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Figure 1.
Study Flowchart
Study Flowchart

Derivation of the study population is shown.

Figure 2.
Geographic Variation in Unnecessary Antibiotic Prophylaxis, 2011-2015
Geographic Variation in Unnecessary Antibiotic Prophylaxis, 2011-2015

Results from the unadjusted analysis are shown.

Table 1.  
Guideline Summary on the Use of Antibiotic Prophylaxis Before Dental Procedures
Guideline Summary on the Use of Antibiotic Prophylaxis Before Dental Procedures
Table 2.  
Descriptive Characteristics of Eligible Dental Visits (2011-2015) and Unadjusted Associations With the Appropriateness of Antibiotic Prophylaxis Among 168 420 Dental Visits
Descriptive Characteristics of Eligible Dental Visits (2011-2015) and Unadjusted Associations With the Appropriateness of Antibiotic Prophylaxis Among 168 420 Dental Visits
Table 3.  
Multivariable Analysis of Factors Associated With Unnecessary Antibiotic Prophylaxis Among 168 420 Dental Visits
Multivariable Analysis of Factors Associated With Unnecessary Antibiotic Prophylaxis Among 168 420 Dental Visits
1.
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/civ076PubMedGoogle Scholar
2.
Koppen  L, Suda  KJ, Rowan  S, McGregor  J, Evans  CT.  Dentists’ prescribing of antibiotics and opioids to Medicare Part D beneficiaries: Medications of high impact to public health.  J Am Dent Assoc. 2018;149(8):721-730. doi:10.1016/j.adaj.2018.04.027PubMedGoogle ScholarCrossref
3.
Durkin  MJ, Feng  Q, Warren  K,  et al; Centers for Disease Control and Prevention Epicenters.  Assessment of inappropriate antibiotic prescribing among a large cohort of general dentists in the United States.  J Am Dent Assoc. 2018;149(5):372-381.e1. doi:10.1016/j.adaj.2017.11.034PubMedGoogle ScholarCrossref
4.
Allen  U.  Infective endocarditis: updated guidelines.  Can J Infect Dis Med Microbiol. 2010;21(2):74-77. doi:10.1155/2010/760276PubMedGoogle ScholarCrossref
5.
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.106.183095PubMedGoogle ScholarCrossref
6.
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. doi:10.1016/j.adaj.2014.11.012PubMedGoogle ScholarCrossref
7.
American Academy of Orthopaedic Surgeons (AAOS)/American Dental Association. Prevention of orthopaedic implant infection in patients undergoing dental procedures: evidence-based guideline and evidence report. http://www.ada.org/~/media/ADA/Member%20Center/FIles/PUDP_guideline.ashx. Published 2012. Accessed February 26, 2017.
8.
Rethman  MP, Watters  W  III, Abt  E,  et al; American Academy of Orthopaedic Surgeons; American Dental Association.  The American Academy of Orthopaedic Surgeons and the American Dental Association clinical practice guideline on the prevention of orthopaedic implant infection in patients undergoing dental procedures.  J Bone Joint Surg Am. 2013;95(8):745-747. doi:10.2106/00004623-201304170-00011PubMedGoogle ScholarCrossref
9.
Duval  X, Alla  F, Hoen  B,  et al.  Estimated risk of endocarditis in adults with predisposing cardiac conditions undergoing dental procedures with or without antibiotic prophylaxis.  Clin Infect Dis. 2006;42(12):e102-e107. doi:10.1086/504385PubMedGoogle ScholarCrossref
10.
Bor  DH, Himmelstein  DU.  Endocarditis prophylaxis for patients with mitral valve prolapse. A quantitative analysis.  Am J Med. 1984;76(4):711-717. doi:10.1016/0002-9343(84)90300-0PubMedGoogle ScholarCrossref
11.
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.2016.4151PubMedGoogle ScholarCrossref
12.
Aizcorbe  A, Liebman  E, Pack  S, Cutler  DM, Chernew  ME, Rosen  AB.  Measuring health care costs of individuals with employer-sponsored health insurance in the U.S.: a comparison of survey and claims data.  Stat J IAOS. 2012;28(1-2):43-51. doi:10.3233/SJI-2012-0743PubMedGoogle Scholar
13.
Dunn  A, Rittmueller  L, Whitmire  B. Introducing the new BEA health care satellite account. https://apps.bea.gov/scb/pdf/2015/01%20January/0115_bea_health_care_satellite_account.pdf. Published January 2015. Accessed February 20, 2017.
14.
Dunn  AC, Liebman  E, Rittmueller  L, Shapiro  A. Defining disease episodes and the effects on the components of expenditure growth. https://www.bea.gov/papers/pdf/definingdisease.pdf. Published April 2014. Accessed February 20, 2017.
15.
Dunn  A, Liebman  E, Pack  S, Shapiro  AH.  Medical care price indexes for patients with employer-provided insurance: nationally representative estimates from MarketScan data.  Health Serv Res. 2013;48(3):1173-1190. doi:10.1111/1475-6773.12008PubMedGoogle ScholarCrossref
16.
Nasseh  K, Vujicic  M, Glick  M.  The relationship between periodontal interventions and healthcare costs and utilization: evidence from an integrated dental, medical, and pharmacy commercial claims database.  Health Econ. 2017;26(4):519-527. doi:10.1002/hec.3316PubMedGoogle ScholarCrossref
17.
Vujicic  M, Nasseh  K. Gap in dental care utilization between Medicaid and privately insured children narrows, remains large for adults. Health Policy Institute Research Brief. American Dental Association. https://pdfs.semanticscholar.org/be52/49ae659fa7235ace41bf1b8882f475536065.pdf?_ga=2.4489979.932753190.1556066334-1001629407.1556066334. Revised 2015. Accessed April 23, 2019.
18.
Health Policy Institute, American Dental Association. The oral health care system: a state-by-state analysis. http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/OralHealthCare-StateFacts/Oral-Health-Care-System-Full-Report.ashx. Accessed February 26, 2017.
19.
Burns  L, Vujicic  M, Blatz  A. Recent trends in the market for endodontics. Health Policy Institute Research Brief. American Dental Association. http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0916_1.pdf?la=en. Revised November 2016. Accessed February 26, 2017.
20.
Yarbrough  C, Vujicic  M, Aravamudhan  K, Schwartz  S, Grau  B. An analysis of dental spending among children with private dental benefits. Health Policy Institute Research Brief. American Dental Association. http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0316_3.pdf?la=en. Revised April 2016. Accessed February 26, 2017.
21.
National Center for Health Statistics, Centers for Disease Control and Prevention. Classification of diseases, functioning, and disability: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). http://www.cdc.gov/nchs/icd/icd10cm.htm. Accessed February 26, 2017.
22.
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;6:301-306. doi:10.2147/TCRM.S9736PubMedGoogle ScholarCrossref
23.
Evans  CT, Smith  B, Parada  JP, Kurichi  JE, Weaver  FM.  Trends in antibiotic prescribing for acute respiratory infection in veterans with spinal cord injury and disorder.  J Antimicrob Chemother. 2005;55(6):1045-1049. doi:10.1093/jac/dki137PubMedGoogle ScholarCrossref
24.
Fitzpatrick  MA, Suda  KJ, Safdar  N,  et al.  Unique risks and clinical outcomes associated with extended-spectrum β-lactamase Enterobacteriaceae in veterans with spinal cord injury or disorder: a case-case-control study.  Infect Control Hosp Epidemiol. 2016;37(7):768-776. doi:10.1017/ice.2016.60PubMedGoogle ScholarCrossref
25.
American Dental Association; American Academy of Orthopedic Surgeons.  Antibiotic prophylaxis for dental patients with total joint replacements.  J Am Dent Assoc. 2003;134(7):895-899. doi:10.14219/jada.archive.2003.0289PubMedGoogle ScholarCrossref
26.
Irvine  JM, Hallvik  SE, Hildebran  C, Marino  M, Beran  T, Deyo  RA.  Who uses a prescription drug monitoring program and how? insights from a statewide survey of Oregon clinicians.  J Pain. 2014;15(7):747-755. doi:10.1016/j.jpain.2014.04.003PubMedGoogle ScholarCrossref
27.
Thornhill  MH, Dayer  MJ, Forde  JM,  et al.  Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after study.  BMJ. 2011;342:d2392. doi:10.1136/bmj.d2392PubMedGoogle ScholarCrossref
28.
Pasquali  SK, He  X, Mohamad  Z,  et al.  Trends in endocarditis hospitalizations at US children’s hospitals: impact of the 2007 American Heart Association antibiotic prophylaxis guidelines.  Am Heart J. 2012;163(5):894-899. doi:10.1016/j.ahj.2012.03.002PubMedGoogle ScholarCrossref
29.
Bikdeli  B, Wang  Y, Kim  N, Desai  MM, Quagliarello  V, Krumholz  HM.  Trends in hospitalization rates and outcomes of endocarditis among Medicare beneficiaries.  J Am Coll Cardiol. 2013;62(23):2217-2226. doi:10.1016/j.jacc.2013.07.071PubMedGoogle ScholarCrossref
30.
Fedeli  U, Schievano  E, Buonfrate  D, Pellizzer  G, Spolaore  P.  Increasing incidence and mortality of infective endocarditis: a population-based study through a record-linkage system.  BMC Infect Dis. 2011;11:48. doi:10.1186/1471-2334-11-48PubMedGoogle ScholarCrossref
31.
Schneeweiss  S, Robicsek  A, Scranton  R, Zuckerman  D, Solomon  DH.  Veteran’s affairs hospital discharge databases coded serious bacterial infections accurately.  J Clin Epidemiol. 2007;60(4):397-409. doi:10.1016/j.jclinepi.2006.07.011PubMedGoogle ScholarCrossref
32.
Cabell  CH, Heidenreich  PA, Chu  VH,  et al.  Increasing rates of cardiac device infections among Medicare beneficiaries: 1990-1999.  Am Heart J. 2004;147(4):582-586. doi:10.1016/j.ahj.2003.06.005PubMedGoogle ScholarCrossref
33.
Day  MD, Gauvreau  K, Shulman  S, Newburger  JW.  Characteristics of children hospitalized with infective endocarditis.  Circulation. 2009;119(6):865-870. doi:10.1161/CIRCULATIONAHA.108.798751PubMedGoogle ScholarCrossref
34.
Mujib  M, Khanna  N, Mazumder  NK,  et al.  Pretransplant coagulopathy and in-hospital outcomes among heart transplant recipients: a propensity-matched Nationwide Inpatient Sample study.  Clin Cardiol. 2015;38(5):300-308. doi:10.1002/clc.22391PubMedGoogle ScholarCrossref
35.
Abbott  KC, Agodoa  LY.  Hospitalizations for bacterial endocarditis after initiation of chronic dialysis in the United States.  Nephron. 2002;91(2):203-209. doi:10.1159/000058393PubMedGoogle ScholarCrossref
36.
Barreto-Filho  JA, Wang  Y, Dodson  JA,  et al.  Trends in aortic valve replacement for elderly patients in the United States, 1999-2011.  JAMA. 2013;310(19):2078-2085. doi:10.1001/jama.2013.282437PubMedGoogle ScholarCrossref
