Educate clients on how a comprehensive oral health treatment (COHAT) benefits their pet by removing the source of possible infection and negating the need for at-home antibiotics. Veterinary dentistry plays a substantial role in small animal preventive medicine and overall health outcomes. As veterinarians, we can make an enormous difference in the global use of antimicrobials by using them mindfully, grounded by evidence-based medicine. Veterinary dentistry practices continue to exhibit deficiencies in the area of antimicrobial use. Practicing antimicrobial stewardship (AS) not only enhances animal health but also lessens the risk of negative One Health impacts. By using antimicrobials responsibly and limiting their use to only when medically necessary, we minimize the risk of developing antimicrobial resistance (AMR) and prevent undue harm (dysbiosis, GI side effects, challenges with medication administration). A vet’s One Health role in dental practices How does One Health relate to dental AS, and what is our role as veterinarians? Responsible choices and oversight are not only recommended but necessary for antimicrobial use in veterinary dentistry. These practices are vital in ensuring the health of our patients, the public, the environment, and all animals.1,2 Decisions regarding antimicrobials, whether prophylactically or therapeutically, should not be taken lightly. They should be based on evidence-driven recommendations, ensuring our actions are always responsible and informed. What does the human literature tell us? In human medicine, the American Dental Association (ADA) recommends pre-dental prophylactic antibiotic therapy for a select number of patients. The ADA states, “There are currently relatively few patient subpopulations for whom antibiotic prophylaxis may be indicated prior to certain dental procedures.” They specifically mention the use of prophylactics in patients with prosthetic joint implants who have had replacement complications and may be receiving a mucosal incision or gingival manipulation. Prophylaxis for infective endocarditis constitutes the secondary population for which antimicrobials are indicated. This applies solely to individuals with a significant risk linked to underlying cardiac disease.3 Otherwise, the ADA and the American Heart Association (AHA) do not recommend other circumstances for pre-dental prophylaxis. They assert further prophylaxis is unnecessary unless a patient is predisposed to infection or immunosuppressed because of a solid organ transplant or some cancer therapies. However, it is up to the individual physician or dental practitioner. These recommendations resulted from a scientific review of the human literature. They asserted the side effects and risks of using antibiotics unnecessarily are far more likely sequelae than actual infection.3 Despite recommendations for the use of pre-dental prophylactic antibiotic therapy in humans, research suggests even this may be unnecessary in most patients.4 The consensus on post-dental antimicrobial therapy is less refined and is still considered excessive based on overall prescribing practices.5 What does the veterinary literature tell us? Sadly, much less high-grade (quality) evidence exists in veterinary medicine on AS and appropriate antimicrobial use within the dental field. However, with extrapolation from human studies and the few studies in veterinary medicine, we can generalize that the overuse of antibiotics in veterinary dentistry is still commonplace. Several studies have evaluated the oral microbiome in dogs, including those with periodontal disease. This groundwork aids in our understanding of normal flora and can improve our knowledge of non-pathogenic vs. potentially pathogenic organisms of concern. This can help guide better antimicrobial selection, improving overall AS moving forward.6,7 Despite the paucity of research, we know the use of antimicrobials pre-, during, and post-dental procedures remains higher than in human medicine and what is ideal. Further, many veterinarians still reach for third-tier medications and critically important, high-priority medications (as classified by the World Health Organization [WHO]) as their first line, increasing the risk of AMR and negatively impacting our patients and our ability to preserve those medications for human use and resistant infections.8–11 Many veterinarians rely on third-tier and high-priority WHO-classified medications as first-line treatments, raising AMR risks and jeopardizing these drugs