According to the WHO, antibiotic resistance (AR) is 1 of the top 10 global health threats.1,2 In fact, AR is already a leading cause of death globally.3 It has been estimated that if it continues at the current rate, by 2050 antimicrobial-resistant infections will be responsible for 10 million deaths annually, surpassing the number of annual deaths caused by cancer.4
Antibiotics are widely used for oral health conditions and oral surgery. In human healthcare within the US, dentists have been found to be responsible for 10% of all outpatient antibiotic prescriptions.5 Given the high prevalence of dental fractures,6 periodontal disease,7 and maxillofacial trauma8 in small animals, it is likely that antibiotics used for oral health conditions also represent a significant portion of veterinary antibiotic prescriptions. As antibiotic misuse and overuse are major contributing factors to AR,9,10 antibiotic use in veterinary dentistry and oral surgery is an important focus for antibiotic stewardship.
The antibiotic stewardship definitions and core principles published by the AVMA advocate for an evidenced-based approach to antibiotic use, including the utilization of relevant guidelines for judicious use.11 The International Society for Companion Animal Infectious Diseases has developed veterinary antibiotic use guidelines regarding urinary12 and respiratory tract13 infections in dogs and cats and superficial bacterial folliculitis in dogs.14 These guidelines are open access and easily accessible to all general practitioners and specialists.
In human dentistry, there are multiple antibiotic prophylaxis guidelines available to dental practitioners. These include guidelines from the American Heart Association (AHA) for the prevention of infective endocarditis (IE),15 guidelines by the American Academy of Orthopaedic Surgeons for the prevention of implant infections,16 and guidelines from the American Dental Association regarding antibiotic use for pain and swelling of endodontic origin.17 The American Animal Hospital Association briefly addresses antibiotic use for dental cleanings and periodontal therapy,18 and the American Veterinary Dental College (AVDC) has published a broad position statement on the use of antibiotics in veterinary dentistry.19 However, there are no widely available guidelines specifically focused on the judicious use of antibiotics in veterinary dentistry and oral surgery. Finally, despite dental procedures being among the most common procedures performed in small animal general practice, neither the prevalence nor the indications for antibiotic use in veterinary dentistry are well documented, limiting any conclusions regarding targets for antibiotic stewardship.
The goal of this survey study was to develop an understanding of the current knowledge, attitudes, and practices regarding antibiotic use among veterinary dentists globally who are board certified by the AVDC. This will help to determine areas of consistency in prescribing practices among dental specialists and areas where further investigation is warranted. Assessing the present state of knowledge, attitudes, and usage of antibiotics is a crucial measure to identify strategies for enhancing antibiotic stewardship in the field of veterinary dentistry and the first step in creating guidelines for judicious antibiotic use.
Methods
A survey containing 30 questions (Supplementary Material S1) was developed using an online survey program (Qualtrics; January 2023). The survey was approved by the AVDC board before being sent. The University of California-Davis Institutional Review Board determined that ethical approval was not needed due to the survey nature of the study. Survey participation was voluntary. The survey was pretested by the members of the AVDC board and 4 residents in dentistry and oral surgery to ensure comprehensiveness and readability before distribution. The survey was sent in December of 2022 through an email listserv to members of the AVDC. The survey was open for a total of 6 weeks, and links to the survey were sent on 2 separate occasions 4 weeks apart. Survey categories were (1) Demographics, which focused on time since veterinary school graduation, time since board certification, type of practice (academia vs private practice), and location of practice; (2) Antibiotic Knowledge, which asked about the overall risk of AR with antibiotic use and indications for intraoperative and postoperative antibiotics; and (3) Antibiotic Practice, which asked about antibiotic use for prevention and treatment of infection. Questions included multiple choice and true/false. The Antibiotic Practice section also allowed for write-in responses. Responses were summarized as frequencies and percentages. Fisher exact test and logistic regression were used to evaluate univariate and multivariable associations, respectively. Statistical significance was determined at P < .05.
Results
There were a total of 116 respondents. Of these, 104 were board-certified veterinary dentists and 12 were current residents in training or veterinarians who had completed a residency but had not yet achieved board certification. For the purposes of this study, only responses from board-certified veterinary dentists are reported here and included in analyses. Not all questions were answered by all respondents.
Demographics
All major geographic regions within the US were represented; 20.2% of responses were obtained from clinicians with practices outside of the US. The majority of respondents (77.8%; 81/104) had been licensed veterinarians for more than 15 years at the time of the survey. Years of board certification were variable; 47.1% (49/104) reported being board certified for more than 10 years and 52.9% (55/109) for less than 10 years. The most common practice setting was dentistry-only private practice (47.1%; 49/104), followed by multispecialist private practice (29.8%; 31/104). The remainder of listed their practice setting as academia (15.4%; 16/104) or other (7.7%; 8/104).
