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Antibiotic Stewardship in Dentistry by Dr. Thomas Paumier

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Categories: Oral Pathology, Pharmacology, and Cariology;
Antibiotic Stewardship in Dentistry 

by Dr. Thomas Paumier

Of all the things dentists do in clinical practice, the one that has the highest likelihood of causing harm to patients, including death, is not conscious sedation, which would be a logical choice.

In a 2017 study by Reuter looking at deaths related to dental care from 1960 to 2015, there were 148 deaths documented, averaging 2.6 deaths per year, nearly half of which were related to anesthesia or sedation.1 That means, on average one to two people die per year from dental sedation complications. These tragic outcomes typically occur during or shortly after the dental appointment.

However, the biggest risk to a patient’s life from dental care is something seemingly much more benign, something you were likely taught can only help patients: Prescribing an antibiotic. It is estimated that nearly 35,000 people die from antibiotic-related superbug infections each year and another 29,000 from antibiotic-related C. difficile (C. diff) infections.2,3

That’s 64,000 deaths each year related to antibiotic use. Dentists are responsible for 10% of antibiotics prescribed in health care, meaning we may contribute to 6,400 antibiotic-related deaths per year. That’s 17 to 18 deaths every day!

Antibiotics transformed medical care after Alexander Fleming discovered penicillin in 1928. Antibiotics saved an estimated 220 lives per 100,000 people in their first 15 years of use, whereas all other medical technologies combined in the next 45 years saved 20 lives per 100,000 people. Unfortunately, the misuse and overuse of antibiotics has led to antibiotic resistance, rendering many antibiotics less effective for “routine infections.”

The most recent Antimicrobial Threats Report from the Centers for Disease Control and Prevention (CDC) lists 18 bacteria and fungi as critical superbug infection risks.4

This same report estimates 2.8 million antimicrobial-resistant infections occur each year in the U.S., resulting in more than 35,000 deaths.4 Adding in deaths related to C. diff infections equates to an antibiotic-use-related death every 8 to 10 minutes in the United States.

Dentists write nearly 26 million prescriptions per year. In dentistry, most antibiotics are used to prevent a potential infection or for prophylaxis. A study by Suda showed more than 80% of all dental antibiotic prophylaxis use did not meet existing guidelines or best practices.5


A growing concern
It is estimated that by 2050, antibiotic resistant superbug infections will kill 8 to 10 million people per year.6 That exceeds yearly deaths from cancer and traffic accidents combined.

Thirty percent of all prescriptions, nearly 47 million per year, are unnecessary, with most written for virus-associated conditions such as colds, flu and bronchitis, as well as sinus and ear infections. The CDC estimates the risk of acquiring a superbug from a hospital stay as 1 in 7 with a short-term hospitalization and 1 in 4 for a long-term stay.

Since 2017, only 13 new antibiotics have been approved by the Food and Drug Administration, 11 of which belong to existing classes.7 So, the pace of antibiotic resistance to existing antibiotics is exceeding the development of new classes of antibiotics.

Resistance to bacteria develops each time we are exposed to antibiotics, as selective pressure is the primary reason bacteria develop resistance. As susceptible bacteria are inhibited, resistant bacteria multiply. The density of antibiotic use and total consumption determine the degree of selection pressure and magnitude of resistant bacteria formation.

Those at highest risk for antimicrobial resistance include the very young and very old, and patients taking immunosuppressive medications for solid organ and bone marrow transplants, rheumatoid arthritis and other conditions. Others at high risk include those undergoing chemotherapy, on hemodialysis for kidney failure, and those having complex surgical procedures.


Following best practices
It is important to not only understand who is at greatest risk of developing antimicrobial resistance by taking a thorough medical history at each patient visit, but also to know current clinical practice guidelines and best practices for responsible and appropriate antibiotic prescribing.

Currently, there are only two ADA clinical practice guidelines related to antibiotic use. In the January 2015 issue of JADA, the use of antibiotic prophylaxis for patients with prosthetic joints was studied.8 The evidence shows there is no association between invasive dental procedures and late prosthetic joint infections (LPJI). Antibiotic prophylaxis did not prevent LPJI and therefore should not be used for patients with a prosthetic joint. The most recent American Academy of Orthopedic Surgeons and American Association of Hip and Knee Surgeons clinical practice guidelines also acknowledges there is no benefit in using antibiotic prophylaxis before dental procedures to prevent a LPJI.9

In November 2019, JADA published a guideline on antibiotic use for managing pulpal- and periapical-related pain and intraoral swelling.10 It covers using antibiotics for symptomatic irreversible pulpitis, symptomatic apical periodontitis, localized acute apical abscess and acute apical abscess with systemic symptoms. In general, antibiotics should only be used when there are systemic symptoms: cellulitis, fever, malaise and/or lymphadenopathy.