for resistant infections and human use. Photo courtesy Dr. Erica Tramuta-Drobnis In a 2020 study,11 researchers retrospectively evaluated the use of antimicrobials in dogs and cats in the U.S. receiving dental care. They reviewed more than 800,000 records and noted 26.5 percent of the time in dogs and 52 percent in cats, drugs classified as clinically important, high-priority antibiotics were prescribed. In dogs, more than 16 percent of patients received either local or systemic antimicrobials for varying durations. Of those receiving antimicrobials, even 13 percent of canines without evidence of periodontal disease received antimicrobials. Finally, in cats, 14 percent of all evaluated received either local or systemic antimicrobials; of those administered, 52 percent were classified as critically important, high-priority medications.11 The study found higher rates of antimicrobial use than current evidence suggests appropriate and, discouragingly, a higher proportion of tier-three drugs. Drugs, such as fluoroquinolones and third-generation cephalosporins, should be reserved for confirmed infections (via culture) and based on MIC, reserved for specific cases and not as first-line drugs.11 Further, the study shows post-operative antimicrobial utilization is still excessive and suggests we aim to improve stewardship by minimizing usage. In another study,12 researchers discuss the overall bacteriome in the oral cavity of healthy dogs. They assess the normal oral flora and show they help maintain a healthy state when in low numbers. They state the empirical use of antimicrobials in all cases of periodontal disease is no longer the standard of care and should only be considered in cases of severe gingival and mucosal damage. They use examples of severe erosions, ulcers, or osteomyelitis cases. The only other patients recommended for the consideration of prophylactic therapy are those that are immunocompromised.12 Client education Gone are the days when we recommended dental care solely by saying, “Your pet needs a dental.” Instead, we want pet parents to understand what a complete dental evaluation, from pre-examination to any bloodwork, to anesthesia, radiographs, and more through their recovery, means to them—improving longevity, lessening the risk of systemic infection from bacteria in the mouth secondary to dental disease, and improving quality of life. We want clients to understand a COHAT or comprehensive oral health assessment and treatment benefits the pet and pet parent and encompasses more than simply cleaning the teeth. However, we also need to ensure they understand that even if we discuss bacteria or infection in the mouth, our COHAT removes that source of possible infection, negating the need for at-home antibiotics in most patients. Ways to minimize impacts Strategies to improve antimicrobial effectiveness while minimizing AMR and adverse health outcomes associated with inappropriate and excessive antibiotic use are imperative. Consider improving your AS by the PROTECT ME recommendation, as described by the BSAVA (British Small Animal Veterinary Association). P: Prescribe when necessary. Prophylaxis for routine COHATs is no longer recommended. R: Replace with non-antimicrobial therapy when feasible. Perform that COHAT and remove any source of recommender. O: Optimize protocols when dosing to prevent underdosing and minimize treatment duration. T: Treat effectively. Base decision choices not on cost, pill size, or just because it is on your shelf; ensure you target the right site, the right type of medication, duration of action, prevent drug interactions, and minimize side effects. E: Employ the narrowest spectrum possible. This limits the negative impact on the microbiome and lessens the risk of AMR. When cultures are performed, a broader antimicrobial may be started, but de-escalation can occur if confirmed by culture. C: Conduct diagnostics: Cytology, culture, sensitivity T: Tailor policies in your practice. Understand resistance patterns for common bugs in your area. M: Monitor for infections we can prevent (e.g. hospital-acquired); keep appraised of what antibiotics should be restricted (classes of drugs) based on WHO recommendations to preserve these drugs. E: Educate others. Ensure owners understand the treatment protocol, why treatment should be completed, any side effects, and more. The human and animal literature stresses:3,5,8,11–16,16–20 Antimicrobial agents should be designated for treating severe infections with established bacterial