October 27, 2017
AAE members' antibiotics prescribing survey
The American Association of Endodontists (AAE) polled its members on their use of antibiotics in practice and compared survey results with previous years’ surveys on the topic. The findings are published in an article in the October issue of Journal of Endodontics.
In prefacing its presentation of survey results, AAE painted a grim picture of the consequences of overuse and misuse of antibiotics. “The inappropriate use of antibiotics contributes to the spread of antibiotic resistance,” AAE wrote. “It is estimated that over 250,000 people per year in the United States are diagnosed with an antibiotic-resistant infection, of which 23,000 will succumb and die.”
AAE also provided a frame of reference for the economic impact of inappropriate use of antibiotics, declaring that the U.S. health care system spends an estimated $20 billion treating antibiotic-resistant infections, and those infections lead to an estimated $35 billion in lost worker productivity.
Researchers polled 3,000 active AAE members using a 17-question survey via www.surveymonkey.com that yielded 686 participants (response rate, 22.86%). The survey collected clinician demographics and their responses about their antibiotic prescribing practices and habits. To analyze the data, researchers used descriptive statistics, χ2 tests, and linear regression analyses.
The survey findings revealed big changes in prescribing habits from those reported in AAE’s 1994 and 1999 surveys. Significantly, the new survey results underscored evolved preferences for the kinds of antibiotics prescribed for certain endodontic conditions, including when they are not indicated and to treat patient pain or to meet patient expectations.
A main stated conclusion from the survey centered on shifts in endodontist prescribing patterns and preferences for first choice of antibiotics. Since 1999, for instance, amoxicillin and clindamycin prescribing has significantly increased, and penicillin prescribing has decreased. Also, researchers noted an increase in the use of clindamycin for patients who are allergic to penicillin.
Another main conclusion the researchers drew was that clinicians are still prescribing antibiotics when they are not indicated for various reasons.
“Antibiotics continue to be prescribed in clinical situations for which they are typically not indicated, most commonly because of patient expectations,” the researchers wrote, with 37% of respondents reporting unnecessarily prescribing antibiotics.
In addition, AAE drew conclusions associated with regional differences in antibiotic prescribing practices by endodontists in the United States, with clinicians in the Southeast cited as being more likely to prescribe antibiotics than their peers in the Northeast and clinicians in the South as being more likely to prescribe antibiotics than those in the West. Type of practice (solo or group) also was associated with frequency of prescribing antibiotic therapy.
Read the original article here.
Consulting Editor: Dr. Susan Wood
Diplomate, American Board of Endodontics
Antibiotics in endodontics literature review
A European study published January 16 in International Endodontic Journal reinforces the need for endodontists to limit use of antibiotics to specific indications to avoid growing problems associated with the misuse of antibiotics globally.
Researchers noted that dentists prescribe approximately 10% of antibiotics dispensed in primary care and emphasized the risks in underestimating the contribution of dentistry to the development of antibiotic-resistant bacteria.
They reviewed the current literature on the indications and use of antibiotics and offered prescribing recommendations based on their review. In framing their findings, they described the circumstances surrounding antibiotic treatment in dentistry. “Odontogenic infections, including endodontic infections, are polymicrobial, and in most cases, the prescription of antibiotics is empirical,” they wrote. “This has led to the increasing use of broad-spectrum antibiotics even in cases where antibiotics are not indicated, such as symptomatic irreversible pulpitis, necrotic pulps and localized acute apical abscesses.”
The researchers also described antibiotic use in endodontics within Europe, citing several surveys conducted there to study the pattern of antibiotic prescribing in the treatment of endodontic diseases. They deduced that many European dentists prescribe antibiotics inappropriately to treat minor infections. As an example, a survey of Spanish Oral Surgery Society members showed that 86% of respondents prescribed antibiotics for cases of irreversible pulpitis, an endodontic condition for which antibiotics are not indicated.
In making a case for curtailing antibiotics in dentistry, the researchers specified the types of limited cases in which antibiotics are indicated. For 1, they recommended considering antibiotics for medically compromised patients who are more susceptible to complications arising from dental infections. These patients include those having systemic diseases with compromised immunity and those with localized congenital or acquired altered defense capacity, such as patients with infective endocarditis, prosthetic cardiac valves, or recent prosthetic joint replacement.
Beyond making recommendations for prescribing antibiotics in normal endodontic procedures, researchers addressed adjunctive prescribing strategies for cases involving abscess formation and for progressive and persistent infections.
For situations in which antibiotics are indicated, guidance is included for types of antibiotics, dosage, and duration of therapy.
Researchers also addressed some of the many types of cases in which antibiotic therapy is inappropriate, such as for symptomatic irreversible pulpitis, necrotic pulps, and localized acute apical abscesses. And, finally, they discussed some of the controversy in the medical community and the literature surrounding decisions regarding antibiotic therapy for patients with locus minoris resistentiae—or body regions that are more vulnerable than others, such as organs or external body regions with a congenital or acquired altered defense capacity.
Read the original article here.
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Brazilian endodontists and antibiotic therapy
Researchers reporting in the August 21 issue of International Endodontic Journal surveyed Brazilian endodontists on their approach to antibiotic therapy and found many indications of inappropriate prescribing habits and applications of the drugs.
