Sunday, May 16, 2010

Why Do Dentists Prescribe Prophylactic Antibiotics So Often?

Because they can.

Why am I dissing my dental colleagues? Because I can.

Perhaps, this is a simple case of Dental Envy, since their profession remains within secure borders far beyond the health care reform line of fire. Consider these dental incidentals:

• Not a syllable in the ~2000 page health care reform law that affects dentists. Every filling is still worth its weight in gold.
• Dentists recover every dime they bill. If their fee is a gazillion dollars, and your generous dental insurance, covers fifty bucks, guess what? There will be a very large cavity in your bank account.
• No middle of the night runs to the emergency room, a drill that we physicians endure
• No hospital work, which for many physicians has become an inefficient hassle which became the root of a new medical specialty
• Dentists don’t need an attorney on retainer, or caps on non-economic damages, as their malpractice situation is calm.
• We still call them, ‘doctor’.

Dentists prescribe prophylactic antibiotics (ATBs) with routine recklessness. Of course, we physicians are also culpable of antimicrobial mania. We all prescribe too many antibiotics for too many days for too many viral illnesses. It has been a tough slog to teach our profession to prescribe antimicrobial agents more judiciously. In fact, it’s been like pulling teeth. Entrenched physician habits and patient expectations are hard to change. Look how long it took for Americans to accept and practice seat belt safety. When I was a kid, I remember my parents buckling the belts behind them so they wouldn’t hear the annoying warning buzzer. It took a generation of intense education to change cigarette smoking behavior.

Many dentists irrationally prescribe ATBs before teeth cleanings and other procedures. It’s more than irrational; it’s a reflex. Here’s a sample patient questionaire that dentists use to determine if prophylactic ATBs are necessary. Answer ‘yes’ to any question, and get ready to swallow some potent germ killers.

Have you ever been told of a heart murmur?

Does your puppy have a heart murmur?

Do you want live to see your next cleaning?
The vast majority of  prophylactic ATBs that dentists prescribe are unnecessary. The theory is to protect the patient’s heart from becoming infected by bacteria that are released into the blood stream during a dental procedure. The missing piece is the absence of a shred of science supporting this practice. Keep in mind that live humans release bacteria into the blood stream during routine tooth brushing and defecation, but I doubt that heart murmur patients are advised to pop penicillin each time they are about to engage in either of these two high risk behaviors.

When physicians and dentists prescribe unnecessary ATBS, there are many adverse consequences. Here is a sampling.

  • Money is wasted.
  • Resistant bacteria emerge that can be more difficult to treat.
  • It teaches patients to expect and demand ATBs when they are not indicated.
  • Potential of serious side-effects and drug interactions.
For example, there is a condition called pseudomembraneous colitis caused by the germ Clostridium difficile, affectionately known as C. diff. The primary cause of this diarrheal disease is ATBs. There isn’t a hospital in the country that is not struggling with this stubborn and serious disease. Some of these patients have died or had their entire colons removed.  Once the germ is present in your large intestine, or colon, it can be impossible to eradicate. I see a case of C. diff at least every week. For some of these unlucky folks, C. diff becomes a chronic disease.

I have seen many C. diff cases that developed from brief courses of antibiotics prescribed by dentists and physicians. Some of these patients now have an incurable gastrointestinal affliction caused by just a few ATB pills. I help these folks as best I can. I don’t think it helps them for me to share that they never needed the ATBs in the first place. This inconvenient truth would be too hard for them to swallow. I wish that their ATBs had been too hard to swallow.

The next time that your dentist, or your physician, recommends an ATB – or you demand one – think again. Is it worth the risk of beating your colon into a pulp?

15 comments:

Kate said...

Amen!
Especially connect with your 6 bullet points. The antibiotic issue is concerning of course; suspect you see more of this in your line of work than I do as a nephrologist. We are always getting calls about patients with renal transplants and "do they need antibiotics for their dental work?". Sigh.

Michael Kirsch, M.D. said...

Kate, your comment has particular value since the smartest physicians pursued a nephrology career. Those who didn't rank quite so high do colonoscopies.

LeisureGuy said...

OTOH, physicians could take a lesson from dentistry, which has seen enormous advances in preventive medicine to the extent that an American's teeth today and in infinitely better shape than an American's teeth 100 years ago. Dentists, in my opinion, have a very heads-up approach to their specialty and have really progressed on almost every front.

Anonymous said...

I'm neither a doctor nor a dentist, nor do I play either on TV. However well taken your point is, much of this can be alleviated by educating consumers (patients) in these topics.

Example - I previously used a dentist approved by my union dental plan. I was required to complete a full medical survey - which I thought was a good thing. Did I know anything about the problems you describe? No - I had no idea, and nobody ever educated me. As a result, I was advised to "premedicate" before any procedure because I had a history of heart disease, mitral valve prolapse, and a previous open heart surgery. I thought this was a GOOD thing.

On his retirement I had a find a new dentist, and I no longer cared about my union covering full expenses or not - I wanted a good dentist. I found a great guy only a few minutes from home. Before my first appointment I asked him if I should premedicate. He asked WHY? To which i replied because I had a history of heart disease, and my previous dentist insisted I take 300mg of antibiotics before being treated. He was incredulous. Then he started telling me all the things my previous dentist had done improperly to save money while billing full amounts. Of course he implied he would deny he ever told me anything like that, dentists being much like doctors or lawyers in proscribing improper behavior by peers. But the point was made - I didn't need any premedication.

Anonymous said...

