PerioVive in Practice: Antibiotic Use and Misuse in Veterinary Dentistry

Most people take antibiotics for granted and assume that if an individual contracts a bacterial disease it can almost always be cured with antibiotics. The majority of us were not alive during the pre-antibiotic era before penicillin came into wide use in the 1940s. Researchers in the following three decades discovered multiple novel antibiotics, but no new classes have been found since the 1970s (1).

The frightening fact is that antimicrobial resistance (AMR) is developing at a far greater rate than new antibiotics are being discovered to combat them (2). AMR is recognized by the World Health Organization (WHO) as one of the leading public health threats of the 21st century (3). In 2019, antibiotic-resistant infections killed approximately 1.27 million people worldwide, and by 2050 that number is predicted to jump to an estimated 10 million deaths annually (4).

Veterinary personnel and pet owners face double risk from multi-drug resistant (MDR) organisms as there is both direct interspecies migration of bacteria, and of antimicrobial resistance genes (ARGs). Canine salivary microbiota contains ARG-rich bacteria that can colonize the human body and cause clinical illness and/or transport ARGs that can transfer antimicrobial resistance to the human microbiota (5).

It is abundantly clear that it is crucial to the health of ourselves and our patients that we as veterinary professionals become better antibiotic stewards. Antimicrobial stewardship is aimed at minimizing the development of AMR by using antimicrobial agents only when necessary and selecting the drug, dosage, and duration of therapy with the lowest chance of propagation of AMR (6). Overall, the goal is to maximize patient benefits while minimizing adverse events and resistance (7). To help guide the appropriate use of antimicrobials by veterinarians, the WHO (3) published a list of Medically Important Antimicrobials (MIA) as a risk management tool for mitigating AMR due to non-human use.

Antibiotic Use in Veterinary Dentistry

Antibiotics generally have limited efficacy in veterinary dentistry because dental infections are localized, and systemic antibiotics can't reach these areas in therapeutic concentrations. Additionally, oral bacteria form protective biofilms, further diminishing the efficacy of antibiotics (8). Gingivitis and routine periodontal disease (regardless of the extent of it) do not respond well to oral antibiotics (9).

Certain patients at high risk of infection/immunocompromised, with delayed wound healing, or with significant systemic disease may at times benefit from a course of antibiotics administered at the time of oral surgery. For high- risk patients, peri-operative use of IV antibiotics administered 30-60 minutes prior to oral surgery is recommended; Postoperative antibiotics are rarely indicated. The risk for dogs and cats developing infective endocarditis following oral surgery is extremely low, and prophylactic antimicrobial therapy for patients not regarded as high risk is not warranted. (10)

Systemic antibiotics are rarely indicated for routine dental prophylaxis, tooth extractions, periapical tooth root abscesses, or most cases of periodontitis (11). However, studies reveal that many veterinarians overuse or misuse antibiotics in dental procedures.

2020 survey showed systemic antimicrobials were administered in 8.8% of dog procedures and 7.8% of cat procedures in the absence of concurrent periodontal disease or extractions (12).

A 2023 survey found that in dog, drugs classified by the WHO MIA List as highest priority critically important (HPCIA) accounted for 39 % of drugs dispensed, while those classified as highly important (HIA) accounted for 61 %. In cats, HPCIA drugs accounted for 46 % of drugs dispensed while HIA drugs accounted for 54 %. (6)

A 2020 study of dental procedures at Banfield hospitals revealed that local or systemic antimicrobial agents were used in 16.4% of procedures in dogs and 14% of procedures in cats. Increasing age, extraction of teeth, and presence of periodontal disease were associated with increased likelihood of AMU. (13)

So, when is the use of antibiotics warranted for dental procedures? In general, antibiotic use should be determined on a case-by-case basis dependent on the patient’s immune status, presence of systemic illness, certain cardiac conditions interfering with blood flow, and conditions such as poorly regulated diabetes that compromise healing (11,14). There are no specific guidelines established in the USA for antibiotic use during dental procedures, including pets with co-morbidities (15). However, several organizations, including AVDC, AVMA, AAHA, and Feline VMA have issued vague guidelines (11,16,17).

Key Guidelines Issued by the AVDC on AMU in Dental Procedures

Routine Procedures: Routine antibiotic use is discouraged to reduce antibiotic resistance.

