Introduction
As research evolves, so do practice guidelines. What was once commonplace for antibiotic use is now viewed under scrutiny, as more information delves into the risks of overuse. Dental providers must be vigilant when it comes to antibiotic prophylaxis (AP) and communication between other health care disciplines, such as orthopedics and cardiology, should be clearer than ever before. Patients who have historically been taking a premedication prophylactically before dental appointments, may not actually need it according to new guidelines and the demographic of those who truly could benefit, is very small. This article provides current, research-based practice guidelines for antibiotic premedication, discusses risks for development of drug resistant bacteria, and offers suggestions for implementation of antibiotic stewardship programs.
When is a Premedication Necessary
By 2030, there are projected to be 1.9 million total hip and knee replacements in the US, largely due to the fact that individuals are living longer leading to an increased prevalence of arthritis.1,2 If each of these patients, hypothetically, visited a dentist twice in a year and received an antibiotic premedication at that time, that would equate to 3.8 million prescriptions in just one year.1 The question at hand is, do all of these patients truly need a premedication? The short answer: No. A retrospective cohort study was conducted from 2011 to 2015 to assess the appropriateness of antibiotic prescriptions before dental procedures that manipulated the gingiva or tooth periapex in patients with an appropriate cardiac diagnosis. The results concluded that more than 80% of antibiotics prescribed were unnecessary and not in accordance with current guidelines.3 Traditionally, orthopedic surgeons have been concerned with risks for prosthetic joint infections following a dental procedure and saw more value in protecting against this by recommending an antibiotic for dental procedures. However, studies are suggesting that in general, prophylactic antibiotics are not recommended to prevent prosthetic joint infections and that really, only about 12% of cases truly need this prescription.1
So, who falls into this 12% category? These patients would include1-5
Diabetes: Hemoglobin A1c > 8 or blood glucose level > 200mg/dL
Severely immunocompromised: Patients with stage III HIV/AIDS, patients on chemotherapy with fever or severe neutropenia with or without fever, patients with rheumatoid arthritis (RA) on treatment with disease-modifying biologic agents including prednisone >10mg/day, patients who have received a solid organ transplant and are on immunosuppressants, patients with hereditary immunosuppressive diseases, and patients with a bone marrow transplant from the pre-transplant period until the end of the immunosuppressive treatment.
Prosthetic joints: Only those with a history of prosthetic joint infection (PJI) requiring an operation. AP for prosthetic joint replacements does not necessarily reduce the risk of PJI and prescribing an antibiotic out of concern for a potential infection could be placing the patient at risk for an adverse drug reaction (ADR). Rather, the patient’s oral health condition prior to the joint replacement is the bigger concern. Numerous studies have concluded that the risks for ADRs far outweigh the minimal chance of a joint infection, with one study concluding no statistical correlation between high-risk procedures without AP and PJI at 6 months or 2 years.1,5 High risk procedures with AP at 6 months showed to be protective, however not at 2 years. In general, APs are not recommended for prosthetic joints unless otherwise recommended by an orthopedic surgeon.
Cardiac concerns: This would include prosthetic cardiac valves, prosthetic material used for heart valve repair, previous infective endocarditis (IE), unrepaired cyanotic congenital heart defect or repaired congenital heart defect, and cardiac transplant with valve regurgitation due to a structurally abnormal valve. What was once recommended for IE is no longer commonplace, as limited research supported antibiotics as a prevention method during dental procedures and showed more bacteremia being introduced from daily oral hygiene.6 The American Heart Association and the American Dental Association are in agreeance in that IE risk can be reduced through maintenance of good oral hygiene and routine dental appointments.
In specific case types, AP is recommended to protect against infection during procedures where the gingiva is manipulated or the apex of the tooth is involved. However, the risks of overprescribing are becoming heightened with antibiotic resistance on the rise and providers must be selective when it comes to prescribing.
Overuse Risks
As defined by the World Health Organization (WHO), antimicrobial resistance (AMR) occurs when bacteria, viruses, fungi and parasites stop responding to antimicrobial medicines like antibiotics, antivirals, antifungals, and antiparasitics. In 2019, AMR was solely responsible for 1.27 million global deaths and contributed to 4.95 million deaths.7 With AMRs increasing and dentists, as well as orthopedic surgeons, being some of the leading prescribers of antibiotics in the nation, their contributions toward prescribing these medications are being evaluated. A systematic review assessing the need for AP prior to dental implant procedures for patients with orthopedic prostheses reported that 63.4% to 71.5% of orthopedic surgeons consider the prescription of APs to be necessary indefinitely for patients with hip prostheses undergoing dental treatment.5 In what was just previously discussed, numerous studies are revealing that the majority of antibiotic prescriptions are not necessary, so what adverse outcomes may result from taking an unnecessary antibiotic?
