Letters: Antibiotic use in dentistry
August 17, 2015
I was pleased to see the ADA take a leadership role in heightening awareness of responsible use of antibiotics (“ADA Supports Responsible Antibiotic Use", June 15 ADA News).
Dentists should be aware that the antibiotics we prescribe have potential to increase risk for Clostridium difficile infection, which incurs significant mortality, morbidity and costs. Clindamycin poses a particularly large risk; the odds of a person developing CDI are 20.43 times greater than a person not on an antibiotic. By contrast, persons using any type of antibiotic are 6.91 times as likely as those not on any antibiotic to suffer CDI (Deshpande et al).1
An estimated two-thirds of cases of community-acquired CDI are linked to antibiotic use, and of those, 15 percent were related to dental or oral surgery procedures. (Chitnis et al.)2 Incidence of CDI is increasing, and mortality risk is greatest among adults over 65, who account for 69 percent of the 5,440 annual CDI deaths (Hall et al).3 To provide an example of the risks incurred by older adults, my friend’s father received a prescription for clindamycin from his local dentist while awaiting an appointment for extraction. While the patient was advised of the potential medication side effects, he did not remember them, nor did he remember what to do once he started having diarrhea. Delay in seeking treatment may have contributed to the severity of his CDI, which required admission to the intensive care unit, surgical removal of the colon, a significant inpatient stay for management with antibiotics, weeks of rehabilitation and a lifetime of setting an alarm to empty his pouch every three hours for the rest of his life. Overall, it was a costly experience for the health care system and a distressing time for a patient and his family.
Insufficient communication may have been the problem in this case, as we know that dentists are aware of the risks. A survey I did of over 300 dentists in New Jersey conducted through the New Jersey Institute for Successful Aging at Rowan University School of Osteopathic Medicine found that most dentists respond appropriately when faced with a call of potential CDI from a patient. The work must be done beforehand, however, by having a meaningful discussion with the patient about the potential risks, the need to seek professional help promptly if a sign or symptom develops, and that symptoms may appear as late as ten weeks after antibiotic treatment has ended. If the front desk staff is going to manage and call in prescriptions, then they also need training to discuss this issue with patients. Sending patients home with written material that they can keep and refer to is a best practice, supported by the ADA’s letter in its “The ADA Practical Guide to Dental Letters: Write, Blog and Email Your Way to Success,” specifically designed to help ensure that patients stay alert to signs of a possible CDI and seek the help they need.
With increasing numbers of older adults in the U.S., and those older adults retaining their teeth, dentists are more likely to face issues of antibiotics with their older patients. Taking the time to question the need for antibiotics is the first step, and the second step is to assure that adequate communication and effective strategies are in place to minimize the risks of side effects, including CDI, using resources currently available to help dentists communicate.
Samuel Zwetchkenbaum, D.D.S.
Newark, New Jersey
- Deshpande A, Pasupuleti V, Thota P, et al. Community-associated Clostridium difficile infection and antibiotics: A meta-analysis. J Antimicrob Chemother. 2013;68:1951-61.
- Chitnis AS, Holzbauer SM, Belflower RM, et al. Epidemiology of community-associated Clostridium difficile infection, 2009 through 2011. JAMA Internal Medicine. 2013;173:1359-67.
- Hall AJ, Curns AT, McDonald C, et al. The roles of Clostridium difficile and Norovirus among gastroenteritis-associated deaths in the United States, 1999–2007. Clin Inf Dis 2012;55(2):216–23.