The Rise of the Superbugs: How Dentists Can Fight Them
Louis F. Rose, DDS, MD
In the late 1920s Alexander Fleming discovered penicillin and ushered in the era of antibiotics, a powerful army of groundbreaking agents to combat infections. Now, it appears we may have had too much of a good thing, unleashing unintended consequences that were never imagined. Indiscriminate use of these wonder drugs has led to an epidemic of antibiotic resistance.
For many years, health professionals have doled out antibiotics with impunity, too often using a “better-safe-than-sorry” approach when these powerful medications were not the appropriate remedy or prescribing them as a preventive measure despite their being either ineffective or unnecessary. Approximately 142,000 people a year visit emergency rooms because of adverse drug reactions related to ingesting an antibiotic. Moreover, antibiotics have been invading the food chain as a byproduct of additives slipped into the lunch pails of cattle to promote growth, which is one reason the United States, Canada, and the European Union are moving toward banning the use of human antibiotics in animal feed.
Smorgasbord of Superbugs
This alarming overuse has become a threat to public health. We now have a smorgasbord of superbugs—infections such as methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, anthrax, gonorrhea, group B streptococcus, typhoid fever, tuberculosis, Shigella, and certain strands of pneumonia and meningitis—that have developed clever ways to outwit the drugs designed to fight them. The tendency of strong antibiotics to kill off protective bacteria in the intestines can cause more serious problems than the drugs were meant to treat. According to the Centers for Disease Control and Prevention, more than 2 million people a year are stricken with antibiotic-resistant infections that kill about 23,000 of them. Also, a report by the World Health Organization warns that without a coordinated effort, what are now common but curable diseases could again become deadly.
The challenge to health providers is not terribly complicated or demanding. As a profession we must simply make a more serious effort to examine how and when we write prescriptions and give consideration to less dangerous alternatives. Often, it is easier to accede to patients’ fears and meet their expectations than it is to follow sound medical principles. Customer satisfaction is a fine term for commerce but not a recommended guideline for healthcare.
Dentists are as culpable as physicians when it comes to overprescribing antibiotics, particularly such popularly abused drugs as penicillin, beta-lactams, and quinolones. Dentists write approximately 10% of outpatient antibiotic scripts—about 25.6 million a year—and it is estimated that approximately 30% to 50% of them could be avoided. One study done in British Columbia, Canada, and published in the Journal of the American Dental Association found that from 1996 to 2013, physician prescriptions declined 18.2% while dental prescriptions increased 62.2%, particularly among dental patients older than 60 years. Explanations for this included overmedicating patients who have had complications from dental implants, concern about litigation, and insurance coverage issues that result in relying on drugs as a treatment to avoid the high cost of surgery.
To reduce their dispensing of antibiotics, dentists should become familiar with the latest information about conditions for which preventive medication was once commonly used. This was the case when it was feared that patients with heart disease or joint replacements would be vulnerable to infections that might enter the bloodstream through a wound in the mouth. However, in 2007 the American Heart Association changed its recommendation that everyone with any type of congenital heart defect should receive an antibiotic 1 hour before a dental procedure, a practice that had encouraged too many dentists to give drugs for even the most routine procedures. The new guideline is much more specific and advises antibiotics for only four groups of patients: those who have an artificial heart valve or a valve repaired with artificial material; those with a history of infective endocarditis; those who have had a cardiac transplant with abnormal valve function; and those who have certain congenital heart defects. Since 2008, prophylaxis for patients with a history of infective endocarditis has been constricted to those with serious underlying cardiac conditions who have the highest risk for an adverse outcome. That’s it!
The indications for patients who have had joint replacement have also been vastly revised. Before 2002, premedication with an antibiotic was a fairly common practice for patients with artificial hips, knees, etc—despite little evidence to support it. Then in 2014, an American Dental Association (ADA) panel reviewed four studies and concluded that three of them failed to show any association between dental procedures and prosthetic joint infection, nor was there any finding of effectiveness from premedication. Based on concerns about the downsides of antibiotic prophylaxis—not to mention the cost that a 2013 report estimated at more than $50 million annually—both the Canadian Dental Association and the ADA no longer recommend administering antibiotics before dental procedures to prevent infection in patients with prosthetic joints. When in doubt, the right path is to consult an orthopedist and let the orthopedist prescribe based on his or her best judgment.
Concerns are also being raised about the increased use of antibiotics in teenaged patients having their wisdom teeth removed and in patients older than 60 years, the target population for dental implants. Researchers in New Zealand studied 95 patients who had had impacted molars removed and found no difference in pain, swelling, or temperature between those who received antibiotics or a placebo. The prevailing belief is that pain and complications are more likely to be related to inflammation than to infection and would be preferably handled by the use of nonsteroidal antiflammatory drugs (NSAIDs). Investigators also have concluded, after a meta-analysis of data, that periapical abscesses should be treated surgically because little benefit is gained from using antibiotics in terms of limiting either infection or pain.
Case by Case
As dentists, we should no longer automatically prescribe antibiotics for most dental procedures or opt for stronger drugs with additional potential side-effects when penicillin is perfectly acceptable. We should deal with patients on a case-by-case basis instead of routinely prescribing them drugs. Certainly, there are times when antibiotics properly used can and do save lives. However, if we are not more discriminating, we stand to lose one of our most valuable assets—the use of antibiotics against bacterial infections.
Think twice before you write your next prescription. Ask yourself, “Is it absolutely essential, and am I ultimately helping or hurting my patient?”
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About the Author
Louis F. Rose, DDS, MD