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Antibiotic resistance might be a term far disconnected from the world of dentistry; however, it remains to be one of the biggest threats to public health in the 21st century. Data from the CDC (Centre of Diseases Control and Prevention) reports that antibiotic resistance is responsible for 25,000 deaths in the EU per year and this is set to increase in years to come. A global report indicated that by 2050, approximately 10 million people per year could die as a direct consequence of antibiotic resistance.
What Has Dentistry Got to Do with All This?
It was reported that dentists are responsible for prescribing 7% of all antibiotics in the UK. Antibiotics of which include beta-lactams, macrolides and tetracyclines. Mis-use of these antibiotics, namely beta lactam antibiotics such as penicillin has contributed to the development of some of the most multi-resistant strains of bacteria; known as superbugs which pose an imminent threat to public health. It is therefore crucial to reflect and reshape how antibiotics are being used within the field as the impact extends far beyond the dental chair.
Dentists can prescribe antibiotics to treat a number of fairly common oral infections. However, it is important to prescribe the correct class of antibiotic. This is dependent on the symptoms and species involved. The ideal antibiotic should target the bacteria causing the infection and kill it with 100% efficacy. In dental diseases such as periodontitis, where antibiotics are sometimes prescribed, the etiology is often polymicrobial, meaning it can be hard to pinpoint which species are responsible for the infection.
These polymicrobial infections have led to dentists relying on broad-spectrum antibiotics, such as amoxicillin/clavulanic acid. Broad-spectrum antibiotics may be able to relieve symptoms in the first instance as they are able to target a variety of bacterial species, but what can happen is that a sub-set of the population survive as they are only semi-susceptible to the antibiotic being used to target them.
This population which survives can proliferate and share the genetic information which conferred positive to their survival. This leads to a population which not only has been able to survive but can now share these antibiotic resistance genes with their own species as well as others. In situations like this, cases of chronic oral infection can result. This can be detrimental to immunocompromised patients and further consequences of resistance affecting oral health can result in an increased morbidity and mortality rate.
When Should Antibiotics Be Indicated?
Antibiotics are of course valid in dental and oral infectious disease, however it is important to reflect on how they are being used. A figure from an Australian journal stated that around 66% of antibiotics prescribed by dentists are not clinically indicated. The British Dental Association also reported that 81% of the antibiotics prescribed in practices in Wales do not adhere to the published prescribing guidelines. This reflects the gravity of the problem and the risk being put onto patients. It is therefore imperative that dentists receive the adequate training on antibiotic prescription.
A group known as the Dental ESPAUR (Dental English Surveillance Programme for Antibiotic Usage and Resistance) along with the BDA, PHE and FGDP has been brought together to monitor and reduce the use of antibiotics in the UK. Alongside this, BAOS (British Association of Oral Surgeons) has also produced e-learning modules which provide information as well as CPD points to dentists and educate them on antibiotic stewardship. The modules along with other articles reflects how antibiotics should be used as an adjunct to dental intervention as opposed to an alternative. It also highlights the reason why narrow-spectrum antibiotics should be indicated in more cases. Narrow-spectrum antibiotics target and kill disease-causing bacteria more specifically, and therefore reduce the presence of semi-susceptible bacteria from surviving and conferring and spreading resistance. However, use of these narrow-spectrum antibiotics will mean that identification of the bacteria also needs to be improved. This could involve the widespread implementation of culture collection within a dental setting to identify the species of bacteria.
Equally important is, for dentists to educate their patients on how to use antibiotics. This is through reinforcing patients to take the full course of antibiotics and not to stop earlier than the recommended date. This is to ensure that the bacteria are exposed to antibiotics long enough to be fully eradicated.
What Is the Future of Antibiotics?
Drug-companies are reliant on development of new classes of antibiotics. As well as developing new classes, revival of old classes of antibiotics through combination with agents is also an avenue being explored.
Is Prevention Better than Cure?
A message constantly drilled into our heads in this new age of dentistry: prevention. This plays a no less important role in the future of antibiotic resistance. If we can work to prevent infections such as caries and periodontal disease through focus on better oral hygiene instruction and evidence-based preventative interventions such as use of fluoride varnish, then we can help to reshape the future and prevent what may be one of the worst public health crises to come.
Conclusion
Dentists play a fundamental role in the prescription of antibiotics. Due to improved knowledge and better access to educational resources, over the last decade alone the percentage of prescriptions by dentists in England has reduced by approximately 20%. It is imperative that antibiotic misuse within dentistry continues to reduce so that the devastations resulting as a consequence of antibiotic resistance can be diminished.
References
- Center for Disease Control and Prevention. Antibiotic/ Antimicrobial Resistance CDC. Center for Disease Control and Prevention. 2015.
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- Rasheed JK, Kitchel B, Zhu W, Anderson KF, Clark NC, Ferraro MJ, et al. New Delhi Metallo-²-Lactamase-Producing Enterobacteriaceae, United States. Emerg Infect Dis. 2013.
- Bunce JT, Hellyer P. Antibiotic Resistance and Antibiotic Prescribing by Dentists in England 2007-2016. British Dental Journal. 2018.
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- Sukumar S, Martin FE, Hughes TE, Adler CJ. Think Before You Prescribe: How Dentistry Contributes to Antibiotic Resistance. Australian Dental Journal. 2020.
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- Cope A. UK Unveils Plan to Tackle Antimicrobial Resistance: But Where Do Dentists Fit in? [Internet]. British Dental Association. 2019. Available from: https://bda.org/news-centre/blog/Pages/UK-unveils-plan-to-tackle-antimicrobial-resistance-but-where-do-dentists-fit-in.aspx
- Llor C, Bjerrum L. Antimicrobial Resistance: Risk Associated with Antibiotic Overuse and Initiatives to Reduce the Problem. Therapeutic Advances in Drug Safety. 2014.
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