Antibiotics have truly revolutionized healthcare by its use to control infections. The use of antibiotics has shown a sharp increase among medical and dental professionals. This in return has caused a worldwide problem of antibiotic resistance and is a cause of concern. In fact, this threat has been referred to as a ‘ticking time bomb’ requiring urgent actions. This outcome, associated with mutational or genetic changes within the bacterial strains under selective pressure, has been inevitably associated with increased consumption of these medicines.
Also, in conjunction with antibiotic resistance, the incidence of side-effects, and hypersensitivity reactions along with superinfections has been commonly documented with antibiotic usage. Furthermore, worryingly an indirect association has been found between the early use of antibiotics in childhood and the risk of allergic asthma.
The inappropriate use of antibiotics has also been reported in children with orofacial infections. As dental professionals, awareness regarding the definitive indications of antibiotics is mandatory. When prescribed systemically, these drugs should be used as adjuncts to treat certain oral infections or for prophylaxis to prevent serious situations of bacteremia. Otherwise undesired issues like resistance may ensue. Abuse by the patient or the parent and inefficient usage can also lead to this problem.
Prescribing trends of antibiotics in pediatric dentistry
Most of the evidence regarding the prescribing behavior of antibiotics in pediatric dentistry was through cross-sectional surveys and studies conducted nationwide or regionally to identify the pattern of antibiotic prescription. An overall assessment of the prescribing practices revealed the use of antibiotics by dental practitioners to be approximately 7–11% of the total antibiotic consumption globally.
An important finding was that pediatric dentists showed comparatively better adherence to the guidelines as compared to general dental practitioners which was statistically significant.
The most commonly prescribed antibiotic was amoxicillin followed by penicillin derivatives and clindamycin, which was prescribed in case of allergy to penicillin.
A survey completed in India on one hundred dentists and one hundred pediatric dental specialists concluded an over-prescription of antibiotics by both dental professionals with general dental practitioners showing a higher incidence of antibiotic over-usage.
Data collected in Jordan [Dar Odeh, et al. 2013], Croatia [Peric et al., 2015], and Jeddah (Saudi Arabia) [Al-Johani et al., 2017] also reported a definite overprescription and over usage of drugs by practicing dentists and non-adherence to guidelines. Similarly, the most commonly prescribed drug was amoxicillin, and other penicillin derivatives were a common finding in these studies.
A study conducted in Brazil revealed: incorrect usage of the drug, inappropriate prescription in terms of the generic name, dosage, and duration of antibiotic therapy.
Factors associated with the prescribing trends
One of the most frequent and significant causes of this increased use of antibiotics is the lack of knowledge regarding the definite indications and need for antibiotics.
Overprescription in non-indicated situations like irreversible pulpitis, dentoalveolar abscesses with localized abscesses, simple traumatic conditions of intrusion, and extrusion were observed in these studies.
A special cause of the observed prescribing behavior in reference to pediatric dentistry could be a result of the pressure or requirements of the parent and the patient. This parental pressure has been reported as one of the main causes leading to unwarranted prescription
Other non-clinical situations acting as determinants for antibiotic use include uncertain diagnosis of the case, need for delay of treatment owing to unavailable appointments, and social relations, etc.
Research suggests that the practitioners assume that using antibiotics is the quickest way to resolve any form of consultation. These non-scientific reasons along with avoidance of any form of negligent claims as a result of problems like ineffective sterilization can be important factors responsible for the overuse of these drugs. The compilation of these barriers of knowledge, attitude, and external factors are accountable for the observed prescribing trends.
Guidelines for antibiotic use in pediatric dentistry
There is currently a lack of guidelines regarding the definite use and indications of antibacterial drugs in pediatric dentistry. Organizations worldwide have published their own national guidelines to assure appropriate usage of these drugs. These include the National Institute of Health and Care Excellence-United Kingdom (NICE) guidelines and guidelines by the American Dental Association, Canadian Dental Association, and Scottish Dental Clinical Guidelines.
However, the only guidelines available to address the indications of antibiotics for the pediatric dental population are the guidelines suggested by the American Academy of Paediatric Dentistry (AAPD).