origins rather than for prophylaxis of potential, unlikely infections. Unnecessarily using antimicrobials has been shown to alter oral environments due to host and microbial factors. These factors, in turn, modify the balance of microbes in one’s digestive tract (dysbiosis), disrupt immune tolerance, and potentially cause an unwanted inflammatory response. Reserve IV perioperative antimicrobial use for high-risk patients, and repeat doses should be based on drug half-life, not surgical duration. If prophylactic antimicrobial treatment is warranted, utilize agents with activity most notably present in cases of infective endocarditis and bacteremia, not the standard organisms known to proliferate in unhealthy oral tissues. The use of at-home antimicrobials in dental procedures is discouraged and often unwarranted. High-risk patients in veterinary medicine may have considerable underlying heart disease and immunosuppression, albeit this is not yet confirmed. While the human literature lists endocarditis as a high-risk factor for post-op infection after dental procedures, the prevalence in small animals is quite low, supporting the idea that most patients do not need take-home antimicrobials. We must ensure clients know what to expect post-operatively following a COHAT procedure, including pain medications (if extractions or other painful procedures) and softened food (when warranted), as well as explain antimicrobials are not generally needed and why. They need to understand we have removed the source of infection, want to minimize undue side effects to the pet, and antibiotics are not without risks. Thus, we do not use them just in case. A pivotal reference is the AAHA 2019 Dental Care Guidelines for Dogs and Cats21 for strategies, procedures, terminology, and recommendations on the use of local and oral antimicrobials. Practicing One Health in veterinary dentistry While we think of veterinary dentistry at the individual animal level, performing COHATs, treating tooth root abscesses, removing diseased teeth, and preserving the human-animal bond (HAB) by ensuring the longevity of our patients, we also have a One Health obligation. We must minimize our footprint on the environment and human health, in addition to preserving the health and welfare of our patients. Prescribing unnecessary antimicrobials negatively impacts GI and immune system health, causes angst and challenges for pet parents administering medications, negatively impacts the HAB, and excessive use increases the risk of AMR. This warrants due diligence on our part to ensure we are current on the latest antimicrobial evidence-based medical recommendations. Thus, by looking at veterinary dentistry practices with a One Health lens, we can minimize patient harm, improve health outcomes, maintain and preserve the HAB, and ensure the practice of proper AS. Based on the AAFP/AAHA Antimicrobial Stewardship Guidelines, the American Veterinary Medical Association (AVMA) endorses them. It states: “Systemic antimicrobials are usually not indicated for routine dental prophylaxis or after tooth extractions. In cases of periodontitis, systemic antimicrobials are not a substitute for surgical treatment. In most periapical tooth root abscesses, debridement of infective tissue is sufficient to control infection.”16,22 Call to action By practicing proper AS, including selecting appropriate antimicrobials for the type of potential infection and, minimizing the use of critically important drugs and medication classes, using antimicrobials only when indeed indicated and not just in case, we can improve the quality of life and care to our patients, strengthen the HAB, and positively impact our environment, demonstrating the true One Health outlook needed when considering the use of antimicrobial therapy in veterinary dentistry. The veterinary dental community should seek to update current recommendations and guidelines. Five years after the most recent recommendations (2019), human and animal studies show continued overuse of antimicrobials in the pre-, peri-and post-dental periods and increasing risks at the individual animal level, including microbiome disruption and side effects. Further, we continue to see AMR and, more broadly, the increase in AMR genes in animal and human populations. Thus, as a veterinary community, we request the guidelines be updated to be less vague and more generalizable in their recommendations. Currently, a lack of consensus among veterinary dentists complicates matters. Therefore, the