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Addressing Antimicrobial Resistance in Dentistry Manjunath BC1, Chandrashekar BR2, Vatchala RRM3, Babaji P4, Singh I5, Arora K6, Madan C7

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Addressing Antimicrobial Resistance in Dentistry Manjunath BC1, Chandrashekar BR2, Vatchala RRM3, Babaji P4, Singh I5, Arora K6, Madan C7 Journal of Oral Health REVIEW ARTICLE Community& Dentistry Addressing Antimicrobial Resistance in Dentistry Manjunath BC1, Chandrashekar BR2, Vatchala RRM3, Babaji P4, Singh I5, Arora K6, Madan C7 ABSTRACT Background: Antimicrobial agents are life saving drugs which are used in management of various life threatening infections but irrational use of antibiotics have led to resurgence of multidrug resistant bacteria which are associated with global increase in mortality due to various infections. Dentists are one among important health care personnel who prescribe antibiotics routinely to treat various oral infections. Objectives: To summarise the evidence of antimicrobial resistance (AMR) encountered in dental practice, discuss factors associated with it and suggest measures to prevent antimicrobial resistance in dentistry. Methodology: Articles were identified by searching in electronic data bases such as PubMed, Medline, Embase, Google Scholar and Cochrane data bases using key words like antibiotics, antimicrobial resistance, and antibiotic resistance in dentistry. The articles fulfilling the objectives were included. Results and Conclusions: Dentists also contribute significantly to the global burden of antimicrobial resistance due to irrational use of antibiotics. Antibiotic stewardship is essential to prevent antimicrobial resistance in dental practice and hence there is an urgent need to educate not only dentists but general public as well. The article describes the gravity of the AMR and the importance of prudent use of antibiotics is discussed. Keywords: Antibiotics, Antimicrobial, Resistance, AMR, Antibiotic stewardship, NDM-1, Superbug, MRSA INTRODUCTION 1Senior Professor and Head 5Senior Lecturer Department of Public Health Dentistry Department of Public Health Dentistry he accidental discovery of a mould Post Graduate Institute of Dental Sciences, Government Dental College, Srinagar, Jammu called “Penicillium Notatum” Rohtak, Haryana, India and Kashmir, India which had the potential of inhibit- 2 6 T Associate Professor Associate Professor ing Staphylococcus colonies by Alexander Department of Public Health Dentistry Department of Periodontics and Implantology Flemming in 1928 paved the way for the People’s Dental Academy, Bhanpur, Bhopal, MP, Manav Rachana Dental College and Hospital, India Faridabad, India miracle drug “Penicillin” which saved mil- lions of lives and opened a new era of 3Senior Lecturer 7 Senior Lecturer Department of Oral Pathology and Microbiology Department of Periodontics and Implantology curative medicine (1).Penicillin is referred Faculty of Dentistry, Jamia Millia Islamia, ESI Dental College, Rohini, New Delhi, India as the mother of all antibiotics and the New Delhi, India discovery proved to be a boon to man- 4Reader kind. There are various generations of an- Department of Pedodontics and Preventive Dentistry, Vyas Dental College & Hospital, tibiotics at present which are effective Jodhpur, Rajasthan, India against wide spectrum of microbes but at the same time many microbes have devel- oped resistance even to last known genera- Contact Author tion of antibiotics and threatening to push Dr. Manjunath BC us to the pre-antibiotic era. [email protected] The resistant microbes become super bugs and the discovery of New Delhi Metallo J Oral Health Comm Dent 2013;7(2)101-107 JOHCD www.johcd.org May 2013;7(2) 101 ADDRESSING ANTIMICROBIAL RESISTANCE IN DENTISTRY β-lactamase-1 (NDM-1) in India by available higher generation of antibiotics community participation, weak or absent Kumarswamy KK et al. in 2010 (2) has where in, it will be difficult to control vari- monitoring systems, availability of poor brought back the issue of antibiotic resist- ous life threatening infections and hence quality medicines, misuse of antibiotics, ance in to spotlight. Recent report sug- all health care practitioners, policy makers, poor infection control protocols in the gests that this super bug (NDM-1) is not patients should be aware about this stark hospitals, low level of accessibility to diag- only confined to some of the hospitals in reality and work together in a coordinated nostics, medicines and vaccines along with India but in drinking water of New Delhi manner to save the life saving antibiotics insufficient research efforts for the devel- as well (3). The newly discovered super bug for our future generations also. opment of new generation of drugs (8,9). NDM-1 is actually an enzyme which gets transmitted to gram negative organisms This article provides evidence regarding re- ANTIBIOTIC RESISTANCE IN INDIA like Escherichia