A contingency prescription can be given for a localized acute apical abscess when treatment (I&D, root canal or extraction) cannot be done immediately and the localized intraoral swelling progresses to facial swelling. If antibiotics are indicated, they should be discontinued 24 hours after symptom resolution, and prescriptions should not be written to “take until gone.” Unfortunately, many clinicians may not be aware of or are ignoring this guideline, as antibiotic prescribing rates for pulpal pain are unchanged since 2018.11

Pain is not an indication for antibiotics. However, many dentists, when faced with an emergency patient who has pulpal pain, will prescribe antibiotics for several days to “reduce pain and inflammation” and postpone definitive or emergency care until “the antibiotics work.”

This is not only ineffective, as many studies show antibiotics have no effect on decreasing pain, but also potentially dangerous.12 Pulpal pain is an immunoinflammatory response, not evidence of infection. Antibiotics are only appropriate for pulpal-related pain if there are systemic symptoms such as cellulitis, lymphadenopathy, fever or malaise. The best treatment is always surgical, whether an I&D, pulpotomy, pulpectomy or extraction. Antibiotics are only adjunctive and should not be used “prophylactically” to prevent a potential infection.


Other risks
Penicillin allergy is another area that impacts appropriate antibiotic use and stewardship in dentistry. With approximately 10% of patients labeled as penicillin allergic, dentists should question patients about their claimed allergy to determine if it is a true IgE mediated allergic response or an adverse reaction such as GI upset, headache, nausea or minor rash.

For all situations where antibiotics are indicated in dentistry, amoxicillin or cephalosporins are the first and best choice. All other classes of antibiotics have poorer coverage of causative organisms and more serious adverse reactions at higher rates than amoxicillin.

Dentists should urge patients to be tested for penicillin allergy in cases that are unclear. Patients who are labeled penicillin allergic, whether truly allergic or not, have a greater risk for surgical site and C. diff infections.13,14

The use of Clindamycin in dentistry deserves special attention. Clindamycin contains a black box warning for increased risk of C. diff infection. Relative to doxycycline, Clindamycin has an 8.8 times higher risk of community-acquired C. diff infection.15

Clindamycin should never be used for prophylaxis. It is ineffective at reducing bacteria in the bloodstream after extraction16,17 and has also been shown to lead to higher infection and failure rates, increased rates of peri-implantitis, and poorer bone regeneration when used at implant placement.18 While Clindamycin has the highest risk, any antibiotic can lead to a C. diff infection.


Becoming a better steward
Dentists have an obligation to be better antibiotic stewards, even when patients pressure us to prescribe an antibiotic because it has been done in the past. We must educate patients on why it is not only unnecessary, but can cause significant harm, including C. diff infections and antibiotic-resistant superbug infections, both of which can lead to death.

Being aware of current guidelines and best practices and understanding appropriate use is the first step to better antibiotic stewardship.

The next step is implementing an antibiotic stewardship program for your practice. Evidence shows simply tracking antibiotic use leads to reductions in prescribed antibiotics. Most practice management software can track the number of prescriptions and for which conditions antibiotics are prescribed. Consider monitoring the following areas to improve antibiotic stewardship: the number of prescriptions written and how many were without a physical exam; concordance with existing guidelines and best practices; appropriate antibiotic, dose and duration; specific number of prescriptions for Clindamycin; the number of contingency prescriptions when care is not immediately available; and how often you questioned patients about penicillin allergy and referral for allergy testing.

Simply tracking these metrics will bring greater awareness to prescribing practices for both dentists and team members and lead to improved outcomes. As individual dentists and as a profession, it is our obligation to be better antibiotic stewards and protect the future of health care from entering a “post-antibiotic” age where antibiotics are less effective in treating and preventing infections. Take action today by prescribing responsibly and implementing an antibiotic stewardship plan in your office!