Antibiotic knowledge and attitudes: risk of AR
The majority (96.0%; 96/100; 95% CI, 92.2% to 99.8%) of respondents believed that antibiotic-resistant organisms can be transmitted between pets and humans and that antibiotic use in pets contributes to the burden of AR in humans. Specifically, 53.5% (53/99; 95% CI, 43.7% to 63.4%) believed this was very likely, 40.4% (40/99; 95% CI, 30.7% to 50.1%) believed this was likely, 5.1% (5/99; 95% CI, 0.7% to 9.4%) thought this was unlikely, and 1.0% (1/99; 95% CI, 0% to 3.0%) thought this was very unlikely. The difference in response between those in private practice or academia was not statistically significant (P = 1.0).
Antibiotic knowledge and attitudes: intraoperative antibiotics
Out of the respondents, 56.6% (56/99; 95% CI, 46.8% to 66.3%) agreed that intraoperative antibiotics have not been shown to reduce distant infections. Conversely, 25.3% (25/99; 95% CI, 16.7% to 33.1%) believed this was true and 18.2% (18/99; 95% CI, 10.5% to 25.8%) were unsure. When asked specifically if IE has been consistently associated with dental prophylaxis and/or oral surgery, 90.0% (90/100; 95% CI, 84.1% to 95.9%) answered this was false, while 4.0% (4/100; 95% CI, 0.2% to 7.8%) said this was true and 6.0% (6/100; 95% CI, 1.4% to 10.7%) were unsure.
Approximately two-thirds of respondents (65.6%; 65/99; 95% CI, 56.3% to 75.0%) felt that intraoperative antibiotics should be given 30 minutes before scaling. The remainder stated they would give the injection at the beginning of scaling (33.3%; 33/99; 95% CI, 24.1% to 42.6%). Only 1 respondent stated they would give the injection at the end of the procedure (1.0%; 1/99; 95% CI, 0% to 3.0%).
Antibiotic knowledge and attitudes: postoperative antibiotics
More than half (57.1%; 56/98; 95% CI, 47.3% to 66.9%) of respondents did not believe that postoperative antibiotics for dental and oral surgery procedures reduce local postoperative infection rates, while 22.4% (22/98; 95% CI, 14.2% to 30.7%) believed this was true and 20.4% (20/98; 95% CI, 12.4% to 28.4%) were unsure. The differences in responses among dentists based on the duration of board certification (P = .81) or type of practice were not statistically significant (P = .18).
When prescribing postoperative antibiotics, 60.0% (60/100; 95% CI, 50.4% to 69.6%) believed that a minimum duration (eg, a 7-day course) should be completed to prevent the emergence of AR. The remainder stated this was false (22.0%; 22/100; 95% CI, 13.9% to 30.1%) or were unsure (18.0%; 18/100; 95% CI, 10.5% to 25.5%).
Antibiotic practice: prevention of infection
Most board-certified veterinary dentists reported that they use prophylactic intraoperative antibiotics sparingly (Table 1). No significant difference in estimated intraoperative antibiotic administration was found between practice type, years as a boarded dentist, and perceived human risk of AR from veterinary antibiotic use using univariate analysis (Table 2). Those who believed postoperative antibiotics reduce local postoperative infection rates were significantly more likely to report administering intraoperative antibiotics to > 10% of patients compared to those who did not believe postoperative antibiotics influence infection rates. This association did not change when adjusted for practice type, years as a boarded dentist, and perceived human risk of AR from veterinary antibiotic use. When intraoperative antibiotics are given, 46.7% (43/92; 95% CI, 36.5% to 56.9%) report they give them 30 to 60 minutes before surgery/scaling and 41.3% (38/92; 95% CI, 31.2% to 51.4%) administer them at the beginning of the surgery/scaling. The remainder responded at the end of scaling (3.3%; 3/92; 95% CI, 0% to 6.9%) or other (8.7%; 8/92; 95% CI, 2.9% to 14.5%).
Percentage of small animal dentistry patients that are reported to receive intraoperative antibiotics as reported by survey of 104 American Veterinary Dental College board-certified dentists.
| Percentage of patients that receive intraoperative antibiotics | Total responses | Error margin (95% CI) |
|---|---|---|
| < 10% | 57.4% (54/94) | 50.4%–69.6% |
| 10%–19% | 20.2% (19/94) | 12.1%–28.3% |
| 20%–89% | 14.9% (14/94) | 7.7%–22.1% |
| 90%–100% | 7.4% (7/94) | 2.1%–12.8% |
Unadjusted and adjusted analyses of selected variables and the reported percentage of patients (> 10%) that receive prophylactic intraoperative antibiotics.