I have mild mitral valve prolapse with a grade 1 murmur and the dentist who I have been seeing for 20 years has FINALLY stopped prescribing ATB before cleanings. For many years I told him that I read on the Internet the updated recommendations for ATB prophylaxis but he would not listen. I think it was a CYA thing with him. Finally, though, he has come into the 21st century and at the last visit let me proceed with the cleaning without the 2 gm of amoxicillin on board.

Victoria said...

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Dan said...

@LeisureGuy,

"physicians could take a lesson from dentistry...American's teeth today and in infinitely better shape than an American's teeth 100 years ago"

Yes, and all medicine has done is eliminated TB, measles, mumps, tetanus, typhus, yellow fever, polio, dysentery (4th MCC of death in 1910), invented a little thing called antibiotics, and added a measly 30 years more of living. What a bunch of slackers.

sam said...

Your summaries are always top-notch. Thanks for keeping us apprised. I’m reading every word here.Lawrenceville dentist

Andrew said...

You talk about releasing bacteria into the bloodstream every time you brush your teeth or defecate, however, a dentist prescribing prophylactic antibiotics is more complicated than the fear of simple bacteremia. Dental procedures are notorious for systemically increasing inflammatory mediators (do a simple pubmed search for the link between periodontal disease and cardiovascular disease). It is this increase in inflammatory mediators that plays a huge role in a dentist's decision to prescribe proph. antibiotics. Yes, defecating may induce a minor bacteremia, but without uncontrolled inflammation in the heart (read: without pro-inflammatory cytokines), the bacteria are harmless. Not to mention the biofilm and microbiological characteristics of the oral cavity and the rectum are completely different. You claim there is not any scientific evidence that prescribing proph. antibiotics is beneficial...this is very ignorant. Have you looked? It's everywhere.

I agree that there is a widespread problem with all health care providers prescribing antibiotics, but for you to single out dentists and not talk about family medicine doctors who prescribe for every sore throat that they see is dangerous, slanderous, and ignorant.

Andrew

Michael Kirsch, M.D. said...

Andrew, thanks for your comment. You will note that I state in the post that physicians "are also culpable of antimicrobial mania. We all prescribe too many antibiotics for too many days for too many viral illnesses. It has been a tough slog to teach our profession to prescribe antimicrobial agents more judiciously", so I reject your claim that dentists were singled out. Moreover, I maintain that persuasive scientific evidence supporting that dental prophylactic antibiotics prevents infective endocarditis is lacking. The risks of antibiotics, however, are definite.

Anonymous said...

well i think, its sufficient enough to point out the danger of ATBs' wout the slurs, as from where i come from, prophylactic antibiotics are rarely prescribed by dentists unless theres a real risk of patient developing future infection and tis is usually done in liaison wit d medical doctors

Anonymous said...

Very witty article. It sounds to me like you're just a little bitter with "dental envy". I'm sorry you spent twice as much time in school and work twice as hard to make the same amount of money. Life just isn't fair sometimes I guess--you should have gone into dermatology. Also, I don't know of any dentists who prescribe antibiotics for mitral valve prolapse....the guidelines on prophylaxis have become quite strict in the past few years. Over time as new research becomes available, the prophylaxis guidelines are reviewed and updated (by a panel of dentists AND physicians). Here is the link to the AAOS. You will read that it is the PHYSICIANS who are actually recommending to dentists to continue giving antibiotic prophylaxis to patients before dental treatment. There was a 2-year post-surgery limit placed but now this has been lifted also. Please do your research before you start insulting other professions. If you thought you had it bad as a physician now, just wait until Obamacare takes full effect. Then you'll really wish you went to dental school.

Anonymous said...

http://www.aaos.org/news/aaosnow/may09/cover2.asp

Michael Kirsch, M.D. said...

Yeah, I should have done dermatology...
While not a double blinded controlled trial, my experience has been that the dental profession is lagging behind us in abandoning the unnecessary use of prophylactic antibiotics. We all agree that no one should be prescribing them. This is not a contest to determine whether the dental or the medical profession is worse.

Why do anonymous commenters want to remain so? What are you guys scared of?

Anonymous said...

Dr. Kirsch-I am so concerned about antibiotic overuse in my case but don't know what else to do. I am in my low 40's and healthy and active but...

I contracted endocarditis several years ago 3 weeks after a cleaning with a positive ID on the bacteria as Haemophilus parainfluenzae (part of the HACEK group). I only had a slight murmur that was diagnosed several years prior.

I now have server regurgitation and a bit of scar tissue mass on my mitral valve that is visible on ultrasounds. Needless to say, I take extremely good care of my teeth now.

The infectious disease specialist that cured me of the endocarditis recommended that I get 2g of ampicillin via IV prior to dental cleanings followed by 1.5g of amoxicillin pills 6 hours after.

But there is no protocol for other work. I had a lot of other dental work done this year and here is what I've been taking (it feels like way too much antibiotics to me but I don't know who else to go to for a second opinion).

Since September I had:
10 days of Amoxicillin for a dental extraction
7 days of Amoxicillin for a dental implant and 5 onlays.
10 days of Amoxicillin for a root canal
4 days of Amoxicillin for a cleaning plus a cap and 3 onlays.
10 days of Doxycyclin as part of an IVF protocol.
1 day of Amoxicilin for root canal cap
1 day of Amoxiciilin for the implant abutment and cap.

Who can I turn to for advice on the assessing the risk with being on antibiotics so long?

For a case like a root canal that invovles 3 visits, Is it better to take antibiotics just ont he day of the procedures or take the prolonged period of time?






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