Introduction
Antimicrobial resistance (AMR) is a global health threat, and antibiotic use in animals contributes to this growing epidemic. In humans, untreatable microbial infections are predicted to surpass cancer as the leading cause of death by the year 2050.1 Antimicrobial resistance occurs secondary to all antibiotic use, both appropriate and inappropriate.2 Due to selective pressure, bacteria subvert the effects of antibiotics to which they were previously susceptible. Therefore, antibiotic prescribing is a major modifiable risk factor for AMR.
Antimicrobial stewardship (AS) is defined by the WHO as “a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials.”3 Similarly, AS is defined by the AVMA as “the actions veterinarians take individually and as a profession to preserve the effectiveness and availability of antimicrobial drugs through conscientious oversight and responsible medical decision-making while safeguarding animal, public, and environmental health.”4 Measurement and critical evaluation of antimicrobial drug use informs practice improvement and is an AVMA Core Principle of AS.4,5
Antibiotics are widely used in veterinary dentistry, including for the treatment of active oral infections, prevention of local infection following oral surgery, and prevention of systemic bacteremia following periodontal treatment and surgery.6–11 In humans, 10% (25.6 million of 262.5 million) of all outpatient antibiotic medications are prescribed by dentists.12 A similarly high prevalence of antibiotic prescribing is likely to occur in veterinary dentistry, though comprehensive data are not available. Dental and oral diseases are among the most diagnosed disorders within veterinary medicine.13–15 A recent study16 that focused on antibiotic use in 1,700 small animal primary care veterinary clinics in 1 corporate practice group in the US found that antibiotics were prescribed in 16% (116,723 of 713,901) and 14.0% (14,264 of 104,249) of dental procedures for dogs and cats, respectively.
There are currently no data on the usage of antibiotics amongst veterinary dental specialists and no published guidance on prescribing antibiotics for dental procedures in dogs and cats. A recent knowledge, attitudes, and practices survey17 among board-certified veterinary dentists highlighted the variability among these professionals of which procedures and comorbidities necessitate prophylactic antibiotics. Such surveys are inherently biased by self-reporting. Without antibiotic-use measurement, there is no way to know how a practitioner’s beliefs translate to real-life prescribing practices. Identification of veterinary dental procedures associated with high levels of antibiotic prescribing can be used to direct future outcomes-based studies to fill current knowledge gaps and inform consensus guidelines for both primary care practitioners and specialists. The objective of this study was to describe antibiotic use for dogs and cats undergoing dental procedures performed by residency-trained and board-certified veterinary dentists.
Methods
Clinic enrollment
Participants were recruited via the American Veterinary Dental College (AVDC) listserv. The AVDC includes approximately 188 board-certified veterinary dentists. Recruitment was also solicited via a small animal AS listserv maintained by the Cummings School of Veterinary Medicine at Tufts University and open to any individual interested in AS in small animal veterinary medicine, direct emails to previous antibiotic-use study participants, and emails to state veterinary medical associations from June to October 2023. Two reminder emails were sent via the AVDC listserv, one on August 30, 2023, and another on September 11, 2023. Clinics interested in participation were screened such that only those in the US with residency-trained or board-certified veterinary dentists performing oral procedures in dogs and cats were included. The University of Minnesota Institutional Review Board and IACUC deemed this research exempt from ethical review.
Data collection and management
At least 1 facility coordinator was selected at each participating clinic and completed a REDCap18 survey (Supplementary Material S1) that gathered information about AS and infection prevention and control practices. This survey was provided to the facility coordinator(s) on September 8, 2023, and completion was requested by September 29, 2023. Three clinics completed the survey after the due date by October 6, 2023. All clinics completed the survey prior to antibiotic-use data entry.
Beginning October 2, 2023, the first 10 consecutive canine or feline patients presenting to a residency-trained or board-certified veterinary dentist for a dental procedure were included, regardless of whether an antibiotic was prescribed. The end date for patient enrollment varied for each clinic depending on their dental procedure caseload and concluded once 10 cats or dogs presenting for dental procedures were identified. Data were entered retrospectively into a secure online data collection tool (REDCap) to allow for completion of the medical record. All data were entered into the database by November 30, 2023.
General information collected included the service date, unique patient identifier, species, age, sex, weight, and comorbidities. A targeted list of comorbidities was provided, including chronic kidney disease (International Renal Interest Society stage 2 or above), degenerative valve disease, diabetes mellitus, other endocrine disease (excluding diabetes mellitus), FIV positivity, FeLV positivity, unspecified heart murmur, history of endocarditis, immunosuppressive medications, joint replacement, liver disease, nonoral neoplasia, surgical implant placement, and subaortic stenosis/other congenital heart disease.
Up to 3 oral clinical conditions/patient could be included, and for each, the medical or surgical intervention(s) were recorded, including whether a surgical implant was placed. If an antibiotic was prescribed, the number of antibiotics prescribed, name of the antibiotic, route, and duration were collected. The intended use for each prescribed antibiotic was recorded: treatment of infection, perioperative prophylaxis, postoperative prophylaxis, nonantimicrobial effects, and undetermined.