| Variable | Q16: percentage of dentists that prescribe antibiotics to > 10% of their patients (%; 95% CI) | Univariate (Fisher exact test) P value | Multivariable (logistic regression) P value | Multivariable (logistic regression) OR (95% CI) |
|---|---|---|---|---|
| Q2: years as boarded dentist | ||||
| > 10 years (n = 44) | 15/44 (34.1; 20.1–48.1) | .15 | .10 | 0.47 (0.19–1.2) |
| < 10 years* (n = 50) | 25/50 (50.0; 36.1–63.9) | |||
| Q4: practice type | ||||
| Private practice (n = 77) | 34/77 (44.2; 33.1–55.3) | .77 | .85 | 1.1 (0.32– 4.0) |
| Academia* (n = 14) | 5/14 (35.7; 10.6–60.8) | |||
| Q7: antibiotic use in animals influences AR in humans | ||||
| Likely/very likely (n = 87) | 36/87 (41.4; 31.0–51.7) | .40 | .34 | 0.41 (0.07–2.6) |
| Unlikely/very unlikely* (n = 6) | 4/6 (66.7; 29.0–100) | |||
| Q8: postoperative antibiotics reduce postoperative oral infection rates | ||||
| True (n = 20) | 14/20 (70.0; 49.9–90.1) | .01 | .01 | 4.6 (1.5–14.3) |
| False/unsure* (n = 72) | 25/72 (34.7; 23.7–45.7) |
Variables include years as a boarded dentist (Q2), practice type (Q4), perceived relationship between antibiotic use in animals and antibiotic resistance (AR) in humans (Q7), and belief that postoperative antibiotics reduce postoperative infection rates (Q8).
Reference value.
Ampicillin was the most commonly reported first-choice injectable intraoperative antibiotic, and clindamycin was the most common second-choice intraoperative injectable antibiotic (Table 3). Others mentioned using penicillin and metronidazole. For postoperative oral antibiotics, amoxicillin/clavulanic acid was the most commonly reported first choice and clindamycin was the most common second choice. Some reported use of cefovecin, cefpodoxime, and cephalexin.
Intra- and postoperative antibiotic selections preferred by 104 American Veterinary Dental College board-certified dentists.
| Intraoperative injectable antibiotic choice | Postoperative oral antibiotic choice | ||||
|---|---|---|---|---|---|
| Antibiotic | First choice % (95% CI) | Second choice % (95% CI) | Antibiotic | First choice % (95% CI) | Second choice % (95% CI) |
| Ampicillin | 38.7 (28.8–48.6) | 16.5 (44.7–65.2) | Amoxicillin/clavulanic acid | 52.7 (48.5–69.6) | 32.2 (22.6–41.9) |
| n = 36/93 | n = 15/91 | n = 49/83 | n = 29/90 | ||
| Ampicillin/sulbactam | 28.0 (18.8–37.1) | 11.0 (4.6–17.4) | Clindamycin | 36.6 (26.8–46.3) | 42.2 (32.0–52.4) |
| n = 26/93 | n = 10/91 | n = 34/93 | n = 38/90 | ||
| Clindamycin | 15.1 (7.8–22.3) | 28.6 (19.3–37.9) | Doxycycline | 3.2 (0–6.8) | 5.6 (0.8–10.3) |
| n = 14/93 | n = 26/91 | n = 3/93 | n = 5/90 | ||
| Cefazolin | 8.6 (2.9–14.3) | 19.8 (11.6–28.0) | Amoxicillin | 2.2 (0–5.1) | 2.2 (0 –5.3) |
| n = 8/93 | n = 18/91 | n = 2/93 | n = 2/90 | ||
| Cefovecin | 6.5 (1.5–11.4) | 16.5 (8.9–24.1) | Metronidazole | 1.1 (0–3.2) | 11.1 (4.6–17.6) |
| n = 6/93 | n = 15/91 | n = 1/93 | n = 10/90 | ||
| Other (penicillin, metronidazole, none) | 3.2 (0–6.8) | 7.7 (2.2–13.2) | Other (cefovecin, cefpodoxime, cephalexin, none) | 4.3 (0.2–8.4) | 6.7 (1.5–11.8) |
| n = 3/93 | n = 7/91 | n = 4/93 | n = 6/90 | ||
The comorbidities for which respondents reported they would likely administer intraoperative antibiotics during professional scaling (with or without extractions) were historic IE and immunosuppression due to steroid use (Table 4). Most (69.2%; 63/91; 95% CI, 59.7% to 78.7%) would not also provide postoperative antibiotics following the scaling, regardless of whether extractions were performed or not.