37.
Broberg  C, McLarry  J, Mitchell  J,  et al.  Accuracy of administrative data for detection and categorization of adult congenital heart disease patients from an electronic medical record.  Pediatr Cardiol. 2015;36(4):719-725. doi:10.1007/s00246-014-1068-2PubMedGoogle ScholarCrossref
38.
Dayer  MJ, Jones  S, Prendergast  B, Baddour  LM, Lockhart  PB, Thornhill  MH.  Incidence of infective endocarditis in England, 2000-13: a secular trend, interrupted time-series analysis.  Lancet. 2015;385(9974):1219-1228. doi:10.1016/S0140-6736(14)62007-9PubMedGoogle ScholarCrossref
39.
Centers for Medicare & Medicaid Services. ICD-10 Clinical Concepts for Cardiology. https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConceptsCardiology1.pdf. Accessed May 22, 2016.
40.
Klement  MR, Penrose  CT, Bala  A, Wellman  SS, Bolognesi  MP, Seyler  TM.  How do previous solid organ transplant recipients fare after primary total knee arthroplasty?  J Arthroplasty. 2016;31(3):609-615.e1. doi:10.1016/j.arth.2015.10.007PubMedGoogle ScholarCrossref
41.
American Health Information Management Association (AHIMA) Distance Education Career-Building Resources. Joint replacement coding. http://campus.ahima.org/audio/2007/RB061407.pdf. Published 2007. Accessed February 26, 2017.
42.
Greenland  S, Finkle  WD.  A retrospective cohort study of implanted medical devices and selected chronic diseases in Medicare claims data.  Ann Epidemiol. 2000;10(4):205-213. doi:10.1016/S1047-2797(00)00037-5PubMedGoogle ScholarCrossref
43.
Skaar  DD, O’Connor  H, Hodges  JS, Michalowicz  BS.  Dental procedures and subsequent prosthetic joint infections: findings from the Medicare Current Beneficiary Survey.  J Am Dent Assoc. 2011;142(12):1343-1351. doi:10.14219/jada.archive.2011.0134PubMedGoogle ScholarCrossref
44.
Lockhart  PB.  Antibiotic prophylaxis guidelines for prosthetic joints: much ado about nothing?  Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116(1):1-3. doi:10.1016/j.oooo.2013.04.009PubMedGoogle ScholarCrossref
45.
Diggle  PJ, Heagerty  P, Liang  KY, Zeger  SL, eds.  Analysis of Longitudinal Data. Oxford, UK: Oxford University Press; 2002.
46.
Suda  KJ, Roberts  RM, Hunkler  RJ, Taylor  TH.  Antibiotic prescriptions in the community by type of provider in the United States, 2005-2010.  J Am Pharm Assoc (2003). 2016;56(6):621-626.e1. doi:10.1016/j.japh.2016.08.015PubMedGoogle ScholarCrossref
47.
Chitnis  AS, Holzbauer  SM, Belflower  RM,  et al.  Epidemiology of community-associated Clostridium difficile infection, 2009 through 2011.  JAMA Intern Med. 2013;173(14):1359-1367. doi:10.1001/jamainternmed.2013.7056PubMedGoogle ScholarCrossref
48.
Bye  M, Whitten  T, Holzbauer  S.  Antibiotic prescribing for dental procedures in community-associated Clostridium difficile cases, Minnesota, 2009-2015.  Open Forum Infect Dis. 2017;4(suppl 1):S1. doi:10.1093/ofid/ofx162.001Google ScholarCrossref
49.
Thornhill  MH, Dayer  MJ, Prendergast  B, Baddour  LM, Jones  S, Lockhart  PB.  Incidence and nature of adverse reactions to antibiotics used as endocarditis prophylaxis.  J Antimicrob Chemother. 2015;70(8):2382-2388. doi:10.1093/jac/dkv115PubMedGoogle ScholarCrossref
50.
Marra  F, George  D, Chong  M, Sutherland  S, Patrick  DM.  Antibiotic prescribing by dentists has increased: why?  J Am Dent Assoc. 2016;147(5):320-327. doi:10.1016/j.adaj.2015.12.014PubMedGoogle ScholarCrossref
51.
Epstein  JB, Chong  S, Le  ND.  A survey of antibiotic use in dentistry.  J Am Dent Assoc. 2000;131(11):1600-1609. doi:10.14219/jada.archive.2000.0090PubMedGoogle ScholarCrossref
52.
Nelson  CL, Van Blaricum  CS.  Physician and dentist compliance with American Heart Association guidelines for prevention of bacterial endocarditis.  J Am Dent Assoc. 1989;118(2):169-173. doi:10.14219/jada.archive.1989.0215PubMedGoogle ScholarCrossref
53.
Löffler  C, Böhmer  F, Hornung  A,  et al.  Dental care resistance prevention and antibiotic prescribing modification: the cluster-randomised controlled DREAM trial.  Implement Sci. 2014;9:27. doi:10.1186/1748-5908-9-27PubMedGoogle ScholarCrossref
54.
Prior  M, Elouafkaoui  P, Elders  A,  et al; Translation Research in a Dental Setting (TRiaDS) Research Methodology Group.  Evaluating an audit and feedback intervention for reducing antibiotic prescribing behaviour in general dental practice (the RAPiD trial): a partial factorial cluster randomised trial protocol.  Implement Sci. 2014;9:50. doi:10.1186/1748-5908-9-50PubMedGoogle ScholarCrossref
55.
Seager  JM, Howell-Jones  RS, Dunstan  FD, Lewis  MA, Richmond  S, Thomas  DW.  A randomised controlled trial of clinical outreach education to rationalise antibiotic prescribing for acute dental pain in the primary care setting.  Br Dent J. 2006;201(4):217-222. doi:10.1038/sj.bdj.4813879PubMedGoogle ScholarCrossref
56.
Chopra  R, Merali  R, Paolinelis  G, Kwok  J.  An audit of antimicrobial prescribing in an acute dental care department.  Prim Dent J. 2014;3(4):24-29. doi:10.1308/205016814813877270PubMedGoogle ScholarCrossref
57.
Chate  RA, White  S, Hale  LR,  et al.  The impact of clinical audit on antibiotic prescribing in general dental practice.  Br Dent J. 2006;201(10):635-641. doi:10.1038/sj.bdj.4814261PubMedGoogle ScholarCrossref
58.
Kudiyirickal  MG, Hollinshead  F.  Antimicrobial prescribing practice by dentists: a study from two primary care centres in UK.  Minerva Stomatol. 2011;60(10):495-500.PubMedGoogle Scholar
59.
Lockhart  PB, Hanson  NB, Ristic  H, Menezes  AR, Baddour  L.  Acceptance among and impact on dental practitioners and patients of American Heart Association recommendations for antibiotic prophylaxis.  J Am Dent Assoc. 2013;144(9):1030-1035. doi:10.14219/jada.archive.2013.0230PubMedGoogle ScholarCrossref
60.
Cherry  WR, Lee  JY, Shugars  DA, White  RP  Jr, Vann  WF  Jr.  Antibiotic use for treating dental infections in children: a survey of dentists’ prescribing practices.  J Am Dent Assoc. 2012;143(1):31-38. doi:10.14219/jada.archive.2012.0015PubMedGoogle ScholarCrossref
61.
Lockhart  PB, Loven  B, Brennan  MT, Fox  PC.  The evidence base for the efficacy of antibiotic prophylaxis in dental practice.  J Am Dent Assoc. 2007;138(4):458-474. doi:10.14219/jada.archive.2007.0198PubMedGoogle ScholarCrossref
62.
Cope  AL, Chestnutt  IG.  Inappropriate prescribing of antibiotics in primary dental care: reasons and resolutions.  Prim Dent J. 2014;3(4):33-37. doi:10.1308/205016814813877333PubMedGoogle ScholarCrossref
63.
Gross  AE, Hanna  D, Rowan  SA, Bleasdale  SC, Suda  KJ.  Successful implementation of an antibiotic stewardship program in an academic dental practice.  Open Forum Infect Dis. 2019;6(3):ofz067. doi:10.1093/ofid/ofz067PubMedGoogle ScholarCrossref
64.
American Dental Association. Oral health topics: Medicare and Medicaid. https://www.medicaid.gov/medicaid/benefits/dental/index.html. Accessed April 23, 2019.
65.
Centers for Medicare & Medicaid Services. Your Medicare coverage: dental services. https://www.medicare.gov/coverage/dental-services.html. Accessed February 26, 2017.
66.
Miller  CS.  Where are the diagnostic codes in dentistry?  Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;111(2):131-132. doi:10.1016/j.tripleo.2010.10.021PubMedGoogle ScholarCrossref
67.
Kalenderian  E, Ramoni  RB, White  JM,  et al.  The importance of using diagnostic codes.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(1):4-5. doi:10.1016/j.tripleo.2011.01.047PubMedGoogle ScholarCrossref
68.
Rogers  AM, Schiller  NB.  Impact of the first nine months of revised infective endocarditis prophylaxis guidelines at a university hospital: so far so good.  J Am Soc Echocardiogr. 2008;21(6):775. doi:10.1016/j.echo.2008.04.001PubMedGoogle ScholarCrossref
69.
Desimone  DC, Tleyjeh  IM, Correa de Sa  DD,  et al; Mayo Cardiovascular Infections Study Group.  Incidence of infective endocarditis caused by viridans group streptococci before and after publication of the 2007 American Heart Association’s endocarditis prevention guidelines.  Circulation. 2012;126(1):60-64. doi:10.1161/CIRCULATIONAHA.112.095281PubMedGoogle ScholarCrossref
70.
Thornhill  MH, Gibson  TB, Cutler  E,  et al.  Antibiotic prophylaxis and incidence of endocarditis before and after the 2007 AHA recommendations.  J Am Coll Cardiol. 2018;72(20):2443-2454. doi:10.1016/j.jacc.2018.08.2178PubMedGoogle ScholarCrossref
71.
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.16.01107PubMedGoogle ScholarCrossref
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    3 Comments for this article
    EXPAND ALL
    Antibiotic stewardship
    Frederick Rivara, MD, MPH | University of Washington
    Another important study highlighting an area in which interventions to promote antibiotic stewardship may have substantial effects. What are the barriers to reducing this unnecessary use?
    CONFLICT OF INTEREST: Editor in Chief, JAMA Network Open.
    Deceptive conclusions
    Scott Fosse, DDS | Private Practice
    Though I agree there is an overuse of antibiotics I find this article placing blame on dentists incredibly deceptive and ignorant of the true prescribing source. I can honestly say that every single preventative antibiotic I prescribe is at the recommendation of the patient's cardiologist and/or orthopedist. I can't count the number of patients I've explained the guideline changes to and yet when I consult with their MDs they disregard everything and place them on lifelong antibiotic prophylaxis. On top of that the MDs never write the prescription themselves thus causing us dentists to step in for our patients. If looking at future studies I'd be curious how many prescriptions cardiologists and orthopedists write for prophylaxis of dental procedures.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Author Response - Conclusions
    KJ Suda, PharmD, M.S. | University of Illinois at Chicago
    Dr. Fosse,

