More Than 80% of Infection Prophylaxis Antibiotics Prescribed by Dentists Are Unnecessary

Dentists write 1 in 10 antibiotic prescriptions in the United States and now a new study has found that more than 80% of the antibiotics prescribed for infection prophylaxis before dental visits are unnecessary.

The article, which was published in JAMA Network Open, assessed prescribing habits prior to dental procedures from 2011 to 2015 and found that rate of prescriptions for antibiotics issued by dentists has remained steady, although the overall rate of antibiotic prescribing has dropped nationally.

For the retrospective cohort study, the investigators analyzed medical and prescription claims data, specifically identifying patients with a prescription claim for any systemic antibiotic that occurred within 7 days before a dental visit. The study team compared antibiotic prescribing patterns with the number of high-risk cardiac patients, which are the only patient population recommended to receive antibiotics prior to a dental procedure, as per national guidelines.

Katie J. Suda, PharmD, MS, an associate professor at the College of Pharmacy at the University of Illinois at Chicago and lead investigator on the study, said that dentists are in a unique situation when it comes to prescribing antibiotics. “Identifying facilitators and barriers to overprescribing of antibiotics by dentists is the next step of this project,” Suda told Contagion® in an interview. “However, we do know that all providers, including dentists, commonly feel pressured to prescribe antibiotics by their patients. Dentists are a unique provider group where they are also pressured by medical providers to prescribe antibiotics.”

During the retrospective period, antibiotic prophylaxis was prescribed for 168,420 dental visits for 91,438 patients. The patient population had a median age of 63 years (range: 55-72 years) and 57.2% of the population were female. According to the claims data, 168,420 visits were associated with 287,029 dental procedures.

In 90.7% of dental visits, a procedure that would necessitate antibiotic prophylaxis in high-risk cardiac patients was performed. The investigators note that prevalent comorbidities included prosthetic joint devices (42.5%) and cardiac conditions at the highest risk of adverse outcomes from infective endocarditis (20.9%). Based on the national guidelines, 80.9% of antibiotic prophylaxis prescriptions before dental visits were found to be unnecessary.

The study also found that clindamycin was found more likely to be unnecessary when compared with amoxicillin (odds ratio [OR], 1.10; 95% CI, 1.05-1.15). Additionally, prosthetic joint devices (OR, 2.31; 95% CI, 2.22-2.41), tooth implant procedures (OR, 1.66; 95% CI, 1.45-1.89), female sex (OR, 1.21; 95% CI, 1.17-1.25), and visits occurring in the western United States (OR, 1.15; 95% CI, 1.06-1.25) were more closely associated with unnecessary antibiotic prophylaxis.

According to Suda, there are steps dentists can take to scale back their reliance on antibiotics for infection prophylaxis.

“A first step is to provide additional resources to aid dentists in their prescribing decisions. Although antibiotic stewardship strategies have been assessed in medical practices, there is only 1 example in dental practices in the US. Dentists also need implementation strategies specific to oral health and dental practice. The [US Centers for Disease Control and Prevention] and [American Dental Association (ADA)] have provided tools for dentists to apply to their practices. The ADA is currently working on new antibiotic prescribing guidelines focused on oral health and dental practice,” Suda said. “Dentists can communicate with these groups on the indications for antibiotic prophylaxis and that the risks associated with antibiotic use exceed the benefit for most patients."

The investigators also note that there is an association between antibiotics prescribed by dentists for infection prophylaxis and community-associated Clostridioides difficile infection. “One dose of clindamycin has been an equivalent risk of C difficile compared with a prolonged course. Therefore, it is alarming that clindamycin was more likely to be inappropriately prescribed than amoxicillin.”

A total of 84.5% of the antibiotic prescriptions for infection prophylaxis in the West were unnecessary, according to the study. This is the highest percentage in the nation, with the lowest being the Northeast, where 78.2% of prescriptions written for infection prophylaxis were unnecessary.

The investigators indicate that 1 limitation of this study was that the claims data only included patients with commercial dental insurance and that a broad definition of the term “high-risk cardiac patient” was used; therefore, the findings of this study may underestimate the rate of unnecessary antibiotics prescribed by dentists.

“Antibiotics are not safe drugs. While antibiotics are life-saving, they are associated with significant adverse effects. Antibiotics prescribed by dentists for prophylaxis, even for short durations, have been associated with C difficile infection,” Suda said. “Because antibiotic drug development is limited, we are running out of antibiotics because bacterial resistance is also increasing. Therefore, antibiotics should only be prescribed when necessary.”