Indicating that antimicrobial resistance related to overuse of antibiotics is a growing global problem, researchers noted that other surveys have polled general dental practitioners about their prescribing habits but none had previously examined the antibiotic prescribing patterns of Brazilian endodontists, in particular, in the treatment of endodontic infections. The researchers indicated that theirs is the first to do so.
They designed their observational study as a survey that questioned 13,853 Brazilian endodontists in specific clinical situations. A total of 615 (response rate, 4.44%) respondents provided personal data, such as age, sex, years of experience, and location of endodontic practice. In addition, respondents answered questions regarding their approach to prescribing antibiotics in dental practice. Researchers had adapted the questions from previously published surveys. They used χ2 and Fisher exact tests to assess significance of possible associations (P < .05).
Among their key findings, researchers determined that, in certain clinical situations, age and years since graduation could be associated with the participant’s approach to prescribing antibiotics. This was a key point made in drawing their main conclusions, which included declaring that younger endodontists prescribed longer courses of antibiotics and more frequently in cases of perforation, root-end surgery, and necrotic pulps with chronic apical periodontitis associated with sinus tract and no pain, likely owing to their inexperience.
When discussing the study’s limitations, researchers warned that caution must be applied in interpreting results, as there are typical risks with questionnaire-based surveys, which often have low response rates and the phenomenon of nonresponder bias (the potential for those who prescribe antibiotics differently to have not responded, in this case).
The study underscored the prevailing wisdom regarding clinical indications for antibiotic therapy in endodontics. “Antibiotic therapy should be reserved for cases when signs such as cellulitis, lymphadenitis, limitation of mouth opening, associated with symptoms such as fever, loss of appetite and general malaise, suggesting that the immune system of the patient is not able to control the infection, which could disseminate to other regions, causing serious health problems,” they wrote, adding that most survey respondents reported use of an antimicrobial for such situations.
The researchers also wrote that their overall findings reinforced the need for continuous education regarding the use of antibiotics.
Read the original article here.
AAE position on antibiotics
The American Association of Endodontists (AAE) published a position paper in the September issue of Journal of Endodontics offering guidance on use of systemic antibiotics in endodontics.
Achieved by means of a systematic literature review on the subject, the available evidence encapsulates data related to prescribing antibiotics, highlights appropriate clinical recommendations, and identifies areas in which personal clinician judgment is warranted to assess risks and benefits in use of antibiotics.
The document’s guidance, AAE cautioned, is not intended as an exhaustive effort and does not address certain types of antibiotic therapy, including systemic or topical application after traumatic injuries to teeth and use of antibiotics as intracanal medicaments.
The position paper begins with a disclainer that addresses the clinician’s role in applying the guidance: “This paper is designed to provide scientifically based guidance to clinicians regarding the use of antibiotics in endodontic treatment. It is not intended to substitute for a clinician’s independent judgment in light of the conditions and needs of a specific patient.”
Also, in prefacing its guidance, AAE provided some frame of reference for the state of antibiotics as an important class of drugs, including declaring that up to 50% of all antibiotics are incorrectly prescribed or used. They noted grave concerns regarding dangerous adverse reactions to the use of oral antibiotics, particularly the development of infections such as yeast overgrowth in the mouth or vagina and Clostridium difficile infection in the gut, which was associated with approximately 29,000 deaths in 2011.
Addressing overuse and misuse of antibiotics, AAE wrote that each year some 2 million people in the United States become infected with multidrug-resistant bacteria, leading to 23,000 deaths attributed to these infections.
AAE divided its subsequent guidance into 6 key areas. Three areas address endodontic application of antibiotics: as an adjunct to debridement and surgical drainage, in the absence of adequate debridement and surgical drainage, and as prophylaxis for surgery.
The remaining 3 areas address other aspects of endodontic application of antibiotics: the association between adjunctive antibiotics and periapical healing, the efficacy of various types, dosage and duration of antibiotics, and indications for performing culture and sensitivity tests.
In relaying its guidance, AAE underscored the need for such advice when it noted finding instances in dental literature in which study designs are substandard and rely on anecdotal evidence that promotes prescription of antibiotics when not indicated to, for instance, alleviate patient apprehension. “Likewise, there are several surveys that show that both general dentists and endodontists routinely prescribe antibiotics for patients with dental pain,” AAE wrote. “This leads to the question of whether prescribing antibiotics for patients in these situations is appropriate, warranted and defensible from a medico-legal perspective.”
Read the original article here.
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AAE white paper supports single standard of endodontic education and care
As the global leaders in advocating the value and quality of endodontics, the American Association of Endodontists supports a single standard of endodontic education and care to provide patients with the highest quality care with the best result—saving their natural teeth. The AAE developed the Endodontic Competency White Paper to identify the knowledge and skill that should provide a standard for all practitioners who diagnose, create treatment plans and perform endodontic treatment for their patients. While all dentists are trained in endodontics, that training varies greatly, as does the clinical experience of each dentist. To help ensure that patients receive the best possible care from all practitioners at the highest standards, the AAE’s emphasis on endodontic competency should spur general dentists to undergo additional training, recognize their limitations, and consult with specialists on treatment planning and referral. The white paper focuses on three key areas critical to competent endodontic treatment: diagnosis, treatment planning and prognosis. Practitioners are encouraged to use it as a reference with endodontic cases and educators should consider the competencies and intents when developing predoctoral curriculum.
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