    Thank you for your comment.

    We recognize that prescribing decisions (and other patient care decisions) are a complex process. There have been several papers describing factors associated with antibiotic prescribing. A recent systematic review includes a focus on dentists (See: https://www.ncbi.nlm.nih.gov/pubmed/31002336).

    Othopedic surgeons and cardiologists prescribe very few antibiotics (see my paper here: https://www.ncbi.nlm.nih.gov/pubmed/25747410). However, dentists prescribe a lot of antibiotics. While dentists primarily prescribe amoxicillin and clindamycin (the antibiotics recommended for prophylaxis), these specialists rarely prescribe these drugs.

    We have received comments from our dentist collaborators and contacts that medical
    clinicians recommend that a dentist prescribe antibiotic prophylaxis even when it is not indicated. This paper is part of a larger project and we hope to contribute to literature on factors associated with unnecessary prescribing. Our long-term goal is to provide customized resources to dentists to aid in prescribing antibiotics and implementing antibiotic stewardship (see what we did at UIC here: https://www.ncbi.nlm.nih.gov/pubmed/30895206).

    Thank you for your interest in our paper,
    KS
    CONFLICT OF INTEREST: PI
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    Original Investigation
    Infectious Diseases
    May 31, 2019

    Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015

    Author Affiliations
    • 1College of Pharmacy, University of Illinois at Chicago
    • 2Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois
    • 3College of Dentistry, University of Illinois at Chicago
    • 4School of Public Health, University of Illinois at Chicago
    • 5College of Medicine, University of Illinois at Chicago
    • 6Oregon State University, Corvallis
    • 7College of Pharmacy, Oregon Health and Science University, Portland
    • 8Northwestern University Feinberg School of Medicine, Chicago, Illinois
    JAMA Netw Open. 2019;2(5):e193909. doi:10.1001/jamanetworkopen.2019.3909
    Key Points español 中文 (chinese)

    Question  Are antibiotics appropriately prescribed for infection prophylaxis before dental procedures?

    Findings  In this cohort study of 91 438 patients who received antibiotic prophylaxis for 168 420 dental visits from 2011 to 2015, a total of 90.7% of dental visits had manipulation of the gingiva or tooth periapex, but only 20.9% of patients had a cardiac condition at the highest risk of adverse outcome from infective endocarditis. Therefore, 80.9% of antibiotic prophylaxis prescriptions were discordant with guidelines.

    Meaning  Most antibiotics prescribed for infection prophylaxis before dental procedures are unnecessary.

    Abstract

    Importance  Antibiotics are recommended before certain dental procedures in patients with select comorbidities to prevent serious distant site infections.

    Objective  To assess the appropriateness of antibiotic prophylaxis before dental procedures using Truven, a national integrated health claims database.

    Design, Setting, and Participants  Retrospective cohort study. Dental visits from 2011 to 2015 were linked to medical and prescription claims from 2009 to 2015. The dates of analysis were August 2018 to January 2019. Participants were US patients with commercial dental insurance without a hospitalization or extraoral infection 14 days before antibiotic prophylaxis (defined as a prescription with ≤2 days’ supply dispensed within 7 days before a dental visit).

    Exposures  Presence or absence of cardiac diagnoses and dental procedures that manipulated the gingiva or tooth periapex.

    Main Outcomes and Measures  Appropriate antibiotic prophylaxis was defined as a prescription dispensed before a dental visit with a procedure that manipulated the gingiva or tooth periapex in patients with an appropriate cardiac diagnosis. To assess associations between patient or dental visit characteristics and appropriate antibiotic prophylaxis, multivariable logistic regression was used. A priori hypothesis tests were performed with an α level of .05.

    Results  From 2011 to 2015, antibiotic prophylaxis was prescribed for 168 420 dental visits for 91 438 patients (median age, 63 years; interquartile range, 55-72 years; 57.2% female). Overall, these 168 420 dental visits were associated with 287 029 dental procedure codes (range, 1-14 per visit). Most dental visits were classified as diagnostic (70.2%) and/or preventive (58.8%). In 90.7% of dental visits, a procedure was performed that would necessitate antibiotic prophylaxis in high-risk cardiac patients. Prevalent comorbidities include prosthetic joint devices (42.5%) and cardiac conditions at the highest risk of adverse outcome from infective endocarditis (20.9%). Per guidelines, 80.9% of antibiotic prophylaxis prescriptions before dental visits were unnecessary. Clindamycin was more likely to be unnecessary relative to amoxicillin (odds ratio [OR], 1.10; 95% CI, 1.05-1.15). Prosthetic joint devices (OR, 2.31; 95% CI, 2.22-2.41), tooth implant procedures (OR, 1.66; 95% CI, 1.45-1.89), female sex (OR, 1.21; 95% CI, 1.17-1.25), and visits occurring in the western United States (OR, 1.15; 95% CI, 1.06-1.25) were associated with unnecessary antibiotic prophylaxis.

