The World Health Organization (WHO) endorsed a global action plan in 2015 to combat increasing antimicrobial resistance, and stewardship was promoted as one of the main strategies to tackle this problem.¹ Antimicrobial stewardship (AMS) is a responsibility of both inpatient and outpatient providers to improve antibiotic prescribing without a negative impact on patient outcomes. Most oral antibiotics are prescribed by outpatient physicians, and dentists order ˜10% of those prescriptions.^{Reference Roberts, Bartoces and Thompson2} Physicians first need to recognize the issue of antibiotic resistance and their inappropriate prescribing practice to convince them to be part of AMS efforts.^{Reference Zetts, Stoesz and Garcia3}

Although most dental diseases are primarily managed by oral hygiene measures and operative intervention, dentists commonly prescribe antibiotics in following scenarios: primary prophylaxis during the perioperative period to decrease the risk of surgical site infection, secondary prophylaxis to prevention infective endocarditis in certain heart conditions before certain dental procedures (involving manipulation of gingival or periapical tissue or perforation of oral mucosa), and treatment of dental infections. In 2007, the American Heart Association (AHA) revised the guidelines to limit prophylaxis to only high-risk individuals to prevent infective endocarditis because the risks outweigh the benefits and because antibiotic resistance is increasing.^{Reference Wilson, Taubert and Gewitz4} In 2015, the American Dental Association (ADA) recommended generally avoiding prophylactic antibiotics for patients with prosthetic joint implants; rather, they recommended discussion regarding antibiotic use between the orthopedic surgeon and patients with a history of complications associated with their joint replacement surgery.^{Reference Sollecito, Abt and Lockhart5} Furthermore, 2019 ADA guidelines recommended against the use of antibiotics for urgent management of pulpal- and periapical-related dental pain and intraoral swelling and emphasized the use of dental treatment only.^{Reference Lockhart, Tampi and Abt6}

The rate of antibiotic prescriptions by dentists has increased over the last decade.^{Reference Marra, George and Chong7} Potential factors behind this increase include lack of awareness of prophylaxis guideline updates or slow adoption of updated guidelines and increased perioperative prophylaxis where recommendations may not be very strong (eg, dental implantation) due to lack of national guidelines for treatment of specific dental conditions. In certain regions with less coverage by dental insurance, antibiotics may be prescribed in lieu of surgery. Sometimes, antibiotics are prescribed due to the patient’s expectation of receiving an antibiotic with a dental procedure.

A study by Thompson et al.^{Reference Thompson, TeoH and Hubbard8} revealed wide variation in dental antibiotic prescribing among the United States, British Columbia, England, and Australia. This variation at the international level may not be entirely surprising because each country has its own guidelines and because access to dental care and the availability of antibiotics vary as well. The United States had the highest rate of antibiotic prescription, and Australia had the lowest prescribing rate. The highest rate was not due to greater population in the United States because this difference existed even when the antibiotic prescriptions were calculated per 1,000 population. Amoxicillin was the most commonly prescribed antibiotics among all 4 countries, followed by clindamycin, which was the second most common prescribed antibiotic in the United States and British Columbia. Other antibiotics used in these countries included penicillin, metronidazole, amoxicillin-clavulanate, and azithromycin. These high numbers represent an opportunity to improve the antibiotic prescribing practices by dentists.

Another factor that deserves attention is recognizing true penicillin allergy in patients. Although 10% of the US patients report history of allergic reaction to penicillin, only <1% have true penicillin allergy.⁹ Penicillin-allergic patients can be referred to local allergists for appropriate testing and can have this label removed if they are confirmed to be nonallergic. This would decrease the use of second-line broad-spectrum options and lead to more optimal prescribing in the future.

Dental AMS programs are needed across North America, as indicated by Thompson et al.^{Reference Thompson, TeoH and Hubbard8} The need for increasing awareness for appropriate use of antibiotics is growing, including an understanding of the indications for antibiotic use in scenarios from dental prophylaxis to treatment. The potential for undesired consequences like drug allergies, gastrointestinal side effects (eg, nausea, vomiting, diarrhea) and Clostridium difficile infections must also be considered. Inappropriate antibiotic use further increases the utilization of healthcare resources at different levels, such emergency rooms, urgent care visits, and hospital admissions for management of adverse effects. Because dental care is primarily an outpatient service, awareness of local antimicrobial resistance patterns and Clostridium difficile infections may be lacking. Inadvertent antibiotic use may continue as those patients seek medical care from their primary care physicians instead or are hospitalized to treat these conditions.

Because most dental practices are private ownerships, it can be challenging to monitor dental prescribing unless it is linked to an academic institution. Nevertheless, several measures at different levels can be implemented to improve the antibiotic prescribing practices. Education should begin at dental schools by including topics about appropriate antibiotic choice, duration, and indications in the curriculum. After transition into their professional careers, this education should continue in mandatory continuous medical education (CME) courses promoted by national dental associations (for licensure) and board (certification). Improving appropriate antibiotic prescriptions is a quality improvement effort that could be merged into a maintenance of certification project. National and international conferences should be used as platforms for increasing awareness. Dentists already practicing stewardship could share their experiences in newsletters or conferences to illustrate real-life challenges so that practical solutions can be sought. Antibiotic prescription audits can be considered by individual dental practices with feedback from local infectious diseases physicians or pharmacists in a targeted approach. These audits may be viewed skeptically initially, but they should not be perceived as “criticism.” It is also important to increase public awareness about the need for appropriate antibiotic prescribing, which could start with informative posters on this topic in waiting rooms.

Dental guidelines should emphasize the appropriate use of antibiotics and should promote the awareness of these guidelines as well. Future studies should include obtaining data on indications for antibiotic use, their dose and duration, reasons for choosing broad-spectrum antibiotics, ascertaining whether a patient has a true penicillin allergy, and prescriptions due to lack of understanding of appropriate choices. Detailed information on these topics can be used to target these areas for better outcomes.

In conclusion, medical providers from different fields should join hands in this important endeavor to improve the quality of patient care by prescribing the right antibiotic, at right dose, for the right duration and the right indication, as proposed by the Centers for Disease Control (CDC). A multipronged approach is needed to address this issue with emphasis on education, increasing awareness of guidelines and audit-and-feedback would help sustain these changes. Change is always difficult in the beginning, but we need to break this inertia to accomplish a meaningful contribution to society. Future research studies will continue to enlighten us about the gravity of increasing antimicrobial resistance and will encourage providers to make right decisions for their patients.