The revised AAPD guidelines suggest the use of antibiotics as adjuncts in certain prophylactic and therapeutic conditions after adequate assessment of the systemic spread of infection and the risk factors of the patient. An important consideration of these guidelines is the avoidance of antibiotics in the case of localized infection and swelling owing to the compromised circulation of pulp thereby avoiding any form of the beneficence of systemic antibiotic use. The guidelines, however, lack data regarding the use of antibiotics in traumatic situations though certain trials suggest the efficacy of doxycycline as a part of adjunctive therapy and for topical application of drugs. The use of antibiotics is also recommended for bacterial infections of salivary glands and facial swelling of dental origin.
Only a minimal number of studies found the presence of drug resistance in the pediatric population. Two long-term clinical trials suggest a high incidence of antibiotic resistance in children as a result of chronic drug therapy in blood cancer and respiratory tract infection. Another research implied the presence of Streptococcus sanguis resistant strains in the dental plaque of the patients as a result of long-term antibiotic therapy for otitis media Reports from other research suggests the presence of resistant strains in the oral microflora of healthy individuals acting as a source of nosocomial infections. However, there is insufficient evidence regarding the correlation of the current trends of antibiotic prescription with the causation of drug resistance.
Antimicrobial resistance is a global concern and needs immediate addressing. The World Health Organization has announced programs to ensure effective handling and use of these drugs. As a part of the prospective practice, it is extremely important to work on holistic approaches like antibiotic stewardship. These programs involve a continued and collaborative care between the physicians and the other medical staff to assure the correct usage of antibiotics in the form of six directions on correct drug usage for the indicated patient at an appropriate dose, correct duration, right route of administration for adequate time, and with effective documentation. Effective cost control by the government through active surveillance can not only curb this resistance but can also help in improving clinical outcomes. Emphasis on topical antibiotic use in the form of double or triple antibiotic paste in the root canals of necrotic primary teeth can offer successful and promising results in dental practice. Another important practical solution to overprescription of antibiotics can be in the form of reinforcement of knowledge through clearer and more specific nationwide guidelines which can help in assessing the definite indications of drug therapy but also describe the appropriate duration and dosage regarding the bodyweight or age of the child.
It is evident that there is a clear lack of evidence to ascertain a link between the current prescribing trends of antibiotics in pediatric dentistry and the causation of drug resistance. Hence, a need for randomized controlled trials and studies addressing this question of the research is required. Though some prospective studies have been conducted on the use of non-conventional approaches of infection management and control, clinical evidence is lacking and hence, more experimental studies are required in the domain. These alternative approaches include using natural therapy for control of infections like propolis, silica, etc. and photodynamic therapy. WHO had rightly mentioned a virtually “dry pipeline” in terms of the development of new antibiotics. Hence, research to assure this refilling can be a significant step to curb antibiotic resistance. Another important area of research that can assure promising future outcomes can be in the form of studies that assess the fast and easy culture of microorganisms. Although the nano culture has been suggested as an effective form of microbial culture, the available clinical trials lack for its effective implementation.
This article has dealt with one of the most important yet the most neglected practice in dentistry, that is the practice of drug prescription, mainly antibiotics. Factors like the lack of knowledge, uncertain diagnosis, parental, and patient pressure have been considered leading to increased use of antibiotics. Furthermore, direct evidence has been found on prescribing behavior with drug resistance, and the increasing prevalence of antibiotic resistance requires a contributory effort by pediatric dentists as well.
In addition, clearer nationwide guidelines are required for an effective understanding of the indications of antibiotics. Holistic approaches like antibiotic stewardship can be considered to assure prudent antibiotic use. Antibiotic therapy is a double-edged sword, the misuse of which can be managed by its prudent use. Sir William Osler had rightly quoted that the desire to ingest medicines is a primary feature demarcating animals from men. Hence, prescribing a dose of a drug is in a broad sense, prescribing or recommending a dose of one’s knowledge. Therefore, definite care must be taken while prescribing any antibiotic as “an appropriate action today can assure an effective cure for tomorrow”.