Sir, over the last seven years, there have only been a small number of changes in the DPF/BNF antibiotic prescribing guidelines for dental practitioners, with the removal of three indications: oral-antral fistula, acute suppurative pulpitis and antibiotic prophylaxis.1,2

While the general DPF/BNF advice that Antibacterial drugs should only be prescribed for the treatment of dental infections on the basis of defined need has not changed over that period, there has been a more general recognition of the need to limit the development of resistant strains by optimising prescribing patterns.3 However, recent research found that high levels of oral antibiotic prescribing in the absence of local measures persists and is of concern.4

Over a period of time I developed an antibiotic prescribing approach, which used available authoritative advice resources in order to optimise therapeutic use. This may be summarised as follows:

  • Examination with particular reference to BNF advice

  • Adopting a local measures approach

  • Where appropriate recalling patients within 24 hours to review their condition in order to determine whether it was stable, resolving or worsening

  • Providing patients with OOH contact advice, analgesics advice and advice to attend A&E in the event that a swelling developed which began to embarrass the airway

  • Providing reassurance to patients on the clinical approach being adopted, frequently with reference to the limitations of antibiotics

  • Where appropriate seeking additional professional pharmacological advice

  • Immediate referral for patients with very severe dental infections, which risked embarrassing the airway (as I recall there were two such cases over 15 months both of which were discussed with the on-call maxillofacial clinician prior to referral).

In order to assess the outcome of this approach, a text backup document generated by keylogger software was analysed for keywords potentially relevant and relevant to acute dental infections over the period November 2007 to January 2009.

Over that period only two instances of prescribing antibiotics for a single acute dental infection were identified (I had originally believed that there were three separate episodes of such antibiotic prescribing – unfortunately the full clinical software package is not readily searchable at the text level, currently). The keywords analysed for the same period and associated number of instances are given in Table 1.

Table 1 The keywords potentially relevant and relevant to acute dental infections over the period November 2007 to January 2009 and associated number of instances
Full size table

Therefore, during that time I estimate that I treated approximately 600-800 emergency patients (dental bureau referrals, new patients and past patients). I would add that I have also not found it necessary to prescribe antibiotics in the period January-April 2009.

In England, in the period 1 April 2007 to 31 March 2008, approximately 20,000 dentists (with NHS activity)5 issued 3.7 million NHS prescriptions for antibiotics in the financial year 2007/8 at a cost of £7.89 million, in England.6 Therefore on average each NHS dentist prescribed 185 courses of antibiotics per year with a total cost of £394. The respective FTE figure per dentist may be expected to be higher and private prescribing per dentist may increase FTE figures for all dentists in England, still further. If my personal case load for acute dental infections is typical of the average practitioner, then my experiences would suggest that prescribing and associated costs could be reduced to approximately 1% of current levels.3

To be candid, such an approach to antibiotic prescribing can be time consuming and stressful, particularly where patient 'expectations' are not being met and where prescribing criteria are close to being met. Furthermore, the costs of the additional effort probably substantially outweigh the financial savings to the NHS in reduced prescription charge expenditure. However, when implemented and established, I believe the benefits to the patient and the clinician more than warrant the effort. I also believe that similar approaches will have been pursued by many colleagues and dissemination of their approaches and experiences would be of benefit to the profession.