In the introduction of the report Antibiotic Resistance Threats in the United States 2019, the director of the Centers for Disease Control and Prevention (CDC) implores us: “Stop referring to a coming post-antibiotic era—it’s already here. You and I are living in a time when some miracle drugs no longer perform miracles and families are being ripped apart by a microscopic enemy.”1 And the report gives some startling statistics including the fact that antibiotic-resistant bacteria infect someone in the US every 11 seconds and kill someone every 15 minutes. That’s nearly three million people infected each year, with 35,000 deaths annually.
The challenge of treating infections
Treating these infections is challenging. Take Clostridioides difficile (C. diff) infections (CDIs) as an example. This inflammation of the colon that causes diarrhea and colitis affects almost half a million people a year in the US.2 The bacteria releasing the exotoxins that cause tissue damage colonize the gastrointestinal tract after the normal gut flora are altered, typically after antibiotic use.
A lab test can confirm the infection, but there are few options to treat it, except for powerful antibiotics. The problem is that many patients contract C. diff after taking antibiotics, and the subsequent antibiotics they take to combat C. diff are not particularly effective. One in six patients who contract C. diff will get it again in the next two months. For patients with health-care-associated C. diff infections in people who are over age 65, one in 11 will die within a month of diagnosis.3
Results of antibiotic overprescribing
Because “poor antibiotic prescribing practices put patients at risk for C. diff infections,”4 and because the general overuse and overreliance on antibiotics have led to significantly greater antibiotic-resistance threats, prescribing practices are at the heart of the CDC antibiotic stewardship campaigns. In hospital settings, the CDC estimates that 30%–50% of antibiotics are unnecessarily or incorrectly prescribed. Fluent et al. identified similar numbers in dentistry.5,6 A more recent review put the overuse in dentistry at 80%.7
Dentistry needs to take antibiotic resistance threats seriously: general and specialty dentists are the third-highest prescribers of antibiotics in all outpatient settings in the US and the number one outpatient prescribers of clindamycin, which is most closely associated with CDIs.7,8
ADA guidelines for antibiotic use
The American Dental Association (ADA) released new guidelines for antibiotic use at the end of 2019, advising against antibiotic use for most pulpal and periapical conditions, and recommending instead only the use of dental treatment with acetaminophen or ibuprofen when needed. According to the new guidelines, systemic antibiotics are warranted for these treatments only when the patient shows signs or symptoms of systemic infection such as fever or swollen lymph nodes.9
This key remark in the guidelines bears emphasis since COVID-19 overshadowed health care: “The use of antibiotics may result in little to no difference in beneficial outcomes (very low certainty) but likely result in a potentially large increase in harm outcomes (moderate certainty), warranting a strong recommendation against their use.”9 Put more succinctly: “Evidence suggests that antibiotics for the target conditions may provide negligible benefits and probably contribute to large harms. The expert panel suggests that antibiotics for target conditions be used only when systemic involvement is present and that immediate DCDT (definitive, conservative dental treatment) should be prioritized in all cases.”9
Read more about antibiotics: Reducing the need for adjunctive antibiotics during scaling and root planing
Tracking cases involving antibiotics
The “harm message” may need more attention to filter down better to wet-gloved dentists. The Minnesota Department of Public Health tracked 2,176 CDIs from 2009 to 2015 in five Minnesota counties. Seventy-five percent of the cases (1,626) were confirmed, of which 57% were prescribed antibiotics prior to the CDI. Fifteen percent (136) of these antibiotic prescriptions were written by dentists. The median age of dental patients was 57, and the most frequently prescribed drug was clindamycin.
The authors conclude that, “Dental antibiotic prescribing rates are likely underestimated. Stewardship programs should address dental prescribing and alert dentists to CDI subsequent to antibiotics prescribed for dental procedures.”10
What can we do in dentistry?
