI hospital admissions in the United Kingdom for which dental records were available. A case-crossover analysis compared IDP incidence in the 3 months before LPJI admission with the preceding 12 months. The English population was used because guidelines do not recommend AP and any relationship between IDPs and LPJI should be fully exposed.

RESULTS

No significant positive association was identified between IDPs and LPJI. Indeed, the incidence of IDPs was lower in the 3 months before LPJI hospital admission than that in the preceding 12 months.

CONCLUSION

In the absence of a significant positive association between IDPs and LPJI, there is no rationale to administer AP before IDPs in patients with prosthetic joints, particularly given the cost and inconvenience of AP, the risk of adverse drug reactions, and the potential for unnecessary AP use that promotes antibiotic resistance. These results should reassure orthopedic surgeons and their patients that dental care of patients who have prosthetic joints should focus on maintaining good oral hygiene rather than on recommending AP for IDPs. Moreover, it should also reassure those in other countries where AP is not recommended that such guidance is sufficient.

Infective endocarditis following invasive dental procedures: IDEA case-crossover study

BACKGROUND

Infective endocarditis is a heart infection with a first-year mortality rate of ≈ 30%. It has long been thought that infective endocarditis is causally associated with bloodstream seeding with oral bacteria in ≈ 40-45% of cases. This theorem led guideline committees to recommend that individuals at increased risk of infective endocarditis should receive antibiotic prophylaxis before undergoing invasive dental procedures. However, to the best of our knowledge, there has never been a clinical trial to prove the efficacy of antibiotic prophylaxis and there is no good-quality evidence to link invasive dental procedures with infective endocarditis. Many contend that oral bacteria-related infective endocarditis is more likely to result from daily activities (e.g. tooth brushing, flossing and chewing), particularly in those with poor oral hygiene.

OBJECTIVE

The aim of this study was to determine if there is a temporal association between invasive dental procedures and subsequent infective endocarditis, particularly in those at high risk of infective endocarditis.

DESIGN

This was a self-controlled, case-crossover design study comparing the number of invasive dental procedures in the 3 months immediately before an infective endocarditis-related hospital admission with that in the preceding 12-month control period.

SETTING

The study took place in the English NHS.

PARTICIPANTS

All individuals admitted to hospital with infective endocarditis between 1 April 2010 and 31 March 2016 were eligible to participate.

INTERVENTIONS

This was an observational study; therefore, there was no intervention.

MAIN OUTCOME MEASURE

The outcome measure was the number of invasive and non-invasive dental procedures in the months before infective endocarditis-related hospital admission.

DATA SOURCES

NHS Digital provided infective endocarditis-related hospital admissions data and dental procedure data were obtained from the NHS Business Services Authority.

RESULTS

The incidence rate of invasive dental procedures decreased in the 3 months before infective endocarditis-related hospital admission (incidence rate ratio 1.34, 95% confidence interval 1.13 to 1.58). Further analysis showed that this was due to loss of dental procedure data in the 2-3 weeks before any infective endocarditis-related hospital admission.

LIMITATIONS

We found that urgent hospital admissions were a common cause of incomplete courses of dental treatment and, because there is no requirement to record dental procedure data for incomplete courses, this resulted in a significant loss of dental procedure data in the 2-3 weeks before infective endocarditis-related hospital admissions. The data set was also reduced because of the NHS Business Services Authority's 10-year data destruction policy, reducing the power of the study. The main consequence was a loss of dental procedure data in the critical 3-month case period of the case-crossover analysis (immediately before infective endocarditis-related hospital admission), which did not occur in earlier control periods. Part of the decline in the rate of invasive dental procedures may also be the result of the onset of illness prior to infective endocarditis-related hospital admission, and part may be due to other undefined causes.

CONCLUSIONS

The loss of dental procedure data in the critical case period immediately before infective endocarditis-related hospital admission makes interpretation of the data difficult and raises uncertainty over any conclusions that can be drawn from this study.

FUTURE WORK

We suggest repeating this study elsewhere using data that are unafflicted by loss of dental procedure data in the critical case period.

TRIAL REGISTRATION

This trial is registered as ISRCTN11684416.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 28. See the NIHR Journals Library website for further project information.

Analysis of Prosthetic Joint Infections Following Invasive Dental Procedures in England

Importance

Dentists in the United States are under pressure from orthopedic surgeons and their patients with prosthetic joints to provide antibiotic prophylaxis before invasive dental procedures (IDP) to reduce the risk of late prosthetic joint infection (LPJI). This has been a common practice for decades, despite a lack of evidence for an association between IDP and LPJI, a lack of evidence of antibiotic prophylaxis efficacy, cost of providing antibiotic prophylaxis, and risk of both adverse drug reactions and the potential for promoting antibiotic resistance.

Objective

To quantify any temporal association between IDP and subsequent LPJI.

Design, Setting, and Participants

This cohort study used a case-crossover and time trend design to examine any potential association between IDP and LPJI. The population of England (55 million) was chosen because antibiotic prophylaxis has never been recommended to prevent LPJI in England, and any association between IDP and LPJI would therefore be fully exposed. All patients admitted to hospitals in England for LPJI from December 25, 2011, through March 31, 2017, and for whom dental records were available were included. Analyses were performed between May 2018 and June 2021.

