Antibiotic Resistance: Smarter Prescribing in Dental Care

Antibiotic resistance is a huge public health threat around the world, affecting every country, every nation. And resistant bacteria affect all of us, animals and humans. Resistant infections are harder to treat. There's lots of consequences related to antibiotic prescribing. So it's a big problem. Welcome to Austin, Texas for the Phil Klein Dental Podcast. Thank you for joining us. In this episode, we're tackling a critical issue in modern dentistry. the responsible prescribing of antibiotics. While antibiotics have saved countless lives, their overuse, and often unnecessary use in dentistry, is fueling a growing crisis, the rise of antibiotic-resistant superbugs. The reality is that in most dental cases, antibiotics simply aren't needed. Yet, some dentists continue to overprescribe, whether out of habit, misdiagnosis, patient pressure, or misconceptions about their effectiveness. So today we'll talk about why this is happening, what the trend is, and more importantly, what can we do as dental health care providers to ensure we're using antibiotics only when absolutely necessary. We'll explore the risks of overprescribing, the latest guidelines for responsible antibiotic use, and actionable steps to minimize antibiotic exposure for our patients without compromising care. Our guest is Dr. Marie Fluent. Dr. Fluent's dental career spans over 35 years and includes all roles within the dental practice. Through her writings, webinars, and invited lectures, she has educated thousands of dental professionals and students nationally and internationally. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Dr. Fluent, it's a pleasure to have you on the show. Thanks for having me here, Phil. I'm delighted to be a guest on your podcast. So we're very happy to have you on the show, Dr. Fluent. We've done some previous podcasts with you that have really gotten great engagement. the episode on the blue light hazard in the operatory, how we're exposed to blue light and how dangerous that could be if we're not protected. These are things that we really have to be aware of, and you handled those discussions so well. Today, we're talking about a pretty important topic because the overprescribing of antibiotics leads to superbugs, which we're experiencing now. And this is particularly meaningful to me because when I practiced endodontics, Many of the cases that were referred to me were vital cases, but nevertheless, the GP had the patient on antibiotics, thinking that maybe there was an infection component to the condition that the patient was undergoing. But in fact, it was pure vitality all the way. And once we did the root canal therapy, the patient was comfortable and so forth. So we have to be very diligent. about prescribing antibiotics in cases only where we need to, of course, and I hate to use the word reckless, but in a way it is reckless to overprescribe, that leads to superbugs. And then that's a big problem in itself, as we know today. So when you talk about antibiotic stewardship, what are you referring to? Well, antibiotic stewardship, I'll just share in my own words initially that last year I went to, I'm off on a tangent, but bear with me. I do have method to my madness here, Phil. This year, our family went to the Grand Canyon. And we looked in awe over the edge of the canyon at the spectacular landscape. And we are able to enjoy it to this day because of a gentleman, a president of ours, Teddy Roosevelt, who was a steward of our great lands. And he developed the national parks as a stewardship initiative. And what he meant by that is that we need to preserve this land, declare it as such, and preserve it so future generations. enjoy this great land of ours. As we translate that definition into antibiotics, nobody enjoys taking antibiotics, but antibiotics are enjoyed by people to cure them of certain infections and prevent infections from becoming out of control and preserve life. in bacterial related infections. So antibiotic stewardship and antimicrobial stewardship is the effort to conserve antibiotics, make sure that they are used at the right time, the right place, in the right duration, and not misused and overused so they are safe and effective for future generations. And that's the Marie Fluent definition, but you get the idea. Before we continue, I've got to give a shout out to our sponsor, NSK. These folks are the real deal. Their air and electric handpieces are not only top tier, they're the highest rated in the industry, peer-reviewed by Dental Product Shopper. Their Timex Z99L electric handpiece actually scored the first ever perfect rating. And the Timex Z990L is the most powerful handpiece on the market. So do yourself a favor. Check out everything they offer at nskdental.com and take advantage of their free trial by reaching out to your local NSK rep. I've heard this many times from many dentists. Once you start using NSK handpieces, you'll never look back. Yeah, I think your comparison to the Gray and Canyon makes a lot of sense. One generation has to be thoughtful of the next. And if we abuse antibiotic prescribing and we do it too much when it's not necessary, we're going to have a continuous emerging problem. of superbugs that are resistant to antibiotic therapy, which leaves future generations in a worse position than we are in now, and we're already seeing it. So with your understanding, Dr. Fluent, how much of an impact, not that I want to blame it on anybody, but how much of an impact is dentistry having on the superbug issue? Well, we're contributing a lot. For human use, we dentists