Percentage of 104 American Veterinary Dental College board-certified dentists recommending intraoperative antibiotics for patients with comorbid conditions undergoing professional scaling and polishing with or without extractions.
| Comorbidity | Percentage (95% CI) of respondents give intraoperative antibiotics with cleaning ONLY (n = 81) | Percentage (95% CI) of respondents give intraoperative antibiotics with cleaning AND extractions (n = 88) |
|---|---|---|
| Historic IE | 76.5 (67.3–85.8) | 73.9 (64.7–83.0) |
| n = 62/81 | n = 65/88 | |
| Immunosuppressive steroids | 69.1 (59.1–79.2) | 76.1 (67.2–85.0) |
| n = 56/81 | n = 67/88 | |
| Prosthetic joint < 6 months ago | 59.3 (48.6–70.0) | 65.9 (56.0–75.8) |
| n = 48/81 | n = 58/88 | |
| Pacemaker | 58.0 (47.3–68.8) | 60.2 (50.0–70.5) |
| n = 47/81 | n = 53/88 | |
| Uncontrolled endocrine disease | 53.1 (42.2–64.0) | 67.0 (57.2–76.9) |
| n = 43/81 | n = 59/88 | |
| Subaortic stenosis | 50.6 (39.7–61.5) | 55.7 (45.3–66.1) |
| n = 41/81 | n = 49/88 | |
| Implant near a joint < 6 months ago | 45.7 (34.8–56.5) | 52.3 (41.8–62.7) |
| n = 37/81 | n = 46/88 | |
| Unrepaired cyanotic congenital heart defect | 42.0 (31.2–52.7) | 42.2 (32.8–53.5) |
| n = 34/81 | n = 38/88 | |
| FIV-positive cat | 32.1 (21.9–42.3) | 36.4 (26.3–46.4) |
| n = 26/81 | n = 32/88 | |
| FeLV-positive cat | 27.2 (17.5–36.9) | 31.8 (22.1–41.6) |
| n = 22/81 | n = 28/88 | |
| Prosthetic joint > 6 months ago | 25.9 (16.4–35.5) | 30.7 (21.1–40.3) |
| n = 21/81 | n = 27/88 | |
| Degenerative valve disease | 23.5 (14.2–32.7) | 27.3 (18.0–36.6) |
| n = 19/81 | n = 24/88 | |
| Severe hepatic disease | 23.5 (14.2–32.7) | 30.7 (21.1–40.3) |
| n = 19/81 | n = 27/88 | |
| Renal disease, IRIS stage 2+ | 19.8 (11.1–28.4) | 25.0 (15.6–34.1) |
| n = 16/81 | n = 22/88 | |
| Implant near a joint > 6 months ago | 17.3 (9.1–25.5) | 25.0 (15.6–34.1) |
| n = 14/81 | n = 22/88 | |
| Controlled endocrine disease | 11.1 (4.3–18.0) | 14.8 (7.4–22.2) |
| n = 9/81 | n = 13/88 | |
| Immunocompetent (ie, no comorbidities) | 11.1 (4.3–18.0) | 12.5 (5.6–19.4) |
| n = 9/81 | n = 11/88 | |
| Anti-inflammatory steroids | 8.6 (2.5–14.8) | 10.2 (3.9–16.6) |
| n = 7/81 | n = 9/88 |
IE = Infective endocarditis. IRIS = International Renal Interest Society.
Respondents were also asked about intraoperative and postoperative antibiotic use in relation to specific procedures in otherwise healthy patients. For each procedure, the percentage of specialists who reported they would use intraoperative and postoperative antibiotics to prevent infection was similar. Jaw fracture was the procedure with the highest percentage of respondents, with 82.9% (62/76) and 83.5% (66/79) of respondents electing to use intraoperative and postoperative antibiotics, respectively (Figure 1).
Percentage of respondents would elect to use intraoperative (n = 76) and postoperative antibiotics (n = 79) based on procedure type. CR/X and VPT = Crown reduction and vital pulp therapy. GTR = Guided tissue regeneration. PD4 = Periodontal disease stage 4. Error bars represent 95% CIs.
Citation: Journal of the American Veterinary Medical Association 261, S2; 10.2460/javma.23.06.0304
When asked for additional comments on specific criteria for antibiotic use, responses generally included comorbidities or specific procedures that were already represented within the multiple-choice questions. Free-text responses indicated that participants felt the following additional situations were indications for antibiotic use: diagnosis of osteomyelitis, history of splenectomy, maxillofacial trauma caused by animal bite wounds, and patients receiving antibiotics at the time of surgery. Respondents also reported a reduction in antibiotic use compared to how they were taught to use antibiotics in their training.
Antibiotic practice: treatment of infection
In the face of active infection, 10.6% (10/94; 95% CI, 4.4% to 16.9%) reported that they perform culture and susceptibility routinely, while 71.3% (67/94; 95% CI, 62.1% to 80.4%) responded this is rare. The majority (72.0%; 67/93; 95% CI, 62.9% to 81.1%) prescribe antibiotics for a duration of 5 to 10 days. When asked what factors influenced antibiotic duration decision-making, the answers could be classified into 3 broad categories: severity/extent of infection, previous experience or education, and patient-specific comorbidities.