The Michigan Antibiotic Resistance Reduction (MARR) Coalition and the Organization for Safety, Asepsis and Prevention (OSAP) are heeding this call to stewardship with scientific updates and practical resources for clinicians.11 The MARR dental resources page is particularly helpful.12
Increasing awareness is step one. Prescribing effective nonantibiotic treatment is step two. Many bacterial-based diseases in dentistry, such as gingivitis or periodontitis, result from biofilm-induced inflammation, which is “refractory to antibiotic agents and host defenses because the causative microbes live in complex communities that persist despite challenges that range from targeted antibiotic agents to phagocytosis.”13
It’s not just that the bacteria have built up resistances to the drugs, but that the biofilm community itself actively resists antibiotics. Researchers suggest that “the regular delivery of nontargeted antibiofilm agents may be an effective strategy for treating biofilms, especially if these agents include oxidative agents that dissolve the biofilm matrix.”13
Alternate treatment modalities
Oxidative agents work well. The delivery of hydrogen peroxide effectively reduces bleeding, inflammation, pocket depths, and gram-negative bacterial loads when administered by prescription trays.14-18 While chlorine-based products and essential oils have shown efficacy,19,20 the benefit of the tray delivery over rinse application is that the prescription tray can place and hold medication deep into the sulcus or periodontal pocket so it can fight the infections deep below the gums where rinses can’t access. Perio Tray (Perio Protect) is an example. The benefit of hydrogen peroxide use is lost without the patented seal of the Perio Tray medicament carrier that allows oxygen to be retained below the gums to fight infection, particularly when biofilms are present, as well as anaerobic organisms.18,21,22
Low concentrations of hydrogen peroxide (e.g., Perio Gel with 1.7% hydrogen peroxide) is particularly effective because it’s a broad-spectrum antimicrobial, physically disrupting the biofilm matrix that protects biofilm communities, and because bacteria do not build up resistance to peroxide as they do to antibiotics. Bacteria can, however, develop resistance to hydrogen peroxide through increased production of degradative enzymes such as catalase. For anaerobic organisms, this would result in the increased production of oxygen, which is deadly to anaerobes. Peroxide does more than just kill bacteria. Its release of oxygen (as it activates, peroxide turns into O2 + H2O) changes the microenvironment of the periodontal pocket so that healthy bacterial species replace pathogenic ones.22
Educate your patients
Let’s be honest with patients and stop blaming them; more brushing and flossing isn’t likely to help manage their disease better. Brushing, flossing, and rinsing just can’t get deep enough. Of course, patients need to brush and floss, but, even when used regularly and well, these tools are insufficient to manage periodontitis or advanced gingivitis. Improving home care is essential.
There are times when everything advocated—initial treatment, surgery, maintenance, and home care—fails, but we can do better—and patients deserve better. Periodontal disease is one of the most underdiagnosed diseases in North America. It is always easier to address disease at the earliest stages. And it’s always easier to maintain gingival health with effective home care.
Part of the solution is patient education. Amanda Hill, RDH, has created a sample handout that highlights the new realities of the postantibiotic age and our need for antibiotic stewardship. You are welcome to use it as a template for your own practice.
Editor’s note: Perio Protect is a financial supporter of Dental Economics. This article appeared in the September 2023 print edition of Dental Economics magazine. Dentists in North America are eligible for a complimentary print subscription. Sign up here.