    Conclusion and Relevance  More than 80% of antibiotics prescribed for infection prophylaxis before dental visits were unnecessary. Implementation of antimicrobial stewardship in dental practices is an opportunity to improve antibiotic prescribing for infection prophylaxis.

    Introduction

    Dentists prescribe 1 in 10 antibiotic prescriptions and are the top specialty prescriber of antibiotics in the United States.1 Antibiotic prescribing by dentists is common, comprising almost 60% of prescriptions to Medicare Part D beneficiaries.2 While decreases in prescribing of antibiotics have been observed nationally, dental prescribing has remained steady.3 This is despite changes in clinical guidelines narrowing the indications for antibiotic prophylaxis before dental procedures.4-8

    Prior infection prophylaxis guidelines recommended that patients with certain conditions (ie, patients with recent prosthetic joint implants) receive antibiotic prophylaxis before a dentist visit. The rationale for prophylaxis was that patients with these conditions have an increased risk for serious distant site infections (eg, infective endocarditis and prosthetic joint infections) secondary to bacteremia introduced during dental care. However, guidelines for the use of antibiotics for the prevention of infective endocarditis and prosthetic joint infections were revised in 2007 and 2013, respectively.5,8 The rationale for these revisions was secondary to poor evidence on the effectiveness of antibiotic prophylaxis, lack of an association between endocarditis and joint infections and dental care, and the risk of antibiotic-associated adverse events.5,6,9 Antibiotic resistance, risk of Clostridioides difficile infection, and general adverse effects outweigh any potential benefit, which is likely to be small.6,9,10 Therefore, antibiotics before dental procedures are only recommended per guidelines in patients with cardiac conditions at the highest risk of adverse outcome from infective endocarditis undergoing invasive dental procedures.5

    While studies in outpatient primary medical care settings have demonstrated that 30% of antibiotics prescribed are unnecessary,11 no study has evaluated the appropriateness of antibiotic prescribing by dentists. Therefore, the objective of this study was to assess the appropriateness of antibiotic prophylaxis before dental procedures.

    Methods

    In this retrospective cohort study, we performed an analysis of adult patients with visits to a dentist from 2011 to 2015 using Truven MarketScan commercial claims and encounters, Medicare supplemental, and coordination of benefits. Truven is a national integrated health claims database of deidentified outpatient medical, hospital, prescription, and dental claims. While the medical claims are nationally representative of the insured US population in terms of age, sex, and geographic area,12-15 the dental domain is a convenience sample of 8 million persons with enrollment in both medical (commercial insurance or Medicare) and dental (commercial) health plans. This is the only national data set with detailed data on dental claims and links medical and prescription claims.16 Per other health services research performed by the American Dental Association,16-20 we collected individual-level demographics (patient age and sex), inpatient and outpatient medical diagnoses (in International Classification of Diseases, Ninth Revision [ICD-9] or International Statistical Classification of Diseases, 10th Revision, Clinical Modification [ICD-10-CM] format), medical procedures (in Current Procedural Terminology and Healthcare Common Procedure Coding System format), retail and mail-order prescription claims, and dental claims (in Code on Dental Procedures and Nomenclature [CDT] format). Dental visit CDT codes were aggregated into categories per a standardized coding structure established by the American Dental Association. Because multiple CDT codes could be coded for a visit, our analyses assessed visits with a specific CDT category coded as compared with visits without the CDT category coded. For all analyses herein, ICD-9 codes before October 1, 2015, were converted to ICD-10-CM codes per guidance from the Centers for Disease Control and Prevention.21 This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. The University of Illinois at Chicago Investigational Review Board deemed that this study was exempt from review and informed consent.

    Study Population

    Prescription claims were identified in the Truven prescription claims data, and dental procedures were identified in the Truven dental commercial claims data (2011-2015), with prevalence of cardiac or other conditions identified in the Truven medical and hospital claims data (2009-2015) before the dispensing of antibiotic prescriptions for the dental visit. The dates of analysis were August 2018 to January 2019. Eligible study patients were those with 12 months of continuous enrollment in plans with medical and prescription coverage and 30 days with dental coverage before and including the date of the visit with a dentist. We identified patients with a prescription claim for any systemic antibiotic with a days’ supply of 2 days or less that occurred within 7 days before the dental visit. In this study, these antibiotics were defined as being prescribed for preprocedural infection prophylaxis and meet the standard from prior studies, manual review of dental records, and per guidance from clinical experts.22 Antibiotics with a days’ supply of 2 days or less dispensed within 7 days before the dental visit met our definition of use for antibiotic prophylaxis vs treatment of an oral or systemic infection (requiring ≥3 days’ treatment).22 We further excluded visits at which patients had a recent hospitalization or active or recent extraoral infection (eg, recent respiratory tract infection) defined by diagnosis codes from any outpatient encounter. A recent hospitalization or extraoral infection was defined as occurring within 14 days before the antibiotic dispense date.23,24

    Because dental visits are typically connected (eg, a tooth requiring extraction is identified at one visit but is extracted at a second visit), we combined all dental visits occurring within 7 days from each other into a single observation or an episode of care. All codes from each visit were combined and represented in the episode of care. For example, a diagnostic dental visit that is followed by a tooth implant dental visit 3 days later is combined into an episode of care with diagnostic and implant codes. Clustering visits into episodes of care excluded 13 825 visits (6.8% of the cohort had 2 visits, and 0.3% had ≥3 visits) (Figure 1). Of the visits clustered into episodes of care, 23.8% had a visit the next day (1 day apart), 14.4% were 2 days apart, 9.6% were 3 days apart, 8.9% were 4 days apart, 11.2% were 5 days apart, 13.5% were 6 days apart, and 18.5% were 7 days apart. Broadening the episode of care definition to 14 and 30 days linked visits that were unlikely to be relevant clinically and thus captured few additional visits. Episodes of care are reported as visits herein but are in fact visits collapsed into episodes of care as described previously.

    Study Definitions

    Guidelines on the use of antibiotics for infective endocarditis prophylaxis are based on specific planned dental procedures and medical history. Recommendations in current and previous guidelines for the use of antibiotic prophylaxis before dental procedures are summarized in Table 1.5,8,25 For antibiotic prophylaxis to be indicated for the prevention of infective endocarditis, both the dental procedure and the medical history need to be consistent with guidelines.26 Dental procedures for which infective endocarditis prophylaxis is considered appropriate are all procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa (referred to as gingival manipulation herein).5 All CDT, Current Procedural Terminology, and Healthcare Common Procedure Coding System codes associated with dental visits during the study period were assessed for gingival manipulation by 6 general and 6 specialty dentist raters. When raters disagreed, consensus was determined by an additional rater team of 3 general dentists and 1 oral surgeon. Patients with cardiac conditions that are associated with the highest risk of adverse outcome from endocarditis are recommended to receive antibiotic prophylaxis for dental procedures that involve gingival manipulation. Cardiac conditions for which antibiotics are indicated per guidelines include prosthetic cardiac valve or material used for cardiac valve repair, previous infective endocarditis, certain congenital heart diseases, and cardiac transplant recipients with cardiac valvulopathy.5 Cardiac conditions occurring from 2009 until the date the antibiotic was dispensed were evaluated and defined consistent with previous investigators.8,27-39

    Antibiotics are not recommended for prosthetic joint infection prophylaxis,6-8 defined as recent (prior 2 years) or historical claims (Table 1). Before 2012, guidelines for prosthetic joint infection prophylaxis recommended antibiotic prophylaxis in patients with select comorbidities (eg, prosthetic joint plus cancer) (Table 1). Hospital and medical claims of any prosthetic joint implant or complication (eg, revision or infection) occurring before the antibiotic dispense date were defined consistent with previous investigators.40-43 Therefore, “appropriate” antibiotic prophylaxis was defined as a prescription dispensed before a dental visit with a procedure that manipulated the gingiva or tooth periapex (as defined by dental raters described in the previous paragraph) in patients with an appropriate cardiac diagnosis as indicated by guidelines.5 In the absence of cardiac conditions, antibiotic prophylaxis was considered unnecessary in the primary analysis.6-8

    Given the varying guidelines and recommendations occurring over the course of the study period (updated prosthetic joint infection prophylaxis guidelines were published in 2013 and reaffirmed in 2015),7,8 we conducted sensitivity analyses varying the definition of what would qualify as an indication for joint-related prophylaxis (1) defining a 2-year window of appropriate antibiotic prescription after prosthetic joint placement (the highest-risk period for infection)7 and (2) using prior guidelines25 per recommendations by Lockhart.44 Other sensitivity analyses estimating the appropriateness of antibiotic prophylaxis included varying selection criteria within plausible scenarios of (1) continuous medical plan enrollment throughout the entire study period, (2) stratified years of estimates to reflect changes in practice and guideline recommendations, and (3) stratification of patients with and without a history of prosthetic joint diagnoses or procedures.

