Antibiotics use is often a debated topic in our profession and between our profession and specialties like orthopedics. What do the guidelines say? How do we advocate for our patients so we don’t create these superbugs because of antibiotic overuse? Dr. Tom Viola is back for another TIPisode on this topic.
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With over 30 years’ experience as a pharmacist, educator, speaker and author, Tom Viola, R.Ph., C.C.P. has earned his reputation as the go-to specialist for delivering quality continuing education content through his informative engaging presentations. Tom’s sellout programs provide an overview of the most prevalent oral and systemic diseases and the most frequently prescribed drugs used in their treatment. Special emphasis is given to dental considerations and strategies for effective patient care planning.
Tom’s homepage – http://www.tomviola.com/
Pharmacology Declassified – http://www.tomviola.com/welcome-to-the-pharmacology-declassified-blog/
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This TIPisode has been transcribed for your viewing pleasure:
Dr. Tom Viola: Well, good morning, everybody. This is Tom Viola from tomviola.com and Pharmacology Declassified coming at you with yet another TIPisode. Well, if you’ve heard my TIPisodes before, you know that Andrew and Michelle are two of my favorite people on this planet. So, when Michelle asked me to do a TIPisode about antibiotic prophylaxis, I was more than happy and jumped at the chance.
It’s definitely a topic that’s had a lot of discussion in our profession, and there’s also a lot of discussion about antibiotic resistance and, for that matter, antibiotic stewardship. What does that mean? Well, it means that we should be using antibiotics in the most efficient, most effective ways, and we should not be using antibiotics when there’s good evidence to support that there is no good reason to use them.
Well, when it comes to antibiotic prophylaxis in dentistry when it refers to joint replacement infection, this has been a hotly debated and contested topic for some time now. One the one hand, we have the orthopedic surgeons who insist, in some cases, that since their patients received a joint replacement, they will need antibiotic prophylaxis when they undergo dental procedures. Okay? Well, first off, is that really true? Is there any evidence to support that? And, second, if you did assume there was evidence to support it, then for how long? I’ve heard everything from two weeks to six months to two years to forever.
Well, again, with the facing of rising antibiotic resistance amongst these people call them “super bugs,” maybe this is not the best idea. When you look at the antibiotic arsenal we have in dentistry, it’s very limited. We have amoxicillin and penicillin, which for most purposes are basically the same. They belong to the penicillin family. If you have a penicillin allergy, well, then we use clindamycin. Although, lately, there’s been a push towards using cephalexin, Keflex, because there’s less than a 10 percent chance of cross-sensitivity. Although, that’s been hotly contested too.
If the patient has gram-negative involvement, sometimes we’ll use metronidazole as an add-on or an adjunct to boost the effectiveness of the other antibiotics. And, other than those, folks, the only other antibiotic we use in dentistry is azithromycin, but azithromycin has always been looked at as a second line in antibiotics in dentistry because it causes drug interactions and because it has been linked, at least in some part, to arrhythmias. And, since we use epinephrine often in dentistry, using an antibiotic that causes arrhythmias or makes an individual more prone to arrhythmias may not be the best idea if we’re also going to be using epinephrine on that patient.
So our arsenal is limited. If resistance were to rise against our limited arsenal, we wouldn’t have much left to treat infection, so again, I guess why we use our antibiotics sparingly and we’re all about antibiotic stewardship to prevent this potential resistance. But what to do about the patient who’s received a joint replacement and the request, or in some cases the demand, of the orthopedic surgeon?
Well, in order to get to the bottom of this, I went to the source, and that is, of course, the American Academy of Orthopedic Surgeons, aaos.org. And, in perusing their website, it didn’t take me very long to find their position on this. What does the Association of Orthopedic Surgeons have to say about the use of antibiotic prophylaxis routinely in patients with joint replacements to prevent infection? Well, if you won’t mind, my friends, I will read to you directly what the website says.
This is according to the Appropriate Use Criteria, AUC. It says, “the chance of oral bacteremia being related to joint infections is extremely low with no evidence for an association.” Furthermore, “oral bacteremia frequently occurs secondary to activities of daily living such as toothbrushing and eating.” And, finally, “virtually all dental office procedures have the potential to create bacteremia.”
So, reading between the lines here, it seems that the association’s saying it’s pretty much likely to happen anyway. But, at the same time, the chance of bacteremia from dental-related procedures leading to joint infection is extremely low, and there may be no evidence for it at all.
Now, they do go on to say that there are some at-risk patients — patients who are considered high risk because they’re immunocompromised or maybe they have poor glycemic control — and so maybe those people might benefit from antibiotic prophylaxis to prevent joint replacement infection. But even there we really have no evidence to support that, and we really don’t know if it’s true.
So bottom line, my friends, is I know you deal with this every day, and I know you have orthopedic surgeons that insist on it. And the association says, further reading here, that if the orthopedic surgeon is insistent on the patient requiring antibiotic prophylaxis, well, then the orthopedic surgeon should write the script. But, as I’m sure you are well aware, that is also hotly contested. There are some orthopedic surgeons who would write the script and some who would say, “No. You write the script because you’re the one treating them.”
So all I can say at this point is we really don’t know. And, if you know me as a speaker and as an educator, I hate saying those words. I always like to have some concrete answer to give you, but we really don’t know. And, therefore, all we can do at this point is go with the guidelines of the association and do our best to convince those doctors out there who want antibiotic prophylaxis or insist on it that perhaps without any real evidence backing it up, the benefit, how slim it might be, is outweighed by the risk of growing resistance — these, as I said, super bugs as people are calling them — against the antibiotics that we love and trust here in dentistry.
Well, thank you, my friends, for taking the time this morning to listen to this TIPisode. Reach out to me anytime at tomviola.com and Pharmacology Declassified. I look forward to talking to you and meeting with you soon. Take care.
Michelle Strange: We hope you enjoyed this week’s TIPisode. Be sure to reach out to our guest experts and let them know how helpful their tips were. Follow A Tale of Two Hygienists on Facebook, Instagram, and head over to ataleoftwohygienists.com and subscribe to our newsletter. You can also email us at firstname.lastname@example.org, and keep listening for more awesome content from your unofficial dental hygiene podcast.