| Abstract|| |
Background: Dental practitioners commonly prescribe antibiotics to treat dental infections. Literature suggests that inappropriate use of antibiotics is common in dental practice. Proper use of antibiotics thus becomes essential to ensure that effective and safe treatment is available and that practices that may enhance microbial resistance are avoided. To improve the standards of care, dentists need to keep themselves updated with the current patterns of antibiotic prescription and their use.
Aim: This study aims to assess the level of knowledge and awareness of antibiotic use/misuse, and prophylactic use among private dental practitioners of Mangalore by studying their prescription pattern.
Subjects and Methods: Questionnaires were distributed to all the private dental practitioners in Mangalore, who willingly consented to participate in the study. The responses obtained were then analyzed. The distribution of variables was described in terms of frequency and percentage.
Results: Penicillin group (amoxicillin) was the most common prescribed antibiotic for almost all dental infections, followed by the combination of amoxicillin and metronidazole. Tetracycline was most commonly prescribed for periodontal diseases. Although dentists had adequate knowledge in prescribing antibiotics for dental infections, some lacked knowledge regarding the indications of antibiotic prophylaxis needed in cardiac conditions, rheumatic fever or sinusitis. There were others who were unaware of the alternative antibiotic choices required in necessary cases.
Conclusion: The therapeutic prescribing of antibiotics in general dental practice varies widely and is suboptimal. There is a clear need for the development of prescribing guidelines and educational initiatives to encourage the rational and appropriate use of the antibiotics in general dental practice.
Keywords: Antibiotics, prescription, private dental practitioners
|How to cite this article:|
Punj A, Shenoy SB, Thomas B, Ramesh A. Knowledge awareness and prescription practice of antibiotics among private dental practitioners in Mangalore. J Educ Ethics Dent 2016;6:72-7
|How to cite this URL:|
Punj A, Shenoy SB, Thomas B, Ramesh A. Knowledge awareness and prescription practice of antibiotics among private dental practitioners in Mangalore. J Educ Ethics Dent [serial online] 2016 [cited 2020 Jun 1];6:72-7. Available from: http://www.jeed.in/text.asp?2016/6/2/72/223000
| Introduction|| |
Dental infections are polymicrobial in nature, involving a combination of Gram-positive, Gram-negative, facultative anaerobes, and strict anaerobic bacteria. This necessitates the use of antibiotics in treating dental infections.
An antibiotic is a chemical produced by a microorganism that kills or inhibits the growth of another microorganism. The word antibiotic came from the word antibiosis, a term coined in 1889 by Louis Pasteur's pupil Paul Vuillemin, which means the process by which life could be used to destroy life. Selman Waksman suggested the word “antibiotic” (coined in 1889 by P. Vuillemin). Antibiotics act as adjuncts in the management of oral/dental infections. They are not a substitute for definitive treatment, but their proper use can shorten the period of infection and minimize the spread of infection to adjacent anatomical spaces or systemic involvement. As a result, antibiotics are said to account for the vast majority of medicines prescribed by dentists. Dentists are said to prescribe between 7% and 11% of all common antibiotics (beta-lactams, macrolides, tetracyclines, clindamycin, and metronidazole).
Thus, the prescribing of antibiotics by dental practitioners forms an important part of dental practice.
In the absence of signs and symptoms of infections, practitioners should refrain from prescribing antibiotics. The value of antibiotics in the management of orofacial infections cannot be denied. However, it should be kept in mind that it is to be used as an adjunct and not as a substitute for a definite treatment. It has been observed that most of the pressure for antibiotic prescription comes from patient pressure, the fear of medical litigation, or just simply poor clinical decision-making.
In the recent years, the inappropriate and excessive use of antibiotics has led to the emergence of antibiotic resistance. Development of antimicrobial resistance in bacteria is now considered, as a threat to public health globally. Hence, for the prevention and containment of resistance, accurate surveillance of antimicrobial use and antimicrobial resistance is required. The role of dentists in this matter is considered substantial. As a consequence, monitoring of antibiotic usage, proper check on antimicrobial resistance, and attempts to improve prescribing attitudes have become important over the years. Based on previous studies,,,,,,,, it has been observed that the prescription of antibiotics is inappropriate or inadequate among dental practitioners. This study aims to find the level of knowledge, awareness among private dental practitioners regarding the use/misuse of antibiotics, and whether it is prescribed properly.
| Subjects and Methods|| |
A cross-sectional survey was designed to determine the antibiotic prescribing practice among the private dental practitioners in Mangalore city, Karnataka, India. The research was conducted according to the principles of the Declaration of Helsinki, and an ethical clearance was obtained from the Ethics Committee.