    Statistical Analysis

    Descriptive characteristics of groups with visits identified as having an appropriate use of antibiotic prophylaxis and those that did not were compared using independent-samples t test for continuous variables and χ2 test for categorical variables. Missing data (55 observations) were included in the analysis and are labeled in the multivariable analysis as unknown. Multivariable logistic regression models were used to calculate adjusted odds ratios (ORs) and 95% CIs with robust standard errors for association between patient-level and visit-level characteristics and appropriate antibiotic use. Also, in analyses that included multiple visits per patient (54.3% in the primary analysis), generalized estimating equations with a first-order autoregressive working matrix were used to estimate corresponding ORs and 95% CIs.45 Variables significant in unadjusted analyses or identified as factors associated with unnecessary antibiotic prophylaxis were included in the model. The most parsimonious model was selected by only including those final variables significantly associated with prescribing. SAS, version 9.4 (SAS Institute Inc), was used for all analyses. A priori hypothesis tests were performed with a 2-sided α level of .05.

    Results

    More than 3 million dental visits and antibiotic prescriptions were identified in the Truven commercial dental database during the study period of 2011 to 2015. After applying inclusion and exclusion criteria, 168 420 eligible dental visits (or episodes of care) with antibiotic prophylaxis for 91 438 unique patients were included in this analysis (Figure 1). The characteristics of the sample are listed in Table 2. The median age of the cohort was 63 years (interquartile range, 55-72 years) and was majority female (57.2%). Overall, these 168 420 dental visits were associated with 287 029 dental procedure codes (range, 1-14 per visit). Most visits with antibiotic prophylaxis occurred in the midwestern United States (46.9%), followed by the southern United States (31.5%), and occurred in an urban setting (56.7%). Most dental procedures conducted during the dental visits with antibiotic prophylaxis were classified as diagnostic (70.2%), followed by preventive (58.8%), and involved some type of gingival manipulation and/or mucosal incision (90.7%). Comorbidities were common in the cohort, especially prosthetic joint devices (42.5%) and cardiac conditions at the highest risk of adverse outcome from infective endocarditis (20.9%). Health care use in the previous 6 months was common, with half having a primary care visit (50.7%) and most having a specialty care visit (80.4%).

    Unadjusted Analysis

    Of the 168 420 eligible dental visits with antibiotic prophylaxis, the most frequent antibiotics prescribed were amoxicillin (69.4%), followed by clindamycin (16.0%) (Table 2). Only 19.1% of antibiotics prescribed were appropriate; therefore, 80.9% of antibiotic prophylaxis prescriptions before dental visits were discordant with guidelines. Those with unnecessary antibiotic prophylaxis had a lower percentage of amoxicillin prescribed but a higher percentage of cephalexin and other types of antibiotics than those with appropriate antibiotic prophylaxis. Compared with those visits with appropriate antibiotic prophylaxis, visits with unnecessary antibiotic prophylaxis were associated with a higher percentage of women, urban locations, and prosthetic joints but a lower percentage of diagnostic and preventive dental procedure categories, gingival manipulation, cardiac conditions, and previous health care use. There was also significant variation by US Census geographic region and the appropriateness of antibiotic prophylaxis. The highest unnecessary prescribing was observed in the West (84.5% of antibiotic prophylaxis prescriptions were unnecessary in the West) and the lowest in the Northeast (78.2% of antibiotic prophylaxis prescriptions were unnecessary in the Northeast). Unnecessary antibiotic prophylaxis decreased over time between 2011 and 2015 from 84.5% to 78.8% overall and across all geographic regions (P < .001) (Figure 2).

    Adjusted Analysis

    In multivariable analyses, unnecessary antibiotic prophylaxis decreased over time (Table 3). Patients 65 years and older and those aged 35 to 44 years had lower odds of being prescribed unnecessary antibiotic prophylaxis compared with patients aged 18 to 34 years, while women (vs men; odds ratio [OR], 1.21; 95% CI, 1.17-1.25) had higher odds of unnecessary prescribing. Significant regional variation remained: compared with the Midwest, the Northeast and South had lower odds of unnecessary antibiotic prophylaxis, while the West (OR, 1.15, 95% CI, 1.06-1.25) had higher odds of unnecessary antibiotic prophylaxis. In addition, being in a rural location was associated with lower odds of unnecessary antibiotic prophylaxis. Dental procedures defined as diagnostic, preventive, oral and maxillofacial surgery, periodontics, and endodontics had lower odds of unnecessary antibiotic prophylaxis compared with those without these CDT procedure categories; adjunctive general services, implant services (OR, 1.66; 95% CI, 1.45-1.89), prosthodontics, orthodontics, and maxillofacial prosthetics had higher odds of unnecessary prescribing. Unnecessary antibiotic prophylaxis was less common in patients with diabetes, immunocompromised conditions, or health care use in the previous 6 months, while having a prosthetic joint device (OR, 2.31; 95% CI, 2.22-2.41) was associated with unnecessary prescribing compared with those not having a prosthetic joint. Finally, unnecessary antibiotic prophylaxis was most associated with antibiotics falling into the “other” category, followed by clindamycin (OR 1.10; 95% CI, 1.05-1.15), compared with amoxicillin.

    Sensitivity analyses were conducted to assess whether our findings were robust to assumptions of selection criteria within a plausible range. In the event that medical coding missed a cardiac condition diagnosis, we limited our cohort to those patients continuously enrolled in the medical plan from 2009 until the date of the visit. In this continuous enrollment analysis, 60.1% (n = 101 231) of the cohort were included, and 80.2% of antibiotic prophylaxis prescriptions were defined as unnecessary. The 2003 guidelines for the prevention of prosthetic joint infections also changed during our study period (updated guidelines were published in 2013 [released online in 2012]) (Table 1).8,25 The results were similar after modifying our definition of appropriate antibiotic prophylaxis with recommendations in the 2003 prosthetic joint infection guidelines25 (75.7% of antibiotic prophylaxis prescriptions were unnecessary overall [76.7% in 2011-2013 and 74.1% in 2014-2015]). The highest-risk period of a prosthetic joint infection after joint implant placement is 2 years.25 After including prosthetic joint placement within 2 years in our definition of appropriate antibiotic prophylaxis, 80.9% of antibiotics prescribed for infection prophylaxis before dental visits were unnecessary. A subanalysis of the cohort with visits clustered into episodes of care (n = 13 825), 82.7% of patients at the first visit, 84.6% at the second visit, and 84.3% at the third visit received unnecessary antibiotic prophylaxis. Stratifying the overall cohort by the presence or absence of a prosthetic joint, 11.2% of patients with a prosthetic joint received appropriate antibiotic prophylaxis secondary to a concomitant cardiac condition (n = 71 651). After excluding those with a prosthetic joint, the percentage of visits with unnecessary antibiotic prophylaxis decreased to 75.0% (n = 96 769). Similar characteristics were found to be associated with unnecessary antibiotic prophylaxis as identified in the full analysis (eTables 1, 2, and 3 in the Supplement).

    Discussion

    Our results demonstrate that most antibiotics prescribed for infection prophylaxis before dental visits are unnecessary. These findings are concerning because dentists prescribe a significant proportion of antibiotics and are the top prescribers of clindamycin in the United States.1,46 Antibiotics prescribed for infection prophylaxis by dentists have been associated with community-associated C difficile infection.27,47,48 One dose of clindamycin has an equivalent risk of C difficile compared with a prolonged course.49 Therefore, it is alarming that clindamycin was more likely to be inappropriately prescribed than amoxicillin. However, there was a significant decrease in antibiotic prophylaxis over the study period. This may indicate that the 2013 guidelines for the prevention of prosthetic joint infections are being applied to patient care.