Almost all (95.8%; 91/95; 95% CI, 91.7% to 99.8%) of veterinary dentists surveyed agreed that the development of more specific antibiotic use guidelines for veterinary dentistry and oral surgery would help to reduce the inappropriate use of antibiotics.
Discussion
The vast majority of surveyed AVDC veterinary dentists believe that AR is a potential problem in animals undergoing dentistry and oral surgery procedures and that AR in animals may pose a risk to AR in humans. Respondents agreed that specific guidelines for the judicious use of antibiotic therapy in veterinary dentistry are essential. Despite the presence of this fundamental knowledge, there was variability in attitudes and practice of prescribing intraoperative and postoperative antibiotics for dental procedures.
Multiple studies in humans have shown that postoperative antibiotics are not protective against local infection after extractions20 or other oral and maxillofacial surgeries.21,22 The majority of veterinary dentists responding to this survey did not believe that postoperative antibiotics reduce local postoperative infection rates. This belief is supported by a recent retrospective study23 of 266 dogs undergoing oral and maxillofacial surgery for the treatment of oral tumors, which showed that antibiotic prophylaxis (intraoperative and postoperative) was not protective against surgical site infection. However, those respondents who did believe that postoperative antibiotics reduce local infection after surgery were also more likely to give intraoperative antibiotics. Perioperative antibiotic use remains controversial. Although there is limited scientific evidence to support the use, studies21,24 in humans often recommend a single preoperative dose of antibiotics for maxillofacial and oral surgeries.
Reported utilization of intraoperative antibiotics by veterinary dentists in this study was not different between those practicing in academia versus private practice or between those boarded for less or more than 10 years. These findings may have been biased by the low numbers of respondents from academia, or practices between academia and private practice may be similar. The belief that antibiotic use leads to AR in humans was also not a factor in the reported use of intraoperative antibiotics. However, given that 92% of respondents felt it was likely or very likely that veterinary antibiotic use leads to AR in humans, the authors cannot discount a type 2 error.
The authors were also interested in what comorbidities or procedures most respondents considered to be an indication for antibiotic use and how this differed when only a dental cleaning was performed versus a cleaning with extractions. Interestingly, extractions did not seem to factor in the decision-making. Rather, respondents reported that they use antibiotics for dental cleanings, both with and without extractions, if their patients had a history of IE, immunosuppressive steroid use, prosthetic joint implant placement within 6 months, a pacemaker, or uncontrolled endocrine disease. In all cases, more than half of respondents would give intraoperative antibiotics for these conditions, and nearly 3 out of 4 dentists report that they routinely prescribe intraoperative antibiotics for historical IE and for patients on immunosuppressive steroid doses.
To date, the authors are aware of only 1 case report25 documenting a patient who developed IE after a dental procedure. Given the high prevalence of periodontal disease in dogs,7 the fact that there remains only a single case report linking the 2 events suggests the risk of IE developing after a dental procedure is low. Additionally, a 2009 study26 that evaluated 76 dogs with endocarditis and 80 control dogs without IE found no association between dental procedures or infection and the development of IE. However, some specific cardiac conditions such as historic IE, aortic or subaortic stenosis, patent ductus arteriosus, unrepaired cyanotic congenital heart disease, and embedded pacemaker leads are likely to be predisposing factors to IE in dogs and have been suggested as criteria for antibiotic prophylaxis in dental procedures that are expected to cause hemorrhage, including periodontal or endodontic surgery.27
In regard to IE in human dental patients, the most recent scientific statement update from the AHA states that antibiotic prophylaxis is only recommended for patients with previous, relapse, or recurrent IE, prosthetic cardiac valve or material, congenital heart defects, and cardiac transplant recipients for procedures where there is manipulation of the gingival tissue, the periapical region of the teeth, or perforation of the oral mucosa.28 Additionally, the AHA states that IE is more likely to occur secondary to routine daily activities, like chewing and brushing, rather than dental procedures, and that maintenance of good oral health is considered more important for the prevention of IE than antibiotic prophylaxis.28
A considerable proportion of veterinary dentists indicated that they would administer intraoperative antibiotics to a patient with an implant near a joint that was placed less than 6 months ago. To the authors' knowledge, there are no studies or case reports that show dogs with implants placed during tibial plateau leveling osteotomy surgery or prosthetic joint implants are at risk of implant infection secondary to dental disease or a dental procedure. Similarly, in human medicine, prosthetic joint infection associated with dental procedures is uncommon.29 Thus, for the majority of patients with prosthetic implants, the American Academy of Orthopaedic Surgeons and the American Dental Association do not recommend antibiotic prophylaxis due to the lack of evidence that dental procedures cause implant infection and due to the potential harms of antibiotic use.16,30
The majority of veterinary dentists considered intraoperative antibiotics to be indicated for patients with uncontrolled endocrine disease who are undergoing a dental cleaning with extractions. A study31 of 239 dogs and cats found that patients with concurrent endocrinopathy were more likely to develop infection after clean-contaminated surgical procedures, but there was no association between antibiotic use and development of wound infection. However, a newer study32 found no association between the risk of surgical site infection and endocrinopathy, but preoperative hyperglycemia and the use of anti-inflammatory steroids were identified as risk factors. Further studies are needed to determine if antibiotic prophylaxis is indicated in clean-contaminated surgeries and specifically dental procedures for patients with endocrinopathies or on steroid medications.