The dental practitioners practising in private dental clinics in Mangalore were approached for the study. The practitioners holding a Bachelor of Dental Surgery or Master of Dental Surgery degrees who regularly engage in routine dental practice were included in this. Questionnaires were distributed to all the dentists along with a letter describing the survey, and requesting participation and consent as well as granting anonymity. All those who willingly consent to participate in the study were asked to complete the questionnaire.
The questionnaire was devised to examine the general dental practitioner's prescribing patterns, and included information regarding demographics (place of clinic, qualification, age, sex, experience, etc.). The questionnaire was aimed to observe the clinical signs, which would render the practitioner to prescribe antibiotics for patients presenting with a dental infection. Information on the antibiotic of choice and its dose, frequency, and monotherapy/combination therapy that the practitioner would prescribe for patients for common dental infection was obtained. Questions regarding decision-making in case patient are allergic, medically compromised or special clinical situations were included in the questionnaire. Information regarding the effect of non-clinical factors on practitioners' prescribing was sought.
Finally, the source of knowledge regarding which the practitioners kept themselves updated was obtained.
The responses obtained were analyzed and presented in the form of frequency and percentage. Descriptive statistics of the parameters studied were calculated and presented with suitable diagrams and graphs.
| Results|| |
Responses from 173 private dental practitioners were considered for statistical analysis who completed the questionnaire. [Table 1] provides the demographic information regarding the dental practitioners gathered from the questionnaire, which shows majority were male, had 5–10 years of experience, were general practitioners, followed group practice, and were located in the urban areas. The following pie charts [Figure 1] represent the responses regarding the prescription pattern of the dentists, which shows that majority of the dental practitioners (43%) provided 10–20 h/week of patient care. Out of the dentists surveyed, 61% of the dentists prescribed antibiotics daily, 66% prescribed them based on symptoms while only 13% took drug cost and guidelines into consideration, and 77% of the dentists did not take nonclinical factors into consideration while prescribing antibiotics. Based on [Table 2] and [Table 3], 74% dentists considered elevated temperature and systemic spread/swelling/periapical pathology in radiograph/restricted mouth opening as indications for prescribing antibiotic and 6.9% considered pain/swelling/prevention of postoperative complications as indications for antibiotic prescription. Majority of the dentists (66%) prescribed antibiotics for abscess/cellulitis/surgical procedures such as extraction, implant placement, and flap surgery after the procedure. Their first drug of choice was penicillin/amoxicillin (80%), and alternatives were macrolides (such as erythromycin, azithromycin) (36.4%), cephalosporin (24.9%), and 15% did not know. Almost half of the surveyed dentists (48%) did not know what action was to be taken if the patient was on penicillin therapy for rheumatic fever. More than half (57%) dentists did not know an alternative antibiotic in case-patient was allergic to penicillin and was unable to take medication. All dentists responded positively towards knowledge about antibiotic resistance, but only 81.5% gave it due consideration while prescribing the same. A good number of dentists (69.4%) knew the cardiac conditions which were strongly indicated for antibiotic prophylaxis while 16.2% did not know and 14.5% prescribed them in all cardiac conditions. Nearly half (49.1%) remained updated with the current antibiotic prescription practice by means of scientific or professional societies. The decision regarding the prescription of antibiotics during routine dental procedures was assessed [Table 4] to which only 4% were found to prescribe antibiotics in all procedures while 96% prescribed antibiotics in indicated conditions.
|Figure 1: From left to right, the top-left pie chart shows the duration of patient care per week (in hours), the top-right pie chart shows the frequency of antibiotics prescribed, bottom-left pie chart shows factors affecting decision-making for antibiotic prescription and bottom-right pie chart shows the nonclinical factors affecting the prescription of antibiotics|
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|Table 2: Distribution of study responses in terms of frequency and percentage|
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The following bar diagram [Figure 2] depicts the most commonly prescribed antibiotics in commonly occurring dental situations. Based on the results, most of the dentists did not prescribe antibiotics for acute pulpitis and chronic marginal gingivitis. Penicillin was the most commonly prescribed antibiotic, followed by the use of combination of antibiotics such as amoxicillin and metronidazole. Tetracycline group of antibiotic (doxycycline) was the most common drug prescribed for chronic periodontitis. Majority of the dentists did not know the antibiotic prescription for sinusitis, chronic marginal gingivitis, and for reimplantation of teeth. Pulpal pathologies (pulpitis, periapical infection, etc.) received a prescription of penicillin/combination therapy/cephalosporin majorly.