    These results are consistent with those from other countries, where 58% to 81% of dental antibiotic prescriptions are inconsistent with guidelines, particularly for infection prophylaxis.50-58 However, dentists are knowledgeable about and generally satisfied with the antibiotic prophylaxis guidelines.59 Regardless, 70% of dentists surveyed reported prescribing antibiotic prophylaxis when not indicated.59 Dentists in the United States identified factors associated with guideline-consistent antibiotic prescribing to be postgraduate education, urban locale, and a smaller patient panel.60 Reasons for higher antibiotic prescribing rates included increasing use of dental implants, an aging population, underinsurance driving antibiotics as an oral surgery substitute, slow adoption of new guidelines, lack of awareness of the role of dentists in antibiotic resistance, and physician and patient pressure.50,61 These characteristics are similar to those associated with physician antibiotic overprescribing.62 Therefore, antibiotic stewardship strategies shown to be effective in outpatient medical clinics may also improve antibiotic prescribing in dentistry. In fact, a recent example has provided early evidence that implementing the Centers for Disease Control and Prevention’s Core Elements of Outpatient Antibiotic Stewardship in dental practices was effective.63

    Limitations and Public Health Implications

    These results are not without limitations. The cohort is a convenience sample of US patients with commercial dental insurance. Therefore, our results may not be representative of the uninsured and underrepresents persons with Medicaid and Medicare benefits. Medicare does not generally cover dental care, and the state provision of dental benefits to adults with Medicaid is optional.64,65 As a result, these persons are not included in our sample unless supplemental commercial dental benefits were purchased. Due to limitations in the data set, the prescriptions cannot be directly linked with the health care encounter or prescriber. We adapted methods used by other investigators to link antibiotic prescriptions to health care encounters and exclude other indications for antibiotics. To increase the specificity of our antibiotic-related dental visits, we conservatively defined a cohort in which other indications for antibiotics are unlikely. In contrast to medical care providers, dentists rarely use diagnostic codes (ICD-9 or ICD-10-CM) and are reimbursed based on procedure codes (CDT).66,67 Therefore, it is difficult to associate a diagnosis with the prescription. To increase the likelihood that an antibiotic was prescribed for infection prophylaxis (vs treatment of an oral infection), the days’ supply for the antibiotic prescription was limited to 2 days or less (whereas oral infections are likely to be treated for ≥3 days). We did not assess dental visits at which an antibiotic was indicated but not dispensed. Although the 2007 infective endocarditis guidelines significantly decreased the number of patients with a prophylaxis indication,5 data are conflicting regarding the association of this change with the incidence of endocarditis.28,29,68-70 However, the sole study70 with results identifying an increase in infective endocarditis in the United States did not include dental visit data and was not able to adjust for increases in infective endocarditis observed with the opioid epidemic. So, it is difficult to elucidate the causal factor (dental visit vs substance misuse). We did not apply 2017 (after our study period) expert panel recommendations of clinical scenarios in which antibiotic prophylaxis may be appropriate in patients with prosthetic joints.71 All scenarios include patients with multiple comorbidities (eg, prosthetic joint plus uncontrolled diabetes and prosthetic joint plus immunocompromised state). Because the comorbidities in the expert panel recommendations71 are similar to those in the 2003 prosthetic joint guidelines,25 we anticipate the results from the expert panel recommendations to be similar to the results from the 2003 prosthetic joint guidelines. Due to the difficulty in identifying specific diagnoses, we broadened the definition for certain conditions to include all cardiac transplantation (removing cardiac valvulopathy), all diabetes (vs just type 1), and all congenital heart diseases. Therefore, unnecessary prescribing is likely higher than our results indicate.

    These findings have strong public health implications. To our knowledge, this is the first national analysis of overprescribing of antibiotics for infection prophylaxis before dental procedures and should initiate a call to action to the public health and dental communities to improve prescribing of antibiotics for infection prophylaxis. Because dentists primarily prescribe antibiotics for infection prophylaxis,49 a decrease in unnecessary antibiotic prophylaxis will significantly decrease overall antibiotic prescribing by dentists. Therefore, specific antibiotic stewardship strategies and prescribing tools targeted to dentists and dental practices should be developed, implemented, and assessed for effectiveness in improving prescribing of antibiotics for infection prophylaxis before dental procedures.

    Conclusions

    More than 80% of antibiotic prophylaxis prescriptions before dental procedures are unnecessary: clindamycin use, the presence of prosthetic joints, and residence in the western United States were associated with unnecessary prescribing. While antibiotic prophylaxis is appropriately prescribed for indicated dental procedures in patients with cardiac conditions, most antibiotic prophylaxis is prescribed to patients in whom guideline-identified risk factors are not present. Although prescribing is slowly improving, the high proportion of antibiotics that were found to be unnecessary in our study is worrisome. Implementing antimicrobial stewardship efforts in dental practices is an opportunity to improve antibiotic prescribing for infection prophylaxis.

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    Article Information

    Accepted for Publication: March 27, 2019.

    Published: May 31, 2019. doi:10.1001/jamanetworkopen.2019.3909

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Suda KJ et al. JAMA Network Open.

    Corresponding Author: Katie J. Suda, PharmD, MS, College of Pharmacy, University of Illinois at Chicago, 833 S Wood St, Room 227 (Mail Code 871), Chicago, IL 60612 (ksuda@uic.edu).

    Author Contributions: Drs Suda and Zhou had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Suda, Calip, Zhou, Gross, Perez, McGregor, Evans.

    Acquisition, analysis, or interpretation of data: Suda, Calip, Zhou, Rowan, Gross, Hershow, McGregor.

    Drafting of the manuscript: Suda, Calip, Zhou, Perez, Evans.

    Critical revision of the manuscript for important intellectual content: Suda, Calip, Zhou, Rowan, Gross, Hershow, McGregor.

    Statistical analysis: Suda, Calip, Zhou, McGregor, Evans.

    Obtained funding: Suda.

    Administrative, technical, or material support: Suda, Gross, Perez.

    Supervision: Suda.

    Conflict of Interest Disclosures: Dr Suda reported receiving funding from the Agency for Healthcare Research and Quality (AHRQ), US Department of Veterans Affairs Health Services Research & Development (VA HSR&D), VA Quality Enhancement Research Initiative, Centers for Disease Control and Prevention, and Roybal Foundation. Dr Rowan reported receiving grants from the AHRQ. Dr Gross reported receiving personal fees from Paratek. Dr McGregor reported receiving grants from the AHRQ, VA HSR&D, and Merck. No other disclosures were reported.

    Funding/Support: Research reported in this publication was supported by the Agency for Healthcare Research and Quality under award R01 HS25177 (Dr Suda).

    Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The opinions expressed are those of the authors and do not represent those of the US Department of Veterans Affairs or the US government.

    Meeting Presentation: This work was presented in part at IDWeek 2018; October 5, 2018; San Francisco, California.