For healthy patients lacking comorbid conditions, veterinary dentists reported that they would provide intraoperative antibiotics for common procedures including jaw fracture repair, maxillectomy/mandibulectomy, and treatment of periapical lucencies or stage 4 periodontal disease. The frequency of antibiotic use in jaw fracture repair and major maxillofacial surgery is consistent with human guidelines, where perioperative antibiotics but not postoperative antibiotics are often recommended for maxillofacial fractures and oncologic surgery.21,22,24 However, in human medicine, the guidelines do not support the use of antibiotics for symptomatic periapical infection without systemic involvement.17 Additionally, in humans with chronic periodontitis, scaling and root planing is the initial treatment of choice, but there are varying recommendations and practices for the use of systemic antibiotics after mechanical debridement.33,34
The majority of dentists reported that they rarely perform culture and susceptibility testing when treating active oral infections. They also reported to most commonly use first-tier antibiotics35 (ie, those that are recommended in the absence of culture and susceptibility testing) to treat oral infections. These included penicillins (ie, amoxicillin, ampicillin), potentiated penicillins (ie, amoxicillin/clavulanic acid, ampicillin/sulbactam), and lincosamides (ie, clindamycin). It is suspected that the low rate of culture and susceptibility testing may be due to the difficulty of obtaining an uncontaminated sample within the oral cavity27 and the delay between the time of testing and results. Cost may also be a potential barrier to culture and susceptibility testing, as has been shown in a previous study36 of veterinary antibiotic prescribing practices.
The majority of veterinary dentists agreed that a minimum duration of antibiotics is needed to prevent the emergence of AR. The concept of a minimum antibiotic duration to prevent the development of AR is a verisimilitude many veterinary practitioners are taught, but it is not evidence based.37,38 Studies39,40 in human medicine have proven this to be false; longer duration of antibiotic courses is associated with increased AR. In the present study, the majority of respondents report prescribing antibiotics for durations between 5 and 10 days. The variability in the reported duration of antibiotic prescriptions reflects the lack of evidence in veterinary dentistry to determine an optimal treatment duration for many conditions and the need for prospective studies.
The limitations of this survey study include that self-selected respondents may not represent all members of the AVDC, as only half (104 of 208 active AVDC-boarded dentists) responded to the survey. Additionally, self-reporting of practices is subject to inherent bias and may not accurately depict true practices. The survey also did not clarify if responses were related only to canine and feline patients or included other species. Finally, there were numerous questions that had insufficient data to perform statistical analyses, making this study largely descriptive. Yet, this is the first study evaluating the current practices of board-certified veterinary dentists regarding antibiotic use.
Duration of board certification and practice type (academia vs private practice) did not appear to impact antibiotic knowledge and practice. Veterinary dentists who believe postoperative antibiotics for dental and oral surgery procedures reduce postoperative infection rates prescribe intraoperative antibiotics at a higher rate than those who do not or are unsure. Antibiotics are reported to be prescribed most commonly for patients with a history of IE or those receiving immunosuppressive medications. Jaw fracture repair, maxillectomy/mandibulectomy, periapical lucencies, and stage 4 periodontal disease were the procedures that most dentists felt warranted antibiotic therapy. Further studies are needed to determine the appropriate use of antibiotics in veterinary dentistry, including indications, antibiotic type, and duration. Until such time, the development of evidence and consensus-based dentistry-specific guidelines is likely the best way to reduce unnecessary antibiotic use, as previous research35 has shown that the development of antimicrobial guidelines can improve antimicrobial stewardship. Finally, nearly all veterinary dentists who responded to the survey agree that the development of specific antibiotic guidelines for use in veterinary dentistry and oral surgery would be beneficial to help reduce the indiscriminate use of antibiotics.
Supplementary Materials
Supplementary materials are posted online at the journal website: avmajournals.avma.org.
Acknowledgments
None reported.
Disclosures
Dr. Stephanie L. Goldschmidt served as Guest Editor for this JAVMA supplemental issue. She declares that she had no role in the editorial direction of this manuscript.
No AI-assisted technologies were used in the generation of this manuscript.
Funding
The authors have nothing to disclose.