References
1. Reuter, N. G., et al. “Death Related to Dental Treatment: A Systematic Review.” Oral Surgery, Oral Medicine, Oral Pathology, and Oral Radiology, vol. 123, no. 2, Feb. 2017.
2. Lessa, F. C., Mu, Y., Bamberg, W. M., et al. “Burden of Clostridium difficile Infection in the United States.” The New England Journal of Medicine, vol. 372, no. 9, 2015, pp. 825–834.
3. Guh, A. Y., Mu, Y., Winston, L. G., et al. “Trends in U.S. Burden of Clostridioides difficile Infection and Outcomes.” The New England Journal of Medicine, vol. 382, no. 14, 2020.
4. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2019. U.S. Department of Health and Human Services, 2019.
5. Suda, K. J., Calip, G. S., Zhou, J., et al. “Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015.” JAMA Network Open, vol. 2, no. 5, 2019, e193909.
6. O’Neill, Jim. Tackling Drug-Resistant Infections Globally: Final Report and Recommendations. The Review on Antimicrobial Resistance, May 2016.
7. World Health Organization. Report on the State of Development of Antibacterials. 14 June 2024.
8. Sollecito, Thomas P., Abt, Elliot, Lockhart, Peter B., et al. “The Use of Prophylactic Antibiotics Prior to Dental Procedures in Patients with Prosthetic Joints: Evidence-Based Clinical Practice Guideline for Dental Practitioners—A Report of the ADA Council of Scientific A airs.” Journal of the American Dental Association, vol. 146, no. 1, 2015, pp. 11–16.e8.
9. American Academy of Orthopaedic Surgeons. The Prevention of Total Hip and Knee Arthroplasty Periprosthetic Joint Infection in Patients Undergoing Dental Procedures: Evidence-Based Clinical Practice Guideline. 18 Nov. 2024.
10. Lockhart, Peter B., Tampi, Maria P., Abt, Elliot, et al. “Evidence- Based Clinical Practice Guideline on Antibiotic Use for the Urgent Management of Pulpal- and Periapical-Related Dental Pain and Intraoral Swelling: A Report from the American Dental Association.” Journal of the American Dental Association, vol. 150, no. 11, 2019, pp. 906–921.e12.
11. Huynh Cam-Van, T., Gouin, Katrina A., et al. “Outpatient Antibiotic Prescribing by General Dentists in the United States from 2018 through 2022.” Journal of the American Dental Association, vol. 156, no. 5, 2025, pp. 382–389.
12. Milani, A., Froughreyhani, M., Taghiloo, H., et al. “The Effect of Antibiotic Use on Endodontic Post-Operative Pain and Flare-Up Rate: A Systematic Review with Meta-Analysis.” Evidence- Based Dentistry, 2022.
13. Thornhill, Michael H., Dayer, Michael J., Prendergast, Bernard, Baddour, Larry M., Jones, Simon, Lockhart, Peter B. “Incidence and Nature of Adverse Reactions to Antibiotics Used as Endocarditis Prophylaxis.” Journal of Antimicrobial Chemotherapy, vol. 70, no. 8, 2015, pp. 2382–2388.
14. Thornhill, Michael H., Dayer, Michael J., Durkin, Michael J., Lockhart, Peter B., Baddour, Larry M. “Risk of Adverse Reactions to Oral Antibiotics Prescribed by Dentists.” Journal of Dental Research, vol. 98, no. 10, 2019, pp. 1081–1087.
15. Zhang, J., Chen, L., Gomez-Simmonds, A., Yin, M. T., Freedberg, D. E. “Antibiotic-Specific Risk for Community-Acquired Clostridioides difficile Infection in the United States from 2008 to 2020.” Antimicrobial Agents and Chemotherapy, vol. 66, no. 12, 2022.
16. Diz Dios, Pedro, Tomás Carmona, Ignacio, Limeres Posse, Javier, Medina Henríquez, Juan, Fernández Feijoo, José, Alvarez Fernández, Manuel. “Comparative E icacies of Amoxicillin, Clindamycin, and Moxifloxacin in Prevention of Bacteremia Following Dental Extractions.” Antimicrobial Agents and Chemotherapy, vol. 50, no. 9, 2006, pp. 2996–3002.
17. Lafaurie, Gladys I., Noriega, Laura A., Torres, Claudia C., et al. “Impact of Antibiotic Prophylaxis on the Incidence, Nature, Magnitude, and Duration of Bacteremia Associated with Dental Procedures: A Systematic Review.” Journal of the American Dental Association, vol. 150, no. 11, 2019, pp. 948–959.e4.
18. Salomó-Coll, O., Lozano-Carrascal, N., Lázaro-Abdulkarim, A., Hernández-Alfaro, F., Gargallo-Albiol, J., Satorres-Nieto, M. “Do Penicillin-Allergic Patients Present a Higher Rate of Implant Failure?” International Journal of Oral and Maxillofacial Implants, vol. 33, no. 6, Nov.–Dec. 2018, pp. 1390–1395.
Author Bio
Dr. Thomas Paumier Dr. Thomas Paumier has a BS in microbiology and is a cum laude graduate of The Ohio State University College of Dentistry. He is the director of the Dental Antibiotic Stewardship Program and on the faculty of the Cleveland Clinic Mercy Hospital GPR. He served on the expert panels that wrote the ADA clinical practice guidelines for appropriate antibiotic use for patients with prosthetic joints and for patients with pulpal or periapical pain. He was the 2019 recipient of the ADA Evidence-Based Dentistry Clinical Practice Award. He is a past president of the Ohio Dental Association.



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