The Silent Threat: Understanding Antimicrobial Resistance in Dental Practice

Antimicrobials are drugs that prevent and treat infectious diseases in humans, animals, and plants. They include antibiotics, antivirals, antifungals, and antiparasitics. When pathogens such as bacteria, viruses, fungi, and parasites stop responding to these medications, it results in antimicrobial resistance (AMR). Antibiotics and other antimicrobials become ineffective due to this resistance, making infections hard or impossible to treat, thereby increasing the risk of disease transmission, serious illness, disability, and even death. Human actions, particularly the misuse and overuse of antimicrobials, significantly contribute to the development and spread of AMR. While AMR is a natural process arising from genetic changes in bacteria, it has been accelerated by human behavior.

The Role Of Antibiotics in Dentistry

Antibiotics are medicines that fight infections caused by bacteria. They work by killing the bacteria that cause infections, or by slowing down the bacteria’s ability to grow. Antibiotic Resistance(ABR) is of particular concern to dental teams, as antibiotics are the class of drugs most prescribed by dentists. Reducing unnecessary antibiotic prescribing is vital to minimize the emergence of antimicrobial-resistant bacteria.

Antibiotics are typically prescribed in dental practice for:

1. The treatment of acute and chronic infections of odontogenic and non-odontogenic origins.

2. As a prophylactic treatment to prevent focal infection in patients at risk (as a result of systemic conditions such as endocarditis, artificial heart valves, and congenital heart disease).

3. To prevent local infection and systemic spread among patients undergoing surgical oral and dental treatment.

When Antibiotics May Not Be Necessary

Patients may not always require antibiotics for dental pain or infection due to several reasons:

1. Pain Not Caused by Infection: Toothaches may not be linked to infections. Conditions like irreversible pulpitis often require dental treatments ( e.g., root canal or extraction) rather than antibiotics. Current research suggests that antibiotics may not effectively relieve pain from this condition, although further studies are needed. Thus, avoiding unnecessary antibiotic use and seeking appropriate dental care is essential for relief.

2. Alternative Treatment Options: Dental treatments like fillings, gum disease management, root canal treatment, or tooth extraction are the most effective ways to address dental pain. Antibiotics should only be used as an additional step to stop the infection.

3. Updated Guidelines: Recommendations regarding antibiotic use may change based on emerging evidence. Dentists must stay informed about these guidelines to determine when antibiotics are appropriate.

When to use antibiotics ?

Immediate antibiotic use is warranted for infections spreading to other areas, accompanied by symptoms like swelling or fever. Always have your dentist prescribe the correct antibiotics rather than using leftover medications, which can lead to adverse effects.

A particular situation in clinical practice that may prompt dentists to prescribe antibiotics is the emergency management of patients with acute dental pain and infection. Limited appointment time, difficulty in obtaining effective local anesthesia, and patient expectations to receive antibiotics may contribute to inappropriate prescriptions.

FACTORS CONTRIBUTING TO AMR IN DENTISTRY

1. Over-prescription of Antibiotics: Lack of knowledge about the appropriate choice of antibiotics or the circumstances under which to prescribe them, along with patient requests, can lead to excessive antibiotic use.

2. Patient Noncompliance: Patients sometimes do not complete their prescribed antibiotic courses, leading to suboptimal drug levels that can promote the development of resistant bacteria.

Implications of AMR for Dental Practice

The rise of AMR has several implications for dental practice:

1. Increased Treatment Failures: Resistant infections may not respond to standard antibiotic therapy, leading to complications and the need for more aggressive treatments

2. Extended Recovery Times: Patients with resistant infections may experience prolonged healing periods, affecting their overall health and well-being.

3. Economic burden: The costs associated with treating resistant infections, including longer hospital stays and more expensive medications, place additional financial strain on healthcare systems.

STRATEGIES FOR MANAGING AMR IN DENTISTRY

To combat AMR in dental practice, several strategies can be implemented:

1. Education and Training: Ongoing education on antibiotic stewardship and the latest evidence-based guidelines is essential for all dental practitioners.

2. Antibiotic Stewardship Programs: Establishing structured programs within dental practices to monitor and optimize antibiotic prescribing can significantly reduce unnecessary use.

3. Patient Education: Educating patients about the importance of completing prescribed antibiotic courses and the potential consequences of misuse can help improve compliance and reduce resistance.

4. Informed Decision-Making: Dentists should engage in shared decision-making with patients regarding the need for antibiotics, discussing alternatives when appropriate.

5. Monitoring and Reporting: Tracking antibiotic prescriptions and resistance patterns within dental practices can identify trends and inform strategies for improvement.

6. Collaboration with Healthcare Professionals: Dentists should collaborate with general practitioners and pharmacists to ensure a comprehensive approach to AMR, sharing knowledge and resources to optimize patient care.

The Role of Oral Microbiome

Oral microbiome plays a major role in shaping oral health or disease state, thus a main challenge for dental practitioners to preserve or restore a balanced oral microbiome. Oral biofilms are complex communities of microorganisms that adhere to teeth and soft tissues. These biofilms play a crucial role in oral health , but when pathogenic, they can lead to infections such as dental caries and periodontitis. The extracellular matrix of biofilms protects bacteria from antibiotics, complicating treatment and contributing to AMR. Strategies to manage oral biofilms include enhanced oral hygiene practices and alternative therapies, such as antimicrobial photodynamic therapy (ADPT), cold atmospheric plasma (CAP), antimicrobial peptides (AMP's) and probiotics.

Common Pathogens and Their Resistance Patterns

Several bacteria are frequently associated with dental infections, and understanding their resistance pattern is vital:

1. Staphylococcus aureus: Known for causing abscesses and periodontitis, methicillin-resistant strains (MRSA) complicate treatment options.

2. Streptococcus mutans: A primary contributor to dental caries, some strains have shown resistance to common antibiotics, highlighting the need for effective prevention strategies.

3. Enterococcus faecalis: Often implicated in root canal infections, this bacterium exhibits resistance to many antibiotics, including penicillin, making treatment challenging.

4. Aggregatibacter actinomycetemcomitans: Associated with aggressive periodontitis, this bacterium can exhibit multi- drug resistance , raising concerns in periodontal therapy.

The rise of antibiotic resistance in dental practice is a clarion call for action. As guardians of oral health, dental professionals must champion a paradigm shift towards more thoughtful and informed prescribing practices. By integrating cutting-edge research, patient education, and collaborative strategies into daily practice, we can combat the tide of AMR effectively. Embracing this proactive stance not only enhances patient outcomes but also fortifies the healthcare system against the looming threat of resistance. Together, we can redefine the role of antibiotics in dentistry, ensuring they continue to serve as vital tools in our fight against infection while preserving their efficacy for future generations.

By Dr. Sruthi Suresh