References
- 1.↑
World health statistics 2022: monitoring health for the SDGs, sustainable development goals. World Health Organization. Accessed May 3, 2023. https://www.who.int/publications-detail-redirect/9789240051157
- 2.↑
Antimicrobial resistance: global report on surveillance. World Health Organization. Accessed May 3, 2023. https://apps.who.int/iris/handle/10665/112642
- 3.↑
Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399(10325):629–655. doi:10.1016/S0140-6736(21)02724-0
- 4.↑
O'Neill, J. Tackling Drug-Resistant Infections Globally: Final Report and Recommendations. Review on Antimicrobial Resistance. Wellcome Trust and HM Government; 2016.
- 5.↑
Hicks LA, Bartoces MG, Roberts RM, et al. US outpatient antibiotic prescribing variation according to geography, patient population, and provider specialty in 2011. Clin Infect Dis. 2015;60(9):1308–1316. doi:10.1093/cid/civ076
- 6.↑
Soukup JW, Hetzel S, Paul A. classification and epidemiology of traumatic dentoalveolar injuries in dogs and cats: 959 injuries in 660 patient visits (2004–2012). J Vet Dent. 2015;32(1):6–14. doi:10.1177/089875641503200101
- 7.↑
Wallis C, Holcombe LJ. A review of the frequency and impact of periodontal disease in dogs. J Small Anim Pract. 2020;61(9):529–540. doi:10.1111/jsap.13218
- 8.↑
De Paolo MH, Arzi B, Pollard RE, Kass PH, Verstraete FJM. Craniomaxillofacial trauma in dogs–part I: fracture location, morphology and etiology. Front Vet Sci. 2020;7:241. doi:10.3389/fvets.2020.00241
- 9.↑
Antimicrobial resistance fact sheet. World Health Organization. Accessed May 3, 2023. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
- 10.↑
Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2019. Centers for Disease Control and Prevention; 2019. doi:10.15620/cdc:82532
- 11.↑
Smith DR, Gaunt PS, Plummer PJ, et al. The AVMA's definitions of antimicrobial uses for prevention, control, and treatment of disease. J Am Vet Med Assoc. 2019;254(7):792–797. doi:10.2460/javma.254.7.792
- 12.↑
Weese JS, Blondeau J, Boothe D, et al. International Society for Companion Animal Infectious Diseases (ISCAID) guidelines for the diagnosis and management of bacterial urinary tract infections in dogs and cats. Vet J. 2019;247:8–25. doi:10.1016/j.tvjl.2019.02.008
- 13.↑
Lappin MR, Blondeau J, Boothe D, et al. Antimicrobial use guidelines for treatment of respiratory tract disease in dogs and cats: Antimicrobial Guidelines Working Group of the International Society for Companion Animal Infectious Diseases. J Vet Intern Med. 2017;31(2):279–294. doi:10.1111/jvim.14627
- 14.↑
Hillier A, Lloyd DH, Weese JS, et al. Guidelines for the diagnosis and antimicrobial therapy of canine superficial bacterial folliculitis (Antimicrobial Guidelines Working Group of the International Society for Companion Animal Infectious Diseases). Vet Dermatol. 2014;25(3):163–e43. doi:10.1111/vde.12118
- 15.↑
Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736–1754. doi:10.1161/CIRCULATIONAHA.106.183095
- 16.↑
Jevsevar DS, Abt E. The new AAOS-ADA clinical practice guideline on prevention of orthopaedic implant infection in patients undergoing dental procedures. J Am Acad Orthop Surg. 2013;21(3):195–197. doi:10.5435/JAAOS-21-03-195
- 17.↑
Lockhart PB, Tampi MP, Abt E, et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: a report from the American Dental Association. J Am Dent Assoc. 2019;150(11):906–921.e12. doi:10.1016/j.adaj.2019.08.020
- 18.↑
Bellows J, Berg ML, Dennis S, et al. 2019 AAHA dental care guidelines for dogs and cats. J Am Anim Hosp Assoc. 2019;55(2):49–69. doi:10.5326/JAAHA-MS-6933
- 19.↑
The use of antibiotics in veterinary dentistry. American Veterinary Dental College. Accessed April 30, 2023. https://avdc.org/about/#pos-stmts
- 20.↑
Yue Yi EK, Siew Ying AL, Mohan M, Menon RK. Prevalence of postoperative infection after tooth extraction: a retrospective study. Int J Dent. 2021;2021:6664311. doi:10.1155/2021/6664311
- 21.↑
Goormans F, Coropciuc R, Vercruysse M, Spriet I, Willaert R, Politis C. Systemic antibiotic prophylaxis in maxillofacial trauma: a scoping review and critical appraisal. Antibiotics (Basel). 2022;11(4):438. doi:10.3390/antibiotics11040483