One study concluded that 1 in 5 (20%) patients prescribed an antibiotic will develop an ADR requiring a visit to the doctor or ER. Whereas, less than 1% of patients not taking an AP will develop a PJI.1 Common ADRs include diarrhea, nausea, vomiting, rashes, and gastrointestinal distress. Clostridioides difficile (C. difficile), previously known as Clostridium difficile, is a Gram-positive, anaerobic spore-forming, toxin-producing bacillus that is transmitted fecal-orally.8 Risks for C. difficile include age, hospitalizations, and in dentistry, exposure to antibiotics, specifically Clindamycin. The risk for developing C. difficile is 8 to 10 times higher during antimicrobial therapy and 4 weeks after therapy, as well as 3 times higher in the following 2 months.8 Although prescription rates of Clindamycin have dropped, antibiotic overuse still places patients at risk for development of this bacterium and orthopedic surgeons that recommend AP for life are contributing to a drug resistant microbiome.1 Again, the risks for ADRs is far greater than that of a PJI. If overuse of antibiotics is to be addressed, then providers must commit to stewardship practices.
Dental Stewardship: What does this mean?
According to the CDC, antibiotic stewardship is, “the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients.”9 A large factor in achieving stewardship is communication between providers. Many patients are left confused when they arrive at the dentist 6 months after their joint replacement and the dental provider is questioning about an AP, yet this is the first they are hearing of this since their orthopedic surgeon did not mention anything. Interprofessional socialization through routine meetings between orthopedic surgeons, dentists, and pharmacists could encourage calibration and avoid miscommunication between providers.1 Additionally, collaboration between dentists and orthopedists could bring awareness to preoperative dental screenings and treatment to reduce high levels of harmful microorganisms in the oral cavity that could contribute to potential infections. A cohort study that evaluated the efficacy of preoperative dental screenings for reducing periprosthetic infections of hip and knee endoprostheses in the first month after surgery, provided statistically significant evidence that patients who were referred to their family dentist for an oral evaluation prior to their joint replacement procedure reduced the prevalence of early PJI by 50%.2
The CDC has developed Core Elements of Antibiotic Stewardship as a resource for providers and facilities to guide their efforts in antibiotic use and to ultimately improve patient safety and outcomes.9 Implementing a consistent education platform for providers across the US to follow can be challenging, however the CDC has developed this resource to address these limitations. Already programs have been put in place within Veterans Affairs (VA) facilities and studies are concluding a 72.9% decrease in antibiotic prescribing purely through education and implementation of a more robust program around who is receiving these prescriptions.1 Providers often get put into difficult situations when patients pressure for medications, however educating patients on the risks for ADRs and explaining the research behind when an antibiotic is truly necessary, could help move providers in the direction of achieving stewardship.1 Interprofessional collaboration will ensure that patients are receiving consistent information from all their health care providers around antibiotic prescription.
Conclusion
Now more than ever, health care professionals must take a comprehensive evaluation of patients before prescribing antibiotics, as the risks may be far greater than the slight chance of preventing an infection. Having a clear understanding of a patient’s medical history along with interprofessional collaboration across health care disciplines, will ensure consistent communication to patients about when an AP is absolutely necessary. There are medical conditions where AP is necessary for dental procedures, however reserving our antibiotic resources for this small subset of patients and committing to a program where oral hygiene is prioritized, could help change the mindset around the frequency and ease of antibiotic prescribing. Rather, educating patients and providers will help everyone become better stewards around antibiotic practices.
References
1. Goff DA, Mangino JE, Glassman AH, et al. Review of Guidelines for Dental Antibiotic Prophylaxis for Prevention of Endocarditis and Prosthetic Joint Infections and Need for Dental Stewardship. Clin Infect Dis. 2020;71(2): 455-462. doi: 10.1093/cid/ciz1118
2. Fenske F, Kujat B, Krause L, et al. Preoperative dental screening can reduce periprosthetic infections of hip and knee endoprostheses in the first month after surgery: results of a cohort study. Infection. 2024;52: 535-543. doi: 10.1007/s15010-023-02128-2
3. 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. 2019;2(5): 1-15. doi: 10.1001/jamanetworkopen.2019.3909
4. Infective Endocarditis. American Heart Association. Accessed June 11, 2024. https://www.heart.org/en/health-topics/infective-endocarditis
5. Salgado-Peralvo AO, Peña-Cardelles JF, Kewalramani N, et al. Is Antibiotic Prophylaxis Necessary Before Dental Implant Procedures in Patients with Orthopaedic Prostheses? A Systematic Review. Antibiotics. 2022;93(11): 1-11. doi: 10.3390/antibiotics11010093
6. Chen PC, Tung YC, Wu PW, et al. Dental Procedures and the Risk of Infective Endocarditis. Medicine. 2015;94(43): 1-6. DOI: 10.1097/MD.0000000000001826.
7. Antimicrobial Resistance. World Health Organization. Accessed June 11, 2024. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
8. Czepiel J, Drózdz M, Pituch H, et al. Clostridium difficile infection: review. Eur J Clin Microbiol Infect Dis. 2019;38: 1211-1221. doi: 10.1007/s10096-019-03539-6
9. Core Elements of Antibiotic Stewardship. Centers for Disease Control and Prevention. Accessed June 11, 2024. https://www.cdc.gov/antibiotic-use/hcp/core-elements/index.html