American College of Veterinary Dentistry (ACVD) should reach a consensus statement regarding patient-specific recommendations (e.g. for patients with comorbidities, immunosuppression) for prophylactic, intra-, and post-dental antimicrobial use, as well as specific procedures where they are warranted. These recommendations should be based on evidence-based medicine and research available to date. This will improve global veterinary dentistry AS and outcomes.23–25 Erica Tramuta-Drobnis, VMD, MPH, CPH, is the CEO and founder of ELTD One Health Consulting, LLC. Dr. Tramuta-Drobnis works as a public health professional, emergency veterinarian, freelance writer, consultant, and researcher. She is passionate about One Health issues and believes pet health, food safety, agricultural health, and more can address the interconnection of human, animal, and environmental health. References Tramuta-Drobnis EL. A closer look at antimicrobial stewardship, a fundamental One Health issue. Vet Pract News. 2024;36(8):22-23. American Veterinary Medical Association (AVMA). Antimicrobial stewardship definition and core principles. American Veterinary Medical Association. 2021. Accessed October 21, 2021. American Dental Association (ADA). Antibiotic Prophylaxis. ADA (American Dental Association). Accessed November 7, 2022. 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. Oberoi SS, Dhingra C, Sharma G, Sardana D. Antibiotics in dental practice: how justified are we. Int Dent J. 2020;65(1):4-10. Davis IJ, Wallis C, Deusch O, et al. A Cross-Sectional Survey of Bacterial Species in Plaque from Client Owned Dogs with Healthy Gingiva, Gingivitis or Mild Periodontitis. PLOS ONE. 2013;8(12):e83158. Dewhirst FE, Klein EA, Thompson EC, et al. The Canine Oral Microbiome. PLOS ONE. 2012;7(4):e36067. World Health Organization (WHO). Critically Important Antibacterial Agents for Human Medicine for Risk Management Strategies of Non-Human Use : Report of a WHO Working Group Consultation, 15-18 February 2005, Canberra, Australia. World Health Organization; 2005. Accessed December 2, 2024. World Health Organization. Critically Important Antimicrobials for Human Medicine 6th Revision 2018. 6th ed. World Health Organization. Regional Office for South-East Asia; 2022. Accessed November 4, 2022. The WHO Advisory Group on Integrated Surveillance of Antimicrobial Resistance (AGISAR). Critically Important Antimicrobials for Human Medicine : 6th Revision. WHO; 2018:1-52. Accessed April 21, 2024. 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. Niemiec BA, Gawor J, Tang S, Prem A, Krumbeck JA. The bacteriome of the oral cavity in healthy dogs and dogs with periodontal disease. Am J Vet Res. 2022;83(1):50-58. Niemiec B, Gawor J, Nemec A, et al. World Small Animal Veterinary Association Global Dental Guidelines. J Small Anim Pract. 2020;61(7):E36-E161. Pelaez-Prestel HF, Sanchez-Trincado JL, Lafuente EM, Reche PA. Immune Tolerance in the Oral Mucosa. Int J Mol Sci. 2021;22(22):12149. Sedghi L, DiMassa V, Harrington A, Lynch SV, Kapila YL. The oral microbiome: Role of key organisms and complex networks in oral health and disease. Periodontol 2000. 2021;87(1):107-131. Frey E, Costin M, Granick J, Weese JS. 2022 AAFP/AAHA Antimicrobial Stewardship Guidelines. JAHA. 2022;58(4). Contaldo M, D’Ambrosio F, Ferraro GA, et al. Antibiotics in Dentistry: A Narrative Review of the Evidence beyond the Myth. Int J Environ Res Public Health. 2023;20(11):6025. doi:10.3390/ijerph20116025 Patangia DV, Anthony Ryan C, Dempsey E, Paul Ross R, Stanton C. Impact of antibiotics on the human microbiome and consequences for host health. MicrobiologyOpen. 2022;11(1):e1260. doi:10.1002/mbo3.1260 Crader MF, Varacallo M. Preoperative Antibiotic Prophylaxis. In: StatPearls. StatPearls Publishing; 2024. Accessed December 2, 2024. Weese JS, Giguère S, Guardabassi L, et al. ACVIM Consensus Statement on Therapeutic Antimicrobial Use in Animals and Antimicrobial Resistance. J Vet Intern Med. 2015;29(2):487-498. doi:10.1111/jvim.12562 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 American Veterinary Medical Association (AVMA). AAFP/AAHA antimicrobial stewardship guidelines | American Veterinary Medical Association. AVMA. Accessed December 2, 2024. 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 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 Morgan J. New study investigates how co-morbidities influence antimicrobial usage during dental procedures. Mars Veterinary Health. September 18, 2024. Accessed December 2, 2024.
