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Antibiotic Use in Dentistry—What We Know and Do Not Know

Antibiotic Use in Dentistry—What We Know and Do Not Know Invited Commentary | Infectious Diseases Emily S. Spivak, MD, MHS Until recently, little attention has been paid to the use of antibiotics in dentistry. Dentists prescribe Related article 10% of outpatient antibiotics and frequently rank in the top 5 of all outpatient antibiotic Author affiliations and article information are 1,2 3 prescribers. Rates of antibiotic use in dentistry remain stable, and little is known about patterns of listed at the end of this article. use or opportunities for improvement. Antibiotic prophylaxis before dental visits was recommended in the past for patients at high risk of infective endocarditis (IE) and for patients with prosthetic joints to prevent prosthetic joint infections (PJIs). Former guidelines for the use of antibiotics for the prevention of IE and PJIs were revised to narrow the indications for prophylaxis in the 2007 and 2013 4,5 versions. Revisions were undertaken due to a lack of evidence supporting an association between dental procedures and secondary infections or any benefit of antibiotic prophylaxis, combined with increased recognition of the risk of antibiotic-associated adverse events. The article by Suda and colleagues assesses the appropriateness of antibiotic prophylaxis for IE and PJIs before dental procedures. Their findings suggest that an astounding 80.9% of antibiotics prescribed for IE and PJI prophylaxis before dental procedures are unnecessary, and they make a call to action for improved antibiotic prescribing in dentistry. Using the Truven MarketScan database, Suda and colleagues performed a retrospective cohort study of adult patients receiving antibiotic prophylaxis before dental visits between 2011 and 2015 to assess the appropriateness of antibiotic prophylaxis for IE and PJIs based on comorbid indications and type of dental procedure. The Truven MarketScan database links commercial dental claims data with medical and prescription claims. Preprocedural antibiotic prophylaxis for IE and PJIs was defined as systemic antibiotic prescription with a days’ supply of 2 days or less occurring within 7 days before a dental visit. Preexisting medical diagnoses and procedures were based on International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and Current Procedural Terminology (CPT) coding. Appropriate antibiotic prophylaxis was defined as both an indicated procedure (ie, causing gingival or periapical manipulation or mucosal perforation) and a medical history consistent with guideline recommendations. Of the 168 420 dental visits with antibiotics included, Suda and colleagues found that 80.9% of antibiotic prophylaxis prescriptions for IE and PJIs were unnecessary. Unnecessary antibiotic prescribing was more common among women, in the western United States, with the use of clindamycin, and in patients with prosthetic joints. Suda and colleagues are to be applauded for conducting the first national evaluation of prophylactic antibiotic use for IE and PJIs before dental procedures. While the use of the Truven MarketScan database affords integration of dental, medical, and pharmacy claims, the cohort has some limitations worth noting. This cohort with commercial dental insurance may be most representative of patients of a higher socioeconomic status, with ready access to care and higher rates of antibiotic use. In addition, patients with diabetes or immunocompromising conditions were not more likely to receive unnecessary antibiotic prophylaxis. This is an interesting finding, suggesting that possibly a “worried well” phenomenon may be driving prescribing. Overall, the cohort may be less reflective of dental antibiotic prescribing for the uninsured or general Medicare population. Nonetheless, much attention has been focused on outpatient medical settings, where an estimated 30% of antibiotics prescribed are unnecessary. If the frequency of unnecessary antibiotic prophylaxis for IE and PJIs before dental procedures in the study by Suda and colleagues was cut in Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2019;2(5):e193881. doi:10.1001/jamanetworkopen.2019.3881 (Reprinted) May 31, 2019 1/3 JAMA Network Open | Infectious Diseases Antibiotic Use in Dentistry half, it would still overshadow unnecessary antibiotic use in outpatient medical settings. These findings highlight the dire need for antibiotic stewardship intervention in dentistry. Aside from unnecessary prophylaxis in patients with prosthetic joints (46.7% of unnecessary prophylaxis), the study by Suda