    References
    1.
    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/civ076PubMedGoogle Scholar
    2.
    Koppen  L, Suda  KJ, Rowan  S, McGregor  J, Evans  CT.  Dentists’ prescribing of antibiotics and opioids to Medicare Part D beneficiaries: Medications of high impact to public health.  J Am Dent Assoc. 2018;149(8):721-730. doi:10.1016/j.adaj.2018.04.027PubMedGoogle ScholarCrossref
    3.
    Durkin  MJ, Feng  Q, Warren  K,  et al; Centers for Disease Control and Prevention Epicenters.  Assessment of inappropriate antibiotic prescribing among a large cohort of general dentists in the United States.  J Am Dent Assoc. 2018;149(5):372-381.e1. doi:10.1016/j.adaj.2017.11.034PubMedGoogle ScholarCrossref
    4.
    Allen  U.  Infective endocarditis: updated guidelines.  Can J Infect Dis Med Microbiol. 2010;21(2):74-77. doi:10.1155/2010/760276PubMedGoogle ScholarCrossref
    5.
    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.106.183095PubMedGoogle ScholarCrossref
    6.
    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. doi:10.1016/j.adaj.2014.11.012PubMedGoogle ScholarCrossref
    7.
    American Academy of Orthopaedic Surgeons (AAOS)/American Dental Association. Prevention of orthopaedic implant infection in patients undergoing dental procedures: evidence-based guideline and evidence report. http://www.ada.org/~/media/ADA/Member%20Center/FIles/PUDP_guideline.ashx. Published 2012. Accessed February 26, 2017.
    8.
    Rethman  MP, Watters  W  III, Abt  E,  et al; American Academy of Orthopaedic Surgeons; American Dental Association.  The American Academy of Orthopaedic Surgeons and the American Dental Association clinical practice guideline on the prevention of orthopaedic implant infection in patients undergoing dental procedures.  J Bone Joint Surg Am. 2013;95(8):745-747. doi:10.2106/00004623-201304170-00011PubMedGoogle ScholarCrossref
    9.
    Duval  X, Alla  F, Hoen  B,  et al.  Estimated risk of endocarditis in adults with predisposing cardiac conditions undergoing dental procedures with or without antibiotic prophylaxis.  Clin Infect Dis. 2006;42(12):e102-e107. doi:10.1086/504385PubMedGoogle ScholarCrossref
    10.
    Bor  DH, Himmelstein  DU.  Endocarditis prophylaxis for patients with mitral valve prolapse. A quantitative analysis.  Am J Med. 1984;76(4):711-717. doi:10.1016/0002-9343(84)90300-0PubMedGoogle ScholarCrossref
    11.
    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.2016.4151PubMedGoogle ScholarCrossref
    12.
    Aizcorbe  A, Liebman  E, Pack  S, Cutler  DM, Chernew  ME, Rosen  AB.  Measuring health care costs of individuals with employer-sponsored health insurance in the U.S.: a comparison of survey and claims data.  Stat J IAOS. 2012;28(1-2):43-51. doi:10.3233/SJI-2012-0743PubMedGoogle Scholar
    13.
    Dunn  A, Rittmueller  L, Whitmire  B. Introducing the new BEA health care satellite account. https://apps.bea.gov/scb/pdf/2015/01%20January/0115_bea_health_care_satellite_account.pdf. Published January 2015. Accessed February 20, 2017.
    14.
    Dunn  AC, Liebman  E, Rittmueller  L, Shapiro  A. Defining disease episodes and the effects on the components of expenditure growth. https://www.bea.gov/papers/pdf/definingdisease.pdf. Published April 2014. Accessed February 20, 2017.
    15.
    Dunn  A, Liebman  E, Pack  S, Shapiro  AH.  Medical care price indexes for patients with employer-provided insurance: nationally representative estimates from MarketScan data.  Health Serv Res. 2013;48(3):1173-1190. doi:10.1111/1475-6773.12008PubMedGoogle ScholarCrossref
    16.
    Nasseh  K, Vujicic  M, Glick  M.  The relationship between periodontal interventions and healthcare costs and utilization: evidence from an integrated dental, medical, and pharmacy commercial claims database.  Health Econ. 2017;26(4):519-527. doi:10.1002/hec.3316PubMedGoogle ScholarCrossref
    17.
    Vujicic  M, Nasseh  K. Gap in dental care utilization between Medicaid and privately insured children narrows, remains large for adults. Health Policy Institute Research Brief. American Dental Association. https://pdfs.semanticscholar.org/be52/49ae659fa7235ace41bf1b8882f475536065.pdf?_ga=2.4489979.932753190.1556066334-1001629407.1556066334. Revised 2015. Accessed April 23, 2019.
    18.
    Health Policy Institute, American Dental Association. The oral health care system: a state-by-state analysis. http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/OralHealthCare-StateFacts/Oral-Health-Care-System-Full-Report.ashx. Accessed February 26, 2017.
    19.
    Burns  L, Vujicic  M, Blatz  A. Recent trends in the market for endodontics. Health Policy Institute Research Brief. American Dental Association. http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0916_1.pdf?la=en. Revised November 2016. Accessed February 26, 2017.
    20.
    Yarbrough  C, Vujicic  M, Aravamudhan  K, Schwartz  S, Grau  B. An analysis of dental spending among children with private dental benefits. Health Policy Institute Research Brief. American Dental Association. http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0316_3.pdf?la=en. Revised April 2016. Accessed February 26, 2017.
    21.
    National Center for Health Statistics, Centers for Disease Control and Prevention. Classification of diseases, functioning, and disability: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). http://www.cdc.gov/nchs/icd/icd10cm.htm. Accessed February 26, 2017.
    22.
    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;6:301-306. doi:10.2147/TCRM.S9736PubMedGoogle ScholarCrossref
    23.
    Evans  CT, Smith  B, Parada  JP, Kurichi  JE, Weaver  FM.  Trends in antibiotic prescribing for acute respiratory infection in veterans with spinal cord injury and disorder.  J Antimicrob Chemother. 2005;55(6):1045-1049. doi:10.1093/jac/dki137PubMedGoogle ScholarCrossref
    24.
    Fitzpatrick  MA, Suda  KJ, Safdar  N,  et al.  Unique risks and clinical outcomes associated with extended-spectrum β-lactamase Enterobacteriaceae in veterans with spinal cord injury or disorder: a case-case-control study.  Infect Control Hosp Epidemiol. 2016;37(7):768-776. doi:10.1017/ice.2016.60PubMedGoogle ScholarCrossref
    25.
    American Dental Association; American Academy of Orthopedic Surgeons.  Antibiotic prophylaxis for dental patients with total joint replacements.  J Am Dent Assoc. 2003;134(7):895-899. doi:10.14219/jada.archive.2003.0289PubMedGoogle ScholarCrossref
    26.
    Irvine  JM, Hallvik  SE, Hildebran  C, Marino  M, Beran  T, Deyo  RA.  Who uses a prescription drug monitoring program and how? insights from a statewide survey of Oregon clinicians.  J Pain. 2014;15(7):747-755. doi:10.1016/j.jpain.2014.04.003PubMedGoogle ScholarCrossref
    27.
    Thornhill  MH, Dayer  MJ, Forde  JM,  et al.  Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after study.  BMJ. 2011;342:d2392. doi:10.1136/bmj.d2392PubMedGoogle ScholarCrossref
    28.
    Pasquali  SK, He  X, Mohamad  Z,  et al.  Trends in endocarditis hospitalizations at US children’s hospitals: impact of the 2007 American Heart Association antibiotic prophylaxis guidelines.  Am Heart J. 2012;163(5):894-899. doi:10.1016/j.ahj.2012.03.002PubMedGoogle ScholarCrossref
    29.
    Bikdeli  B, Wang  Y, Kim  N, Desai  MM, Quagliarello  V, Krumholz  HM.  Trends in hospitalization rates and outcomes of endocarditis among Medicare beneficiaries.  J Am Coll Cardiol. 2013;62(23):2217-2226. doi:10.1016/j.jacc.2013.07.071PubMedGoogle ScholarCrossref
    30.
    Fedeli  U, Schievano  E, Buonfrate  D, Pellizzer  G, Spolaore  P.  Increasing incidence and mortality of infective endocarditis: a population-based study through a record-linkage system.  BMC Infect Dis. 2011;11:48. doi:10.1186/1471-2334-11-48PubMedGoogle ScholarCrossref
    31.
    Schneeweiss  S, Robicsek  A, Scranton  R, Zuckerman  D, Solomon  DH.  Veteran’s affairs hospital discharge databases coded serious bacterial infections accurately.  J Clin Epidemiol. 2007;60(4):397-409. doi:10.1016/j.jclinepi.2006.07.011PubMedGoogle ScholarCrossref
    32.
    Cabell  CH, Heidenreich  PA, Chu  VH,  et al.  Increasing rates of cardiac device infections among Medicare beneficiaries: 1990-1999.  Am Heart J. 2004;147(4):582-586. doi:10.1016/j.ahj.2003.06.005PubMedGoogle ScholarCrossref
    33.
    Day  MD, Gauvreau  K, Shulman  S, Newburger  JW.  Characteristics of children hospitalized with infective endocarditis.  Circulation. 2009;119(6):865-870. doi:10.1161/CIRCULATIONAHA.108.798751PubMedGoogle ScholarCrossref
    34.
    Mujib  M, Khanna  N, Mazumder  NK,  et al.  Pretransplant coagulopathy and in-hospital outcomes among heart transplant recipients: a propensity-matched Nationwide Inpatient Sample study.  Clin Cardiol. 2015;38(5):300-308. doi:10.1002/clc.22391PubMedGoogle ScholarCrossref
    35.
    Abbott  KC, Agodoa  LY.  Hospitalizations for bacterial endocarditis after initiation of chronic dialysis in the United States.  Nephron. 2002;91(2):203-209. doi:10.1159/000058393PubMedGoogle ScholarCrossref