For patient-level analyses, antibiotics were considered unique based on generic drug name. If a patient was prescribed 2 formulations of the same drug (eg, IV clindamycin transitioned to oral clindamycin), these were considered a single antibiotic drug. Alternatively, if a patient was prescribed 2 chemically distinct drugs (eg, IV ampicillin-sulbactam transitioned to oral amoxicillin–clavulanic acid), these were considered 2 antibiotic drugs. If the same antibiotic drug name had more than 1 indication for use, each was reported. For the purposes of reporting antibiotic-use frequency, if the same antibiotic drug was used to treat more than 1 problem for a patient, it was counted once. Antibiotic prescription durations were reported for each indication. Patients could have more than 1 clinical condition recorded in the medical record, making the number of conditions analyzed greater than the number of patients.
Statistical analysis
Analyses were performed with SAS (version 9.4; SAS Institute Inc). The data were summarized as frequencies and percentages. To determine whether variables had an impact on antibiotic prescribing for patients with periodontal disease, weight (< 10 kg, > 10 kg), presence of a comorbid condition (yes, no), number of tooth extractions (1 to 4, 5 to 10, ≥ 11), and presence of stage 4 periodontal disease (stages 1 to 3, stage 4) were first evaluated via a χ2 test. A Student t test was used to evaluate whether age, a continuous variable, had an impact on antibiotic prescribing for patients with periodontal disease. Variables that had a P value of < .25 on univariate analysis (age, weight, number of tooth extractions, and presence of stage 4 periodontal disease) were included in a multivariable logistic regression as the independent variables; the dependent variable was a presence or absence of an antibiotic prescription for patients with periodontal disease. The multivariable logistic regression was run several times, removing independent variables that were not significant to see how the fit improved.
A χ2 test was used to evaluate whether placement of an implant or presence of any comorbidity was associated with antibiotic prescribing. Specific comorbidities (degenerative valve disease, unspecified heart murmurs, endocrine diseases, chronic kidney and/or liver disease) were also evaluated via a χ2 test to assess whether a patient had an increased risk of antibiotic prescribing. Statistical significance was determined at P < .05.
Results
Participating practices
Three veterinary teaching hospitals and 19 referral practices participated. All geographic regions were represented: 10 clinics from the West, 6 from the South, 4 from the Midwest, and 2 from the Northeast.19 Nine of the 22 clinics (40.9%) indicated that they utilize published small animal antibiotic-use guidelines for specific conditions. Over one-third (8 of 22 [36.4%]) take a formal approach to AS with an established program, policy, or protocol, and 2 of 22 (9.1%) have an AS committee. Common barriers to taking action regarding AS included a lack of awareness of the importance of an AS committee (40.9% [9 of 22]), lack of training regarding AS practices and initiatives (40.9% [9 of 22]), lack of formal commitment or interest from clinic leadership (31.8% [7 of 22]), uncertainty of how to initiate the establishment of an AS committee (31.8% [7 of 22]), and lack of staff time dedicated to AS activities (27.3% [6 of 22]). Thirteen of the 22 clinics (59.1%) take a formal approach (eg, established program, protocols, policy) to infection prevention and control.
Patient demographics
A total of 220 patients were included (183 dogs [83.2%] and 37 cats [16.8%]). Of the 183 dogs, 99 were male (54.1%) and 84 were female (45.9%). Of the 37 cats, 13 were male (35.1%) and 24 were female (64.9%). The median (range) age was 8.0 years (0.2 to 18.1 years) for dogs and 9.0 years (1.0 to 17.3 years) for cats. The median (range) weight of dogs and cats was 12.4 kg (1.5 to 58.1 kg) and 4.6 kg (2.3 to 8.2 kg), respectively.
Comorbid conditions were present in 21.3% (39 of 183) of canine patients and 27.0% (10 of 37) of feline patients. The most common comorbidities in dogs included degenerative valve disease (38.5% [15 of 39]), unspecified heart murmur (20.5% [8 of 39]), and non–diabetes-mellitus endocrine diseases (15.4% [6 of 39]). The most common comorbidities in cats were chronic kidney disease (30.0% [3 of 10]), non–diabetes-mellitus endocrine diseases (30.0% [3 of 10]), unspecified heart murmur (30.0% [3 of 10]), and FIV (20.0% [2 of 10]).
Oral clinical conditions and interventions
The most common oral clinical condition was periodontal disease (32.4% [107 of 330]), which was present in 92 of 273 dogs (33.7%) and 15 of 57 cats (26.3%). Stage 4 periodontal disease was most common (54.2% [58 of 107]), affecting 53 of 92 dogs (57.6%) and 5 of 15 cats (33.3%). Tooth fractures were the second most common condition for dogs (16.5% [45 of 273]) but were uncommon in cats (5.3% [3 of 57]). Complicated tooth fractures (80.0% [36 of 45]) were a greater proportion of tooth fractures than uncomplicated fractures (20.0% [9 of 45]) in dogs (Table 1). Tooth resorption was the second most frequent condition in cats (24.6% [14 of 57]). Tooth extractions and periodontal treatment were the most common interventions conducted for both dogs and cats (Table 2). When tooth extraction was performed, surgical extractions were most common for both species.
