The dangers of microbial resistance in the dental practice

In 1902, English author W.W. Jacobs published the short story “The Monkey’s Paw.” In it, the protagonists are gifted a mummified monkey’s paw, said to bestow three wishes – which it certainly does. Regrettably, each wish is granted with a macabre twist.

Antibiotics - the 20th century’s miracle drug - was discovered two decades after “The Monkey’s Paw” was published, and it has , itself, become a real-world manifestation of Mr. Jacobs’s literary masterpiece. There’s no denying that antibiotics have saved millions, if not billions, of lives. However, we’ve learned that they also come with strings attached.

The lowdown

“Antibiotics were the wonder discovery of the 20th century,” says Dr. Marie Fluent, DDS, an educational consultant for The Organization for Safety, Asepsis and Prevention (OSAP). “Alexander Fleming discovered penicillin in 1928, and it really was not widely used until the1940s, but bacterial resistance quickly developed. Shortly thereafter, adverse events - and sometimes life-threatening events - were associated with the use of antibiotics. According to the CDC, there are currently at least 2,049,000 antibiotic resistance infections per year, and about 23,000 deaths directly associated with antibiotic resistance per year. This costs the United States about $30 billion annually.”

While microbial resistance is a problem that most commonly affects medical professionals, there are also issues specific to the dental community.

Dr. Fluent observes:

• Dentists write approximately 10 percent of all antibiotic prescriptions for humans.

• Dental personnel may receive pressure from patients and other clinicians to write antibiotic prescriptions.

• There’s difficulty collecting data on whether or not the prescriptions written in dentistry are appropriate.

• Dental students receive limited education on antibiotics.

• While there are specific guidelines for antibiotic prophylaxis, there are limited guidelines for prescribing antibiotics in dentistry for the treatment of infections.

• There’s concern that there are unnecessary and inappropriate prescribing practices of antibiotics in dentistry.

“Overprescribing antibiotics has been prevalent in the medical and dental profession for over four decades and, as a result, that over prescription of antibiotics has selected out antibiotic-resistant microorganisms because they are the ones that are surviving,” says Jackie Dorst, RDH, BS, an infection prevention consultant and speaker. “So we’re seeing more and more of these antibiotic-resistant microorganisms because of antibiotics’ overuse.

“We all know that you have to recolonize by taking a probiotic or eating yogurt after you’ve taken a regimen of antibiotics,” Dorst continues. “Now the ones that are resistant are being selected out. They may stay on a surface or be on our bodies and not causing infection until there’s an opportunity; until there is a weakness in the immune system; until there’s a break in the skin that they’re introduced, and then that’s where they have the opportunity to multiply, thrive and go on to cause a serious infection. But the physicians have nothing to treat the patient with because those microorganisms are resistant to all of the antibiotics that are currently available.” 

The theory of evolution

Charles Darwin has a good explanation as to why microbial resistance occurs - survival of the fittest.

“It’s when a microorganism mutates, evolves and changes,” Dorst explains. “Microorganisms become resistant to that antibiotic, so they continue to multiply and produce more resistant cells. And it gets back to the theory of evolution and selection of the fittest. The fittest survive and these microorganisms, where they can divide as rapidly as 20 minutes, have multiple opportunities within a 24-hour period to mutate, to evolve, to resist that antibiotic, and the fittest survive and they continue to multiply.”

Dr. Fluent adds that microbial resistance occurs when there are a lot of germs and a few of them are resistant.

“Antibiotics kill the bacteria causing the illness as well as good bacteria protecting the body from infection. The drug-resistant bacteria are allowed to grow and takeover, but some bacteria give their drug resistance on to other bacteria, causing more problems. Unfortunately, each time a new antibiotic is developed, resistance to that antibiotic develops shortly thereafter. And, unfortunately, the number of new antibacterial agents being developed and available for use has been dwindling. In other words: new antibiotics have not been produced and aren’t able to keep up with resistant microorganisms. So we are now in trouble.”

What to do (and what not to do)

Microbial resistance may be a tough nut to crack, but there are definitely things dental professionals can do to lessen their risks.

“One of the keys is to be more reserved,” Dorst says. “Formerly, we gave the patients an antibiotic three days before the appointment and a day after the appointment so that they had antibiotics in their system and an infection would not develop. Now we are much more selective.

“It has been found that the antibiotic prophylactic is not needed,” Dorst continues. “If it is needed, we will give the patient maybe a large dose of antibiotics one hour before the appointment and maybe one follow-up dose, rather than that three-day regimen that was used in the past. But if dentists don’t keep up with the changing protocols … then they may still be prescribing an excessive amount of antibiotics.”

Antibiotics should never be a long-term solution, and the real root of a dental problem needs to be addressed.

“For instance, if you’ve got a pulp exposure that’s infected, a root canal is indicated in addition to an antibiotic,” Dr. Fluent says. “If you’ve got a wisdom tooth that has a spreading infection, extraction plus an antibiotic is needed. Antibiotics are never a substitute for dental treatments; they are considered an adjunct to dental treatment.”