|Figure 2: Drugs prescribed included penicillin (penicillin, amoxicillin, and ampicillin), cephalosporin, tetracycline (tetracycline, doxycycline), macrolide (erythromycin, clarithromycin, azithromycin, clindamycin, roxithromycin), quinolones (ciprofloxacin, ofloxacin), nitroimidazole (metronidazole, ornidazole), combination (amoxicillin and metronidazole, metronidazole and ciprofloxacin, amoxicillin and clavulanic acid)|
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| Discussion|| |
Antibiotic prescription practice for a dental practitioner in India begins during the 3rd year, final year of graduation or internship. During this period, books, teachers, internet sources, and educational programs conducted at college level are the only readily available sources of knowledge. This provides a limited amount of time duration to master the proper prescription of antibiotics for dental graduates who directly go into private practice. On the other hand, specialized dentists who have had some extra years in getting trained in a particular specialization may enable them to practice their prescribing skills or may limit them if training is not provided in this important aspect of prescribing drugs. Although private practitioners have ample opportunities to broaden their knowledge, their lack of initiative, inability to attend educational programs may limit their knowledge and awareness regarding antibiotic prescription.
As per the results, most of the private practitioners were general practitioners and dental graduates with <5–10 years of experience in clinical practice. The dentists surveyed had knowledge about the broad indications/contraindications/posology for prescribing antibiotics, but the minute details which can play an important factor while treating patients was found to be lacking. For example, penicillin group was the most common response to almost all dental infections, but when asked about alternative drugs only a few had responded, and most were unsure about the dosage. In general, based on the responses, it was observed that the knowledge regarding antibiotic prescription was adequate, but lacked in terms of awareness of other group of drugs which could be used.
Although majority of the dentists were diligent enough to avoid the influence of nonclinical factors in their prescription practice, lesser percent of dentists gave importance to guidelines and gave more importance to symptoms while prescribing antibiotics. Many did not known the exact dosage of drugs prescribed. Few inappropriately prescribed antibiotics prophylactically in conditions which did not require prophylactic therapy. Antibiotics to prevent the recurrence of rheumatic fever is not required which was not known by majority of the dentists who is under physician's care. This points toward the inappropriate and inadvertent use of antibiotics, which could raise the concern of antibiotic resistance.
The private dental practitioners based on the responses attended scientific/professional societies and university training sessions, but to what extent they keep themselves updated cannot be fathomed. The private dental practitioners who are solely working in a private clinic and are not associated with an institution may find it difficult to keep themselves updated with the current trends in prescription practice.
The findings observed in this study are supported by a study done by Hammad  where it was observed that majority of the dental practitioners did not follow the proper guidelines for antibiotic prophylaxis.
A cross-sectional survey by Jayadev et al. was carried out to assess the knowledge and pattern of antibiotic prescription for pulpal/periapical pathologies among dentists which concluded that there was lack of uniformity among the dental practitioners regarding antibiotic prescription. In the same study, amoxicillin was the most common drug of choice for dental infections, and the same was observed in the present study. Garg et al. carried out a cross-sectional survey among Indian oral health-care providers, which revealed that the health-care practitioners overprescribed antibiotics, which could pose the problem of antimicrobial resistance. Al-Huwayrini et al. in a questionnaire-based survey among dentists in private clinics, observed an acceptable level of knowledge regarding antibiotics but advocated improvements in training and updating knowledge regarding antibiotic prophylaxis and its pertinent use. A survey done by Ocek et al. highlighted the need for regular courses for the continuous refreshment of knowledge in the application of antibiotics in dental practice. Peedikayil and Narayan  reported the overuse of antibiotic by dentists in many conditions which did not require antibiotic prescription.
A larger sample size could have provided better results. Statistical tests such as Chi-square tests were applied to check for the association between the study variables, but since they gave rise to multiple results, which were beyond the scope of the present survey those results have not been included. Responses regarding antibiotic prescription in implant therapy have not been included as only few practitioners routinely placed implants.
| Conclusion|| |
Thus, the majority of the dentists exhibited adequate amount of knowledge and awareness in prescribing antibiotics for various clinical situations, still, there were areas where the dentists need to work upon. The antibiotic prescription practice lacked in providing alternative antibiotics when required. Knowledge of the dental practitioners needs to be updated to increase awareness and improve prescribing practice to provide good patient care and avoid the occurrence of any adverse events arising as a result of erroneous drug prescription which could endanger patient's life. Hence, it is recommended that the local bodies associated with continuing dental education and dental associations conduct programs to help private practitioners update their knowledge and be in sync with the ever-changing field of medicine. The programs should be easily accessible and specific to the changes occurring in prescription of antibiotic therapy. The focus should be on reinforcing the existing knowledge and updating it with newer antibiotic regimen, their posology and proper use based on the clinical situation. The private dental practitioners should be self-motivated to be a part of this continuum. This would be a step not only for the well-being of the patient but also for dentist to avoid any untoward adverse event just because of sheer lack of awareness.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Anahita Punj
Department of Periodontics, A.B Shetty Memorial Institute of Dental Sciences, NITTE University, Deralakatte, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]