    36.
    Barreto-Filho  JA, Wang  Y, Dodson  JA,  et al.  Trends in aortic valve replacement for elderly patients in the United States, 1999-2011.  JAMA. 2013;310(19):2078-2085. doi:10.1001/jama.2013.282437PubMedGoogle ScholarCrossref
    37.
    Broberg  C, McLarry  J, Mitchell  J,  et al.  Accuracy of administrative data for detection and categorization of adult congenital heart disease patients from an electronic medical record.  Pediatr Cardiol. 2015;36(4):719-725. doi:10.1007/s00246-014-1068-2PubMedGoogle ScholarCrossref
    38.
    Dayer  MJ, Jones  S, Prendergast  B, Baddour  LM, Lockhart  PB, Thornhill  MH.  Incidence of infective endocarditis in England, 2000-13: a secular trend, interrupted time-series analysis.  Lancet. 2015;385(9974):1219-1228. doi:10.1016/S0140-6736(14)62007-9PubMedGoogle ScholarCrossref
    39.
    Centers for Medicare & Medicaid Services. ICD-10 Clinical Concepts for Cardiology. https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ClinicalConceptsCardiology1.pdf. Accessed May 22, 2016.
    40.
    Klement  MR, Penrose  CT, Bala  A, Wellman  SS, Bolognesi  MP, Seyler  TM.  How do previous solid organ transplant recipients fare after primary total knee arthroplasty?  J Arthroplasty. 2016;31(3):609-615.e1. doi:10.1016/j.arth.2015.10.007PubMedGoogle ScholarCrossref
    41.
    American Health Information Management Association (AHIMA) Distance Education Career-Building Resources. Joint replacement coding. http://campus.ahima.org/audio/2007/RB061407.pdf. Published 2007. Accessed February 26, 2017.
    42.
    Greenland  S, Finkle  WD.  A retrospective cohort study of implanted medical devices and selected chronic diseases in Medicare claims data.  Ann Epidemiol. 2000;10(4):205-213. doi:10.1016/S1047-2797(00)00037-5PubMedGoogle ScholarCrossref
    43.
    Skaar  DD, O’Connor  H, Hodges  JS, Michalowicz  BS.  Dental procedures and subsequent prosthetic joint infections: findings from the Medicare Current Beneficiary Survey.  J Am Dent Assoc. 2011;142(12):1343-1351. doi:10.14219/jada.archive.2011.0134PubMedGoogle ScholarCrossref
    44.
    Lockhart  PB.  Antibiotic prophylaxis guidelines for prosthetic joints: much ado about nothing?  Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116(1):1-3. doi:10.1016/j.oooo.2013.04.009PubMedGoogle ScholarCrossref
    45.
    Diggle  PJ, Heagerty  P, Liang  KY, Zeger  SL, eds.  Analysis of Longitudinal Data. Oxford, UK: Oxford University Press; 2002.
    46.
    Suda  KJ, Roberts  RM, Hunkler  RJ, Taylor  TH.  Antibiotic prescriptions in the community by type of provider in the United States, 2005-2010.  J Am Pharm Assoc (2003). 2016;56(6):621-626.e1. doi:10.1016/j.japh.2016.08.015PubMedGoogle ScholarCrossref
    47.
    Chitnis  AS, Holzbauer  SM, Belflower  RM,  et al.  Epidemiology of community-associated Clostridium difficile infection, 2009 through 2011.  JAMA Intern Med. 2013;173(14):1359-1367. doi:10.1001/jamainternmed.2013.7056PubMedGoogle ScholarCrossref
    48.
    Bye  M, Whitten  T, Holzbauer  S.  Antibiotic prescribing for dental procedures in community-associated Clostridium difficile cases, Minnesota, 2009-2015.  Open Forum Infect Dis. 2017;4(suppl 1):S1. doi:10.1093/ofid/ofx162.001Google ScholarCrossref
    49.
    Thornhill  MH, Dayer  MJ, Prendergast  B, Baddour  LM, Jones  S, Lockhart  PB.  Incidence and nature of adverse reactions to antibiotics used as endocarditis prophylaxis.  J Antimicrob Chemother. 2015;70(8):2382-2388. doi:10.1093/jac/dkv115PubMedGoogle ScholarCrossref
    50.
    Marra  F, George  D, Chong  M, Sutherland  S, Patrick  DM.  Antibiotic prescribing by dentists has increased: why?  J Am Dent Assoc. 2016;147(5):320-327. doi:10.1016/j.adaj.2015.12.014PubMedGoogle ScholarCrossref
    51.
    Epstein  JB, Chong  S, Le  ND.  A survey of antibiotic use in dentistry.  J Am Dent Assoc. 2000;131(11):1600-1609. doi:10.14219/jada.archive.2000.0090PubMedGoogle ScholarCrossref
    52.
    Nelson  CL, Van Blaricum  CS.  Physician and dentist compliance with American Heart Association guidelines for prevention of bacterial endocarditis.  J Am Dent Assoc. 1989;118(2):169-173. doi:10.14219/jada.archive.1989.0215PubMedGoogle ScholarCrossref
    53.
    Löffler  C, Böhmer  F, Hornung  A,  et al.  Dental care resistance prevention and antibiotic prescribing modification: the cluster-randomised controlled DREAM trial.  Implement Sci. 2014;9:27. doi:10.1186/1748-5908-9-27PubMedGoogle ScholarCrossref
    54.
    Prior  M, Elouafkaoui  P, Elders  A,  et al; Translation Research in a Dental Setting (TRiaDS) Research Methodology Group.  Evaluating an audit and feedback intervention for reducing antibiotic prescribing behaviour in general dental practice (the RAPiD trial): a partial factorial cluster randomised trial protocol.  Implement Sci. 2014;9:50. doi:10.1186/1748-5908-9-50PubMedGoogle ScholarCrossref
    55.
    Seager  JM, Howell-Jones  RS, Dunstan  FD, Lewis  MA, Richmond  S, Thomas  DW.  A randomised controlled trial of clinical outreach education to rationalise antibiotic prescribing for acute dental pain in the primary care setting.  Br Dent J. 2006;201(4):217-222. doi:10.1038/sj.bdj.4813879PubMedGoogle ScholarCrossref
    56.
    Chopra  R, Merali  R, Paolinelis  G, Kwok  J.  An audit of antimicrobial prescribing in an acute dental care department.  Prim Dent J. 2014;3(4):24-29. doi:10.1308/205016814813877270PubMedGoogle ScholarCrossref
    57.
    Chate  RA, White  S, Hale  LR,  et al.  The impact of clinical audit on antibiotic prescribing in general dental practice.  Br Dent J. 2006;201(10):635-641. doi:10.1038/sj.bdj.4814261PubMedGoogle ScholarCrossref
    58.
    Kudiyirickal  MG, Hollinshead  F.  Antimicrobial prescribing practice by dentists: a study from two primary care centres in UK.  Minerva Stomatol. 2011;60(10):495-500.PubMedGoogle Scholar
    59.
    Lockhart  PB, Hanson  NB, Ristic  H, Menezes  AR, Baddour  L.  Acceptance among and impact on dental practitioners and patients of American Heart Association recommendations for antibiotic prophylaxis.  J Am Dent Assoc. 2013;144(9):1030-1035. doi:10.14219/jada.archive.2013.0230PubMedGoogle ScholarCrossref
    60.
    Cherry  WR, Lee  JY, Shugars  DA, White  RP  Jr, Vann  WF  Jr.  Antibiotic use for treating dental infections in children: a survey of dentists’ prescribing practices.  J Am Dent Assoc. 2012;143(1):31-38. doi:10.14219/jada.archive.2012.0015PubMedGoogle ScholarCrossref
    61.
    Lockhart  PB, Loven  B, Brennan  MT, Fox  PC.  The evidence base for the efficacy of antibiotic prophylaxis in dental practice.  J Am Dent Assoc. 2007;138(4):458-474. doi:10.14219/jada.archive.2007.0198PubMedGoogle ScholarCrossref
    62.
    Cope  AL, Chestnutt  IG.  Inappropriate prescribing of antibiotics in primary dental care: reasons and resolutions.  Prim Dent J. 2014;3(4):33-37. doi:10.1308/205016814813877333PubMedGoogle ScholarCrossref
    63.
    Gross  AE, Hanna  D, Rowan  SA, Bleasdale  SC, Suda  KJ.  Successful implementation of an antibiotic stewardship program in an academic dental practice.  Open Forum Infect Dis. 2019;6(3):ofz067. doi:10.1093/ofid/ofz067PubMedGoogle ScholarCrossref
    64.
    American Dental Association. Oral health topics: Medicare and Medicaid. https://www.medicaid.gov/medicaid/benefits/dental/index.html. Accessed April 23, 2019.
    65.
    Centers for Medicare & Medicaid Services. Your Medicare coverage: dental services. https://www.medicare.gov/coverage/dental-services.html. Accessed February 26, 2017.
    66.
    Miller  CS.  Where are the diagnostic codes in dentistry?  Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;111(2):131-132. doi:10.1016/j.tripleo.2010.10.021PubMedGoogle ScholarCrossref
    67.
    Kalenderian  E, Ramoni  RB, White  JM,  et al.  The importance of using diagnostic codes.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(1):4-5. doi:10.1016/j.tripleo.2011.01.047PubMedGoogle ScholarCrossref
    68.
    Rogers  AM, Schiller  NB.  Impact of the first nine months of revised infective endocarditis prophylaxis guidelines at a university hospital: so far so good.  J Am Soc Echocardiogr. 2008;21(6):775. doi:10.1016/j.echo.2008.04.001PubMedGoogle ScholarCrossref
    69.
    Desimone  DC, Tleyjeh  IM, Correa de Sa  DD,  et al; Mayo Cardiovascular Infections Study Group.  Incidence of infective endocarditis caused by viridans group streptococci before and after publication of the 2007 American Heart Association’s endocarditis prevention guidelines.  Circulation. 2012;126(1):60-64. doi:10.1161/CIRCULATIONAHA.112.095281PubMedGoogle ScholarCrossref
    70.
    Thornhill  MH, Gibson  TB, Cutler  E,  et al.  Antibiotic prophylaxis and incidence of endocarditis before and after the 2007 AHA recommendations.  J Am Coll Cardiol. 2018;72(20):2443-2454. doi:10.1016/j.jacc.2018.08.2178PubMedGoogle ScholarCrossref
    71.
    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.16.01107PubMedGoogle ScholarCrossref
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