Clinical conditions of the first 10 dogs and cats undergoing dental procedures performed by board-certified or residency-trained veterinary dentists in 22 referral clinics beginning on October 2, 2023.
| Clinical condition | No. (%) of canine diagnoses (n = 273) | No. (%) of feline diagnoses (n = 57) | Total (%) (n = 330) |
|---|---|---|---|
| Periodontal disease | 92 (33.7) | 15 (26.3) | 107 (32.4) |
| Stage 1 | 15 (16.3) | 3 (20.0) | 18 (16.8) |
| Stage 2 | 14 (15.2) | 4 (26.7) | 18 (16.8) |
| Stage 3 | 7 (7.6) | 3 (20.0) | 10 (9.3) |
| Stage 4 | 53 (57.6) | 5 (33.3) | 58 (54.2) |
| Not recorded in medical record | 3 (3.3) | 0 (0) | 3 (2.8) |
| Tooth fracture | 45 (16.5) | 3 (5.3) | 48 (14.5) |
| Uncomplicated crown fracture | 6 (13.3) | 0 (0) | 6 (12.5) |
| Complicated crown fracture | 20 (44.4) | 2 (66.7) | 22 (45.8) |
| Uncomplicated crown-root fracture | 3 (6.7) | 0 (0) | 3 (6.3) |
| Complicated crown-root fracture | 13 (28.9) | 0 (0) | 13 (27.1) |
| Root fracture | 3 (6.7) | 1 (33.3) | 4 (8.3) |
| Oral mass | 20 (7.3) | 5 (8.8) | 25 (7.6) |
| Odontogenic | 9 (45.0) | 2 (40.0) | 11 (44.0) |
| Nonodontogenic | 8 (40.0) | 2 (40.0) | 10 (40.0) |
| Open diagnosis | 2 (10.0) | 1 (20.0) | 3 (12.0) |
| Not recorded in medical record | 1 (5.0) | 0 (0) | 1 (4.0) |
| Tooth resorption | 7 (2.6) | 14 (24.6) | 21 (6.4) |
| Retained tooth root | 10 (3.7) | 6 (10.5) | 16 (4.8) |
| Periapical infection (lucency) | 15 (5.5) | 0 (0) | 15 (4.5) |
| Maxillofacial trauma | 11 (4.0) | 2 (3.5) | 13 (3.9) |
| Open | 10 (90.9) | 0 (0) | 10 (76.9) |
| Closed | 1 (9.1) | 2 (100) | 3 (23.1) |
| Malocclusion | 9 (3.3) | 2 (3.5) | 11 (3.3) |
| Oronasal fistula | 10 (3.7) | 1 (1.8) | 11 (3.3) |
| Gingival enlargement | 6 (2.2) | 1 (1.8) | 7 (2.1) |
| Nonvital tooth (no fracture present) | 7 (2.6) | 0 (0) | 7 (2.1) |
| Impacted tooth | 5 (1.8) | 1 (1.8) | 6 (1.8) |
| Gingivostomatitis | 0 (0) | 5 (8.8) | 5 (1.5) |
| Osteomyelitis | 4 (1.5) | 1 (1.8) | 5 (1.5) |
| Definitive | 3 (75.0) | 0 (0) | 3 (60.0) |
| Presumptive | 1 (25.0) | 1 (100) | 2 (40.0) |
| None (no problems identified) | 9 (3.3) | 0 (0) | 9 (2.7) |
Interventions performed for dogs and cats described in Table 1 undergoing dental procedures.
| Clinical condition | No. (%) of canine interventions (n = 384) | No. (%) of feline interventions (n = 85) | Total (%) (n = 469) |
|---|---|---|---|
| Tooth extractions | 153 (39.8) | 37 (43.5) | 190 (40.5) |
| Surgical/open extraction | 87 (56.9) | 23 (62.2) | 110 (57.9) |
| Nonsurgical/closed extraction | 30 (19.6) | 1 (2.7) | 31 (16.3) |
| Both | 36 (23.5) | 13 (35.1) | 49 (25.8) |
| No. of teeth extracted | 153 (39.8) | 37 (43.5) | 190 (40.5) |
| 1–4 teeth | 99 (64.7) | 18 (48.6) | 117 (61.6) |
| 5–10 teeth | 25 (16.3) | 11 (29.7) | 36 (18.9) |
| 11 or more teeth | 29 (19.0) | 8 (21.6) | 37 (19.5) |
| Periodontal treatment | 122 (31.8) | 18 (21.2) | 140 (29.9) |
| Dental scaling and polish | 83 (68.0) | 16 (88.9) | 99 (70.7) |
| Root planing—closed | 20 (16.4) | 1 (5.6) | 21 (15.0) |
| Root planing—open | 9 (7.4) | 1 (5.6) | 10 (7.1) |
| Gingivectomy/gingivoplasty | 9 (7.4) | 0 (0) | 9 (6.4) |
| Guided tissue regeneration | 1 (0.8) | 0 (0) | 1 (0.7) |
| Maxillofacial surgery | 40 (10.4) | 12 (14.1) | 52 (11.1) |
| Skin flap to close a surgical site | 6 (15.0) | 8 (66.7) | 14 (26.9) |
