Dental antibiotics

Editor, – I note the comments by Associate Professor Michael McCullough from the Australian Dental Association that antibiotics are not needed for the majority of dental infections (Aust Prescr 2010;33:71). However, access to public dentistry is limited and the wait for private dentists' appointments is often many weeks. Dental receptionists may tell patients who ring up for an appointment with a painful dental condition to go to the local doctor to get antibiotics. They often say 'because the dentist won't treat you unless you are on antibiotics'. Faced with a patient with a long and painful wait to see a dentist and a belief they have to be on antibiotics, it is impossible to not give a prescription. Why doesn't the dentist organise the antibiotics which 'must' be given?

Many of these patients may improve temporarily with anti-inflammatory drugs and perhaps the antibiotics. Then they decide they cannot afford to visit the dentist (if they were ever given an appointment at all).

Janet Watterson
General Practitioner
Pambula Medical Centre
Pambula, NSW

Associate Professor Michael McCullough, the author of the dental note, comments:

Dr Watterson's letter has prompted much discussion and much consternation amongst the members of the Dental Therapeutics Committee of the Australian Dental Association. She raises multiple concerns, including the under-resourced nature of public dentistry, the unprofessional activity of private dentists who do not offer prompt emergency appointments for their patients in pain, patients' expectations that antibiotics will cure toothache and their reluctance to seek appropriate definitive dental treatment, and the perceived high cost of dental treatment and the shortages of dentists, particularly in rural areas.

The vast majority of dental pain can be alleviated successfully by dental treatment without the need for systemic antibiotics. In many instances prescribing antibiotics could be seen as inappropriate. This has been one of the fundamental principles underlying dental education for the past several decades and permeates the recent Therapeutic Guidelines: Oral and Dental book made available to every member of the Australian Dental Association and to dental students. There are rare exceptions when a patient should take antibiotics before dental treatment and in these circumstances the antibiotics usually need to be taken immediately before treatment. Dentists are very capable of organising these prophylactic antibiotics. It would be inappropriate to rely on our medical colleagues to prescribe antibiotics many days – or even worse, weeks – before dental treatment without a dentist first examining and diagnosing the patient's dental problem.

Although a patient's pain may improve temporarily with anti-inflammatory drugs and antibiotics, this is not definitive treatment and it has the potential to lead to both the development of antibiotic resistance and a disastrous outcome for the patient. Every large tertiary hospital in Australia has cases requiring hospitalisation for extensive, potentially lethal, head and neck infections of dental origin. One survey reported 44 patients in one calendar year with 40% of these patients requiring intubation, high dependency or intensive care and prolonged hospitalisation. The majority of these patients had previously taken one or more courses of antibiotics to unsuccessfully treat their dental pain.¹

The perception that dentists will not treat patients unless they are taking a course of antibiotics is fundamentally wrong. Any dentist who believes this, or allows their staff to portray this attitude, needs to re-think their practice and attend further continuing education courses. Moreover, under the Dental Board of Australia's recently released Guidelines for Mandatory Notifications²it is stated that: '–the National Law defines 'notifiable conduct' as where a practitioner has – placed the public at risk of harm because the practitioner has practised the profession in a way that constitutes a significant departure from accepted professional standards'. It could well be argued that this behaviour is a significant departure from accepted professional standards.

The responsibility for the treatment of dental pain should lie entirely with the dentists. However, in reality there are large numbers of patients who seek medical care for their dental pain. Developing a relationship between local doctors and dentists and creating a dialogue such that patients in dental pain presenting to doctors can be helped to make appropriate emergency appointments with the local dentists will go a long way towards decreasing inappropriate treatment. Furthermore, dentists should also provide feedback to doctors on the treatment provided, as well as information regarding any patients who fail to attend appointments and delay seeking treatment. Such a dialogue would be in the best interests of the patients and would perhaps go a long way towards altering perceptions regarding the shortages of availability of dentists and the affordability of dental treatment. A very positive suggestion would be for local doctors and dentists to meet to address the problems. The Australian Dental Association via its state branches and local groups would probably be very pleased to facilitate such meetings.

To alleviate the shortage of dentists, there has been a significant increase in dental schools in Australia (from five in 2005 to the current number of nine). All new graduating dentists will be taught that, in the vast majority of patients, dental pain can be treated with dental treatment, without the need for either pre-treatment, or post-treatment antibiotics.