|Year : 2015 | Volume
| Issue : 2 | Page : 90-94
Antibiotic use in dentistry: A cross-sectional survey from a developing country
Sivaramakrishnan Gowri1, Deeksha Mehta1, Sridharan Kannan2
1 Departments of Prosthodontics, Subharti Dental College, Delhi-Haridwar Bypass Road, Meerut, Uttar Pradesh, India
2 Department of Pharmacology, Subharti Medical College and Hospital, Delhi-Haridwar Bypass Road, Meerut, Uttar Pradesh, India
|Date of Web Publication||17-Nov-2015|
Dr. Sridharan Kannan
Department of Pharmacology, Subharti Medical College and Hospital, Delhi-Haridwar bypass road, Meerut - 250 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Antimicrobial resistance is a well-known entity and the most common factor leading to this is the irrational use of antibiotics. Several studies from the West have substantiated the irrational use of antibiotics in dentistry. Aims: The aim was to assess the knowledge, attitude, and practice (KAP) of antimicrobial drug use among dental fraternity in a tertiary care teaching dental college and hospital. Materials and methods: A cross-sectional survey of various dental fraternities using a structured validated questionnaire. The study was initiated following approval from Institutional Ethics Committee and interns, junior residents and faculty members of various departments in dentistry were enrolled after obtaining written informed consent. A structured validated questionnaire was developed to assess the above-mentioned objectives. Statistical analysis: Descriptive statistics was used for representing each category of response and kappa statistics were used to assess the reliability in the initial cohort. Chi-square test for independence was used to evaluate the difference in proportion between different professional cadres. Results: A total of 120 participants were recruited out of which 81.6% (98/120) of the participants accepted their frequent antibiotic usage. The most common dental indication of antibiotics among dentists was post dental extraction, attributing to 30.8% (37/120), followed by dental abscess 21.6% (26/120) and 60% (72/120) prescribed antibiotics after most minor surgical procedures. Surprisingly, 37.5% (45/120) of the participants opined that they use antibiotics against viral infection. Regarding the spectrum of antibiotic usage, 74.1% (89/120) preferred broad spectrum instead of narrow spectrum 25.8% (31/120). The commonly prescribed antibiotics were amoxicillin 71.7% (86/120), metronidazole 33.3% (40/120), amoxicillin with clavulanic acid 26.6% (32/120). A total of (43/120) 35.8% opted generic name for mentioning the antibiotics while the rest (77/120) 64.2% preferred to prescribe using their brand name. Furthermore, (76/120) 63.3% did not know about the recent antibiotic policy/guidelines from the Government of India. There was no significant difference observed in any of the responses between various academic levels. Conclusion: We found poor KAP regarding antimicrobial use in dentistry thereby conferring increasing potential for the development of more serious antimicrobial resistance. Immediate constitution of hospital antibiotic committee and scrutinizing the prescription of antibiotics is mandatory in dental hospitals as well.
Keywords: Antimicrobials, dentistry, irrational drug use
|How to cite this article:|
Gowri S, Mehta D, Kannan S. Antibiotic use in dentistry: A cross-sectional survey from a developing country
. J Orofac Sci 2015;7:90-4
|How to cite this URL:|
Gowri S, Mehta D, Kannan S. Antibiotic use in dentistry: A cross-sectional survey from a developing country
. J Orofac Sci [serial online] 2015 [cited 2019 Nov 13];7:90-4. Available from: http://www.jofs.in/text.asp?2015/7/2/90/164310
| Introduction|| |
Antibiotics are widely used, and they form an indispensible part as both prophylactic and treatment modalities in documented as well as suspected infections. In dental practice, antibiotics are used mainly after oral surgical and periodontal procedures.  However, resistance to antibiotics has been a rising global problem and modalities for preventing resistance are being undertaken. The WHO theme on World Health day 2011 states "Combat Antimicrobial Resistance: No Action Today, No Cure Tomorrow."  It is the duty of every dentist to arrive at the correct diagnosis in order to avoid the indispensable use of antibiotics. Various studies have been conducted on the injudicious use of antibiotics in dental practice in the western countries. , Most studies revealed the irrational use of antibiotics and also being used for a longer duration. It also revealed that uncertainties existed regarding the indications of antibiotic use.  Similar kind of situation exists in India as well. The relatively relaxed regulation on antibiotics without prescription (over-the-counter) worsens the scenario. Knowledge, attitude, and practice (KAP) among dental specialists towards antibiotics have to be analyzed in order to decrease the incidence of antibiotic resistance. This study aimed to identify the KAP of antibiotic use among dental fraternity in Subharti Dental College. The purpose of the present study was to survey the extent of and indications of antibiotic use among Indian dentists.
| Materials and Methods|| |
The study was conducted between June and November 2014 after obtaining approval from the Institutional Ethics Committee. Interns, junior residents and faculty members of various departments in dentistry (prosthodontics, periodontics, pedodontics, endodontics, oral medicine) were enrolled in the study after obtaining written informed consent. A structured validated questionnaire was developed to assess the above-mentioned objectives. The questionnaire was administered to an initial cohort of 30 participants and assessed for the reliability by re-administering the same after a period of 1-week.