prescribe approximately 10% of the antibiotic prescriptions for human use. And of course, other prescribers like pediatricians, internal medicine docs, ER docs, nurse practitioners, et cetera, they prescribe as well. But as far as for human use, we comprise approximately 10% of the antibiotic prescriptions written for people. This accounts to approximately 25 million prescriptions per year, and this amounts to approximately 200 antibiotic prescriptions per dentist per year. in the United States. It's estimated that 30 to 85 percent of the antibiotic prescriptions that are written in dentistry are suboptimal. That means that they're either not in accordance to the two prescribing policies and practices. or they're not indicated in the first place. So antibiotic resistance is a huge public health threat around the world, affecting every country, every nation. And resistant bacteria affect all of us, animals and humans. Resistant infections are harder to treat. There's lots of consequences related to antibiotic prescribing. And one dose of any antibiotic can result in bacteria becoming resistant. So it's a big problem. And there are many side effects associated with antibiotic prescribing as well. So the main objective, Dr. Fluent, of this podcast episode is to bring everybody up to date on what... best practices when it comes to prescribing antibiotics. Now, in the past, dentists would prescribe antibiotics if the patient was in pain with a toothache. They want to play it safe. They don't want to get an infection or they may have an infection and they just want to make sure it doesn't get worse. It was kind of defensive in their strategy when they prescribed antibiotics instead of using it only when necessary and more of an offensive strategy. So talk to us about the major paradigm shift as far as... antibiotics, what is recommended, what is considered best practice. Well, now we have new guidelines that tell us when we should and shouldn't prescribe an antibiotic and different indications. But before we do that, let's talk about some paradigm shifts that have occurred in prescribing patterns and how I was taught to prescribe antibiotics when I graduated from dental school many, many years ago. We were taught in dental school years ago that if we were in doubt, to prescribe just in case. And now the new paradigm is you only prescribe when absolutely necessary. The second paradigm that we were taught way back when was that antibiotics are going to cure you. And we were taught to teach this to our patients. And now we are taught that antibiotics are not going to cure your tooth. You need some type of definitive care on your tooth, whether it be an extraction, endodontic therapy, a pulpotomy, etc. And that definitive care will cure your tooth. And then the next paradigm was that if we saw a patient with a self-reported penicillin allergy, we would automatically switch gears and prescribe a different classification of antibiotic. And now we're saying, hey, not so fast. Let's reassess this penicillin allergy. and ensure it truly is an allergy and not a side effect to the antibiotic because we always want to prescribe the first line of antibiotic. choice if possible. The next paradigm shift is that we were taught to hit an infection hard and fast and furious with the antibiotic and typically prescribed for a 10-day duration of therapy. And now we're saying, nope, a 10-day duration of therapy is much too long. And in the new guidelines, the standard duration of therapy is three to seven days. And you advise the patient to discontinue their antibiotic 24 to 48 hours. after the resolution of their symptoms. And then the final paradigm shift, of course, involves pain management. Historically, we would prescribe narcotics for pain. And now, as we all know, narcotics are not needed for pain that we are encouraging patients to manage discomfort with over-the-counter medications such as Tylenol or Motrin or a combination of the above. So those are our paradigm shifts that we should keep in mind. as we're prescribing antibiotics. And as you just described in your scenario, don't prescribe just in case. Prescribe absolutely when only necessary. Before we continue with our guest, a big shout out to GC America. A leader in dental materials, GC is all about minimally invasive dentistry, preserving natural tooth structure and helping to keep it healthy long after the restoration is placed. That's where glass onomer technology shines, and GC's new glass hybrid, Equia Forte HT, fits right in. It chemically fuses with the tooth for strong, long-lasting aesthetic results. It's fast, packable, moisture tolerant, and requires no bonding or conditioning. Plus, it delivers continuous fluoride protection. Yeah, I think you covered that very well, Dr. Fluent. And I just think it's important for general dentists who are seeing patients, they're the first ones that are going to see these patients that are presenting with dental pain. they absolutely have to have a good understanding of endodontic disease. In other words, they need to be able to ascertain the difference between vital and non -vital and when it's important to use antibiotics to fight an infection that could be threatening to the patient. Otherwise, stay away from antibiotics. So in addition to fully understanding endodontic disease, at least on the diagnostic level, as best a general dentist can, What else can we do as a profession to minimize or to lower the number of antibiotic prescriptions that are submitted to the pharmacist these days? Well, first of all, I want to commend you for being an endodontist because I don't think I could have done it. I don't think I would have had the patience to do it. And diagnostic uncertainty, as you just described, is one reason for overprescribing that we're just not sure what we're treating. So sometimes we treat empirically of what we think the infection might be. So there are guidelines that were published by the American Dental Association Council of Scientific Affairs. that were published in December. 