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Dental Tribune Middle East & Africa Edition No. 5, 2015

6 Dental Tribune Middle East & Africa Edition | September-October 2015mCME Use and abuse of antibiotics mCME articles in Dental Tribune have been approved by: HAAD as having educational content for 2 CME Credit Hours DHA awarded this program for 2 CPD Credit Points CAPPmea designates this activity for2continuingeducationcredits. Fig. 1. Asymptomatic api- cal periodontitis. (Photos/ Provided by American Association of Endodon- tists) Fig. 2. Chronic apical abscess. Fig. 3. Acute apical abscess with intraoral local- ized swelling. Table 1. (Tables/Provided by American Association of Endodontists) > Page 7 By Steven G. Morrow, USA F or the past 80 years, anti- biotic therapy has played a major role in the treat- ment of bacterial infectious diseases. Since the discovery of penicillin in 1928 by Flem- ing and sulfanilamide in 1934 by Domagk, the entire world has benefited from one of the greatest medical advancements in history. The discovery of safe, systemic antibiotics has been a major factor in the control of infectious diseases and, as such, has increased life expectancy and the quality of life for mil- lions of people. According to the Centers for Disease Control and Preven- tion, life expectancy of individu- als in the United States born in 1900 was 47 years, while those born in 2005 is projected to be 78 years.1 At the beginning of the 20th century, the infant (< 1 year) mortality rate in the United States was 100/1,000 live births compared to 6.7/1,000 in 2006.2 The major reason for these phenomenal achieve- ments has been the ability to control infectious diseases.3 Development of antibacterial drug resistance Along with the dramatic ben- efits of systemic antibiotics, there has also been an explo- sion in the number of bacteria that have become resistant to a variety of these drugs. The problem is not the antibiotics themselves. They remain one of medicine’s most potent weap- ons against diseases. Instead, the problem is in the way the drugs are used. The inappropri- ate overuse of antibiotics has resulted in a crisis situation due to bacterial mutations develop- ing resistant strains. Many worldwide strains of Staphylococcus aureus exhibit resistance to all medically im- portant antibacterial drugs, including vancomycin; and methicillin-resistant S. aureus has become one of the most fre- quent nosocomial, or hospital- acquired, pathogens. The rate at which bacteria develop re- sistance to antibacterial drugs is alarming, demonstrating resist- ance soon after new drugs have been introduced. This rapid development of resistance has contributed significantly to the morbidity and mortality of in- fectious diseases, especially no- socomial infections.4 A nosocomial infection is a hospital-acquired infection that develops in a patient after ad- mission. It is usually defined as an infection that is identified at least 48 to 72 hours following admission, so infections incu- bating, but not clinically appar- ent at admission, are excluded. Nosocomial infections are cost- ly, resulting in increased mor- bidity, requiring longer periods of hospitalization and limiting access of other patients to hos- pital resources. The direct costs of hospital-acquired infections in the United States are estimat- ed to be $4.5 billion per year. Nosocomial infections also con- tribute to the emergence and dissemination of antimicrobial- resistant organisms. Antimicro- bial use for treatment or pre- vention of infections facilitates the emergence of more resist- ant organisms. Patients with in- fections caused by antimicrobi- al-resistant organisms are then a source of infection for hospi- tal staff and other hospitalized patients. These drug-resistant infections may subsequently spread to the community.5 The British Society for Antimi- crobial Chemotherapy pub- lished a review in the Journal of Antimicrobial Chemotherapy. This review examined the con- tributions antibiotic prescribing by general dentists in the Unit- ed Kingdom has made to the se- lection of antibiotic resistance in bacteria of the oral flora.6 The review concluded that in- appropriate antibacterial drug prescribing by dental practi- tioners is a significant contrib- uting factor in the selection of drug-resistant bacterial strains. The American Dental Asso- ciation reported the results of a survey of antibiotic use in dentistry in the November 2000 Journal of the American Den- tal Association.7 The authors surveyed all licensed dentists practicing in Canada and found that confusion about prescrib- ing antibiotics and inappropri- ate prescribing practices were evident, and that inappropriate antibiotic use, such as improper dosing, duration of therapy and prophylaxis are all factors that may affect development of