and colleagues leaves unanswered questions regarding what additional factors may be driving antibiotic prophylaxis. Possible reasons include delayed application of revised IE prophylaxis guidelines and continued use for previous indications, such as mitral valve prolapse. In addition, intravascular prosthetic material, such as cardiovascular implantable electronic devices or vascular grafts, may be considered indications for prophylaxis. It is plausible that certain dental procedures are driving antibiotic prophylaxis in the absence of medical indications, suggesting that a more detailed analysis of Current Dental Terminology (CDT) codes associated with antibiotic use is necessary. Finally, while significant amounts of unnecessary antibiotic prophylaxis for IE and PJIs were identified in the study by Suda and colleagues, it should be noted that 2 659 245 (79.7%) of antibiotic prescriptions evaluated were written for a days’ supply of at least 3 days and were excluded. Private sector dentists do not use ICD diagnostic codes; therefore, Suda and colleagues were unable to decipher whether these antibiotics were prescribed for IE and PJI prophylaxis or for treatment of an infection. Data from other groups indicate that most antibiotic use in dentistry is for infection prophylaxis regardless of duration, suggesting additional problems with appropriate administration of prophylaxis, as well as likely inclusion of prophylaxis used to prevent local procedure-related infection. The almost 80% of prescriptions written for at least 3 days that were excluded represent a significant gap in our understanding of antibiotic use in dentistry and an important area of future investigation. Suda and colleagues have made a strong argument for the urgent need for antibiotic stewardship efforts in dental settings. In addition, their data underscore what we do not know about a large quantity of antibiotic use in dentistry and how much more we have to learn. ARTICLE INFORMATION Published: May 31, 2019. doi:10.1001/jamanetworkopen.2019.3881 Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Spivak ES. JAMA Network Open. Corresponding Author: Emily S. Spivak, MD, MHS, Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, 30 N 1900 E, Room 4B319, Salt Lake City, UT 84132 (emily.spivak@hsc. utah.edu). Author Affiliation: Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, Salt Lake City. Conflict of Interest Disclosures: Dr Spivak reported receiving funding from the Centers for Disease Control and Prevention, a portion of which was for analysis of dental antibiotic prescribing practices. Additional Contributions: Katherine Fleming-Dutra, MD, at the Centers for Disease Control and Prevention, assisted with proofreading the manuscript. No compensation was received. REFERENCES 1. Hicks LA, Bartoces MG, Roberts RM, et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis. 2015;60(9):1308-1316. 2. Durkin MJ, Hsueh K, Sallah YH, et al; Centers for Disease Control and Prevention Epicenters. An evaluation of dental antibiotic prescribing practices in the United States. JAmDentAssoc. 2017;148(12):878-886.e1. doi:10. 1016/j.adaj.2017.07.019 3. Durkin MJ, Feng Q, Warren K, et al; Centers for Disease Control and Prevention Epicenters. Assessment of inappropriate antibiotic prescribing among a large cohort of general dentists in the United States. JAmDent Assoc. 2018;149(5):372-381.e1. doi:10.1016/j.adaj.2017.11.034 JAMA Network Open. 2019;2(5):e193881. doi:10.1001/jamanetworkopen.2019.3881 (Reprinted) May 31, 2019 2/3 JAMA Network Open | Infectious Diseases Antibiotic Use in Dentistry 4. Wilson W, Taubert KA, Gewitz M, et al; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736-1754. doi: 10.1161/CIRCULATIONAHA.106.183095 5. Rethman MP, Watters W III, Abt E, et al; American Academy of Orthopaedic Surgeons; American Dental Association. The American Academy of Orthopaedic Surgeons and the American Dental Association clinical practice guideline on the prevention of orthopaedic implant infection in patients undergoing dental procedures. J Bone Joint Surg Am. 2013;95(8):745-747. doi:10.2106/00004623-201304170-00011 6. Suda KJ, Calip GS, Zhou J, et al. Assessment of the appropriateness of antibiotic prescriptions for infection prophylaxis before dental procedures, 2011 to 2015. JAMA Netw Open. 2019;2(5):e193909. doi:10.1001/ jamanetworkopen.2019.3909 7. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864-1873. doi:10.1001/jama.2016.4151 JAMA Network Open. 2019;2(5):e193881. doi:10.1001/jamanetworkopen.2019.3881 (Reprinted) May 31, 2019 3/3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Network Open American Medical Association