When to Use: Antibiotics are recommended when systemic infection is present, the patient is immunocompromised, or in cases of severe underlying disease (e.g., severe renal/hepatic disease, subaortic stenosis).

Prophylaxis: Pre-treatment with antibiotics may be used to reduce bacteremia in patients with high-risk systemic conditions.

Clinical Decision Making: Selection of antibiotics should ideally be based on known oral pathogen susceptibility, rather than empiric, routine use.

Not a Substitute: Antibiotics should not be used as a substitute for necessary surgical treatment, such as dental debridement or extraction. (17).

Key AAHA Dental Antibiotic Guidelines

Judicious Use: Antibiotics should not replace mechanical debridement (scaling, root planing) or extractions for periodontal disease.

When to Use: Reserved for cases with severe inflammation, deep periodontal pockets, or systemic infection signs (e.g., fever).

Prophylactic Use: Routine use of antibiotics before dental cleaning is generally discouraged and should only be considered for very high-risk patients.

Recommended Choices: Clindamycin (PO q12hrs) or Amoxicillin-clavulanic acid (PO q12hrs).

Duration: Full treatment should be continued for 7–14 days.

Alternatives: Topically applied antiseptic preparations (e.g., chlorhexidine) are preferred over systemic antibiotics for treating periodontal disease where possible. (16)

Strategies for Controlling AMR in Veterinary Dentistry

Development of and adherence to strict guidelines for antimicrobial use (AMU)

Minimizing inappropriate use of antibiotics such as for treating viral infections.

Education, training, and improved policies to prevent AMR (7,12,18)

Judicious use of antibiotics classified by the WHO as highest priority critically important (HPCIA) or highly important (HIA) (3).

Use of PPE by all dental personnel to reduce the risk of cross-infection with multi-drug resistant (MDR) strains of bacteria including MRSA and Porphyromonas gingivalis (19), and of interspecies migration of bacteria and antimicrobial resistance genes (ARGs) (5)

Increased funding and resources devoted to the development of new antibiotics.

Emphasize infection prevention through oral hygiene, early treatment, proper tissue handling, and strict infection control (11).

Strengthening practices to prevent rather than treat infections, including oral hygiene, early dental treatment, and strict infection control. Dental environments can harbor resistant bacteria, emphasizing the importance of infection control measures. (19)

Utilizing proper techniques including gentle tissue handling to minimize trauma to gums and bone, thorough flushing with sterile saline to remove debris, and careful surgical closure of extraction sites and use of sutures to protect exposed tissue and support healing (11,14,20).

Use of adjuvants including hyaluronic acid instead of local antibiotics, support periodontal treatment by reducing inflammation and promoting tissue healing.

Conclusions

There is a continuing race between the discovery and development of new antibiotics and the bacteria that will respond to selective pressure by developing resistance mechanisms. Retarding the development of AMR has potential implications for both animal and public health. For this reason, veterinarians need to halt the indiscriminate use of antibiotics and stop practices that accelerate the emergence of AMR. Antibiotic stewardship guidelines strongly recommend treating dental infections with local, mechanical care first, relying on antibiotic therapy only as a secondary measure when there is clear justification for the use (20).

The use PerioVive, a hyaluronic acid dental adjuvant, provides a safe, effective alternative to local antibiotic use and can help combat the progression of AMR. PerioVive is not only a better choice for responsible antibiotic stewardship, but it is also more effective than topical antibiotics, including Doxirobe and Clindoral, with a high level of AMR to pathogenic oral bacteria (21). The efficacy and mechanisms of action of hyaluronic acid in dentistry have been demonstrated in over 100 published articles and include, angiogenesis, osteoinduction, anti-inflammatory action, formation of a antimicrobial barrier where placed, and analgesia. Veterinary dental clinical applications include extraction sites, furcation defects, periodontal pockets, gingivitis and stomatitis.

A new hyaluronic acid water supplement, PerioPearls, can help to maintain good oral health by combating gingivitis and periodontitis. PerioPearls is a simple, tasteless, odorless tablet that is dissolved in 8 ounces of drinking water once a day.

PerioVive in practice highlights the importance of responsible antibiotic use and misuse in veterinary dentistry while supporting better oral health outcomes for pets.

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