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Dental Antibiotics: Life-saving or Life-threatening Drugs?

Learn more about the benefits and risks of antibiotic usage, and how requirements differ depending on the situation.
Balancing the benefits and risks of antibiotics is an important aspect of shared decision-making between clinicians and patients. Antibiotics can save the life of someone with a serious infection. Using antibiotics only when necessary increases the safety of our patients, by reducing the risk of these adverse reactions and the development and spread of infections resistant to antibiotics. Guidelines are available to support clinical decision-making and help to optimise dental antibiotic prescribing. Ensuring that you use guidelines which are relevant in your local context is very important, including local standard treatment guidelines – STGs.
Some considerations for treatment decisions where you are may be different to where I am, in Tanzania. For example, there may be limited supplies of certain types of antibiotics. Patterns of antibiotic resistance differ between place and over time. In places where substandard or fake drugs infest the market, ensuring access to high-quality antibiotics is important. Or maybe people can buy antibiotics freely from local shops without need of a prescription. Whilst we know that procedures– not prescriptions– are best for dental pain and infection, access to dental services differs around the world. Some people may find the cost of accessing dental care prohibitive.
In some places, especially low- and middle- income countries, people may even need to travel for days to seek care for their dental pain or infection. The systems and processes to ensure access to information about antibiotics and dental care are critical. Sharing timely information has been streamlined by online access. But again, not all parts of the world have equal access, and the local context is really important to consider when deciding how to implement plans to tackle antibiotic resistance. Ensuring access to the right care for the right patient, at the right time, so as to keep our patients safe, is key to optimise the use of antibiotics for acute dental conditions.
The dental profession has an essential role in tackling the global problem of antibiotic resistance.

Failure of antibiotics to effectively treat an infection in the mouth or elsewhere in the body can pose a life-threatening risk.

Higher in-hospital death rates associated with antibiotic-resistant bacteria have been found, yet hospitals are often reluctant to advise individuals (or their surviving families) that a resistant infection is/was implicated due to the hospital’s fear of being blamed for failing.

Sepsis and the spread of infection toward vital structures may occur rapidly for people with dental infections and these conditions can be life-threatening (see image below). Ensuring quick, appropriate and effective treatment is extremely important – for these people effective antibiotics are vital. Infections that are resistant to antibiotics pose a serious risk to dental patient safety.

image of patient with severe dental swelling

Image sourced from the FDI White Paper (Reproduced with permission of Prof (Dr) M Verma and Dr S Mohanty).

Most dental infections are, however, amenable to treatment by a dental procedure (such as extraction of the tooth) to remove the source of the infection without the need for antibiotics. Dentists are surgeons, skilled and equipped to diagnose and treat acute dental conditions during urgent appointments. This highlights the importance of ensuring access to dental, rather than medical, care for people with acute dental conditions. It also reminds us of the importance of unscheduled dental appointments being long enough to provide a dental procedure rather than just an antibiotic prescription.

Optimising dental prescribing will, at the same time, increase patient safety by reducing the risk of adverse reactions. Reports have indicated that dental prescribing has contributed to the incidence of Clostridoides difficile (C. difficile) in the community. Antibiotic‐related colitis caused by C. difficile is associated with significant morbidity and can be life threatening, especially for elderly and medically compromised patients. Clindamycin is recognised as being associated with significant rates of fatal and non-fatal adverse drug reactions associated with C. difficile infections.

Increasing rates of allergy/anaphylaxis due to antibiotics have also been reported. Furthermore, incorrect labelling of patients as penicillin-allergic has been shown to result in increased morbidity, mortality and healthcare costs due to the use of broad-spectrum alternatives.

In the exercise which follows, you will be introduced to a series of real cases where patients experienced adverse reactions to antibiotics prescribed by dentists. The medico-legal outcomes are also included. For clinicians, basing decisions on relevant guidelines may be a valuable way to defend against accusations of clinical negligence.

Balancing the benefits and risks of antibiotics is an important aspect of dental antibiotic prescribing. Guidelines are available to support you in this, and as you saw last week, ensuring you use guidelines which are locally relevant to your context is really important. Prescribing in accordance with your local guidelines improves outcomes for all of us and especially for the most vulnerable in our society. Ensuring access to the right care for the right patient at the right time is an essential element of this optimisation.

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Tackling Antibiotic Resistance: What Should Dental Teams Do?

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