| Oronasal fistula repair | 11 (27.5) | 1 (8.3) | 12 (23.1) |
| Maxillofacial trauma repair | 8 (20.0) | 2 (16.7) | 10 (19.2) |
| Maxillectomy | 3 (7.5) | 0 (0) | 3 (5.8) |
| Mandibulectomy | 3 (7.5) | 1 (8.3) | 4 (7.7) |
| Cyst enucleation | 5 (12.5) | 0 (0) | 5 (9.6) |
| Oral laceration or lip avulsion repair | 3 (7.5) | 0 (0) | 3 (5.8) |
| Cleft palate repair | 1 (2.5) | 0 (0) | 1 (1.9) |
| Endodontic treatment | 25 (6.5) | 1 (1.2) | 26 (5.5) |
| Standard root canal | 15 (60.0) | 1 (100.0) | 16 (61.5) |
| Surgical root canal | 1 (4.0) | 0 (0) | 1 (3.8) |
| Crown reduction and vital pulp therapy for malocclusion | 2 (8.0) | 0 (0) | 2 (7.7) |
| Restoration | 4 (16.0) | 0 (0) | 4 (15.4) |
| Crown preparation or placement | 3 (12.0) | 0 (0) | 3 (11.5) |
| Orthodontic appliance placement | 1 (0.3) | 0 (0) | 1 (0.2) |
| Oral biopsy | 21 (5.5) | 6 (7.1) | 27 (5.8) |
| Other | 22 (5.7) | 11 (12.9) | 33 (7.0) |
Antibiotic use
Thirty-five percent (77 of 220) of patients were prescribed 1 or more antibiotics for systemic administration, including 33.9% (62 of 183) of dogs and 40.5% (15 of 37) of cats. Overall, 22.4% (41 of 183) of dogs were prescribed prophylactic antibiotics, 15.3% (28 of 183) were prescribed antibiotics for the treatment of infection, and 1.6% (3 of 183) were prescribed antibiotics for nonbactericidal properties of the antibiotic; for 1.1% (2 of 183), the reason for antibiotic prescription could not be determined from the medical record. For cats, 18.9% (7 of 37) were prescribed antibiotics for prophylaxis and 21.6% (8 of 37) for the treatment of infection; for 2.7% (1 of 37), the reason could not be determined from the medical record.
A total of 104 antibiotics were prescribed to the 77 cats and dogs. The most common antibiotics prescribed for dogs were amoxicillin–clavulanic acid, ampicillin-sulbactam, and clindamycin, with clindamycin the most common for cats (Table 3). No topical antibiotics were prescribed.
Antibiotic drugs for systemic administration prescribed for dogs and cats described in Table 1 undergoing dental procedures.
| Antibiotic | No. (%) of canine prescriptions (n = 85) | No. (%) of feline prescriptions (n = 19) | Total No. (%) of prescriptions (n = 104) |
|---|---|---|---|
| Amoxicillin–clavulanic acid | 34 (40.0) | 3 (15.8) | 37 (35.6) |
| Ampicillin-sulbactam | 22 (25.9) | 3 (15.8) | 25 (24.0) |
| Clindamycin | 13 (15.3) | 5 (26.3) | 18 (17.3) |
| Cefovecin | 5 (5.9) | 3 (15.8) | 8 (7.7) |
| Ampicillin | 5 (5.9) | 2 (10.5) | 7 (6.7) |
| Penicillin G | 0 (0) | 3 (15.8) | 3 (2.9) |
| Metronidazole | 2 (2.4) | 0 (0) | 2 (1.9) |
| Doxycycline | 2 (2.4) | 0 (0) | 2 (1.9) |
| Cefazolin | 1 (1.2) | 0 (0) | 1 (1.0) |
| Enrofloxacin | 1 (1.2) | 0 (0) | 1 (1.0) |
Half (50.6% [43 of 85]) of all prescriptions for dogs were for perioperative (25.9% [22 of 85]) or postoperative (24.7% [21 of 85]) prophylaxis. For dogs, amoxicillin–clavulanic acid was the most prescribed antibiotic for postoperative prophylaxis and ampicillin-sulbactam was the most common perioperative prophylactic antibiotic (Table 4). There were 7 of 19 prophylactic antibiotic prescriptions (36.8%) for cats, including 5 of 19 (26.3%) for perioperative use and 2 of 19 (10.5%) for postoperative use.
Perioperative and postoperative prophylactic antibiotics prescribed for dogs and cats described in Table 1 undergoing dental procedures.
