|Year : 2018 | Volume
| Issue : 2 | Page : 144-148
Dental practitioner's knowledge and practices regarding antibiotic prescription and development of resistance: A cross-sectional study
Manjunath P Puranik, Bhavna Sabbarwal, Sreekanth Bose
Department of Public Health Dentistry, Government Dental College and Research Institute, Bengaluru, Karnataka, India
|Date of Submission||01-Feb-2018|
|Date of Acceptance||03-Apr-2018|
|Date of Web Publication||24-May-2018|
Dr. Manjunath P Puranik
Department of Public Health Dentistry, Government Dental College and Research Institute, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Background and Objectives: Antibiotics are pharmacotherapeutic adjuncts prescribed by dentists for managing dental infections. Over the years, the overuse of antibiotics has been noticed which may lead to the development of resistance by certain species of bacteria. Hence, the study was conducted to assess knowledge and practice regarding antibiotic prescription and development of resistance among dental practitioners. Materials and Methods: A cross-sectional study was conducted among 400 dental practitioners in Bengaluru city, India. Data were collected using a structured pro forma regarding demographic details and knowledge and practices about antibiotic prescription and development of resistance. Descriptive statistics were calculated. Chi-square test and binary logistic regression analysis were performed. P < 0.05 was considered as statistically significant. Results: A majority of participants were postgraduates (59.5%). UG/PG training (95.0%) and scientific materials (91.7%) were the major sources of knowledge. A high percentage of the study participants were prescribing antibiotics for conditions such as tooth fracture (56.7%), dental caries (53%), and simple extraction (54.5%). Dental practitioners with postgraduate qualification believed that self-prescription by patient (odds ratio [OR] = 1.06, [P = 0.80]) and overprescription by dentist (OR = 1.10, [P = 0.62]) may lead to the development of antibiotic resistance. Conclusion: Knowledge related to antibiotic prescription was low. Although the majority of participants were aware of the antibiotic resistance, still indiscriminate prescription of antibiotics was found indicating a need for updating regarding appropriate antibiotic use through Continuing Dental Education programs.
Keywords: Anti-bacterial agents, antibiotic prophylaxis, dentists, drug resistance, knowledge, over-prescription, professional practice
|How to cite this article:|
Puranik MP, Sabbarwal B, Bose S. Dental practitioner's knowledge and practices regarding antibiotic prescription and development of resistance: A cross-sectional study. J Indian Assoc Public Health Dent 2018;16:144-8
| Introduction|| |
Antibiotics have emerged as a boon to humanity and this advancement has led to a better quality of life and reduction of morbidity and mortality. These are chemical substances that are capable of destroying and inhibiting the growth of specific microorganisms, such as infectious bacteria and fungi. Dental infections are polymicrobial in nature. Majority of the orofacial infections require both systemic and local management. Systemic management is mostly by antibiotics, and hence, these antibiotics are pharmacotherapeutic adjuncts prescribed by dentists.,
Inappropriate, indiscriminate, and irrational use of antibiotics has led to the development of antibiotic resistance. Even more alarming is the rate at which bacteria develop resistance; microorganisms exhibiting resistance to new drugs often are isolated soon after the drugs have been introduced. The main reason behind antibiotic resistance is due to overprescription by the health-care personnel, improper use by patients, and also due to the resistance developed by the bacteria. There is a significant relationship between the increase of antibiotic resistance and utilization, with higher resistance levels in bacteria isolated from areas of high antibiotic utilization., Dentists prescribe between 7% and 11% of all common antibiotics. As per the National Center for Disease Control and Prevention, approximately one-third of all outpatient antibiotic prescriptions are unnecessary. Dentistry's contribution to antibiotic resistance is unknown.
With increasing prescription of antibiotics and bacterial resistance, newer drug combinations are being introduced. Hence, keeping in the mind trend of prescribing practices in dentistry, it is required to assess the knowledge and practice among dental practitioners. Limited studies have assessed the antibiotic prescription pattern and knowledge regarding the development of resistance among dentists in India. Hence, the study was conducted with the objective to assess dental practitioner's knowledge and practices regarding antibiotic prescription and development of resistance.
| Materials and Methods|| |
A cross-sectional study was conducted among 400 dental practitioners in Bengaluru, India, from January to March 2017. Ethical approval was taken from the Institutional Ethical Committee. Informed consent was obtained from all the participants.
A pilot study was conducted among 25 dental practitioners to estimate the sample size and to check the feasibility of the study. The sample size was calculated with 80% statistical power, α = 0.05, 95% confidence interval, 10% margin of error (E), and knowledge regarding antibiotic resistance (50%). The final sample size was found to be 380, which was rounded off to 400. A self-structured questionnaire to elicit knowledge and practices regarding antibiotic prescription and development of resistance was developed based on the previous literature. Internal consistency of questionnaire was found to be good (Cronbach's alpha = 0.84).
