ADA council highlights need for evidence-based antibiotic prescribing

CDC releases new antibiotic stewardship resource for dentists

The ADA Council on Scientific Affairs highlights the importance of antibiotic stewardship in dentistry in a new clinical practice statement published in The Journal of the American Dental Association.

While data shows antibiotic prescribing by medical clinicians has decreased over time, prescribing by dentists remained essentially unchanged from 2012 to 2022, with dentists accounting for about 10% of all outpatient antibiotic prescriptions in recent years, according to the statement.

“These trends highlight the urgent need for a paradigm shift within the profession, moving from a largely precautionary just-in-case approach to an evidence-based when absolutely needed model. … Effective antibiotic stewardship in dentistry is now a public health priority to preserve the effectiveness of the existing antibiotic armamentarium, as the increase in antibiotic-resistant pathogens allows the otherwise susceptible bacteria to survive antibiotic treatment,” the council wrote in the statement.

Dentists have historically prescribed antibiotics to manage diagnostic uncertainty or patient expectations, but systemic antibiotics can lead to a significant loss of microbiome diversity in the gut, creating a favorable environment for bacteria such as Clostridioides difficile, or C. diff, to grow, according to the statement. C. diff infection can cause symptoms ranging from mild diarrhea to fatal pseudomembranous colitis and intestinal perforation.

“The risk of these life-altering or fatal adverse events far outweighs the unproven benefits of just-in-case prescribing for dental pain or localized infections without systemic involvement,” the council wrote.

The statement, published online ahead of print Aug. 7, is the second article to be published as part of Association Reports, a new feature in JADA. It highlights evidence-based guidance from the ADA on antibiotic use, including a 2019 clinical practice guideline on antibiotic use for the urgent management of dental pain and intraoral swelling.

The guideline recommends that localized oral conditions such as symptomatic irreversible pulpitis, symptomatic apical periodontitis or localized acute or chronic apical abscesses in immunocompetent adults be managed through pulpotomy, pulpectomy, root canal treatment, incision and drainage, or extraction. It also states antibiotics should be reserved for cases with systemic involvement or signs of spreading infection.

A 2015 ADA clinical practice guideline on the nonsurgical treatment of chronic periodontitis — also highlighted by the council — recommends scaling and root planing as the initial treatment for chronic periodontitis and notes that adjunctive systemic doxycycline at a subantimicrobial dose may yield a small additional clinical attachment gain in select moderate to severe cases of the disease.

“The ADA continues to prioritize antibiotic stewardship through evidence-based clinical practice guidelines, chairside tools, and education,” the council wrote. “Expansion of these priorities is ongoing through the publication of living guidelines, with a focus on addressing emerging clinical questions around the use of antibiotics in relation to implants and extractions to support guideline-concordant care.”

A new living guideline on antibiotic prophylaxis for dental implant procedures is in development, with the first recommendation expected to be published this winter. It will address antibiotic prophylaxis for healthy patients undergoing dental implant placement surgery.

The council statement also shares antibiotic stewardship recommendations from the ADA based on resources and core principles from the Centers for Disease Control and Prevention. These strategies dentists can use to support antibiotic stewardship include: verify patient history and risk factors, prioritize definitive dental treatment, limit antibiotic use, optimize antibiotic selection and duration, standardize prescribing practices, communicate risks and educate patients, and adhere to evidence-based guidelines.

The CDC released a new antibiotic stewardship resource for dentists this summer titled Antibiotic Stewardship Strategies: Outpatient Dental Settings. It highlights similar strategies to the ones above as well as factors that may impact antibiotic prescribing, such as patient requests and a lack of access to medical records.

The CDC also updated its outpatient stewardship guidance, which provides a framework to improve antibiotic use and guide stewardship efforts for all health systems, outpatient facilities and prescribing clinicians. It also includes an assessment tool for evaluating stewardship efforts, a resource for measuring antibiotic use and fact sheets that tailor stewardship strategies to specific outpatient settings.

These and other resources are available at cdc.gov/antibiotic-use.

Moving forward, the ADA Council on Scientific Affairs is expected to write and publish about three to four statements each year on various topics as part of Association Reports. The council previously published a position statement on an orthopedic guideline on dental care for prosthetic joint patients in April.