| Antibiotic | No. (%) of perioperative prescriptions | No. (%) of postoperative prescriptions | ||||
|---|---|---|---|---|---|---|
| Canine (n = 22) | Feline (n = 5) | Total (n = 27) | Canine (n = 21) | Feline (n = 2) | Total (n = 23) | |
| Ampicillin-sulbactam | 17 (77.3) | 2 (40.0) | 19 (70.4) | 1 (4.8) | 0 (0) | 1 (4.3) |
| Ampicillin | 1 (4.5) | 2 (40.0) | 3 (11.1) | 0 (0) | 0 (0) | 0 (0) |
| Amoxicillin–clavulanic acid | 2 (9.1) | 0 (0) | 2 (7.4) | 12 (57.1) | 0 (0) | 12 (52.2) |
| Cefovecin | 1 (4.5) | 1 (20.0) | 2 (7.4) | 4 (19.0) | 1 (50.0) | 5 (21.7) |
| Cefazolin | 1 (4.5) | 0 (0) | 1 (3.7) | 0 (0) | 0 (0) | 0 (0) |
| Clindamycin | 0 (0) | 0 (0) | 0 (0) | 4 (19.0) | 1 (50.0) | 5 (21.7) |
Thirty-six canine prescriptions (42.4% [36 of 85]) were for treatment of infection. Amoxicillin–clavulanic acid (55.6% [20 of 36]) was the most prescribed antibiotic for dogs for this purpose, followed by clindamycin (19.4% [7 of 36]), ampicillin-sulbactam (11.1% [4 of 36]), ampicillin (11.1% [4 of 36]), and enrofloxacin (2.8% [1 of 36]). For cats, 11 of 19 (57.9%) prescriptions were intended to treat infections. Clindamycin (36.4% [4 of 11]) was the most common antibiotic prescribed for cats for infection, followed by penicillin G (27.3% [3 of 11]), amoxicillin–clavulanic acid (18.2% [2 of 11]), ampicillin-sulbactam (9.1% [1 of 11]), and cefovecin (9.1% [1 of 11]).
The median prescription duration of systemically administered antibiotics used to treat infections was 10 days, with a range of 1 to 56 days for dogs and cats (Table 5). The median prescription duration for postoperative prophylactic use was 7 days, with a range of 5 to 14 days for dogs and cats.
Duration of antibiotic prescriptions for postoperative prophylaxis and infection treatment for dogs and cats described in Table 1 undergoing dental procedures.
| Antibiotic | Postoperative prophylaxis | Infection treatment | ||||||
|---|---|---|---|---|---|---|---|---|
| Canine prescriptions | Feline prescriptions | Canine prescriptions | Feline prescriptions | |||||
| n | Median (range) days | n | Median (range) days | n | Median (range) days | n | Median (range) days | |
| Amoxicillin–clavulanic acid | 12 | 7 (5–14) | — | — | 20 | 10 (5–56) | 2 | 10 (10) |
| Cefovecin | 4 | 14 (14) | 1 | 14 (14) | — | — | 1 | 14 (14) |
| Clindamycin | 4 | 7 (5–14) | 1 | 5 (5) | 6 | 10 (7–42) | 4 | 1 (1–5) |
| Enrofloxacin | — | — | — | — | 1 | 56 (56) | — | — |
| Penicillin G | — | — | — | — | — | — | 3 | 1 (1) |
| All antibiotics | 20 | 7 (5–14) | 2 | 9.5 (5–14) | 27 | 10 (5–56) | 10 | 1 (1–14) |
Risk factors for antibiotic prescribing
Patients with degenerative valve disease (P = .45), unspecified heart murmurs (P = .16), endocrine diseases (P = .31), and chronic kidney and/or liver disease (P = .73) were not significantly more likely to be prescribed an antibiotic than patients without these comorbid conditions. A quarter (25.7% [26 of 101]) of patients with periodontal disease were prescribed antibiotics. Periodontal disease alone was not a risk factor for antibiotic prescribing (P = .64). A multivariable logistic regression of patients with periodontal disease revealed that only tooth extractions were a risk factor for antibiotic use (P = .002). Patients with 11 or more teeth extracted were 6.3 times as likely to be prescribed an antibiotic than patients with 1 to 4 teeth extracted (95% CI, 1.8 to 21.7). There was no difference in the likelihood of being prescribed an antibiotic for patients with 5 to 10 teeth extracted versus those with 1 to 4 teeth extracted.
Patients with an implant placed during their procedure were not more likely to be prescribed an antibiotic than those that did not have an implant (P = .46). Of the 11 patients that had an implant placed during their procedure, 5 (45.5%) received an antibiotic prescription.
Discussion
The frequency of antibiotic prescribing for dogs and cats presenting for a dental procedure to residency-trained or board-certified veterinary dentists was 35.0% (77 of 220) in this study. The most common indication for antibiotic use was prophylaxis. Patients with stage 4 periodontal disease and tooth extractions were frequently prescribed antibiotics.
In this study, residency-trained and board-certified veterinary dentists prescribed antibiotics in 33.9% (62 of 183) of dogs and 40.5% (15 of 37) of cats undergoing a dental procedure. In a study by Weese et al16 reporting antibiotic prescribing for dental procedures in primary care practices, 16% (116,723 of 713,901) of dental procedures in dogs and 14.0% (14,264 of 104,249) of those in cats were associated with antibiotic use. The variation in prescribing rates is potentially due to the inherent differences in patient population between primary care practices and specialty dental practices; there was a higher proportion of dogs and cats with periodontal disease and surgical interventions in this study compared to the study by Weese et al.16 In both studies, tooth extractions were a risk factor for antibiotic prescribing. Among patients presenting to primary care practices, periodontal disease was also a risk factor for antibiotic prescribing. Conversely, in the present study, periodontal disease alone was not a risk factor for antibiotic prescribing. Moreover, nearly 100% (14,155 of 14,162) of canine and feline patients with any reported stage of periodontal disease received antibiotics in the primary care practice setting compared to 25.7% (26 of 101) of animals in this study. This suggests a higher tolerance to avoid antibiotic use for periodontal disease alone among residency-trained and board-certified veterinary dentists compared to primary care practitioners.
