|Year : 2015 | Volume
| Issue : 2 | Page : 116-120
Antibiotic prescription: An oral physician's point of view
Mahendra Patait1, N Urvashi2, M Rajderkar3, S Kedar4, Kinjal Shah5, Reeta Patait6
1 Professor and Head, Department of Oral Medicine and Radiology, S. M. B. T. Dental College, Hospital and PG Research Institute, Sangamner, Maharashtra, India
2 Post Graduate Student, Department of Oral Medicine and Radiology, S. M. B. T. Dental College, Hospital and PG Research Institute, Sangamner, Maharashtra, India
3 Pro Vice Chancellor, Maharashtra University of Health Sciences, Nashik, India
4 Reader, Department of Oral Medicine and Radiology, S. M. B. T. Dental College, Hospital and PG Research Institute, Sangamner, Maharashtra, India
5 Consultant Endodontis, Allur Hospital, Mumbai, India
6 Esthetic Dental Surgeon, Nashik, India
|Date of Submission||29-Mar-2014|
|Date of Decision||10-Aug-2014|
|Date of Acceptance||20-Oct-2014|
|Date of Web Publication||1-Apr-2015|
Dr. Mahendra Patait
Professor and Head, Department of Oral Medicine and Radiology, S. M. B. T. Dental College, Hospital and PG Research Institute, Sangamner, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Antibiotics are important in the management and prophylaxis of infections in patients at a risk of experiencing microbial disease. Uses of systemic antibiotics in dentistry are limited since management of acute dental conditions is primarily based upon extraction of teeth or extirpation of the pulp. However, the literature provides evidence of inappropriate prescribing practices by practitioners, due to a number of factors from inadequate knowledge to social factors. Aim: The aim was to assess the therapeutic prescription of antibiotics in the dental office. Materials and Methods: In the current study, 42 faculty members of two dental colleges in the same vicinity were included. A questionnaire was drafted and sent to the dentists to collect data pertaining to the conditions in which antibiotics were prescribed and most commonly prescribed antibiotic. Results: During the study period, 42 faculty members from various departments in the institutes were surveyed, of which 41 questionnaires were completely filled. Amoxicillin was the most commonly prescribed antibiotic followed by other amoxicillin combinations; Metronidazole was most widely prescribed antibiotic for anaerobic infections. Conclusion: We have entered an era where cures may be few due to increasing microbial resistance. The biggest force for change will be if all practicing dentists looked at their prescribing and made it more rational.
Keywords: Antibiotics, dental practice, microbial disease recommended practice
|How to cite this article:|
Patait M, Urvashi N, Rajderkar M, Kedar S, Shah K, Patait R. Antibiotic prescription: An oral physician's point of view. J Pharm Bioall Sci 2015;7:116-20
|How to cite this URL:|
Patait M, Urvashi N, Rajderkar M, Kedar S, Shah K, Patait R. Antibiotic prescription: An oral physician's point of view. J Pharm Bioall Sci [serial online] 2015 [cited 2021 Mar 9];7:116-20. Available from: https://www.jpbsonline.org/text.asp?2015/7/2/116/154434
The most effective way to manage pain of dental or oral origin is to remove the underlying cause. The '3-Ds' should be used to manage dental pain, namely: Diagnosis, drug (if required), and dental treatment. The rationale use of antimicrobials is based upon three variables: A defined indication, the appropriateness of the antimicrobial and adverse effects associated with the drug.
There are very few indications for antimicrobials in dentistry, and they should be judicially used.  In the absence of signs and symptoms of infections, practitioners should refrain from prescribing antibiotics for relieving pain. Nobody can deny the value of antibiotics in the management of orofacial infections. But it should be kept in mind that it is to be used as an adjunct and not a substitute for a definite treatment.  Much of the pressure to prescribe comes from patient pressure, the fear of medical litigation or just simply poor clinical decision making. 
An antibiotic is a chemical produced by a microorganism that kills or inhibits the growth of another microorganism.
The word antibiotic came from the word antibiosis a term coined in 1889 by Louis Pasteur's pupil Paul Vuillemin, which means the process by which life could be used to destroy life. Selman Waksman suggested the word "antibiotic" (coined in 1889 by P. Vuillemin).
- 1928 penicillin discovered by Fleming
- 1932 sulfonamide antimicrobial effect by Ehrlich
- 1943 drug companies begin mass production of penicillin
- 1948 emergence of cephalosporin precursors
- 1952 erythromycin derived from Streptomyces erythreus
- 1956 vancomycin introduced for penicillin-resistant Staphylococcus
- 1962 quinolone antibiotics first discovered
- 1970s linezolide discovered but not pursued
- 1980s fluorinated quinolones introduced, making then clinically useful
- 2000 Linezolide introduced into clinical practice [Figure 1]a.
|Figure 1: (a) Classification of antibiotics; (b) Mechanism of action of antibiotics on micro-organisms|
Click here to view
Mechanism of actions of antibiotics [Figure 1]b:
Problems that arise with the use of antibiotics:
- Super infections
- Masking of an infection.