The sampling frame consisted of dental practitioners working in dental colleges and private practice. There are about 16 dental colleges in Bengaluru, India. Dental practitioners working in dental colleges and private practice were invited to participate in this study. The final sample consisted of dental practitioners from five dental colleges and those engaged in private practice. The data were collected in the respective workplaces. The study tool included demographic details and a self-structured questionnaire. The study pro forma was distributed and collected back on the same day and checked for its completeness. The response rate was 100%.
The data were analyzed using the Statistical Package for the Social Science version 22.0 (IBM Corp, Armonk, Newyork, United States). Descriptive statistics were performed. Chi-square test and binary logistic regression analysis were done to assess the association between knowledge and practices to qualification (BDS/MDS). For analysis, responses regarding knowledge and practice were dichotomized as correct and incorrect. P < 0.05 (confidence interval of 95%) was considered as statistically significant.
| Results|| |
A total of 400 dental practitioners participated in the study, of which 54.3% were male, and 45.7% were female with 56.0% ≤35 years of age. Majority of participants (59%) were postgraduates. Most of them (72.3%) had work experience of up to 10 years [Table 1]. Undergraduate and postgraduate training (95.0%) was found to be the most common factor affecting the choice of antibiotic prescribed, followed by scientific materials (91.7%) [Table 2].
|Table 1: Demographic characteristics and work experience of study participants|
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Statistically significant difference was found between graduate and postgraduate dental practitioners with respect to prescription for flap surgery (P = 0.02), dental caries (P = 0.02), apical periodontitis (P = 0.002), periapical surgeries (P = 0.002), endodontic treatment (P < 0.001), pericoronal abscess (P = 0.01), and open extraction (P = 0.03) [Table 3].
|Table 3: Responses for various oral conditions regarding antibiotic prescription|
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Up to two-fifths of the participants prescribed antibiotics for viral infections (24.2%), juvenile diabetes (19.5%), blood dyscrasias (13.2%), and respiratory disorders (38%). Majority of study participants preferred antibiotic prescription in case of subacute bacterial endocarditis (87%). However, the difference between graduate and postgraduate dental practitioners was not statistically significant [Table 4].
|Table 4: Responses to various systemic conditions regarding antibiotic prescription|
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The majority (71.7%) prescribed antibiotics for 5 days with no statistically significant difference based on qualification [Table 5]. Amoxicillin was the most preferred antibiotic alone (91.75%) or in combination with clavulanic acid (93.25%) and metronidazole (63.25%), followed by metronidazole alone (42%), tetracycline/doxycycline (41%), azithromycin (31.5%), cephalosporins (22.5%), and ciprofloxacin (4%).
Majority of participants established pus drainage without antibiotic premedication (79.0%) for the management of periapical abscess. For recurrent orofacial infection, 80.5% favored antibiotic sensitivity testing [Table 6].
|Table 6: Responses of study participants regarding management of dental infections|
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The study participants with postgraduate qualification were more likely to respond correctly to the knowledge questions: aseptic conditions are enough (odds ratio [OR] = 1.50 [P = 0.07]); antibiotics are an absolute necessity of in treating dental infections (OR = 2.50 [P = 0.002]). Similarly, they were more likely to believe that self-medication by patient (OR = 1.06 [P = 0.80)) and overprescription (OR = 1.10 [P = 0.62]) by a dentist can cause antibiotic resistance.
The study participants with postgraduate qualification were more likely to respond correctly to the practice questions: dental practitioners with a postgraduate degree were more likely to advise patients about consequences of noncompliance with the antibiotic course and inquired about the recent antibiotic course taken [Table 7].
|Table 7: Correct responses for knowledge and practice regarding antibiotic prescription and resistance|
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| Discussion|| |
Most human orofacial infections originate from odontogenic infections. The prescribing of antibiotics by dental practitioners has become an important aspect of dental practice. Dentists were benefited greatly from the discovery of penicillin because it is a broad-spectrum antibiotic and covers most of the odontogenic infections. On the other hand, antibiotic use is the key driver of resistance. This is mainly due to its overuse in many parts of the world, particularly for minor infections, misuse due to lack of access to appropriate treatment, and underuse due to lack of financial support and awareness to complete full treatment courses. Hence, a critical approach to the use of antibiotics in the treatment of odontogenic infections dictates precisely defined criteria for the indication of antibiotic therapy. The present study was conducted keeping in view the findings of previous research that suggests a contribution of dentistry toward the development of antibiotic resistance.
Majority of study participants were under 35 years of age and male which is similar to few studies.,,, More than half of them had a postgraduate qualification and up to 10 years of work experience.