Exposures

Exposure to IDP.

Main Outcomes and Measures

The main outcome was the incidence of IDP in the 3 months before LPJI hospital admission (case period) compared with the incidence in the 12 months before that (control period).

Results

A total of 9427 LPJI hospital admissions with dental records (mean [SD] patient age, 67.8 [13.1] years) were identified, including 4897 (52.0%) men and 4529 (48.0%) women. Of these, 2385 (25.3%) had hip prosthetic joints, 3168 (33.6%) had knee prosthetic joints, 259 (2.8%) had other prosthetic joints, and 3615 (38.4%) had unknown prosthetic joint types. There was no significant temporal association between IDP and subsequent LPJI. Indeed, there was a lower incidence of IDP in the 3 months prior to LPJI (incidence rate ratio, 0.89; 95% CI, 0.82-0.96; P = .002).

Conclusions and Relevance

These findings suggest that there is no rationale to administer antibiotic prophylaxis before IDP in patients with prosthetic joints.

Antimicrobial prescription patterns among oral implantologists of Kerala, India: A cross-sectional survey

Background and Objectives:

Antimicrobial resistance is a grave public health concern, and it is important to optimize the use of antimicrobials in dental surgeries. Antimicrobial prescriptions in dental implant placements are often empiric and not guided by consensus or specific guidelines. The aim of this study was to elucidate antibiotic prescribing patterns among oral implantologists. The objectives were to identify the frequency of antimicrobial usage and preferences regarding the perioperative timing of prescriptions, type of antibiotic, dosage, and duration in different implant placement scenarios.

Subjects and Methods:

An anonymized web-based survey was carried out. Participants were drawn from the lists of oral implantologists from all local branches of the Indian Dental Association in the state of Kerala, India, until the required sample size was met. Responses were recorded using an Internet-based validated questionnaire sent via e-mail to the participants. The questionnaire contained five sections with both open-ended and closed-ended questions.

Results:

Among the 93 participants, 59% of the dental implantologists preferred 0.2% povidone-iodine as a preprocedural mouth rinse in the backdrop of the COVID-19 pandemic, and 68% prescribed 0.12%–0.2% chlorhexidine as the postoperative mouth rinse. The majority of the participants (73%) routinely prescribed systemic antibiotics perioperatively during implant placement surgery. Interestingly, while none of the participants preferred a solely preoperative regimen, 92.4% of the dentists in our survey prescribed both pre- and postoperative antibiotics. Antibiotics of choice as the preoperative agents were amoxicillin and amoxicillin plus clavulanic acid. The most preferred postoperative agent was amoxicillin plus clavulanic acid. The popularly reported rationale behind a preoperative antibiotic was to decrease or eliminate local or systemic infections (79%), and the majority of the participants (60%) prescribed postoperative antibiotics to prevent postoperative infection.

Conclusions:

Systemic antibiotic prescriptions in implant placement surgery are not based on currently available evidence. Most oral implantologists who participated in the survey prescribed systemic antibiotics to prevent perioperative infection, even in simple and straightforward implant placements. Specific guidelines need to be generated in complex implant placement situations and implant placement in medically compromised patients to prevent excessive prescriptions.

Antibiotics in Dentoalveolar Surgery, a Closer Look at Infection, Alveolar Osteitis and Adverse Drug Reaction

PURPOSE

To execute an evidence-based review answering the following questions: "What antibiotic type and mode of delivery are most effective at reducing inflammatory complications in third molar and dental implant surgery? What are the types and rates of antibiotic-related adverse reactions in the context of third molar surgery, infective endocarditis, medication-related osteonecrosis of the jaw (MRONJ) and osteoradionecrosis (ORN)?"

MATERIAL AND METHODS

We performed a comprehensive literature review of peer-reviewed studies using MEDLINE/PubMed, Cochrane, Scopus/Elsevier, Google Scholar, and Wiley online library databases.

RESULTS

Twenty-five studies were reviewed for third molar surgery. Although there is some evidence that systemic antibiotics reduce inflammatory complications (infection and alveolar osteitis), routine use is not recommended for third molar surgery. For at-risk cases, a single preoperative dose of amoxicillin is preferred. Clindamycin, amoxicillin-clavulanic acid and erythromycin have a high adverse risk profile. Eight studies were reviewed for dental implant surgery. Antibiotics with dental implant placement showed little reduction in post surgery infection and minimal improvement in long-term success. A comprehensive search found limited data on antibiotic-related adverse effects in the context of infective endocarditis, MRONJ and ORN.

CONCLUSIONS

A set of clinical recommendations are presented to better guide evidence-based and standardized antibiotic usage on the basis of the literature discussed in this review. This review highlights the need for further research focusing on antibiotic type and timing of delivery with adverse drug reaction as a primary outcome measure when assessing treatment outcomes and complications in dentoalveolar surgery. This will better elucidate the risks vs benefits of antibiotic in dentoalveolar surgery.