The aim of the study was to assess the therapeutic prescription of antibiotics in the dental office [Table 1].
| Materials and Methods|| |
In the current study, 42 faculty members of two dental colleges in the same vicinity were included. A questionnaire [Table 2] was drafted and sent to the dentists to collect data pertaining to the conditions in which antibiotics wereprescribed and most commonly prescribed antibiotic.
| Results|| |
During the study period, 42 faculty members from various departments in the institutes were surveyed; of which 41 questionnaires were completely filled.
The data were put together and analyzed [Table 3].
|Table 3: % of dentists prescribing antibiotics in various dental conditions|
Click here to view
Amoxicillin was the most commonly prescribed antibiotic followed by other amoxicillin combinations; metronidazole was most widely prescribed antibiotic for anaerobic infections [Figure 2]a and b.
|Figure 2: (a) Graphical representation depicting the use of antibiotics in various dental conditions. (b) Graphical representation showing most commonly prescribed antibiotic|
Click here to view
| Discussion|| |
Ninety-eight percent of the questionnaires returned were completed. To encourage cooperation with data collection, the questionnaire was designed to be brief and easy to complete. Most oral diseases presented to the dentist are primarily inflammatory conditions that are associated with pain. A considerable percentage of dental pain originates from acute and chronic infections of pulpal origin, which necessitates operative intervention, rather than antibiotics.
Many of the dentists prescribed antibiotics for pulpitis, but pulpitis is inflammatory in nature and local treatment only could have removed and relieved the pain and infection.
Pulpitis cannot be treated with antimicrobials. The pulp of a tooth is enclosed in a "closed box" and is becoming necrotic, antimicrobials cannot penetrate or be effective in such a situation; despite this, and they are often prescribed without other interventions.  Acute or chronic pulpitis can be treated successfully by either endodontic therapy or exodontia; antimicrobials are not required or indicated.
Some dentists prescribed antibiotics for abscess. When the periapical tissues become involved, and an abscess is formed the treatment is drainage either by exodontia or simple excision. If antimicrobials are used, they are an adjunct to the treatment and are used to limit swelling and also prevent metastasis of the infection to vital organs.
Chronic inflammatory periodontal conditions are also not indicated for antibiotics; systemic antimicrobials should only be used in periodontal conditions where drainage or debridement is impossible, where there is local spread of the infection or where systemic upset has occurred. 
Submicrobial dose of doxycycline is widely used in periodontal therapy as an adjunct to mechanical therapy, although resistance is not reported if taken for a short period but there are studies which have reported doxycycline resistance if SDD is prescribed for prolonged periods.
In 1998, the Standing Medical Advisory Committee published The Path of Least Resistance. In it, it stated that dentists account for 7% of all community prescriptions of antimicrobials. 
The major concern of superfluous usage of antibiotics is the emerging resistant strains of microorganisms. Microbial resistance refers to the unresponsiveness of microorganism to an antimicrobial agent. 
Resistance to amoxicillin, penicillin, and metronidazole in the oral flora has been reported.
Aminopenicillins are one of the three antibiotic types most commonly prescribed in dentistry. Amoxicillin resistance has been described in Veillonella spp. and Prevotella denticola isolated from root canals.  In one study, all 34 strains of facultative anaerobic bacteria isolated from the same root canals were susceptible to amoxicillin, as were 52 of 54 (96%) strains of obligate anaerobes.
In 1986, streptococci producing β-lactamase were isolated from the subgingival plaque of adults with periodontitis. Potgieter et al. report four blood culture isolates of Streptococcus mitis that were resistant to penicillin (minimum inhibitory concentrations 16-32 mg/L); they were also resistant to the aminoglycosides gentamicin, kanamycin, and tobramycin. Streptococcus mutans is cariogenic, and several studies have reported on its susceptibility to penicillin and other antimicrobials.
Roche and Yoshimori found that eight out of 97 isolates from odontogenic abscesses were resistant to metronidazole. These included five isolates of Lactobacillus spp., two isolates of Gemella morbillorum and an isolate of Actinomyces israelii.
Resistance may be developed by:
Resistant organisms can be drug tolerant, drug destroying, drug impermeable or rapid ejection of drug [Figure 3]a and b.
|Figure 3: (a) Pathways by which micro-organisms show resistance to antibiotics. (b) Mechanisms by which micro-organisms exhibit resistance. (c) Factors promoting antimicrobial resistance|
Click here to view
Alternatives to conventional antibiotics are:
- Resistance-modifying agents
- Phage therapy
- Antisense agents
- Broad spectrum antibiotics from plants and animals.