2019. And as you recall from that period of time, the world was just about to be shut down due to COVID-19 within a couple of months. So I think a couple of things happened. Number one, the guidelines got pushed to the wayside because we had bigger fish to fry. Number two, our offices were closed for the vast majority of the following several months. So the only thing that we could do would be to prescribe an antibiotic and say, see you when our office is open. So we had a big setback with regard to antibiotic stewardship. But having said that, these guidelines that were published by the American Dental Association, our Council of Scientific Affairs, by the way, are dependent on a couple of things. Can you perform definitive conservative dental treatment that day? Or can you not? This is the term that they described in this article, DCDT, Definitive Conservative Dental. therapy, whether it can be performed immediately or you have to reschedule the patient for an upcoming procedure. So whether DCDT is available or it's not available and what are the pulpal or periapal conditions of the tooth. So if it's an irreversible pulpitis with or without symptomatic apical periodontitis, an antibiotic is not indicated. And if you have pulp necrosis, as you just described, Phil, and have some apical periodontitis. If you can perform dental treatment that day, great. An antibiotic is not necessary, but if you cannot perform dental care that day, then you would monitor the patient and possibly prescribe a delayed prescription. to be taken if their symptoms worsen. And then the same goes with the next pulpal condition, pulp necrosis, localized acute apical abscess without systemic involvement. Once again, if you can provide immediate dental care that day, an antibiotic is not indicated. And if you cannot, then get care right away and prescribe an antibiotic. And then the last category would be those systemic infections. pulp necrosis, localized acute apical abscess with systemic involvement. And in all of those scenarios, whether definitive care is or is not available on that day, then an antibiotic would be prescribed and the patient should have immediate referral and have that tooth taken care of ASAP. From the standpoint of me being an endodontist, and I listened to that very carefully, what you just said, that is very conservative and that makes sense to me. Again, the liability that dentists are afraid of as far as releasing a patient where it gets worse, you know, that is what scares them. you know, and that, and that influences their strategy, their prescribing strategy. Yeah. And it's unfortunate because, you know, we're in a litigious world and a patient comes in and you never know who that patient is, especially if it's an emergency patient, one of those typical patients that only come in. when they have an emergency, they may have a higher tendency possibly to blame the dentist if things don't work out perfectly for them. So the dentist says, hey, I don't want to get involved in that. So from that point of view, you could understand the position of the dentist. So let me ask you this, Dr. Fluent. Where are we now with the superbugs? With all this over-prescribing, and this has been going on for decades and decades, for the longest period of time. I mean, antibiotics was, what, developed in the 1940s? Dentists probably started prescribing it. you know, two days after the thing came available in the drugstore. So we've clearly been over-prescribing for a long time. Are we at the point now with superbugs where we should be concerned? Absolutely. As a matter of fact, I want to back up. You said that antibiotics became widespread in use in the 1940s in the World War II era. And Alexander Fleming, who is the discoverer of penicillin, when he accepted his Nobel Prize for the discovery, said he had a quote, recognizing that antibiotic resistance was a problem then and there. And that was 1947. Alexander Fleming said when he accepted his Nobel Prize that the thoughtless person playing with penicillin treatment is morally responsible for the death of the man who succumbs to infections with the penicillin-resistant organism. And that was stated in 1947. So this is nothing new. So we can fast forward to just a few years ago when Dr. Margaret Chan was the director of the World Health Organization. said, we're entering a post -antibiotic era. And that means an end to modern medicine as we know it. Things as common as strep throat or a child's scratched knee could once again kill, which is horrible and scary. So CDC puts out a statement on threats and the state of the union, if you will, with regard to antibiotic resistance. And they estimate that there's approximately 2 .8 million antibiotic resistance. in the United States each year. And this leads to approximately 36,000 deaths per year. And they estimate with regard to clostridioids difficile infection, C. diff infection, and it's related to antibiotic use, misuse, and overuse, that there's a quarter of a million cases per year in the United States and approximately 13,000 deaths per year. And many studies say that that's a way under estimation that our numbers are actually much higher than that. But as far as