Prophylaxis accounted for nearly half of antibiotic prescriptions in this study. Dental extractions represented a significant risk factor for prescribing antibiotics for patients with periodontal disease. In humans, there is no reported difference in postextraction infection rates in those who did or did not receive antibiotics.20–22 The human literature23 supports that the transient bacteremia due to dental procedures is no more significant than common oral health activities, such as tooth brushing. Thus, prophylaxis is not indicated in a systemically healthy patient. Currently, prophylactic use of antibiotics for dental extractions in dogs is not evidence-based. Only 1 study24 reports the infection rate with and without antibiotic use for oromaxillofacial surgery in dogs and found that there was no significant difference between postoperative infection rates between dogs that were administered prophylactic antibiotics and those that were not. Veterinary literature assessing the effects of prophylactic antibiotics on the rate of postoperative infection following dental extractions for periodontal disease is lacking. However, patients with specific comorbidities that increase risk of distant and local infection may benefit from targeted prophylaxis.25–32
In a study33 evaluating antibiotic use in primary care settings for dogs and cats with comorbid conditions undergoing dental procedures, hepatorenal, endocrine, or viral-immune conditions or concurrent removal of skin or subcutaneous neoplasms were risk factors for antibiotic prescribing. In the current study, no evaluated comorbidities were shown to be associated with an increased frequency of antibiotic prescribing, which might be due to differences in patient populations, provider training, or sample size. Given that prophylactic prescribing in this study was common for dogs and cats with local disease (ie, periodontal disease) and tooth extractions, it is possible that the driver for prophylactic use among residency-trained and board-certified veterinary dentists is control of local infection, rather than concern for bacteremia or systemic infection. According to the 2019 American Animal Hospital Association dental care guidelines for dogs and cats, intraoperative antibiotics are considered for patients with systemic health conditions, such as orthopedic implants, systemic immunosuppression, and subaortic stenosis.34 In humans, there is a lack of evidence to support a need for antibiotic prophylaxis in patients to prevent prosthetic joint infections or infective endocarditis.25–32 The American Dental Association and American Academy of Orthopedic Surgeons released a joint statement in 2017 asserting that dental antibiotic prophylaxis was rarely indicated for a majority of patients with prosthetic implants.26,27 The current American Heart Association recommendations state that dental antibiotic prophylaxis should be targeted only to patients with specific comorbid conditions, such as previous infective endocarditis, prosthetic cardiac implants, and congenital heart defects, that undergo the most at-risk procedures.31 Larger outcomes-based studies are needed to establish the role of antibiotics in preventing systemic infection for dogs and cats with these comorbidities.
If prophylaxis is indicated, it is essential that the correct antibiotic regimen is chosen. In this study, potentiated penicillins (amoxicillin–clavulanic acid and ampicillin-sulbactam) and clindamycin comprised the majority of antibiotic prescriptions. These antibiotics are effective at treating periodontal pathogens based on clinical trials and pharmacokinetics.8,35 However, cephalosporins (cefovecin and cephalexin) were also prescribed to a minority of patients (7.1% [6 of 85] of dogs and 15.8% [3 of 19] of cats). The oral cavity in dogs and cats harbors a mixed population of gram-positive, gram-negative, anaerobic, and aerobic bacteria,36,37 which shift to primarily gram-negative anaerobes in periodontal disease.35,37,38 As cephalosporins have poorer anaerobic coverage than potentiated penicillins and clindamycin, they are not an optimal choice for the treatment of common periodontal pathogens. The long-acting injectable formulation of cefovecin may provide impetus for prescribing cephalosporins, particularly in patients that are difficult to administer oral medications to, despite its 14-day duration. When surveyed, most board-certified veterinary dentists believed that a minimum duration of 7 days for postoperative antibiotics was required to prevent the emergence of AMR.17 This belief could have influenced the median postoperative prophylaxis duration of 7 days in this study, compared to a median duration of 10 days prescribed by primary care veterinarians.16 There are no published recommendations for the duration of prophylactic antibiotic prescribing following dental procedures. In humans, when prophylactic antibiotics are indicated, a single 24-hour course is recommended.39
A limiting factor in this study was the small sample size, particularly among cats. Underrepresentation of patients with specific comorbid conditions, especially orthopedic implants, immunosuppression, and subaortic stenosis, precluded the assessment of these conditions as risk factors for antibiotic prescribing. The limited number of veterinary dental clinics in the US and time-consuming nature of data collection was a barrier to robust participation. Elective enrollment in this study may have biased data in this study, as those willing to participate may have had more knowledge about AS, potentially underestimating antibiotic usage among residency-trained and board-certified veterinary dentists.
