Whether or not someone should or should not take any antibiotics prior to dental visits such as wisdom teeth surgery is often a question that comes up. The purpose of doing so would be to potentially prevent an infection from developing from teh dental procedure. Research spearheaded by a group at the University of Illinois at Chicago shows that in the majority of cases antibiotics given before dental visits are not needed and instead can lead to serious side effects. The researchers presented results in October 2019 during IDWeek 2019, which is the Infectious Diseases Society of America’s annual meeting conducted in Washington, DC. The researchers also presented results in an article titled “Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015” published on May 31, 2019 in JAMA Network Open (Suda et al., vol. 2, no. 5, e193909).
The authors arrived at a final study cohort including 168,420 dental visits for 91,438 patients. The visits occurred between 2011 and 2015 and the analysis was performed using data obtained from Truven MarketScan integrated health claims database of deidentified claims. Those included in the study had 12 months of continuous enrollment in plans with medical and prescription coverage and 30 days with dental coverage before and including the date of the visit with a dentist. Patients were included that had a prescription claim for a systemic antibiotic with a days’ supply of 2 days or less that occurred within 7 days before a dental visit. Thus the antibiotics used were all for preprocedural infection prophylaxis. Patients were excluded if they had been hospitalized within 14 days before the dental visit. Furthermore the authors treated multiple dental visits, such as identifying a tooth requiring extraction and on a later day having the tooth extracted, as a single dental visit if these multiple visits occurred within 7 days of each other.
After consulting guidelines from medical and dental groups including the American Heart Association and the American Dental Association, the authors concluded that it is appropriate to give an antibiotic prescription as a preventative measure before a dental visit for a procedure that manipulates the gingiva or tooth periapex in patients with certain cardiac diagnosis. This is to prevent infective endocarditis in these patients which are at highest risk. Giving antibiotic prophylaxis before a dental visit is considered unnecessary in the absence of these cardiac conditions.
The authors found that only 32,243 of the dental visits, or 19.1%, included patients that had a cardiac diagnosis that warranted the use of antibiotics prior to the dental procedure. Thus the authors found that for 136,177 of the dental visits, or 80.1%, the antibiotics given prior to the dental procedure were unnecessary. The most common antibiotics given in order of highest to lowest included amoxicillin (69.4%), clindamycin (16%), cephalexin (8.2%), azithromycin (3.1%), penicillin (2.1%), and doxycycline (1%). The most common dental procedure category in order of highest to lowest included diagnostic (70.2%), preventive (58.8%), restorative (18.4%), periodontics (7.1%), oral and maxillofacial surgery (6.4%), adjunctive general services (2.9%), endodontics (2.1%), implant services (1.5%), prosthodontics (1.3%), orthodontics (0.1%), and maxillofacial prosthetics (0.01%). The patients included in the study had an average age of 62.2 years, were 57.2% female, and were primarily from the Midwest (46.9%) and South (31.5%) regions of the U.S. The authors state
Our results demonstrate that most antibiotics prescribed for infection prophylaxis before dental visits are unnecessary. These findings are concerning because dentists prescribe a significant proportion of antibiotics and are the top prescribers of clindamycin in the United States.”
The authors found that among the 136,177 dental visits they identified where an antibiotic was prescribed unnecessarily, 5,260 (3.8%) of these dental visits resulted in an adverse event with 14 days. This included 9 (0.007%) Clostridioides difficile (C difficile) infections, 1,568 (1.1%) emergency room visits, and 3,912 (2.9%) allergic reactions with some requiring hospitalization. The authors mentioned that a single dose of clindamycin can cause a C difficile infection or allergic reaction. Further, a single dose of amoxicillin can cause a severe allergic reaction. Additionally, it is noted that taking antibiotics when not necessary can also contribute to antibiotic resistance. One of the researchers involved with this work (Suda) states
“While the vast majority of dental patients who take preventive antibiotics will not have a severe reaction, this is a reminder that antibiotics are not innocuous, even if taken for only a day or two”
The authors pointed out several limitations of the study population they used. One is that the results may not represent the uninsured and those with Medicaid and Medicare benefits. Another is that antibiotic recommendations for those with prosthetic joints changed in 2013 which was in the middle of the study period. An additional issue was that the authors could not link prescriptions given to a health care provider.
The authors are hopeful that the results of their work will help contribute to a decrease in unnecessary antibiotics prescribed by dentists. They recommend that specific antibiotic stewardship strategies and prescribing tools targeted to dentistry may help in controlling the prescribing of antibiotics given for infection prevention purposes prior to dental procedures.
Lauren Martin, Infectious Diseases Society of America, “Taking Antibiotics Before Dental Visits May Cause Serious Side Effects 80% Prescribed Unnecessarily, Study Shows,” IDWeek 2019, Oct. 2-6, 2019, https://www.idsociety.org/news–publications-new/articles/2019/taking-antibiotics-before-dental-visits-may-cause-serious-side-effects/