As part of this year’s European Antibiotic Awareness Day on 19 November, dentists were asked to make a pledge to become Antibiotic Guardians – Scotland’s ‘superheroes’ in the fight against antibiotic resistance.
While a recent report by the Scottish Antimicrobial Prescribing Group (SAPG, based within the Scottish Medicines Consortium) showed that Scotland is working hard to reduce the number of prescriptions for antibiotics, with a decrease of 6.5 per cent in 2013-14, there is still much work to be done.
“Antibiotic resistance is a major public health issue and a threat to the future of healthcare,” said Dr Jacqueline Sneddon, project lead for SAPG. “The World Health Organisation has warned of a post-antibiotic era in which common infections and minor injuries can kill. Far from being an apocalyptic fantasy, this is a very real possibility in the next few decades.
“Without effective antibiotics, safe and effective healthcare will become increasingly difficult. And while Scotland has made substantial progress in improving the quality of antibiotic prescribing, we still have more to do to.”
Dr Sneddon’s view is shared by Dr Alexander Crighton, consultant in oral medicine at Glasgow Dental Hospital and School and the SAPG dental representative.
“Dental prescribing accounts for 8.9 per cent of all antibiotics dispensed in Scotland,” explained Dr Crighton.
“That might sound like a small number, but each unnecessary antibiotic prescribed is important to the entire population. Dentists must remember that an antibiotic will only be effective if the patient has an infection and where the infection is sensitive to the drug chosen. Although it may seem obvious to say that if there is no infection present an antibiotic is not appropriate, unfortunately the ‘decision to prescribe’ is still the biggest prescribing error made by dentists. Examples include giving an antibiotic ‘just in case it helps’ or on some occasions, to postpone surgery until more clinical time is available.”
While prescribing medicines is an essential part of dental care, Dr Crighton points out that the decision to prescribe is a complex one, as the dentist has to understand not only the possible benefits to the patient but also the potential risks. This is particularly the case with antibiotics.
“Inflammatory diseases of the pulp, such as pulpitis, will have no treatable infective cause and are not indications for antibiotics. The dentist should be able to tell from the patient’s history and clinical examination whether an infection is likely.
“To justify issuing an antibiotic, there must be a clear diagnosis of an infection such as ‘a periapical abscess’ or ‘acute ulcerative gingivits’ where other forms of treatment cannot be used or have failed,” says Dr Crighton.
“If a dental abscess is drained or the tooth extracted, there is usually no need to prescribe an antibiotic as the healthy patient’s immune system can deal with most residual infection as long as the source is removed. It is only when there is a spreading or systemic infection with pyrexia or if a patient that has an immune deficiency that supplemental antibiotics should be used.”
The dentist should always consider alternatives to systemic antibiotics or other antimicrobials. If there is an acute mucosal condition such as a denture stomatitis, it may resolve spontaneously if the trigger is removed by the patient being instructed in better denture hygiene. Dr Crighton advises that antiseptics such as chlorhexidene can often be as effective as giving an antiviral or antifungal for minor mucosal infections.
When dental infections do require an antibiotic, most can be adequately treated using standard doses of amoxicillin or metronidazole. Antibiotic prescribing protocols for dentistry are outlined in the Scottish Dental Clinical Effectiveness Programme (SDCEP) Drug Prescribing for Dentistry booklet and dentists in Scotland are to be commended for increasingly following this guidance.
SDCEP recommends dentists avoiding antibiotics which have been associated with a high risk of C difficle infection, particularly co-amoxiclav, azithromycin, cephalosporins and clarithromycin. These should not normally be prescribed by a dentist unless instructed by a specialist – something which usually follows microbiological analysis of a pus sample. Although most dentists wouldn’t do this for an abscess, oral microbiologists, such as Professor Andrew Smith of the University of Glasgow, are keen that dentists send pus samples to the microbiology laboratory in the same way that soft tissue is routinely sent to the pathology lab. Both attract a fee for the dentist.
Getting lots of samples of pus from dentists allows the oral organisms causing dental infections in the general population to be kept under surveillance. If there is a change in the common organisms present that requires a change in the antibiotic prescribing guidance for Scotland, this information can be passed to the dental profession quickly. Of course, a sample from an individual patient will also confirm the most suitable antibiotic for that patient. This information may take a few days, but is essential if the ‘best guess’ antibiotic started initially is not effective.
One of the key factors recommended by SAPG to help improve antimicrobial stewardship is auditing clinical practice against guidelines, something Dr Crighton feels is a vital part of prescribing.
“Auditing the prescribing patterns of each dentist in a practice, or the practice as a whole, is an important part of ensuring quality in prescribing,” he said.
“This can help produce effective change in prescribing patterns by allowing dentists to compare their prescribing rate and choice with other dentists in the practice and with regional or national averages.”
Within such an audit, dentist should look at the number of prescriptions issued, which drugs were prescribed, the quantity and dose of the drug and the clinical indication. After an initial data collection period, the prescribing habits of the practice can be assessed and any need for change identified.
But, perhaps the most difficult part of antibiotic prescribing can be persuading patients that antibiotics are not required. While many patients may feel they need antibiotics for toothache, most dental pain can be managed by the appropriate use of analgesics and local treatment. Avoiding prescribing and educating patients about when antibiotics are required is important to tackle antimicrobial resistance.
Patients and doctors have been through this already with the use of antibiotics for sore throats having declined markedly and patients now accepting that an antibiotic is not always the best treatment for this condition. Similar education needs to happen in some patients who might wonder why the dentist has not given an antibiotic for their toothache.
And, as for those who are prescribed antibiotics, Dr Crighton says that dentists must ensure patients follow instructions properly.
He said: “Patients are often poor at recalling instructions given in the dental chair, especially after a stressful procedure or if they are in pain. The most effective way to pass on the important information about the medicine is by giving written as well as verbal instructions.”
As dentists use a relatively small range of medicines, it is possible to have patient information leaflets prepared in advance. These can also be provided in large type and in a range of languages. A contact telephone number can also be useful as patients can have questions about taking the medication once they have read the ‘Patient Information Leaflet’ included with the dispensed drug.
“When antibiotics are prescribed by a health professional, it is important t
he patient always takes them as directed. They should not be partially saved for future use or shared with others,” says Dr Crighton.
“Everyone has a part to play in reducing the risk of antibiotic resistance – dentists and their patients are no exception. The longstanding relationship between most dentists and their patients means the dentist can play a key role in providing a better understanding in their patients about antibiotic resistance and the need to reduce antibiotic use as much as is practical.
“If we act now, we can preserve these medicines for use long into the future.”