In conclusion, this report characterized antibiotic use among residency-trained and board-certified veterinary dentists. Antibiotic prescribing in this study centered on prophylactic use. Evidence-based antibiotic prescribing guidelines, especially for prophylactic use, are needed for veterinary dentistry. Outcomes-based studies are required to inform such guidelines, particularly for dental extractions and patients with comorbid conditions.
Acknowledgments
The authors sincerely thank the veterinary dental clinics for participating in this research.
Disclosures
No AI-assisted technologies were used in the generation of this manuscript. Views expressed in this publication do not necessarily reflect the official policies of the Department of Health and Human Services, nor does any mention of trade names, commercial practices, or organizations imply endorsement by the US Government.
Funding
This project was supported by the US Food and Drug Administration (FDA) of the US Department of Health and Human Services (HHS) as part of a financial assistance award [1U01FD007061-01] totaling $999,972 with 100 percent funded by FDA/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by FDA/HHS, or the US Government.
Supplementary Materials
Supplementary materials are posted online at the journal website: avmajournals.avma.org.
ORCID
S. L. Goldschmidt https://orcid.org/0000-0001-5944-4202
E.R. Bollig https://orcid.org/0000-0002-5997-3208
J. L. Granick https://orcid.org/0000-0001-8330-3848
References
- 1.↑
O’Neill J. Tackling Drug-Resistant Infections Globally: Final Report and Recommendations. Government of the UK; 2016. Accessed August 12, 2024. https://apo.org.au/sites/default/files/resource-files/2016-05/apo-nid63983.pdf
- 2.↑
Pallasch TJ. Antibiotic resistance. Dent Clin North Am. 2003;47(4):623-639. doi:10.1016/S0011-8532(03)00039-9
- 3.↑
Antimicrobial resistance. WHO. November 21, 2023. Accessed August 5, 2024. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
- 4.↑
AVMA. Antimicrobial stewardship definition and core principles. Accessed August 5, 2024. https://www.avma.org/resources-tools/avma-policies/antimicrobial-stewardship-definition-and-core-principles
- 5.↑
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
- 6.↑
Nieves MA, Hartwig P, Kinyon JM, Riedesel DH. Bacterial isolates from plaque and from blood during and after routine dental procedures in dogs. Vet Surg. 1997;26(1):26-32. doi:10.1111/j.1532-950X.1997.tb01459.x
- 7.
Välkki KJ, Thomson KH, Grönthal TSC, et al. Antimicrobial prophylaxis is considered sufficient to preserve an acceptable surgical site infection rate in clean orthopaedic and neurosurgeries in dogs. Acta Vet Scand. 2020;62(1):53. doi:10.1186/s13028-020-00545-z
- 8.↑
Sarkiala E, Harvey C. Systemic antimicrobials in the treatment of periodontitis in dogs. Semin Vet Med Surg (Small Anim). 1993;8(3):197-203.
- 9.
Peralta S, Arzi B, Nemec A, Lommer MJ, Verstraete FJ. Non-radiation-related osteonecrosis of the jaws in dogs: 14 cases (1996-2014). Front Vet Sci. 2015;2:7. doi:10.3389/fvets.2015.00007
- 10.
Ford KR, Anderson JG, Stapleton BL, et al. Medical management of canine chronic ulcerative stomatitis using cyclosporine and metronidazole. J Vet Dent. 2023;40(2):109-124. doi:10.1177/08987564221148755
- 11.↑
White SD, Rosychuk RA, Janik TA, Denerolle P, Schultheiss P. Plasma cell stomatitis-pharyngitis in cats: 40 cases (1973-1991). J Am Vet Med Assoc. 1992;200(9):1377-1380. doi:10.2460/javma.1992.200.09.1377
- 12.↑
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
- 13.↑
O’Neill DG, James H, Brodbelt DC, Church DB, Pegram C. Prevalence of commonly diagnosed disorders in UK dogs under primary veterinary care: results and applications. BMC Vet Res. 2021;17(1):69. doi:10.1186/s12917-021-02775-3
- 14.
Girard N, Servet E, Biourge V, Hennet P. Periodontal health status in a colony of 109 cats. J Vet Dent. 2009;26(3):147-155. doi:10.1177/089875640902600301
- 15.↑
State of Pet Health 2016 Report. Banfield Pet Hospital; 2016. Accessed August 5, 2024. https://www.banfield.com/en/about-banfield/newsroom/press-releases/2016/banfield-releases-state-of-pet-health-2016-report
- 16.↑
Weese JS, Battersby I, Morrison J, Spofford N, Soltero-Rivera M. Antimicrobial use practices in canine and feline dental procedures performed in primary care veterinary practices in the United States. PLoS One. 2023;18(12):e0295070. doi:10.1371/journal.pone.0295070
- 17.↑
Montebello JA, Granick JL, Bollig ER, Goldschmidt SL. Variation in knowledge, attitude, and practices toward antibiotic use among diplomates of the American Veterinary Dental College: a survey-based study. J Am Vet Med Assoc. 2023;261(S2):S6-S13. doi:10.2460/javma.23.06.0304
- 18.↑
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010
- 19.↑
Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864-1873. doi:10.1001/jama.2016.4151
- 20.↑
Suda KJ, Henschel H, Patel U, Fitzpatrick MA, Evans CT. Use of antibiotic prophylaxis for tooth extractions, dental implants, and periodontal surgical procedures. Open Forum Infect Dis. 2017;5(1):ofx250. doi:10.1093/ofid/ofx250
- 21.