Clindamycin as an Alternative Option in Optimizing Periodontal Therapy

Periodontal disease is an oral infectious and inflammatory disease caused by microorganisms that determine the host-mediated destruction of soft and hard periodontal tissues, which ultimately leads to tooth loss. Periodontitis affects a large part of the population, with various degrees of severity. Treatment consists of etiologic therapy: the removal of biofilm through mechanical debridement plus microbial elimination by supplementary measures. Antibiotic administration, either systemically or through local delivery, has been shown to improve clinical outcomes after mechanical periodontal treatment. Clindamycin is a lincosamide with a broad spectrum, being active against aerobic, anaerobic, and β-lactamase-producing bacteria. This antibiotic offers several advantages and some disadvantages and has been used in periodontal treatment both systemically and locally with various degrees of success. Among the properties that recommend it for periodontal treatment is the bacteriostatic effect, the inhibition of bacterial proteins synthesis, the enhancement of neutrophil chemotaxis, phagocytosis and the oxidative burst–oxidative stress storm. Furthermore, it is easily absorbed at the level of oral tissues in a considerable amount. This substantial tissue penetration, especially inside the bone, is synergistic with a stimulating effect on the host immune system. The aim of this review is to explore the applicability of this antibiotic agent and to evaluate its antimicrobial potential and limitations at the level of the oral biofilm associated with periodontal disease.

Development of an antibacterial nanocomposite hydrogel for human dental pulp engineering

Hydrogel-based regenerative endodontic procedures (REPs) are considered to be very promising therapeutic strategies to reconstruct the dental pulp (DP) tissue in devitalized human teeth. However, the success of the regeneration process is limited by residual bacteria that may persist in the endodontic space after the disinfection step and contaminate the biomaterial. The aim of this work was to develop an innovative fibrin hydrogel incorporating clindamycin (CLIN)-loaded Poly (d,l) Lactic Acid (PLA) nanoparticles (NPs) to provide the hydrogel with antibacterial properties. CLIN-PLA-NPs were synthesized by a surfactant-free nanoprecipitation method and their microphysical properties were assessed by dynamic light scattering, electrophoretic mobility and scanning electron microscopy. Their antimicrobial efficacy was evaluated on Enteroccocus fæcalis by the determination of the minimal inhibitory concentration (MIC) and the minimal biofilm inhibition and eradication concentrations (MBIC and MBEC). Antibacterial properties of the nanocomposite hydrogel were verified by agar diffusion assays. NP distribution into the hydrogel and release from it were evaluated using fluorescent PLA-NPs. NP cytotoxicity was assessed on DP mesenchymal stem cells (DP-MSCs) incorporated into the hydrogel. Type I collagen synthesis was investigated after 7 days of culture by immunohistochemistry. We found that CLIN-PLA-NPs displayed a drug loading of 10 ± 2 μg per mg of PLA polymer and an entrapment efficiency of 43 ± 7%. Antibiotic loading did not affect NP size, polydispersity index and zeta potential. The MIC for Enterococcus fæcalis was 32 μg mL-1. MBIC50 and MBEC50 were 4 and 16 μg mL-1, respectively. CLIN-PLA-NPs appeared homogenously distributed throughout the hydrogel. CLIN-PLA-NP-loaded hydrogels clearly inhibited E. faecalis growth. DP-MSC viability and type I collagen synthesis within the fibrin hydrogel were not affected by CLIN-PLA-NPs. In conclusion, CLIN-PLA-NP incorporation into the fibrin hydrogel gave the latter antibacterial and antibiofilm properties without affecting cell viability and function. This formulation could help establish an aseptic environment supporting DP reconstruction and, accordingly, might be a valuable tool for REPs.

Concordance of antibiotic prescribing with the American Dental Association acute oral infection guidelines within Veterans' Affairs (VA) dentistry

OBJECTIVE

United States dentists prescribe 10% of all outpatient antibiotics. Assessing appropriateness of antibiotic prescribing has been challenging due to a lack of guidelines for oral infections. In 2019, the American Dental Association (ADA) published clinical practice guidelines (CPG) on the management of acute oral infections. Our objective was to describe baseline national antibiotic prescribing for acute oral infections prior to the release of the ADA CPG and to identify patient-level variables associated with an antibiotic prescription.

DESIGN

Cross-sectional analysis.

METHODS

We performed an analysis of national VA data from January 1, 2017, to December 31, 2017. We identified cases of acute oral infections using International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes. Antibiotics prescribed by a dentist within ±7 days of a visit were included. Multivariable logistic regression identified patient-level variables associated with an antibiotic prescription.

RESULTS

Of the 470,039 VA dental visits with oral infections coded, 12% of patient visits with irreversible pulpitis, 17% with apical periodontitis, and 28% with acute apical abscess received antibiotics. Although the median days' supply was 7, prolonged use of antibiotics was frequent (≥8 days, 42%-49%). Patients with high-risk cardiac conditions, prosthetic joints, and endodontic, implant, and oral and maxillofacial surgery dental procedures were more likely to receive antibiotics.

CONCLUSIONS

Most treatments of irreversible pulpitis and apical periodontitis cases were concordant with new ADA guidelines. However, in cases where antibiotics were prescribed, prolonged antibiotic courses >7 days were frequent. These findings demonstrate opportunities for the new ADA guidelines to standardize and improve dental prescribing practices.