A number of factors affect the choice of antibiotic prescription. In this study, UG/PG training, scientific material, Continuing Dental Education (CDE) programs, and cost of drug-affected antibiotic prescription whereas patient's preference and availability of drugs at the pharmacy influenced to a smaller extent. These findings were similar to a study. CDE program is an important source of knowledge for dental health-care professionals, to refresh or upgrade their clinical skills regarding the appropriate use of antibiotics which in turn will affect prescribing practices.
The conditions such as tooth fracture, dental caries, simple extraction, and pericoronitis do not require antibiotic course as these can be managed adequately with local interventions. Extractions performed in aseptic conditions do not require an antibiotic while pericoronitis is an inflammatory condition which can be managed with anti-inflammatory/analgesics. Similarly, endodontic conditions such as irreversible pulpitis and apical periodontitis can be managed with root canal therapy. In previous studies, pericoronitis, surgical removal of impacted molar, dry socket, cellulitis,, dentoalveolar abscess,,,, acute pulpitis, acute necrotizing ulcerative gingivitis,, and chronic periodontitis  were reported with high rate of antibiotic prescription. These findings were also observed in the current study where more than half of the study participants would prescribe antibiotics for conditions such as tooth fracture (56.7%), dental caries (53%), simple extraction (54.5%), and pericoronitis (28.7%) which suggest overuse of antibiotics.
In the present study, tendency toward antibiotic prescription in viral infections (24.2%) and juvenile diabetes (19.5%) was observed indicating a lack of knowledge. Although there was no significant difference based on educational qualification, lack of prophylactic guidelines may have led the dentists to prescribe antibiotics as a precautionary measure.
The drugs advocated for antibiotic therapy should have characteristics such as the rapid onset of action, bactericidal activity, lack of propensity to induce resistant mutants, easy penetrability into tissues, activity against nondividing bacteria, not being affected by adverse infection conditions, administration at an optimal dose, and optimal dosing regimen. Short courses are preferred to long courses, particularly when treating children since children's compliance with conventional courses is poor. Majority prescribed antibiotics for 5 days. The prescription pattern was similar to some of the previous studies.,
The rationale for the choice of amoxicillin could have been its wide spectrum with a low incidence of resistance with minimum adverse effects. In most of the previous studies, amoxicillin and its combination with clavulanic acid were found to most common prescription.,,,,,,,,, Amoxicillin is the most preferred antibiotic in the current study either alone or in combination. For the management of dentoalveolar abscess and recurrent orofacial infection, majority of study participants preferred drainage and antibiotic sensitivity testing, respectively, with no significant difference based on qualification.
When knowledge regarding antibiotic prescription, resistance, and measures taken to avoid development of resistance was assessed, dental practitioners with MDS degree were found to having higher odds of giving the correct response. Studies have reported higher knowledge among study participants with higher qualification.,
The strength of the study is large sample size and inclusion dental practitioners attached to dental colleges as well as private practitioners, thus overcoming the limitations of few of the previous studies. Bias inherent in the questionnaire studies may be present in the current study. The study was done using questionnaire with close-ended questions which give study participants less freedom to explain about instances of antibiotic resistance they encountered and the line of treatment provided, which we consider as a limitation of the study. Some of the challenges faced in India to combat the issue of antibiotics are the lack of surveillance system and operating guidelines for antibiotics prescription. Over-the-counter sale of antibiotics, lack of public awareness, and commitment on the part of policymakers are other issues.
At the level of policymakers, it is recommended to have a national action plan, improved surveillance system, regulation and promotion of guidelines, and survey of the impact of information to follow-up whether the improvement is there or not. At the level of health-care workers promotion of hand, instrument, and environmental sanitation to avoid development of infection in the first place, antibiotic prescription only when needed, right drug, dose, and duration while prescribing and test to confirm when in doubt is recommended. For the general public or the patients, it is required that they use antibiotics only when prescribed, take full prescription, discard leftover, do not share their prescription with friends or family, and prevent infection by maintaining hygiene.
From the dental perspective, it is, therefore, suggested that antibiotics should be used as an adjunct and not a substitute for a definite treatment. In the absence of signs and symptoms of infections, dental practitioners should refrain from prescribing antibiotics for relieving pain. It is required to analyze the condition before prescribing antibiotics to the patients.
| Conclusion|| |
Dental practitioners relied on drug therapy in many orofacial and general conditions where it was not necessary. Overall knowledge related to antibiotic prescription was low. Educational qualification is a factor affecting the prescription practices. A national level surveillance system and guidelines can provide a solution to this scenario. CDE programs and emphasis on dental pharmacology in curriculum are recommended to address the issue of antibiotic resistance.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]