Dar-Odeh NS, Abu-Hammad OA, Al-Omiri MK, Khraisat AS, Shehabi AA. Antibiotic prescribing practices by dentists: a review. Ther Clin Risk Manag. 2010;301-306. doi:10.2147/TCRM.S9736
- 22.↑
Caniff KE, Young LR, Truong S, et al. Postextraction infection and antibiotic prescribing among veterans receiving dental extractions. Infect Control Hosp Epidemiol. 2021;42(12):1431-1436. doi:10.1017/ice.2021.15
- 23.↑
Sconyers JR, Crawford JJ, Moriarty JD. Relationship of bacteremia to toothbrushing in patients with periodontitis. J Am Dent Assoc. 1973;87(3):616-622. doi:10.14219/jada.archive.1973.0453
- 24.↑
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
- 25.↑
Watters W III, Rethman MP, Hanson NB, et al.; American Academy of Orthopedic Surgeons; American Dental Association. Prevention of orthopaedic implant infection in patients undergoing dental procedures. J Am Acad Orthop Surg. 2013;21(3):180-189. doi:10.5435/JAAOS-21-03-180
- 26.↑
Quinn RH, Murray JN, Pezold R, Sevarino KS. Management of patients with orthopaedic implants undergoing dental procedures. J Am Acad Orthop Surg. 2017;25(7):e138-e141. doi:10.5435/JAAOS-D-17-00006
- 27.↑
Quinn RH, Murray JN, Pezold R, Sevarino KS; Members of the Writing and Voting Panels of the AUC for the Management of Patients with Orthopaedic Implants Undergoing Dental Procedures. The American Academy of Orthopaedic Surgeons Appropriate Use Criteria for the Management of Patients with Orthopaedic Implants Undergoing Dental Procedures. J Bone Joint Surg Am. 2017;99(2):161-163. doi:10.2106/JBJS.16.01107
- 28.
Van der Meer JT, Van Wijk W, Thompson J, Vandenbroucke JP, Valkenburg HA, Michel MF. Efficacy of antibiotic prophylaxis for prevention of native-valve endocarditis. Lancet. 1992;339(8786):135-139. doi:10.1016/0140-6736(92)90207-J
- 29.
Wilson W, Taubert KA, Gewitz M, et al.; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. 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. Published correction appears in Circulation. 2007;116(15):e376-e377. doi:10.1161/CIRCULATIONAHA.107.185599
- 30.
Goff DA, Mangino JE, Glassman AH, Goff D, Larsen P, Scheetz R. Review of guidelines for dental antibiotic prophylaxis for prevention of endocarditis and prosthetic joint infections and need for dental stewardship. Clin Infect Dis. 2020;71(2):455-462. doi:10.1093/cid/ciz1118
- 31.↑
Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(25):e1159-e1195. doi:10.1161/CIR.0000000000000503
- 32.↑
Tong DC, Rothwell BR. Antibiotic prophylaxis in dentistry: a review and practice recommendations. J Am Dent Assoc. 2000;131(3):366-374. doi:10.14219/jada.archive.2000.0181
- 33.↑
Soltero-Rivera M, Battersby I, Morrison J, Spofford N, Weese JS. Antimicrobial use practices in canine and feline patients with co-morbidities undergoing dental procedures in primary care practices in the US. PLoS One. 2024;19(7):e0305533. doi:10.1371/journal.pone.0305533
- 34.↑
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
- 35.↑
Radice M, Martino PA, Reiter AM. Evaluation of subgingival bacteria in the dog and susceptibility to commonly used antibiotics. J Vet Dent. 2006;23(4):219-224. doi:10.1177/089875640602300404
- 36.↑
Dewhirst FE, Klein EA, Bennett ML, Croft JM, Harris SJ, Marshall-Jones ZV. The feline oral microbiome: a provisional 16S rRNA gene based taxonomy with full-length reference sequences. Vet Microbiol. 2015;175(2-4):294-303. doi:10.1016/j.vetmic.2014.11.019
- 37.↑
Dewhirst FE, Klein EA, Thompson EC, et al. The canine oral microbiome. PLoS One. 2012;7(4):e36067. doi:10.1371/journal.pone.0036067. Published correction appears in PLoS One. 2012;7(6). doi:10.1371/annotation/c2287fc7-c976-4d78-a28f-1d4e024d568f
- 38.↑
Riggio MP, Lennon A, Taylor DJ, Bennett D. Molecular identification of bacteria associated with canine periodontal disease. Vet Microbiol. 2011;150(3-4):394-400. doi:10.1016/j.vetmic.2011.03.001
- 39.↑
Oppelaar MC, Zijtveld C, Kuipers S, et al. Evaluation of prolonged vs short courses of antibiotic prophylaxis following ear, nose, throat, and oral and maxillofacial surgery: a systematic review and meta-analysis. JAMA Otolaryngol Head Neck Surg. 2019;145(7):610-616. doi:10.1001/jamaoto.2019.0879