Antibiotics to prevent complications following tooth extractions

BACKGROUND

The most frequent indications for tooth extractions, generally performed by general dental practitioners, are dental caries and periodontal infections. Systemic antibiotics may be prescribed to patients undergoing extractions to prevent complications due to infection. This is an update of a review first published in 2012.

OBJECTIVES

To determine the effect of systemic antibiotic prophylaxis on the prevention of infectious complications following tooth extractions.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health Trials Register (to 16 April 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2020, Issue 3), MEDLINE Ovid (1946 to 16 April 2020), Embase Ovid (1980 to 16 April 2020), and LILACS (1982 to 16 April 2020). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised, double-blind, placebo-controlled trials of systemic antibiotic prophylaxis in patients undergoing tooth extraction(s) for any indication.

DATA COLLECTION AND ANALYSIS

At least two review authors independently performed data extraction and 'Risk of bias' assessment for the included studies. We contacted trial authors for further details where these were unclear. For dichotomous outcomes, we calculated risk ratios (RR) and 95% confidence intervals (CI) using random-effects models. For continuous outcomes, we used mean differences (MD) with 95% CI using random-effects models. We examined potential sources of heterogeneity. We assessed the certainty of the body of evidence for key outcomes as high, moderate, low, or very low, using the GRADE approach.

MAIN RESULTS

We included 23 trials that randomised approximately 3206 participants (2583 analysed) to prophylactic antibiotics or placebo. Although general dentists perform dental extractions because of severe dental caries or periodontal infection, only one of the trials evaluated the role of antibiotic prophylaxis in groups of patients affected by those clinical conditions. We assessed 16 trials as being at high risk of bias, three at low risk, and four as unclear.  Compared to placebo, antibiotics may reduce the risk of postsurgical infectious complications in patients undergoing third molar extractions by approximately 66% (RR 0.34, 95% CI 0.19 to 0.64; 1728 participants; 12 studies; low-certainty evidence), which means that 19 people (95% CI 15 to 34) need to be treated with antibiotics to prevent one infection following extraction of impacted wisdom teeth. Antibiotics may also reduce the risk of dry socket by 34% (RR 0.66, 95% CI 0.45 to 0.97; 1882 participants; 13 studies; low-certainty evidence), which means that 46 people (95% CI 29 to 62) need to take antibiotics to prevent one case of dry socket following extraction of impacted wisdom teeth. The evidence for our other outcomes is uncertain: pain, whether measured dichotomously as presence or absence (RR 0.59, 95% CI 0.31 to 1.12; 675 participants; 3 studies) or continuously using a visual analogue scale (0-to-10-centimetre scale, where 0 is no pain) (MD -0.26, 95% CI -0.59 to 0.07; 422 participants; 4 studies); fever (RR 0.66, 95% CI 0.24 to 1.79; 475 participants; 4 studies); and adverse effects, which were mild and transient (RR 1.46, 95% CI 0.81 to 2.64; 1277 participants; 8 studies) (very low-certainty evidence).  We found no clear evidence that the timing of antibiotic administration (preoperative, postoperative, or both) was important. The included studies enrolled a subset of patients undergoing dental extractions, that is healthy people who had surgical extraction of third molars. Consequently, the results of this review may not be generalisable to all people undergoing tooth extractions.

AUTHORS' CONCLUSIONS

The vast majority (21 out of 23) of the trials included in this review included only healthy patients undergoing extraction of impacted third molars, often performed by oral surgeons. None of the studies evaluated tooth extraction in immunocompromised patients. We found low-certainty evidence that prophylactic antibiotics may reduce the risk of infection and dry socket following third molar extraction when compared to placebo, and very low-certainty evidence of no increase in the risk of adverse effects. On average, treating 19 healthy patients with prophylactic antibiotics may stop one person from getting an infection. It is unclear whether the evidence in this review is generalisable to patients with concomitant illnesses or patients at a higher risk of infection. Due to the increasing prevalence of bacteria that are resistant to antibiotic treatment, clinicians should evaluate if and when to prescribe prophylactic antibiotic therapy before a dental extraction for each patient on the basis of the patient's clinical conditions (healthy or affected by systemic pathology) and level of risk from infective complications. Immunocompromised patients, in particular, need an individualised approach in consultation with their treating medical specialist.

Antibiotic Therapy in Dentistry

Dental caries, pulpal necrosis, trauma, and periodontal diseases can result in dental infections which could have severe consequences that affect both soft and hard tissues of the oral cavity. Dental infections commonly present with symptoms of pain, fever, and swelling. Surgical and endodontic treatments are the early management of infected teeth, followed by antibiotic therapy. Some alternative methods also exist for treating infection such as low-level laser therapy and photodynamic therapy. Antibiotics are generally used in dental procedures to treat odontogenic infections, nonodontogenic infections, local infection, focal infection, and prophylaxis. Antibiotic prophylaxis is prescribed for patients with immunosuppressed conditions, infective endocarditis, metabolic disorders, and patients with prosthetic joints. To reduce the complications of unnecessary antibiotic prescriptions especially bacterial resistance, comprehensive guidelines should be established. It has been noted that only about 12% of dentists adequately and correctly prescribe antibiotics, which shows the importance of comprehensive guidelines. Antibiotics prescription may result in some adverse effects such as hypersensitivity reactions and dermatological and allergic disorders. Furthermore, unnecessary prescription of antibiotics could result in several serious sequelae, for example, bacterial resistance, gastric and hematological problems, and diversion of bacterial microbiota. The present review attempts to summarize the indications of antibiotic therapy in dentistry and discuss the common types of antibiotics that are routinely used in dental practice based on pharmacologic classes. Moreover, types of antibiotics that are considered safe during pregnancy and childhood are also reviewed.

