Most Preventive Antibiotics Before Dental Procedures Are Unnecessary, Study Finds

Health Letter, December 2019

By Azza AbuDagga, M.H.A., Ph.D.

antibiotics

Image: Kulniz/Shutterstock.com

Dentists are the fourth most frequent prescribers of oral antibiotics in the U.S., accounting for one in ten pharmacy prescriptions.[1] Many of these antibiotics are taken before dental procedures as prophylaxis to prevent infection from the release of bacteria from the mouth into the bloodstream.

A recent large, federally funded study showed that more than three-quarters of the prophylactic (preventive) antibiotics prescribed by dentists before dental procedures for individuals with commercial insurance are unnecessary.[2] The study was published in the May 2019 issue of the Journal of the American Medical Association (JAMA) Network Open.

This finding raises serious concerns because inappropriate use of antibiotics contributes to the general problem of antibiotic resistance and exposes patients to an increased risk of diarrhea, particularly a severe type of diarrhea caused by Clostridium difficile infection in the intestine, and other adverse effects.

Learn about the new study and about when an antibiotic is needed before dental procedures to protect yourself and your loved ones from the risks of unnecessary use of antibiotics.

Recommendations by clinical practice guidelines

Compared with previous recommendations, current guidelines limit prophylactic antibiotics to a narrow group of patients with certain heart conditions that are associated with the highest risk of adverse outcomes from infective endocarditis (infection of the inner lining or valves of the heart) who are undergoing specific planned dental procedures.[3]

Specifically, the 2007 guidelines of the American Health Association (AHA) consider prophylactic antibiotics to be appropriate if two conditions are met. First, the patient has a prosthetic or artificial heart valve or material used for cardiac valve repair, has a history of infective endocarditis, has a certain type of congenital heart disease or is a heart transplant recipient with a heart-valve disease. Second, the patient is planned to undergo a dental procedure involving gingival manipulation (manipulation of the gum tissue or the root of a tooth, or perforation of the mucous membrane in the mouth).

Importantly, the joint guidelines by the American Academy of Orthopaedic Surgeons and the American Dental Association have not favored the use of prophylactic antibiotics for patients with prosthetic joint devices since 2013.[4]

The JAMA Network Open article[5]

To examine oral or injectable antibiotic prophylaxis in relation to dental visits, the researchers used a U.S. commercial database that contains dental, medical and pharmacy claims. They identified from this database over 168,000 dental visits for a total of approximately 91,000 patients who had received a prophylactic antibiotic (identified by a prescription for a two-day supply or less of an antibiotic that was dispensed within seven days before the dental visit) from 2011 to 2015. These patients also had no history of hospitalization or infection outside the mouth (such as upper respiratory tract infection) within 14 days before the antibiotic dispense date. The median age of these patients was 63 years and 57% of them were female.

The researchers classified each of the more than 168,000 prophylactic antibiotics for dental visits as appropriate or inappropriate according to the 2007 AHA guidelines. They found that over 136,000 (81%) of these prescriptions were inappropriate ― that is, either the dental visit did not involve a procedure code indicating a gingival manipulation procedure or the patient did not have a diagnosis code for any of the four heart conditions specified in the guidelines. However, there was a significant decrease in the use of antibiotic prophylaxis over the study period, which may have resulted from the application of 2013 guidelines for the prevention of prosthetic joint infections.

Importantly, over 63,600 (47%) of the dental visits with unnecessary antibiotics involved patients with prosthetic hip devices, which is inconsistent with the current guidelines. Additionally, certain dental procedures, such as implant services, prosthodontics (fitting of artificial replacements for the teeth) and orthodontics (correction of improperly positioned teeth or jaws) were associated with higher rates of unnecessary prescribing. Other reasons for the unnecessary use of antibiotics were not clear, suggesting that many dentists simply may have failed to limit their prescription practices according to the current guidelines.[6]

Clindamycin (CLEOCIN) had higher odds of being prescribed inappropriately than amoxicillin (AMOXIL, LAROTID) in this study. This is a concerning finding because a recent analysis showed that clindamycin is associated with a higher risk of Clostridium difficile diarrhea compared with other antibiotics prescribed for dental procedures.[7]

The new study also showed that dental visits occurring in urban areas and the West of the U.S. were associated with higher rates of unnecessary antibiotic prophylaxis than those occurring in rural areas and other regions.

What You Can Do

Discuss this article with your dentist and cardiologist if you are considering invasive dental work. You generally do not need a prophylactic antibiotic prescription unless your dental procedure will involve gingival manipulation and you have any of the four high-risk heart conditions specified in the AHA guidelines.


References

[1] Hicks LA, Bartoces MG, Roberts RM, et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis. 2015;60(9):1308-1316.

[2] Suda KJ, Calip GS, Zhou J, et al. Assessment of the appropriateness of antibiotic prescriptions for infection prophylaxis before dental procedures, 2011 to 2015. JAMA Netw Open. 2019;2(5):e193909.

[3] Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736-1754.

[4] Rethman MP, Watters W, Abt E, et al. The American Academy of Orthopaedic Surgeons and the American Dental Association clinical practice guideline on the prevention of orthopaedic implant infection in patients undergoing dental procedures. J Bone Jt Surg Am. 2013;95(8):745-777.

[5] Suda KJ, Calip GS, Zhou J, et al. Assessment of the appropriateness of antibiotic prescriptions for infection prophylaxis before dental procedures, 2011 to 2015. JAMA Netw Open. 2019;2(5):e193909.

[6] Spivak ES. Antibiotic use in dentistry-what we know and do not know. JAMA Netw Open. 2019;2(5):e193881. doi:10.1001/jamanetworkopen.2019.3881.

[7] Bye M, Whitten T, Holzbauer S. Antibiotic Prescribing for Dental Procedures in Community-Associated Clostridium difficile cases, Minnesota, 2009–2015. Open Forum Infect Dis. 2017;4(Supplement 1):S1. doi:10.1093/ofid/ofx162.