7
Volume3 Issue1
|
CDA
at
W
ork
AlastairNicoll, bdsh
ons
I
n recent yearswehaveheardagreat deal
aboutmultidrug-resistant organisms in
scholarly journals aswell as thepopular
media, but this issue isnot new. Thepo-
tential for antimicrobial resistancewas first
recognized in the1940s after thediscoveryof
penicillin-resistant
Staphylococci
. Theproblem
of antimicrobial resistancehas evolved, inpart,
becauseof thewidespreadandperhaps inap-
propriateuseof antibiotics.
Balancing risks
Inalmost all instances indentistry, theevidence
supportsuseof antibiotics as apurelyadjunctive
treatment; first-line treatments shouldbe
surgical interventions, suchaspulpectomy,
incisionanddrainage, or extraction. Antibiotics
shouldbe reserved for thosecaseswith
wider or systemic involvement suchas fever
or cellulitis. InCanada, a few keydocuments
providecompellingevidenceon this issue. The
first is anarticleonantimicrobial resistance
and the implications for dentistry, published in
JCDA
in1988.
1
Then in2004, theCanadian
CollaborationonClinical PracticeGuidelines
inDentistrypublishedevidence-based
guidelines that donot indicateantibiotic
therapy for the twomost common
conditions causingdental pain: acute
apical periodontitis andacuteapical
abscess (althoughantibiotic therapymay
be indicated for acuteapical abscessonly
whendrainagecannot beachieved).
2
Moreevidenceagainst prophylactic
antibioticusecame in2007,
when theAmericanHeart
Associationpublished
guidelineson the
preventionof infective
endocarditis (IE) that recommendantibiotic
prophylaxisonly for thoseconditions and
procedureswith thehighest riskof IE.
3
The
authors recognize that thebacteremias that
maybe implicated in IEareassociatedwith
dailyactivities—not fromdental procedures—
andobserve that thecumulativeexposure to
bacteremiaover oneyear as a result of daily
activities is about 5.6million timesgreater than
that froma single toothextraction. Theyalso
note the risksof antibiotics: nonfatal adverse
reactions toantibiotics arecommonand fatal
anaphylaxisoccurs 15-25 timespermillion
patientswho receiveadoseof penicillin,with
64%of deaths inpatientswithnohistoryof
penicillinallergy. The implicationof these
observations is that the risksof prophylactic
antibiotics indentistryoutweigh thepotential
benefits inall but a few specific situations.
Aperfect storm
In2014, theBritishDental Associationconvened
anexpert summit onantimicrobial resistance in
dentistryand issuedaconsensus report.
4
The
report noted that “aperfect stormhadbeen
createdby theconfluenceof increasing lossof
effectiveantimicrobials to resistanceand stalling
in thediscoveryof newantimicrobial agents.”
In theU.K., 9%of antibioticprescriptions are
writtenbydentists (amounting to41.6million
prescriptions in2013), and70-80%of antibiotic
prescriptionswrittenbydentistsdonot follow
recommendationsof various evidence-based
guidelines.
InCanada, theantibioticprescribingbehaviours
of dentists—and theappropriatenessof their
prescriptions—are less clear. However, data
from theBritishColumbiaPharmaNet program,
From thePresident
PrescribingPractises
AntimicrobialResistance and