Antibiotics in treatment of peritonsillar infection: clindamycin versus penicillin

OBJECTIVE

This study aimed to compare antibiotic treatment with clindamycin versus penicillin V or G in terms of time to recovery and recurrence in patients with peritonsillar infection, including both peritonsillar cellulitis and peritonsillar abscess.

METHOD

This retrospective cohort study examined the records of 296 patients diagnosed with peritonsillar infection. Based on the ENT doctor's choice of antibiotics, patients were divided into clindamycin and penicillin groups.

RESULTS

Mean number of days in follow up was 3.5 days in the clindamycin group and 3.4 days in the penicillin group. The recurrence rate within 2 months was 7 per cent in the clindamycin group and 4 per cent in the penicillin group.

CONCLUSION

This study found no significant differences in either recovery or recurrence between the groups. This supports the use of penicillin as a first-line treatment, considering the greater frequency of adverse effects of clindamycin shown in previous studies, as well as its profound collateral damage on the intestinal microbiota, resulting in antibiotic resistance.

Effect of educational intervention on the appropriate use of oral antimicrobials in oral and maxillofacial surgery: a retrospective secondary data analysis

BACKGROUND

In Japan, oral third-generation cephalosporins with broad-spectrum activity are commonly prescribed in the practices of dentistry and oral surgery. However, there are few reports on the appropriate use of antibiotics in the field of oral surgery. This study aimed to evaluate the appropriateness of antibiotic use before and after an educational intervention in the Department of Oral and Maxillofacial Surgery, Kobe University Hospital.

METHODS

The use of oral antibiotics was investigated among inpatients and outpatients before and after an educational intervention conducted by the antimicrobial stewardship team. Additionally, the frequency of surgical site infection after the surgical removal of an impacted third mandibular molar under general anesthesia and the prevalence of adverse effects of the prescribed antibiotics were comparatively evaluated between 2013 and 2018.

RESULTS

After the educational intervention, a remarkable reduction was noted in the prescription of oral third-generation cephalosporins, but increased use of penicillins was noted among outpatients. There was reduced use of macrolides and quinolones in outpatients. Although a similar trend was seen for inpatients, the use of quinolones increased in this population. Despite the change in the pattern of antibiotic prescription, inpatients who underwent mandibular third molar extraction between 2013 and 2018 did not show a significant increase in the prevalence of surgical site infections (6.2% vs. 1.8%, p = .336) and adverse effects of drugs (2.1% vs. 0%, p = .466).

CONCLUSIONS

This study suggests that the judicious use of oral antibiotics is possible through conscious and habitual practice of appropriate antibiotic use. However, further investigation is required to develop measures for appropriate use of oral antibiotics.

Healthcare Challenges and Future Solutions in Dental Practice: Assessing Oral Antibiotic Resistances by Contemporary Point-Of-Care Approaches

Antibiotic resistance poses a global threat, which is being acknowledged at several levels, including research, clinical implementation, regulation, as well as by the World Health Organization. In the field of oral health, however, the issue of antibiotic resistances, as well as of accurate diagnosis, is underrepresented. Oral diseases in general were ranked third in terms of expenditures among the EU-28 member states in 2015. Yet, the diagnosis and patient management of oral infections, in particular, still depend primarily on empiric means. On the contrary, on the global scale, the field of medical infections has more readily adopted the integration of molecular-based systems in the diagnostic, patient management, and antibiotic stewardship workflows. In this perspective review, we emphasize the clinical significance of supporting in the future antibiotic resistance screening in dental practice with novel integrated and point-of-care operating tools that can greatly support the rapid, accurate, and efficient administration of oral antibiotics.

Prescribing of antibiotic prophylaxis to prevent infective endocarditis

BACKGROUND

In 2007, the American Heart Association recommended that antibiotic prophylaxis (AP) be restricted to those at high risk of developing complications due to infective endocarditis (IE) undergoing invasive dental procedures. The authors aimed to estimate the appropriateness of AP prescribing according to type of dental procedure performed in patients at high risk, moderate risk, or low or unknown risk of developing IE complications.

METHODS

Eighty patients at high risk, 40 patients at moderate risk, and 40 patients at low or unknown risk of developing IE complications were randomly selected from patients with linked dental care, health care, and prescription benefits data in the IBM MarketScan Databases, one of the largest US health care convenience data samples. Two clinicians independently analyzed prescription and dental procedure data to determine whether AP prescribing was likely, possible, or unlikely for each dental visit.