Antibiotic Use in Dentistry—What We Know and Do Not Know

JAMA Network Open , Volume 2 (5) – May 31, 2019

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Copyright 2019 Spivak ES. JAMA Network Open.
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Abstract

Invited Commentary | Infectious Diseases Emily S. Spivak, MD, MHS Until recently, little attention has been paid to the use of antibiotics in dentistry. Dentists prescribe Related article 10% of outpatient antibiotics and frequently rank in the top 5 of all outpatient antibiotic Author affiliations and article information are 1,2 3 prescribers. Rates of antibiotic use in dentistry remain stable, and little is known about patterns of listed at the end of this article. use or opportunities for improvement. Antibiotic prophylaxis before dental visits was recommended in the past for patients at high risk of infective endocarditis (IE) and for patients with prosthetic joints to prevent prosthetic joint infections (PJIs). Former guidelines for the use of antibiotics for the prevention of IE and PJIs were revised to narrow the indications for prophylaxis in the 2007 and 2013 4,5 versions. Revisions were undertaken due to a lack of evidence supporting an association between dental procedures and secondary infections or any benefit of antibiotic prophylaxis, combined with increased recognition of the risk of antibiotic-associated adverse events. The article by Suda and colleagues assesses the appropriateness of antibiotic prophylaxis for IE and PJIs before dental procedures. Their findings suggest that an astounding 80.9% of antibiotics prescribed for IE and PJI prophylaxis before dental procedures are unnecessary, and they make a call to action for improved antibiotic prescribing in dentistry. Using the Truven MarketScan database, Suda and colleagues performed a retrospective cohort study of adult patients receiving antibiotic prophylaxis before dental visits between 2011 and 2015 to assess the appropriateness of antibiotic prophylaxis for IE and PJIs based on comorbid indications and type of dental procedure. The Truven MarketScan database links commercial dental claims data with medical and prescription claims. Preprocedural antibiotic prophylaxis for IE and PJIs was defined as systemic antibiotic prescription with a days’ supply of 2 days or less occurring within 7 days before a dental visit. Preexisting medical diagnoses and procedures were based on International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and Current Procedural Terminology (CPT) coding. Appropriate antibiotic prophylaxis was defined as both an indicated procedure (ie, causing gingival or periapical manipulation or mucosal perforation) and a medical history consistent with guideline recommendations. Of the 168 420 dental visits with antibiotics included, Suda and colleagues found that 80.9% of antibiotic prophylaxis prescriptions for IE and PJIs were unnecessary. Unnecessary antibiotic prescribing was more common among women, in the western United States, with the use of clindamycin, and in patients with prosthetic joints. Suda and colleagues are to be applauded for conducting the first national evaluation of prophylactic antibiotic use for IE and PJIs before dental procedures. While the use of the Truven MarketScan database affords integration of dental, medical, and pharmacy claims, the cohort has some limitations worth noting. This cohort with commercial dental insurance may be most representative of patients of a higher socioeconomic status, with ready access to care and higher rates of antibiotic use. In addition, patients with diabetes or immunocompromising conditions were not more likely to receive unnecessary antibiotic prophylaxis. This is an interesting finding, suggesting that possibly a “worried well” phenomenon may be driving prescribing. Overall, the cohort may be less reflective of dental antibiotic prescribing for the uninsured or general Medicare population. Nonetheless, much attention has been focused on outpatient medical settings, where an estimated 30% of antibiotics prescribed are unnecessary. If the frequency of unnecessary antibiotic prophylaxis for IE and PJIs before dental procedures in the study by Suda and colleagues was cut in Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2019;2(5):e193881. doi:10.1001/jamanetworkopen.2019.3881 (Reprinted) May 31, 2019 1/3 JAMA Network Open | Infectious Diseases Antibiotic Use in Dentistry half, it would still overshadow unnecessary antibiotic use in outpatient medical settings. These findings highlight the dire need for antibiotic stewardship intervention in dentistry. Aside from unnecessary prophylaxis in patients with prosthetic joints (46.7% of unnecessary prophylaxis), the study by Suda and colleagues leaves unanswered questions regarding what additional factors may be driving antibiotic prophylaxis. Possible reasons include delayed application of revised IE prophylaxis guidelines and continued use for previous indications, such as mitral valve prolapse. In addition, intravascular prosthetic material, such as cardiovascular implantable electronic devices or vascular grafts, may be considered indications for prophylaxis. It is plausible that certain dental procedures are driving antibiotic prophylaxis in the absence of medical indications, suggesting that a more detailed analysis of Current Dental Terminology (CDT) codes associated with antibiotic use is necessary. Finally, while significant amounts of unnecessary antibiotic prophylaxis for IE and PJIs were identified in the study by Suda and colleagues, it should be noted that 2 659 245 (79.7%) of antibiotic prescriptions evaluated were written for a days’ supply of at least 3 days and were excluded. Private sector dentists do not use ICD diagnostic codes; therefore, Suda and colleagues were unable to decipher whether these antibiotics were prescribed for IE and PJI prophylaxis or for treatment of an infection. Data from other groups indicate that most antibiotic use in dentistry is for infection prophylaxis regardless of duration, suggesting additional problems with appropriate administration of prophylaxis, as well as likely inclusion of prophylaxis used to prevent local procedure-related infection. The almost 80% of prescriptions written for at least 3 days that were excluded represent a significant gap in our understanding of antibiotic use in dentistry and an important area of future investigation. Suda and colleagues have made a strong argument for the urgent need for antibiotic stewardship efforts in dental settings. In addition, their data underscore what we do not know about a large quantity of antibiotic use in dentistry and how much more we have to learn. ARTICLE INFORMATION Published: May 31, 2019. doi:10.1001/jamanetworkopen.2019.3881 Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Spivak ES. JAMA Network Open. Corresponding Author: Emily S. Spivak, MD, MHS, Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, 30 N 1900 E, Room 4B319, Salt Lake City, UT 84132 (emily.spivak@hsc. utah.edu). Author Affiliation: Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, Salt Lake City. Conflict of Interest Disclosures: Dr Spivak reported receiving funding from the Centers for Disease Control and Prevention, a portion of which was for analysis of dental antibiotic prescribing practices. Additional Contributions: Katherine Fleming-Dutra, MD, at the Centers for Disease Control and Prevention, assisted with proofreading the manuscript. No compensation was received. REFERENCES 1. Hicks LA, Bartoces MG, Roberts RM, et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis. 2015;60(9):1308-1316. 2. Durkin MJ, Hsueh K, Sallah YH, et al; Centers for Disease Control and Prevention Epicenters. An evaluation of dental antibiotic prescribing practices in the United States. JAmDentAssoc. 2017;148(12):878-886.e1. doi:10. 1016/j.adaj.2017.07.019 3. Durkin MJ, Feng Q, Warren K, et al; Centers for Disease Control and Prevention Epicenters. Assessment of inappropriate antibiotic prescribing among a large cohort of general dentists in the United States. JAmDent Assoc. 2018;149(5):372-381.e1. doi:10.1016/j.adaj.2017.11.034 JAMA Network Open. 2019;2(5):e193881. doi:10.1001/jamanetworkopen.2019.3881 (Reprinted) May 31, 2019 2/3 JAMA Network Open | Infectious Diseases Antibiotic Use in Dentistry 4. Wilson W, Taubert KA, Gewitz M, et al; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736-1754. doi: 10.1161/CIRCULATIONAHA.106.183095 5. Rethman MP, Watters W III, Abt E, et al; American Academy of Orthopaedic Surgeons; American Dental Association. The American Academy of Orthopaedic Surgeons and the American Dental Association clinical practice guideline on the prevention of orthopaedic implant infection in patients undergoing dental procedures. J Bone Joint Surg Am. 2013;95(8):745-747. doi:10.2106/00004623-201304170-00011 6. Suda KJ, Calip GS, Zhou J, et al. Assessment of the appropriateness of antibiotic prescriptions for infection prophylaxis before dental procedures, 2011 to 2015. JAMA Netw Open. 2019;2(5):e193909. doi:10.1001/ jamanetworkopen.2019.3909 7. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864-1873. doi:10.1001/jama.2016.4151 JAMA Network Open. 2019;2(5):e193881. doi:10.1001/jamanetworkopen.2019.3881 (Reprinted) May 31, 2019 3/3

Journal

JAMA Network OpenAmerican Medical Association

Published: May 31, 2019

References