dentistry is concerned, C. diff should be on the decline because we're not, that's really associated with clindamycin and we don't really use clindamycin too much now, hopefully in dentistry. Yes. And we should be getting away from clindamycin or cliocin use. Cliocin is the brand name. Clindamycin is the generic name, if you will. And any antibiotic can lead to C. diff infection, but the one that's most, the biggest culprit, of course, is clindamycin. So we should be staying away from clindamycin as much as possible. Yeah. And let's talk about also how things have changed regarding antibiotic prophylaxis. Today's episode is sponsored by Sunstar, makers of gum products. Gum's premium line of interdental cleaners, soft picks, and toothbrushes offers innovative, easy-to-use solutions for better oral care. Introduce your patients to gum, the tools they need to maintain healthier smiles. Learn more today by visiting sunstargum.com. regarding mitral valve prolapse and all that other stuff i know that's been totally revamped over the years where are we now with recommendations as far as pre-medicating patients with antibiotics i know these cases are few and far between where you need to do this but if you could touch on that that would be great Sure. Well, we provide antibiotic prophylaxis for two main reasons in dentistry. One is to prevent infective endocarditis. And the second reason is to prevent joint infection, prosthetic joint infection after joint replacement. So let's start on cardiac conditions or the prevention of infective endocarditis. Now, the major article that we cite with regard to antibiotic prophylaxis for heart conditions was published in JADA in 2020 by Lockhart. And this article concludes that there's only a small subset of patients who require or would benefit from antibiotic prophylaxis to prevent infective endocarditis. And would you like to hear who those would include? That's probably some congenital heart disease. Right. That's part of it. Yes. And there's three specific areas of patients who have congenital heart disease, and they include unrepaired cyanotic congenital heart disease, including palliative shunts and conduits, repaired CHD defects with prosthetic material during the first six months after the procedure, and then finally repaired CHD with residual defects. And then there are three other conditions that would be put. patients at a higher risk as well. And these include patients with a prosthetic cardiac valve or prosthetic material used for valve repair, previous situations of infective endocarditis, and then cardiac transplant patients who develop valvulopathy. And obviously, Dr. Fluent, from the practical perspective. general dentist or any dentist is not going to have all this in the back of their head, what you just rattled off, which is all good to know. But the reality is the dentist should be communicating and collaborating with the cardiologist once that medical history is taken. And then they will know, based on the instructions from the cardiologist, what to premedicate, if necessary, what to premedicate the patient with prior to the dental appointment. So that's something that obviously has to be between the cardiologist and the general dentist. Correct. Correct. And when in doubt, let's face it, I'm not a cardiologist. So some of these definitions would be foreign to me. And I wouldn't hesitate to call the patient's cardiologist for clarity if I were in doubt. So let's talk about the patient who's allergic to penicillin or reports that they are allergic to penicillin. And it's been determined that it's important and necessary that that patient gets on a regimen of antibiotics. because of the condition of the tooth and the soft tissue, and it meets all the criteria that we went over earlier in this episode, what is the next best choice when they're allergic to penicillin or report to be? Well, if you have a patient who comes in with a self-reported history of penicillin allergy, the first thing you want to do is assess that. And you want to ask what happened, how it happened, when it happened, how it was treated, how drastic were your symptoms, and what was recuperation like. And you want to know when it happened because patients with a true penicillin allergy lose their antibody response within 10 years. of having that allergy. So in other words, if you were penicillin allergic as a child, and now you are a full-grown adult, the chances of having that penicillin allergy would be much, much, much less. So you want to assess what happened, how it happened, and the severity of it as well. So once you have assessed it, you want to look at the ADA guidelines regarding penicillin allergy and determine, did the patient a history of anaphylaxis, angioedema, or hives with penicillin, ampicillin, or amoxicillin. And if they did not, Ceflexin or Ceflex would be your drug of choice. And that would be 500 milligrams QID for three to seven days. And you would have the patient discontinue 24 to 48 hours after their resolution of their symptoms. And if that's not working, ADA recommends adding metronidazole, 500 milligrams three times a day for seven days on top of that. Now, if the patient does have a history of anaphylaxis, angioedema, or hives with penicillin, ampicillin, or amoxicillin, then you switch gears. Then your drug of choice, according to ADA, would be azithromycin, a loading dose of 500 milligrams on day one, followed by 250 on days two through four, or clindamycin which surprises me it surprises me that they add clindamycin as an option but having said that when they added clindamycin as an option they said gave the