RESULTS

In patients at high risk of developing IE complications, 64% were unlikely to have received AP for invasive dental procedures, and in 32 of 80 high-risk patients (40%) there was no evidence of AP for any dental visit. When AP was prescribed, several different strategies were used to provide coverage for multiple dental visits, including multiday courses, multidose prescriptions, and refills, which sometimes led to an oversupply of antibiotics.

CONCLUSIONS

AP prescribing practices were inconsistent, did not always meet the highest antibiotic stewardship standards, and made retrospective evaluation difficult. For those at high risk of developing IE complications, there appears to be a concerning level of underprescribing of AP for invasive dental procedures.

PRACTICAL IMPLICATIONS

Some dentists might be failing to fully comply with American Heart Association recommendations to provide AP cover for all invasive dental procedures in those at high risk of developing IE complications.

Is the penetration of clindamycin into the masseter muscle really enough to treat odontogenic infections?

OBJECTIVES

This study aims to determine the penetration of clindamycin into the masseter muscle of rats by microdialysis and correlate with the main microorganisms involved in odontogenic infections.

MATERIALS AND METHODS

Tissue concentrations of clindamycin in healthy muscle tissue were measured by microdialysis after administration of a single intravenous dose of 51 mg/kg and multiple doses of 17 mg/kg (8/8 h). It was quantified in plasma after a single administration of 51 mg/kg. Microdialysis samples were collected at 30-min intervals and clindamycin was assayed by LC-MS. Pharmacokinetic parameters and tissue penetration were determined. Pharmacokinetic/pharmacodynamic index (ƒ%T > minimum inhibitory concentration (MIC)) was considered to assess dosing regimens.

RESULTS

The pharmacokinetic parameters determined by non-compartmental plasma analysis for the dose of 51 mg/kg were similar to that determined by compartmental analysis. The maximum free interstitial concentration (C_max) of clindamycin in muscle tissue was 14.20 (10.63-14.89) and 4.82 (3.35-6.66) mg/L for 51 mg/kg and 17 mg/kg 8/8 h, respectively. In addition, the area under the curve (AUC_0-inf) for plasma and tissue of clindamycin were 44.78 (28.82-65.65) and 16.54 (13.83-18.35) h.mg/L for 51 mg/kg, respectively, and the tissue penetration factor determined was 1.10. Considering that the main bacteria that cause odontogenic infections generally present MIC ≤ 0.5 mg/L, the ƒ%T > MIC index is reached when the dose regimen of 17 mg/kg 8/8 h is employed.

CONCLUSIONS

This investigation showed that clindamycin excellently penetrates muscle tissue of rats. It provides effective antibacterial concentrations at the target site when 17 mg/kg 8/8 h is employed and can be applied to treat the main bacteria causing odontogenic infections.

CLINICAL RELEVANCE

It reinforces the use of clindamycin in odontogenic infections with significant tissue penetration.

Prescribing antibiotics by dentists in Colombia: Toward a conscientious prescription

OBJECTIVES

Inappropriate prescription of antibiotics contributes to antibiotic resistance. Therefore, the objective of this study was to determine the awareness, attitudes, and intention to practice of dentists prescribing antibiotics in Colombia in order to design a virtual learning environment on this subject.

METHODS

In a descriptive study across seven cities, 700 dentists from different Colombian cities were requested to complete a validated questionnaire containing five sections: general information, awareness on antibiotic effectiveness and antibiotic resistance, attitudes regarding prescription decision, intention to practice concerning clinical cases, and complementary information. The level of awareness, attitudes, and intention to practice was determined and Chi-square test was used to determine the existence of significant differences among cities.

RESULTS

The majority of dentists showed a medium level regarding the number of correct answers on awareness (62.4 percent) and attitudes (88.7 percent) and a high level on intention to practice (91.7 percent). Common errors within the awareness section included the meaning of the term "antibiotic resistance" (35 percent) and most dentists were not convinced that such resistance could be derived from prescription of antibiotics (51.2 percent). In the attitudes section, only 45 percent declared that they prescribe antibiotics based mainly on symptoms, and the intention to practice section showed a significant percentage of unnecessary prescription (51 percent for pacemaker users) or absence of prescription (53.9 percent for ventricular septal defect) in antibiotic prophylaxis for infectious endocarditis (IE).

CONCLUSION

The dentists interviewed should be trained and made aware of antibiotic resistance, microbiological and clinical foundations, and current antibiotic prophylaxis guidelines.

Prophylactic antibiotic prescribing in dental practice: Findings from a National Dental Practice-Based Research Network questionnaire

BACKGROUND

Little is known about antibiotic prescribing practices of dentists. The objective of this study was to gain a better understanding of dentists' beliefs and behaviors regarding the use of antibiotic prophylaxis (AP) before invasive dental procedures.

METHODS

A multidisciplinary team developed and disseminated a questionnaire to 3,584 dentist members of the National Dental Practice-Based Research Network.

RESULTS

Overall, 2,169 network dentists (61%) responded. Respondents saw patients at risk of developing infective endocarditis (IE) and prosthetic joint infection (PJI) at least once per week (35% and 65%, respectively). Although 78% of dentists agreed that the 2007 American Heart Association guidelines for the prevention of IE are well-defined and clear, only 49% agreed concerning PJI guidelines. Differences for the IE and PJI patient populations also existed for questions regarding dentists' understanding of the specific patient groups at risk, the recommended antibiotic regimens, and the need to consult with a patient's cardiologist or orthopedic surgeon.

