Dentists still write millions of prescriptions a year for an antibiotic with life-threatening risks

Owens’ hands, arms, and legs became swollen, and the skin on her arms became discolored. Her granddaughter, Aisha Ruiz, said she hesitated to apply hand lotion to Owens’ skin for fear that it would tear.

Flournoy remains haunted by his mother’s suffering. One question keeps repeating in his mind: Why are dentists still prescribing clindamycin?

Doing as they were taught

For decades, dental schools taught dentists to prescribe antibiotics to prevent procedure-related infections, Abt said.

Dentists were taught to prescribe a type of penicillin, called amoxicillin, because of its effectiveness and safety record. For patients such as Owens, whose medical record listed a penicillin allergy, dentists were taught to prescribe clindamycin.

Because bacteria from the mouth can travel around the body, dentists were taught to prescribe antibiotics to patients with certain heart conditions to prevent a rare but dangerous infection of the lining of the heart and valves, called infective endocarditis, Abt said. Dentists also routinely prescribed antibiotics to people with artificial joints, even if they were otherwise healthy, for fear that the joints could become infected, said Antonia F. Chen, MD, MBA, chair and professor of orthopedic surgery at University of Texas Southwestern.

Experts began to rethink these recommendations as the risks of clindamycin became more apparent. In 2015, researchers reported that a single dose of clindamycin could cause serious complications, including deaths, related to C difficile. 

“Dentists did not believe that their prescribing was associated with resistance or C difficile because they perceived their prescribing to be of short duration,” said Katie J. Suda, PharmD, a professor of medicine at the University of Pittsburgh. “They felt that one dose of antibiotic prior to a dental procedure was not associated with an adverse event.”

Dentists in separate silos

Hospitals have made significant progress against C difficile and antimicrobial resistance in recent decades, in large part because they’re required to implement antibiotic stewardship programs, which aim to reduce inappropriate antibiotic use.

But dentists, who work largely in private practice clinics outside hospitals, are seldom included in stewardship efforts. “Dentistry is at the beginning of antibiotic stewardship,” said Emily McDonald, MD, MPH, a medical officer in the office of antibiotic stewardship at the Centers for Disease Control and Prevention.

Although a dentist can check a database to see if someone has been prescribed opioids, there’s usually no way for dentists to learn which antibiotics a patient has taken, said Erinne Kennedy, DDS, a board member of the Association for Dental Safety. That’s because doctors and dentists tend to use incompatible electronic health record systems that can’t share information.

Without access to a person’s medical records, a dentist may have no way to know if a patient has previously been treated for C difficile, a major risk factor for a recurrent infection, unless the patient volunteers that information, Kennedy said.

Dentists also may not see the complications caused by inappropriate antibiotic use, said Christian Lillis, co-founder and CEO of the Peggy Lillis Foundation, an advocacy group that raises awareness about C difficile. Hospital-based physicians and nurses may be more aware of the risk of C difficile because patients with the infection, like Owens, tend to be hospitalized.

“When you get diarrhea after you go to the dentist, you don’t call your dentist. You go to the hospital or ER,” said Lillis, whose family launched the foundation after their mother died in 2010 due to a C difficile infection at age 56. “My mother was dead for three weeks before her dentist knew.”

Updating guidelines

In recent years, professional societies have worked to educate health care providers about the risks of antibiotics, recommending that dentists restrict their use to a relatively small group of patients with the greatest need or highest risk.

“Antibiotics are a very, very precious resource and a finite resource,” said Purnima Kumar, DDS, PhD, an ADA spokesperson and chair of periodontics and oral medicine at the University of Michigan School of Dentistry. “They must be reserved for a time when it is required and always be conserved for the patient who needs it.” 

But the ADA’s recommendations on clindamycin are nuanced.

While ADA guidelines still say that clindamycin can be used for treatment, the society has ruled it out as a prevention strategy, said B. Jason Kyles, DDS, clinical assistant professor of oral and maxillofacial pathology, radiology and medicine at the New York University College of Dentistry.

ADA guidelines state that antibiotics aren’t needed to treat dental infections that cause pain and swelling, except in limited circumstances. The guidelines include clindamycin as a possible choice to treat patients who are allergic to penicillin.

“The ADA has entirely abandoned recommending clindamycin for preventing heart and joint infections and strongly discourages it for treating them unless absolutely no other safe options exist,” Kyles said. Clindamycin is “now considered more of a last resort. Dentists are encouraged to use alternatives.”

Some dentists prescribe antibiotics more often than needed because of outside pressure, such as the fear of a lawsuit if a patient develops a serious infection. 

Pressure can also come from patients. Some expect antibiotics before or after invasive dental procedures, especially if they are used to receiving a prescription. Changing patient expectations isn’t easy, Kumar said.