comment, due to concerns about the high risk of C. diff infection, patients should be instructed to call their primary care provider if they develop fever, abdominal cramping, or three or more loose bowel movements per day. And then I want to follow up by saying they should be instructed to discontinue their antibiotic, call their primary health care provider, and then do not take over-the-counter antidiarrheal medications such as Imodium in that scenario. So in order to promote antibiotic stewardship within a given practice, when there are multiple dentists in the practice, it could be a large private practice or DSO, whatever, what are some of the things an office could do to make sure that everybody's on the same page with this and we're all prescribing antibiotics responsibly and appropriately? The CDC has developed a core elements for outpatient antibiotic stewardship. And in dentistry, we fall in that category. We are an outpatient facility. So the four core elements include, number one, you make a commitment with your entire dental team. Maybe you can do this by hanging a poster saying, hey, we're really abiding by and observing our prescribing practices. ask us these particular questions maybe you want to communicate via your office website or via newsletters or social media to your patients that you're implementing a stewardship program and make sure the entire team is on board and have their expectations included as well. Number two, you act on the commitment, and that is you prescribe per the guidelines that I just mentioned for the treatment of dental infections and also for the prevention of infections by antibiotic prophylaxis situations. And you prescribe, of course, to the tools that I just gave you. In other words, minimizing or rarely using, if ever, using clindamycin, including the patient on your decision-making process. Practicing penicillin allergy stewardship, and we touched upon that a little bit. Reducing your duration of therapy, not a standard 10-day duration of therapy, but three to seven days, and that would be 24 to 48 hours. after the resolution of the symptoms, and then only prescribe per the guidelines that I mentioned as well. Number three, you track and report your prescribing practices. How are you prescribing? Are you over -prescribing, under-prescribing? Are you prescribing based on the guidelines, including the dose, duration, and the frequency? Are you providing a thorough review of the patient's medical history, including their C. diff history? complications when taking an antibiotic? Did you come to a thorough and definitive diagnosis? And how did you obtain that diagnosis? What are the indications for antibiotics? And did you abide by them? And did you provide dental treatment, DCDT, in other words, some type of therapy to cure the infection. So these are ways that you can track and report your prescribing patterns. And then finally, the fourth core element would be providing education to yourself, your dental team, and to your patients. You want to talk to your dental team and make sure that they understand penicillin allergy assessment, early discontinuation of antibiotics. what to do with leftover antibiotics if the patient has extra, how to manage pain with over-the -counter medications, how do you assess for clostridioids difficile infection, what is delayed prescribing, what is the shorter duration of therapy, what resources are available for you, et cetera. And then utilize a lot of the resources that are available, either from the Association for Dental Safety, Centers for Disease Control and Prevention, In my state, we have MAR, Michigan Antibiotic Resistance Reduction Coalition, that can help you prescribe according to the guidelines and get you the help that you would need. Yeah, well, that's a lot of information. Now, in closing, do you think we are improving in this effort to move forward to minimize the prescribing rate of antibiotics? Are we improving? Are we getting better with more awareness that we should not over-prescribe antibiotics? There is some evidence to show that, yes, we are indeed improving. There does seem to be greater awareness for the need for stewardship endeavors. There are studies that show the rate of prescribing of dentists compared to other medical providers. And of course, we had a downturn with COVID-19, but now that COVID is at bay, it seems like we have picked up where we've left off and we are seeing decreased prescribing patterns. So that's a good thing. And the further that we get away from COVID-19, I think that we'll have better data to show exactly how our prescribing patterns have improved. And I am optimistic, Phil. I think that we are collectively doing a good job and we have a heightened awareness compared to where we were five or 10 years ago. Okay, great. Optimistic way to end the podcast episode. I'm all for that. Yes, I agree. Thank you so much, Dr. Fluent. Appreciate your input. And let's all keep in mind, I'm talking to the listeners, before you take out, well, now everything's digital. You don't even write prescriptions on a pad anymore. But before you send that prescription to the pharmacist, do everything you can to think about how you can avoid prescribing antibiotics. Because most of the time, it's not necessary when it comes to dental conditions, as we've talked about in this podcast episode. And it's going to save. lives down the road, generations to come. And it's something that we all should keep in mind and be responsible healthcare providers. Thanks again, Dr. Fluent for your insight. Excellent, excellent discussion. Thank you, Phil. Appreciate being here.