- Antibiotic resistance threats in the United States, 2019. Centers for Disease Control and Prevention. Updated December 2019. https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf
- Yoo J, Lightner AL. Clostridium difficile infections: what every clinician should know. Perm J. 2010;14(2):35-40. doi:10.7812/TPP/10-001
- What is C. diff? Centers for Disease Control and Prevention. Updated September 7, 2022. https://www.cdc.gov/cdiff/what-is.html
- Information for healthcare professionals about C. diff. Centers for Disease Control and Prevention. Updated July 15, 2021. https://www.cdc.gov/cdiff/clinicians/index.html
- Fluent MT, Jacobsen PL, Hicks LA; OSAP, the Safest Dental Visit. Considerations for responsible antibiotic use in dentistry. J Am Dent Assoc. 2016;147(8):683-686. doi:10.1016/j.adaj.2016.04.017
- Outpatient antibiotic prescriptions — United States, 2021. Centers for Disease Control and Prevention. Updated October 4, 2022. https://www.cdc.gov/antibiotic-use/data/report-2021.html
- Dall C. Researchers highlight serious side effects of unneeded dental antibiotics. Center for Infectious Disease Research & Policy. University of Minnesota. October 4, 2019. https://www.cidrap.umn.edu/antimicrobial-stewardship/researchers-highlight-serious-side-effects-unneeded-dental-antibiotics
- Antibiotics for dental pain and swelling guideline. American Dental Association. 2019. https://www.ada.org/resources/research/science-and-research-institute/evidence-based-dental-research/antibiotics-for-dental-pain-and-swelling
- Lockhart PB, Tampi MP, Abt E, et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling. J Am Dent Assoc. 2019;150(11):906-921. doi:10.1016/j.adaj.2019.08.020
- Bye M, Whitten T, Holzbauer S. Antibiotic prescribing for dental procedures in community-associated Clostridium difficile cases, Minnesota, 2009–2015. Open Forum Infect Dis. 2017;4(Suppl 1):S1. doi:10.1093/ofid/ofx162.001
- Antibiotic stewardship for prescribers. Organization for Safety, Asepsis and Prevention (OSAP). https:/www.osap.org/antibiotic-stewardship-for-prescribers
- Resources to support antibiotic stewardship in the dental office. Michigan Antibiotic Resistance Reduction Coalition (MARR). https://www.mi-marr.org/dental-resources/
- Schaudinn C, Gorur A, Keller D, Sedghizadeh PP, Costerton JW. Periodontitis: an archetypical biofilm disease. J Am Dent Assoc. 2009;140(8):978-986. doi:10.14219/jada.archive.2009.0307
- Putt MS, Mallatt ME, Messmann LL, Proskin HM. A 6-month clinical investigation of custom tray application of peroxide gel with or without doxycycline as adjuncts to scaling and root planing for treatment of periodontitis. Am J Dent. 2014;27(5):273-284.
- Putt MS, Proskin HM. Custom tray application of peroxide gel as an adjunct to scaling and root planing in the treatment of periodontitis: a randomized, controlled three-month clinical trial. J Clin Dent. 2012;23(2):48-56.
- Putt MS, Proskin HM. Custom tray application of peroxide gel as an adjunct to scaling and root planing in the treatment of periodontitis: results of a randomized controlled trial after six months. J Clin Dent. 2013;24(3):100-107.
- Cochrane RB, Sindelar B. Case series report of 66 refractory maintenance patients evaluating the effectiveness of topical oxidizing agents. J Clin Dent. 2015;26(4):109-114.
- Keller DC, Cochrane B. Composition of microorganisms in periodontal pockets. J Oral Health Dent. 2019:2(2):123-136.
- Krayer JW, Leite RS, Kirkwood KL. Non-surgical chemotherapeutic treatment strategies for the management of periodontal diseases. Dent Clin North Am. 2010;54(1):13-33. doi:10.1016/j.cden.2009.08.010
- Charles CH, Mostler KM, Bartels LL, Mankodi SM. Comparative antiplaque and antigingivitis effectiveness of a chlorhexidine and an essential oil mouthrinse: 6-month clinical trial. J Clin Periodontol. 2004;31(10):878-884. doi:10.1111/j.1600-051X.2004.00578.x
- Dunlap T, Keller DC, Marshall MV, et al. Subgingival delivery of oral debriding agents: a proof of concept. J Clin Dent. 2011;22(5):149-158.
- Marshall MV, Cancro LP, Fischman SL. Hydrogen peroxide: a review of its use in dentistry. J Periodontol. 1995;66(9):786-796. doi:10.1902/jop.1918.104.22.1686.