Factors promoting antimicrobial resistance:
- Exposure to suboptimal levels of microorganisms.
- Exposure to microbes carrying resistant genes. ,
- Prolonged period of drug regimen [Figure 3]c.
How can we combat antimicrobial resistance?
- Speedy development of new antibiotics.
- Track resistance data nationwide.
- Restrict antimicrobial use.
- Use narrower spectrum antibiotics (by conducting sensitivity tests).
- Use antimicrobial cocktails. 
What are sensitivity tests?
A laboratory test which determines how effective antibiotic therapy is against bacterial infections.
Various types of sensitivity tests:
- Kirby-Bauer test [Figure 4]a
|Figure 4: (a) Kirby-Bauer Test, most commonly used antibiotic sensitivity test. (b) E-Test, a type of antibiotic sensitivity test|
Click here to view
- E-test [Figure 4]b.
Selection of antibiotic prescription:
The clinician should first determine whether antimicrobial therapy is warranted for a given patient. The following things are kept in mind before prescribing antibiotics:
- Is an antimicrobial agent indicated on the basis of clinical findings? Or is it prudent to wait until such clinical findings become apparent?
- Have appropriate clinical specimens been obtained to establish a microbiological diagnosis?
- What are the likely etiological agents for the patient's illness?
- Is there clinical evidence that antimicrobial therapy will confer clinical benefit for the patient?
Once a specific cause is identified based on specific microbiologic tests, the following further criteria may be considered:
- If a specific microbial pathogen is identified, can a narrower spectrum agent be substituted for the initial empiric drug?
- Is one agent or combination of agent necessary?
- What are the optimal dose, route of administration, and duration of drug therapy?
- What specific tests should be undertaken if the patient is nonresponsive to empirical treatment?
- What adjunctive measures can be undertaken to eradicate the infection. ,,,
| Conclusion|| |
- Antibiotics are superfluously used in nonindicated clinical cases.
- Limit injudicious use of antibiotics.
Superfluous and injudicious use of antibiotics can be prevented by,
- Using it as an adjunct and not alone as a treatment option
- Using antibiotic sensitivity tests and using infection specific antibiotics
- Using narrow spectrum antibiotics.
- Limit prophylactic antibiotic prescription
Prescribing antibiotics as prophylaxis is a subject of debate. Limiting prophylactic antibiotic prescription in healthy individuals with those having no underlying systemic diseases or no immunocompromised conditions is recommended.
We have entered an era where cures may be few due to increasing microbial resistance.
The biggest force for change will be if all practicing dentists looked at their prescribing and made it more rational.
| References|| |
Faculty of General Dental Practitioners (UK) Royal College of Surgeons, England. Adult Antimicrobial Prescribing in Primary Dental Care for General Dental Practitioners; 2000.
Senate of Dental Specialities. Good practices in Dental Specialities. November 2011. p. 14.
Steed M, Gibson J. An audit of antibiotic prescribing in general dental practice. Prim Dent Care 1997;4:66-70.
Abbott PV. Selective and intelligent use of antibiotics in endodontics. Aust Endod J 2000;26:30-9.
Palmer NA, Pealing R, Ireland RS, Martin MV. A study of prophylactic antibiotic prescribing in national health service general dental practice in England. Br Dent J 2000;189:43-6.
Martin MV, Kanatas AN, Hardy P. Antibiotic prophylaxis and third molar surgery. Br Dent J 2005;198:327-30.
Wilcox MH. The tide of antimicrobial resistance and selection. Int J Antimicrob Agents 2009;34 Suppl 3:S6-10.
Dar-Odeh N, Ryalat S, Shayyab M, Abu-Hammad O. Analysis of clinical records of dental patients attending Jordan University Hospital: Documentation of drug prescriptions and local anesthetic injections. Ther Clin Risk Manag 2008;4:1111-7.
Marsh PD, Martin MV. Oral complications of infection in compromised patients. In: Oral Microbiology. 5 th
ed. Edinburgh: Churchill Livingstone; 2009. p. 191-203.
Dar-Odeh NS, Abu-Hammad OA, Al-Omiri MK, Khraisat AS, Shehabi AA. Antibiotic prescribing practices by dentists: A review. Ther Clin Risk Manag 2010;6:301-6.
Longman LP, Martin MV. The use of antibiotics in the prevention of post-operative infection: A re-appraisal. Br Dent J 1991;170:257-62.
Lewis MA. Why we must reduce dental prescription of antibiotics: European union antibiotic awareness day. Br Dent J 2008;205:537-8.
Dailey YM, Martin MV. Are antibiotics used appropriately in dental practice? An overview. Br Dent J 2001;191:7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]