coli and Klebsiella sistance of various oral micro organisms Indian subcontinent is perceived as a hot pnuemoniae which are resistant even to to wide spectrum of antimicrobial drugs, bed for resistant microbes and a plethora carbapenem group of drugs (2,3). A wide explains factors affecting prescription of of factors are responsible such as irrational variety of gram negative microorganisms antibiotics among dentists and suggests prescription of antibiotics by health care are present in oral cavity which are associ- guidelines to prevent antibiotic resistance practitioners like prescription of antibiot- ated with periodontal diseases and if in dentistry. ics for viral infections, advising NDM-1 enzyme gets transmitted to them, antimicrobials without a culture and sensi- then there may be catastrophic consequences ANTIMICROBIAL RESISTANCE tivity report, use of higher generation of in the oral cavity and hence as dentists, we (AMR) antibiotics, increased pressure to prescribe should be updated regarding current sce- Antimicrobial resistance (AMR) is a fast newer antibiotics, self medication and of- nario and prevent superbugs in the oral emerging global public health problem and ten non-compliance of full course of anti- cavity. can be defined as resistance of a microbial biotics by patients, availability of antibiot- agent against an antimicrobial drug to ics over the counter (OTC), poor quality It is not only the problem of the which it was susceptible before. AMR is of the drugs, coupled with primitive infec- superbugs but many microbes which cause the result of misuse of antimicrobial medi- tion control in hospitals and weak or defi- life threatening infections like tuberculo- cines and develops when a microorganism cient sanitation (10,11). It is also com- sis, malaria, influenza, pneumonia, and mutates or acquires a resistance gene (8). pounded through weak surveillance sys- viruses like HIV have become resistant to tems and non-availability of antibiotic standard and even to combination of an- MECHANISM policy at the national level but now India is timicrobial drugs. The problem is further Development of resistance to drugs by all set to see its first antibiotic policy being compounded by Methicillin-resistant Sta- microorganisms is a natural phenomenon passed by the central government very soon phylococcus aureus (MRSA), pathogenic co- but is enhanced by irrational use of which is a positive step in tackling antimi- agulase negative staphylococcus aureus and antimicrobials. Naturally resistant strains crobial resistance (12). Vancomycin resistant enterococci (VRE) (4). and those which have acquired resistance, emerge due to selective pressure exerted by ANTIBIOTIC USE IN DENTISTRY Even though, World Health Organisation exposure to antimicrobial drugs. The ge- Dentists account for approximately 7-11% (WHO) had warned about the threat of netic information is passed on through of all antibiotic prescriptions in the world antimicrobial resistance as early as 2000 (5), horizontal gene transfer between microbes (13-17). Although, the percentage is less it was neglected in aftermath of 9/11 but which allow resistance determinants to when compared to medical practitioners, at present we are staring at an impending spread within harmless environmental or antibiotics are one among frequently pre- deep public health crisis and realising its commensal microorganisms and patho- scribed drugs which significantly contrib- impact on mankind, World Health Organi- gens, thus creating a reservoir of resistance. utes to national and or global patient con- sation (WHO) has dedicated the theme of Resistance is also spread by the replication sumption of antibiotics and hence a mat- World Health Day 2011 to combat drug of microbes that carry resistance genes, a ter of deep concern (13, 14). The rate of resistance with a slogan of “No action to- process that produces genetically identical resistance development may be delayed if day; No cure tomorrow (6).” (clonal) progeny (9). dentists, along with other health care prac- titioners use antibiotics more judiciously. Dentists prescribe antibiotics for treating FACTORS AFFECTING ANTIBIOTIC In dental practice, antibiotics are invaluable various oral infections and reports high- RESISTANCE adjuncts in treatment of oro-facial infec- light that many oral microbes have devel- According to World Health Organisation, tions which are usually prescribed for man- oped resistance to wide variety of antibiot- the antimicrobial resistance is a multifacto- agement of acute odontoge-nic infections, ics largely due to irrational use (7). At the rial problem and can be summarized due non-odontogenic infections, as prophylaxis present rate of antimicrobial resistance to deficient antimicrobial policies and against focal infection in patients at risk (AMR), we are at the risk of utilising all the guidelines at the national level, inadequate (en-docarditis and
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