CONCLUSIONS

The survey results indicate that decision making regarding the use of AP occurs frequently among dentists. Moreover, dentists reported uncertainty about the appropriate use of AP as defined by both IE and PJI guidelines, which may have resulted in a lack of concordance between dentists' beliefs and their practice behaviors.

PRACTICAL IMPLICATIONS

The results reported by the authors highlight the need to develop better educational programs that address antimicrobial stewardship in AP for patients at risk of developing IE and PJI and target the dental profession.

Amoxicillin Is the Most Effective Oral Antibiotic Prophylaxis Regimen for Reducing Post-Invasive Dental Procedure Bacteremia

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Prevention of Postdental Procedure Bacteremia: A Network Meta-analysis. Zeng BS, Lin SY, Tu YK, et al. J Dent Res 2019 Oct;98(11):1204-1210.

SOURCE OF FUNDING

There were no sources of funding associated with the work.

TYPE OF STUDY/DESIGN

Systematic review with meta-analysis of data.

Antimicrobial stewardship in dental practice

BACKGROUND

Antibiotic resistance is a global public health problem that is responsible for increased patient morbidity and mortality and financial burden. Dental antibiotic prescribing contributes to approximately 10% of all antibiotic prescriptions, and an estimated 80% of that prescribing is deemed inappropriate. Dental antimicrobial stewardship (AMS) has an important role to play in international efforts to tackle antibiotic resistance. The aim of the authors was to comment on the implementation of AMS strategies in outpatient dental practices.

METHODS

The authors included previous studies regarding outpatient antibiotic stewardship, longitudinal studies quantifying dispensed dental antibiotic prescription use, and interventional studies aimed at implementing AMS interventions in dentistry.

RESULTS

Researchers in several studies conducted trials regarding the use of various interventions, mostly comprising a combination of audit, feedback, dissemination of guidelines, and educational components to improve dental prescribing.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

In regard to the establishment of an AMS strategy, aspects to be considered should include raising awareness about the risks of unnecessary use of antibiotics. Engaging and educating the entire dental team and patients, as well as collaborating with other specialized professionals, are important elements. Context-specific interventions with a methodical and measured approach are ideal.

Improvement of dental prescribing practices using education and a prescribing tool: A pilot intervention study

AIMS

Antibiotic resistance is a global public health problem. Around 55% of dental antibiotic prescribing is deemed inappropriate. The aim of this multimodal interventional pilot study was to assess the effect on prescribing of education and a dentally designed prescribing website.

METHODS

Twenty-six dentists were recruited for the 12-week study using a pre-post design. Dentists self-recorded their prescribing of antibiotics, analgesics and anxiolytics for 6 weeks. After dentists were provided education and website access, they recorded their prescribing for a further 6 weeks. Four outcomes were measured comparing the prescribing before and after the intervention: (i) the number of inappropriate indications for which antibiotics were prescribed; (ii) the number of prescriptions; (iii) accuracy of the prescriptions according to the Australian therapeutic guidelines; and (iv) the confidence of practitioners towards the prescribing website. Participants were interviewed for feedback.

RESULTS

There was a substantial reduction of 44.6% in the number of inappropriate indications for which antibiotics were prescribed after the intervention and a decrease of 40.5% in the total number of antibiotics. Paracetamol with codeine substantially reduced by 56.8%. For the 3 most commonly prescribed antibiotics (amoxicillin, phenoxymethylpenicillin and metronidazole), there was the improvement in the accuracy of the prescriptions ranging from 0-64.7 to 74.2-100%.

CONCLUSION

This pilot study showed the intervention of targeted education and the prescribing tool was effective in improving dental prescribing, knowledge and confidence of practitioners, as well as providing an effective antibiotic stewardship tool. This context-specific intervention shows substantial promise for implementation into dental practice.

Methodology for the development of a national Dental Practice-Based Research Network survey on dentist's beliefs and behaviors concerning antibiotic prophylaxis

BACKGROUND

Dentists are high prescribers of antibiotics for both treatment and prevention of infection, although there are few guidelines to aid clinicians. Given the worldwide concerns about unnecessary use of antibiotics, there is a need for a better understanding of dentists' use of these drugs for antibiotic prophylaxis (AP) to prevent distant site infections (i.e., infective endocarditis and prosthetic joint infection).

OBJECTIVE

The aim of this study was to develop and implement an effective, self-reporting, cross-sectional, survey instrument that optimized the response rate and maximized reliability and validity for determining the beliefs and behaviors of a large and nationally representative group of generalist and specialist dentists concerning their use of AP.

STUDY DESIGN

A 15-question survey (58 items) was developed in a structured process by a multidisciplinary team and configured for automated online dissemination to 3584 national Dental Practice-Based Research Network (DPBRN; hitherto referred to as "Network") practitioners. The implementation phase consisted of 3 waves of greater than 1000 Network members. Additionally, 47 randomly selected dentists were surveyed twice to assess test-retest reliability.