- 22.↑
Kamolratanakul P, Jansisyanont P. A review of antibiotic prophylaxis protocols in oral and maxillofacial surgery. J Oral and Maxillofac Surg Med Pathol. 2018;30(5):395–404. doi:10.1016/j.ajoms.2018.03.008
- 23.↑
Rigby BE, Malott K, Hetzel SJ, Soukup JW. Incidence and risk factors for surgical site infections following oromaxillofacial oncologic surgery in dogs. Front Vet Sci. 2021;8:760628. doi:10.3389/fvets.2021.760628
- 24.↑
Milic T, Raidoo P, Gebauer D. Antibiotic prophylaxis in oral and maxillofacial surgery: a systematic review. Br J Oral Maxillofac Surg. 2021;59(6):633–642. doi:10.1016/j.bjoms.2020.09.020
- 25.↑
Tou SP, Adin DB, Castleman WL. Mitral valve endocarditis after dental prophylaxis in a dog. J Vet Intern Med. 2005;19(2):268–270. doi:10.1892/0891-6640(2005)192.0.co;2
- 26.↑
Peddle GD, Drobatz KJ, Harvey CE, Adams A, Sleeper MM. Association of periodontal disease, oral procedures, and other clinical findings with bacterial endocarditis in dogs. J Am Vet Med Assoc. 2009;234(1):100–107. doi:10.2460/javma.234.1.100
- 27.↑
Weese JS. Antimicrobials in veterinary dentistry. In: The Veterinary Dental Patient: a Multidisciplinary Approach. John Wiley & Sons Ltd; 2021:87–107.
- 28.↑
Wilson WR, Gewitz M, Lockhart PB, et al. Prevention of viridans group streptococcal infective endocarditis: a scientific statement from the American Heart Association. Circulation. 2021;143(20):e963–e978. doi:10.1161/CIR.0000000000000969
- 29.↑
Danilkowicz RM, Lachiewicz AM, Lorenzana DJ, Barton KD, Lachiewicz PF. Prosthetic joint infection after dental work: is the correct prophylaxis being prescribed? A systematic review. Arthroplast Today. 2021;7:69–75. doi:10.1016/j.artd.2020.11.007
- 30.↑
Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: evidence-based clinical practice guideline for dental practitioners–a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2015;146(1):11–16.e8. doi:10.1016/j.adaj.2014.11.012
- 31.↑
Nicholson M, Beal M, Shofer F, Brown DC. Epidemiologic evaluation of postoperative wound infection in clean-contaminated wounds: a retrospective study of 239 dogs and cats. Vet Surg. 2002;31(6):577–581. doi:10.1053/jvet.2002.34661
- 32.↑
Espinel-Rupérez J, Martín-Ríos MD, Salazar V, Baquero-Artigao MR, Ortiz-Díez G. Incidence of surgical site infection in dogs undergoing soft tissue surgery: risk factors and economic impact. Vet Rec Open. 2019;6(1):e000233. doi:10.1136/vetreco-2017-000233
- 33.↑
Smiley CJ, Tracy SL, Abt E, et al. Evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts. J Am Dent Assoc. 2015;146(7):525–535. doi:10.1016/j.adaj.2015.01.026
- 34.↑
Ioannidou E, Geurs N, Lipman R, et al. Antibiotic prescription patterns among US general dentists and periodontists. J Am Dent Assoc. 2022;153(10):979–988. doi:10.1016/j.adaj.2022.06.013
- 35.↑
Weese JS. Investigation of antimicrobial use and the impact of antimicrobial use guidelines in a small animal veterinary teaching hospital: 1995–2004. J Am Vet Med Assoc. 2006;228(4):553–558. doi:10.2460/javma.228.4.553
- 36.↑
Fowler H, Davis MA, Perkins A, et al. A survey of veterinary antimicrobial prescribing practices, Washington State 2015. Vet Rec. 2016;179(25):651. doi:10.1136/vr.103916
- 37.↑
Langford BJ, Morris AM. Is it time to stop counselling patients to :finish the course of antibiotics”? Can Pharm J (Ott). 2017;150(6):349–350. doi:10.1177/1715163517735549
- 38.↑
Sousa CA, Chatfield J, File TM, et al. Hostage to history – questioning the duration of systemic antimicrobial therapy for the treatment of canine superficial bacterial folliculitis. J Am Vet Med Assoc. 2022;260(10):1153–1156. doi:10.2460/javma.22.03.0113
- 39.↑
Singh N, Rogers P, Atwood CW, Wagener MM, Yu VL. Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for indiscriminate antibiotic prescription. Am J Respir Crit Care Med. 2000;162(2 Pt 1):505–511. doi:10.1164/ajrccm.162.2.9909095
- 40.↑
Chastre J, Wolff M, Fagon JY, et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA. 2003;290(19):2588–2598. doi:10.1001/jama.290.19.2588