an- tibiotic resistant microorgan- isms. There is a glimmer of hope A report from Aker University in Oslo, Norway, strongly sug- gests that bacterial resistance to antibacterial agents can be reversed.8 While dangerous and contagious staph infec- tions kill thousands of patients in the most sophisticated hospi- tals in Europe, North America and Asia, there is virtually no sign of this “killer superbug” in Norway. The reason? Norway stopped using so many antibiot- ics. “We don’t throw antibiotics at every person with a fever. We tell them to hang on, wait and see, and we give them a Tyle- nol to feel better,” said Dr. John Haug, infectious disease spe- cialist at Aker University Hos- pital.8 In Norway’s simple solu- tion, there is a glimmer of hope. The proper clinical use of an- tibacterial drugs In 1997, the ADA Council on Scientific Affairs issued a po- sition statement on Antibiotic Use in Dentistry.9 The Council stated: “Microbial resistance to antibiotics is increasing at an alarming rate. The major cause of this public health problem is the use of antibiotics in an inap- propriate manner, leading to the selection of dominance of resistant microorganisms and/ or the increased transfer of re- sistance genes from antibiotic- resistant to antibiotic-suscepti- ble microorganisms.”9 Thecouncil’spositionstatement further identified that “Antibiot- ics are properly employed only for the management of active infectious disease or the pre- vention of metastatic infection, such as infective endocardi- tis, in medically high-risk pa- tients.”9 One method of education is to teach from errors rather than principles. Psychologists from the University of Exeter have identified an “early warning signal” in the brain that helps us avoid repeating previous mistakes. Published in the Jour- nal of Cognitive Neuroscience,10 their research identifies for the first time, a mechanism in the brain that reacts, in just one- tenth of a second, to things that have resulted in us making er- rors in the past. Evaluating the following eight misconceptions or “myths” may help to estab- lish general guidelines to aid us in making clinical decisions regarding the use of antibiotic therapy, thereby leading to op- timum use and therapeutic suc- cess.11 Myth No. 1: Antibiotics cure pa- tients. Except in patients with a compromised immune system, antibiotics are not curative, but instead function to assist in the re-establishment of the proper balance between the host’s de- fenses (immune and inflamma- tory) and the invasive agent(s). Antibiotics do not cure patients; patients cure themselves. Myth No. 2: Antibiotics are sub- stitutes for surgical interven- tion. Very seldom are antibiot- ics an appropriate substitute for removal of the source of the infection (extraction, endo- dontic treatment, incision and drainage, periodontal scaling and root planing). Occasionally, when the infection is too diffuse or disseminated to identify a ni- dus for incision, or the clinical situation does not allow for im- mediate curative treatment, the prudent dentist will choose to place the patient on appropriate antibacterial therapy until such time as curative treatment can be implemented. It is impera- tive to remove the cause of the infection prior to, or concomi- tant with, antibiotic therapy, when the cause is readily iden- tifiable. Whenever antibiotic therapy is used, the risk of bac- terial selection for antibiotic re- sistance is present. Myth No. 3: The most impor- tant decision is which antibiotic to use. To avoid the deleterious effects of needless antibiotics on patients and the environ- ment, the most important initial decision is not which antibiotic to prescribe but whether to use one at all. It has been estimated that up to 60 percent of human infections resolve by host de- fenses alone following removal of the cause of the infection without antibiotic intervention. Endodontic disease is infec- tious. Microorganisms cause virtually all pathoses of the pulp and periapical tissues. There is ample evidence to support that opportunistic normal oral microbiata colonize in a symbi- otic relationship with the host, resulting in endodontic infec- tions.12 The majority of endo- dontic infections do not require systemic antibiotic therapy when the cause of the infection Endodontics: Colleagues for Excellence Table 1 Primary Reasons for Revision of Infective Endocarditis Guidelines 1. IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremias caused by a dental, GI tract or GU tract procedure. 2. Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who undergo a dental, GI tract or GU tract procedure. 3. The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy. 4. Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE. Table 2 Anitbiotic Prophylaxis Recommendations

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