Why do dentists prescribe antibiotic prophylaxis so often?

Because they can.

Why am I dissing my dental colleagues? Because I can.

Perhaps, this is a simple case of dental envy, since their profession remains within secure borders far beyond the health care reform line of fire. Consider these dental incidentals:

• Not a syllable in the ~2000 page health care reform law that affects dentists. Every filling is still worth its weight in gold
• Dentists recover every dime they bill. If their fee is a gazillion dollars, and your generous dental insurance, covers fifty bucks, guess what? There will be a very large cavity in your bank account
• No middle of the night runs to the emergency room, a drill that we physicians endure
• No hospital work, which for many physicians has become an inefficient hassle which became the root of a new medical specialty
• Dentists don’t need an attorney on retainer, or caps on non-economic damages, as their malpractice situation is calm
• We still call them “doctor”

Dentists prescribe prophylactic antibiotics (ATBs) with routine recklessness. Of course, we physicians are also culpable of antimicrobial mania. We all prescribe too many antibiotics for too many days for too many viral illnesses. It has been a tough slog to teach our profession to prescribe antimicrobial agents more judiciously. In fact, it’s been like pulling teeth.

Entrenched physician habits and patient expectations are hard to change. Look how long it took for Americans to accept and practice seat belt safety. When I was a kid, I remember my parents buckling the belts behind them so they wouldn’t hear the annoying warning buzzer. It took a generation of intense education to change cigarette smoking behavior.

Many dentists irrationally prescribe ATBs before teeth cleanings and other procedures. But the vast majority of prophylactic ATBs that dentists prescribe are unnecessary. The theory is to protect the patient’s heart from becoming infected by bacteria that are released into the blood stream during a dental procedure. The missing piece is the absence of a shred of science supporting this practice. Keep in mind that live humans release bacteria into the blood stream during routine tooth brushing and defecation, but I doubt that heart murmur patients are advised to pop penicillin each time they are about to engage in either of these two high risk behaviors.

When physicians and dentists prescribe unnecessary ATBS, there are many adverse consequences. Here is a sampling.

* Money is wasted.
* Resistant bacteria emerge that can be more difficult to treat.
* It teaches patients to expect and demand ATBs when they are not indicated.
* Potential of serious side-effects and drug interactions.

For example, there is a condition called pseudomembranous colitis caused by the germ Clostridium difficile, affectionately known as C. diff. The primary cause of this diarrheal disease is ATBs. There isn’t a hospital in the country that is not struggling with this stubborn and serious disease. Some of these patients have died or had their entire colons removed. Once the germ is present in your large intestine, or colon, it can be impossible to eradicate. I see a case of C. diff at least every week. For some of these unlucky folks, C. diff becomes a chronic disease.

I have seen many C. diff cases that developed from brief courses of antibiotics prescribed by dentists and physicians. Some of these patients now have an incurable gastrointestinal affliction caused by just a few ATB pills. I help these folks as best I can. I don’t think it helps them for me to share that they never needed the ATBs in the first place. This inconvenient truth would be too hard for them to swallow. I wish that their ATBs had been too hard to swallow.

The next time that your dentist, or your physician, recommends an ATB –- or you demand one -– think again. Is it worth the risk of beating your colon into a pulp?

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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