Interview: “The story of antibiotics reads better than fiction”

Dr Sukumar, how did you become interested in the topic?
I became interested in antibiotic resistance by accident. Research was a component of my master’s degree in conservative dentistry at University College London Eastman Dental Institute. All the research topics were gone by the time I got there, and I was left with photodynamic therapy and its effect on methicillin-resistant Staphylococcus aureus. I never looked back.

The success of the drugs was diminished by their effectiveness and eventually they were overwhelmed by the defence mechanisms of the microorganisms they sought to destroy.

Antibiotic resistance has been established as a global public health crisis. What is the role of the dentist in attempting to limit the progression of antibiotic resistance?
We have certain responsibilities as prescribing clinicians. Firstly, we need to think carefully before we prescribe. It is easy to think “what difference will it make if I write a hurried script in a surgery tucked away from the chaos of hospitals and life-threatening emergencies?”. The reality is that it is the prescriptions written on a daily or weekly basis that feed into this well-established cycle of resistance.

The story of antibiotics reads better than fiction—its serendipitous discovery ushered in a new age of medicine.

Secondly, we should educate ourselves and our dental team, including auxiliaries, oral health therapists and receptionists, about antibiotic resistance. Antibiotics are not a quick fix to tide the patient over. The literature is unequivocal about this—antibiotics are an adjunct to almost all surgical interventions in dentistry.

Thirdly, we have a role to play in educating our patients. Sometimes these discussions are not easy, as there is a common belief that antibiotics are magic bullets that fix everything. I spend a significant amount of time explaining to my patients why they do not need antibiotics. Sometimes these conversations occur over multiple visits.

Many studies have shown that dentists often inappropriately prescribe antibiotics prior to a dental procedure. What are the reasons for overprescription of antibiotics in dentistry?
One of the main reasons for overprescription is a poor understanding of how antibiotics work. The most common misconception is that antibiotics reduce pain in acute endodontic episodes. A review of over 30 years of literature shows that antibiotics are not effective in doing this, yet the statistics indicate that many dentists worldwide persist in prescribing them. Patient demand also contributes to the issue. There is an especially telling US study that identifies common reasons why children are prescribed antibiotics, namely pressure from parents or unavailability of immediate appointments. Finally, we simply fail to follow the guidelines which specify what to prescribe and when.

What are some of the challenges in reducing antibiotic prescription and resistance?
I think some of the challenges we face were best illustrated in 2008 when the NICE [National Institute for Health and Care Excellence] clinical guidelines were amended in the UK. These guidelines essentially challenged the long-held belief that antibiotic prophylaxis was required prior to dental treatment for at-risk populations to prevent infective endocarditis. These changes caused an uproar, but more importantly, they pressed for a review of standard practice around the world. Consequently, reassessing best practices for providing dental care made dental professionals think about the evidence behind what we do, and that scrutiny and rigour continue today.

Our forte as dentists is to provide preventive advice—we are in the driver’s seat when it comes to initiating a conversation about inappropriate antibiotic prescription and resistance.

Nonetheless, the main challenge dental professionals are faced with is that a significant number of clinicians are still guided by what they were taught in dental schools or have learned from anecdotal evidence.

What is the government’s role in ensuring effective and appropriate dental care intervention?
This is a difficult question. In Australia, we only have universal medical care and access to dental care in the country is a significant issue. Various stakeholders are interested in improving oral health but have very different ideas about how to achieve this.

Effective and appropriate dental care means regular visits to the dentist and should result in improved oral health outcomes. Ideally, this would mean a reduction in acute episodes which may require adjunctive antibiotic prescription. However, we are increasingly aware of the role of oral health and disease and its systemic associations. Therefore, a healthier mouth should also result in improved general health outcomes. Healthy people are less likely to need a prescription for antibiotics or other medications.

The current review, titled “Think before you prescribe: How dentistry contributes to antibiotic resistance”, was published online on 15 October 2019 in the Australian Dental Journal, ahead of inclusion in an issue.

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