Quite often, however, patients are initially prescribed antibiotics for emergency needs. But after that emergency has been resolved, it’s up to the patient to get the follow-up treatment necessary.

“This is common, especially in emergency rooms,” Dr. Fluent says. “Many patients go to the emergency room for a dental infection, they’re given a prescription for an antibiotic and told to follow up with their dentist. Insurance, or lack of insurance, and finances in general may be a factor as to why they do not follow up with dental treatment. In most cases, the emergency room physician has prescribed antibiotics for dental infections yet doesn’t have the ability to follow up with appropriate dental care.”

Dental professionals must ensure that the appropriate medicine is prescribed based on the patient’s medical history.

“Many patients will check, ‘Yes’ to a penicillin allergy, as approximately 10 percent of the population reports that they have an allergy,” Dr. Fluent says. “But in actuality less than 1 percent of the population is truly allergic. So what do you do? You really need to assess what type of reaction they had to determine if it’s a true allergic reaction. If they had diarrhea, vomiting and an upset stomach, those are not considered allergies but normal side effects or adverse events of antibiotics. You really have to assess whether it is the true allergy or not before you prescribe.”

Keeping up with changes

Microbial resistance is very dynamic, and so, too must be dental professionals’ efforts to stay on top of this ever-changing subject. Resources include the American Dental Association, Academy of General Dentistry, American Association of Oral and Maxillofacial Surgeons, American Association of Endodontists and American Academy of Orthopedic Surgeons, among others. Dorst also recommends attending continuing education meetings to stay informed of the latest changes in protocols.

“Many resources are available to provide guidance for the treatment of dental infections and for assistance in prescribing for prophylactic regimens, including Epocrates, Lexicomp, The Little Dental Drug Booklet, Dental Cheat Sheets and others,” Dr. Fluent adds. “Of course, your trusted pharmacists may assist as well."

However, resistance isn’t the only concern of antibiotics. There are also adverse advents associated with antibiotic use.

“Clostridium difficile (C. diff) infection is one of the most serious consequences of antibiotic use,” Dr. Fluent explains. “This disease can range from asymptomatic to a fever with moderate diarrheal illness to severe illness and even death. It is estimated that there are about 450,000 cases per year and that antibiotics used in dentistry are commonly associated with C. diff infections.”

Managing potential C. diff threats requires specific prevention steps that are more advanced than conventional infection control measures.

“This infection will alter our infection control protocol,” Dr. Fluent says. “For instance, C. diff is spread by spores that are very resistant and difficult to kill, and so our intermediate-level surface disinfectants are ineffective; they don’t work. Alcohol hand sanitizers are ineffective. So if you should have a patient in the dental chair with identified or suspected C. diff, we absolutely must wash our hands and not use alcohol-based hand sanitizers. If you are cleaning and disinfecting your operatory, especially the clinical contact surfaces, it’s very imperative that you clean thoroughly. According to the CDC, cleaning removes over 99 percent of the microorganisms on the surface, so diligent cleaning is a must.”

It’s crucial that everyone on the dental team be on the same page when addressing infection prevention. This ensures that the patient receives the same advice and instruction.

“There are many times when a dentist leaves the operatory and the patient may say to the dental assistant or hygienist, ‘What would you do if you were me?’” Dr. Fluent says. “So it is very important that we provide consistent messaging with regard to patient education. Patient education for responsible antibiotic use includes: Never save the antibiotics for another illness, never share antibiotics with another person, take prescriptions exactly as directed, and if any side effects or adverse effects occur from the antibiotics to call your dentist immediately.”

“It’s critically important for the entire dental team to be aware of diseases that can be transmitted in saliva and blood and what are the correct techniques for disinfection and sterilization to prevent that disease transmission,” Dorst adds. “I have a list that I often share with audiences that is 26 diseases that can be transmitted in oral fluids in the dental office. It brings home to us that so often the dental team is focused on what is termed the ‘bloodborne pathogen,’ because of OSHA’s Bloodborne Pathogen Standard and focusing on hepatitis B and hepatitis C and the human immunodeficiency virus. That information has been driven home since 1991.”

Additionally, organizations such as the CDC and OSAP have information on their websites that are exceptional resources for dental professionals. The CDC also has information on its microbial resistance stewardship program, which endeavors to preserve microbial resistance efforts.

“To be a steward means that you are in charge of and responsible for protecting something.,” Dr. Fluent says. “Antibiotic stewardship means you are protecting the resources of antibiotics, so they are safe and effective for future generations as well.”

The plot twists in “The Monkey’s Paw” saw the protagonist’s son killed, his corpse resurrected and then - well, if you’ve not read the story, we don’t want to ruin the ending. While the story of antibiotics isn’t as dramatic, it does come with its own dark turns of fate. Unlike Mr. Jacobs’s short story, however, antibiotics’ ill effects can be mitigated, but it takes more than desperately praying on an Indian relic.