This is part 3 in a three-part series on potential harms from taking antibiotics for dental procedures. Part 1 was published February 24 and Part 2 yesterday. All three are available here.

If you’ve ever had a wisdom tooth removed, you probably received an antibiotic from your dentist. 

Dentists wrote 27.3 million antibiotic prescriptions last year, according to data provided exclusively to CIDRAP News by the IQVIA Institute for Human Data Science, an organization based in Parsippany, New Jersey, that provides research and analysis on health care data. Many of these antibiotics are unnecessary.

In a three-part series this week, CIDRAP News is investigating the overuse of antibiotics in dentistry, including changes that dentists and consumers can make to reduce the risk of harm.

Although 10% to 15% of dental antibiotics prescriptions are written for people with current infections, the rest are prescribed to people before or after a dental procedure “just in case” an infection develops, said Katie J. Suda, PharmD, a professor of medicine at the University of Pittsburgh. Research by Suda and her colleagues found that 80% of such preventive dental antibiotics are inappropriate.

Patients aren’t helped by taking unneeded medications, Suda said. Furthermore, any antibiotic can cause serious harm, including allergic reactions; infections with a superbug called Clostridioides difficile, or C difficile; and antimicrobial resistance, in which pathogens become impervious to even powerful medications.

“The more we use an antibiotic, the less effective it becomes,” said Debra Goff, PharmD, a professor of pharmacy practice at The Ohio State University College of Pharmacy and an infectious disease specialist at Ohio State’s Wexner Medical Center.

People can take a number of steps to avoid being exposed to inappropriate antibiotics, experts say.

Maintaining good oral health helps to prevent dental infections. If you develop pain or swelling in your mouth, call a dentist right away. With early treatment, many patients don’t need antibiotics, said Erinne Kennedy, DDS, MPH, a board member of the Association for Dental Safety. 

Research shows that most people who undergo dental procedures or who experience pain and swelling don’t need antibiotics, said Kennedy, who is also assistant dean for curriculum and learning at Kansas City College of Dental Medicine in Missouri. That evidence has led medical and dental societies to recommend them only for people with very specific health conditions or who have compromised immune systems. 

The American Dental Association (ADA) recommends antibiotics for people with tooth pain who also have a fever, chills, or other signs of a systemic infection (those affecting multiple organ systems). Although the best way to cure a dental infection is to immediately treat the tooth—such as by performing a root canal or extraction—ADA guidelines state that antibiotics may be appropriate for patients who can’t have definitive treatment right away, in order to prevent a localized infection from spreading, Kennedy said.

The American Heart Association (AHA) used to recommend preventive antibiotics before invasive dental procedures for people with a variety of heart conditions. Cardiologists were concerned about the very small risk that oral bacteria might travel to the heart and cause infective endocarditis, an inflammation of the lining of the heart or valves, in people undergoing such procedures, said Walter Wilson, MD, an infectious disease specialist at the Mayo Clinic in Rochester, Minnesota.

Today, Wilson said, the AHA recommends preventive antibiotics only for specific patients:

• People who have received an artificial heart valve or valve repair with artificial material
• Those who previously had infective endocarditis
• Patients with cyanotic congenital heart disease, a condition in which one or more structural problems with the heart's chambers, valves, or blood vessels are present at birth
• People who have had a heart transplant with valve disease 

Those four specific conditions put dental patients at the highest risk of death or severe illness from infective endocarditis. In its 2021 guidelines, the AHA singled out clindamycin as an antibiotic to avoid.

If your dentist suggests clindamycin, which has a high risk of causing C difficile infections, ask for a different antibiotic, said Amesh Adalja, MD, an infectious disease physician, critical care expert, and senior scholar at the Johns Hopkins Center for Health Security. C difficile infections, which cause severe diarrhea, can be life-threatening. 

But other antibiotics should be questioned as well.

“Any time a dentist wants to give you an antibiotic, ask, ‘Do I really need this?’” Adalja said.

If a dentist suggests an antibiotic, ask about its typical side effects, said Kevin C. Lee, MD, DDS, assistant professor of oral and maxillofacial surgery at the University of Washington Harborview Medical Center. While all drugs have side effects, if you are concerned about a particular antibiotic’s side effects, your dentist may be able to prescribe an alternative.

Additional questions to ask include: Which side effects are normal? Which side effects might signal a serious complication? Under which circumstances should I call you? How can I reach you after hours? When should I contact a medical doctor or go to the emergency department?