RESULTS

Of 3584 eligible Network members, 2169 (60.5%) completed the survey. The age and geographic distributions of responders was similar to those of dentists in the 2019 American Dental Association census. Furthermore, test-retest weighted kappa values for the survey were acceptable (median 0.56; interquartile range 0.42-0.64).

CONCLUSIONS

We developed a highly structured survey with a high response rate and good reliability that will allow us to obtain unique data on dentists' beliefs and practices regarding AP prescribing.

Oral antibiotic prescribing by NHS dentists in England 2010-2017

Introduction Dentists prescribe a significant proportion of all antibiotics, while antimicrobial stewardship aims to minimise antibiotic-prescribing to reduce the risk of developing antibiotic-resistance and adverse drug reactions.Aims To evaluate NHS antibiotic-prescribing practices of dentists in England between 2010-2017.Methods NHS Digital 2010-2017 data for England were analysed to quantify dental and general primary-care oral antibiotic prescribing.Results Dental prescribing accounted for 10.8% of all oral antibiotic prescribing, 18.4% of amoxicillin and 57.0% of metronidazole prescribing in primary care. Amoxicillin accounted for 64.8% of all oral antibiotic prescribing by dentists, followed by metronidazole (28.0%), erythromycin (4.4%), phenoxymethylpenicillin (0.9%), clindamycin (0.6%), co-amoxiclav (0.5%), cephalosporins (0.4%) and tetracyclines (0.3%). Prescriptions by dentists declined during the study period for all antibiotics except for co-amoxiclav. This increase is of concern given the need to restrict co-amoxiclav use to infections where there is no alternative. Dental prescribing of clindamycin, which accounted for 43.9% of primary care prescribing in 2010, accounted for only 14.6% in 2017. Overall oral antibiotic prescribing by dentists fell 24.4% as compared to 14.8% in all of primary care.Conclusions These data suggest dentists have reduced antibiotic prescribing, possibly more than in other areas of primary-care. Nonetheless, opportunities remain for further reduction.

Aging and Oral Care: An Observational Study of Characteristics and Prevalence of Oral Diseases in an Italian Cohort

Background: Poor oral health is a common condition in patients suffering from dementia. Several aspects of this systemic pathology contribute to causing oral problems: cognitive impairment, behavior disorders, communication and, motor skills deterioration, low levels of cooperation and medical-nursing staff incompetency in the dental field. Objectives: The objectives of this study were to evaluate the prevalence and the characteristics of oral pathology in a demented elderly population, as well as to check the association between the different degree of dementia and the oral health condition of each patient. Materials and Methods: In this observational study (with cross-sectional design) two groups of elderly patients suffering from dementia, living in two different residential care institutions were recruited. The diagnosis of dementia of each included patient was performed using the Clinical Dementia Rating Scale. In order to evaluate the oral health condition of the included subjects, each patient underwent a physical examination of the oral cavity, during which different clinical parameters were analyzed (number of remaining teeth, oral mucosa, periodontal tissues, bone crests). To each parameter, a score was assigned. Spearman’s Rho test was used. Results: Regarding the prevalence of oral pathology in elderly suffering from dementia, it emerged that 20.58% of the included patients had mucosal lesions and/or new mucosal formations (in most cases undiagnosed and therefore untreated). The prevalence of periodontal disease was equal to 82.35% and a marked clinically detectable reabsorption of bone crests was found in almost all patients (88.23%). 24.13% of patients, who underwent the oral examination, had totally edentulous maxillae and/or with retained roots, without prosthetic rehabilitations. The correlation index r showed the presence of a linear correlation (inverse relationship) between the degree of dementia and the state of health of the oral cavity of each patient. Conclusions: Several factors contribute to poor oral health in the elderly suffering from dementia: cognitive functions deterioration, behavioral disorders and inadequate medical-staff nursing training on oral hygiene. This study also demonstrated that the lower the dementia degree is, the lower tends to be the oral health status. In order to guarantee a complete assistance to these patients, residential care institutions should include in their healthcare program specific dental protocols.

Adverse drug reactions due to oral antibiotics prescribed in the community setting - England

Background: Prescribing of oral antibiotics in the community setting is commonplace with ongoing efforts to optimize this practice. There are several concerns related to such prescriptions including antibiotic cost, development of bacterial resistance, and associated adverse drug reactions. We therefore performed an analysis of adverse drug reactions associated with oral antibiotics prescribed in community care (non-hospital) in England to determine adverse drug reaction reporting rates and severity of adverse reactions. Methods: Data for all oral antibiotic use in the primary care settings in England and the National Yellow Card Interactive Drug Analysis Profile was extracted for 2010 through 2017. Results: There were 320,599,292 prescriptions issued for oral antibiotics during the eight-year survey. Although the overall adverse drug reaction rate was relatively low at 58/1,000,000 prescriptions, the reported rates of serious (63.6%) and fatal (1.21%) reactions were striking and probably due to reporting bias as minor adverse drug reactions are less likely to be reported. Conclusions: Continued monitoring of adverse drug reactions rates for oral antibiotics prescribed in the community is warranted, considering the prevalence of serious and fatal reactions identified during the eight-year study period in the Yellow Card profile. These data should be useful in developing strategies to secure optimal prescribing practices.