Descriptive statistics was used for representing each category of response and kappa statistics was used to assess the reliability of the initial cohort. Kappa statistic was found to be 0.84 and the same questionnaire was used in the main study (initial cohort participants were not included). As there were no prior data available from Indian context and the study being a form of hypothesis generation, no formal sample size calculation was performed. Chi-square test was used to assess the significance in the difference in the proportion of responses between various academic levels. A P < 0.05 was considered significant.
| Results|| |
A total of 120 participated in the study. Of the 120, 6 (5%) belonged to pedodontics, 14 (11.6%) from prosthodontics, 17 (14.1%) from conservative dentistry, 11 (9.1%) from orthodontics, 15 (12.5%) from periodontics, 12 (10%) from oral medicine, 14 (11.6%) from community dentistry, 12 (10%) from oral pathology and 19 (15.8%) from oral surgery. 50 (41.7%) interns, 10 (8.3%) demonstrators, 43 (35.8%) postgraduates, 12 (10%) assistant professors, 9 (7.5%) readers, and 8 (6.6%) professors were involved. 81.6% (98/120) participants accepted their frequent antibiotic usage.
Conditions of antibiotic use
The most common dental indication of antibiotics among dentists was post dental extraction attributing to 30.8% (37/120), followed by dental abscess which was 21.6% (26/120), periapical discharge and infection 15% (18/120), cellulitis, ludwig's angina and other space infection 12.5% (15/120), periodontitis 7.5% (9/120), pericoronitis 4.1% (5/120), periodontal surgery 3.3% (4/120), gingivitis 5% (6/120), pulpitis 2.5% (3/120), implant surgery 2.5% (3/120), dry socket 1.6% (2/120). 0.8% (1/120) mentioned alveoloplasty, operculectomy, oro antral fistula. 8.3% (10/120) prescribed antibiotics after root canal treatment and 1.6% (2/120) after orthognathic surgery. In general, 60% (72/120) of them prescribed antibiotics after every minor surgical procedure. A total of 3.3% (4/120) out of these also mentioned about antibiotic prophylaxis in systemically compromised cases without mention over the dental procedure and the systemic condition. Surprisingly, 37.5% (45/120) of the participants opined that they used antibiotics against viral infection and this question was left unanswered by 2.5% (3/120) of the participants inferring a possibility of lack of knowledge in relation to the use of antibiotics on viruses. Furthermore, 65% (78/120) participants felt antibiotics would speed up the recovery of cold.
Type of antibiotic prescribed
When asked regarding the spectrum of antibiotic use, a majority (89/120, 74.1%) preferred broad spectrum instead of narrow spectrum (31/120, 25.8%). The commonly prescribed antibiotics were amoxicillin 71.7% (86/120), metronidazole 33.3% (40/120), amoxicillin with clavulanic acid 26.6% (32/120), ofloxacin with ornidazole 20% (24/120), ciprofloxacin 19.1% (23/120), ofloxacin 18.3% (22/120), doxycycline 17.5% (21/120), azithromycin 16.6% (20/120), cefixime 15% (18/120), ampicillin 8.3% (10/120). Few participants also mentioned cloxacillin 2.5% (3/120), cotrimoxaxole 0.8% (1/120), dicloxacillin 5% (6/120), amoxycillin with cloxacillin 0.8% (1/120), cephalexin 1.6% (2/120), ciprofloxacin with tinidazole 3.3% (4/120), roxithromycin 0.8% (1/120), clindamycin 7.5% (9/120), tetracycline 6.6% (8/120), and erythromycin 1.6% (2/120). One participant (0.8%) also mentioned vancomycin, cetriaxone, sparfloxacin and moxifloxacin for dental related conditions.
A total of 43/120 (35.8%) opted generic name for mentioning the antibiotics while the rest (77/120, 64.2%) preferred to prescribe using their brand name. Furthermore, (76/120) 63.3% did not know about the recent antibiotic policy/guidelines from the Government of India. However, 85% (102/120) felt that the frequent use of antibiotics decreased the efficacy of treatment on reuse of the same antibiotic. Interestingly, 4.1% (5/120) did not know the existence of antibiotic resistance.
| Discussion|| |
The present study envisaged the various antibiotics prescribed for odontogenic infections from a tertiary care private dental college in India. This study also outlined the knowledge of antibiotic use among dentists from all the departments in the dental fraternity. In short, an assessment on the knowledge, practice, and attitude of dentists on antibiotic use was analyzed. We found that 86.6% of the dentist admitted to the frequent antibiotic use besides 4.1% not knowing the existence of antibiotic resistance. The development of resistance to antibiotics is on the rise with irrational antibiotic use. Various guidelines have been laid down which intended to provide guidance over judicious antibiotic use as mentioned in [Table 1]. ,,,,,,,, Contrary to these guidelines, in the present study, antibiotics were prescribed for dental abscesses, post root canal treatment, post dental extraction and after most minor surgical procedures with no mention on the systemic counterpart. This explains the fact that the guidelines are not being adhered to and understood. However, none of the national bodies have laid down specific dental guidelines for antibiotic use although general guidelines have been framed by Government of India, which two-third of the study participants were unaware of. Most oro-facial infections of odontogenic origin lapse spontaneously requiring two principles of treatment: Elimination of cause, local drainage, and debridement.  The dentist can bring about the difference using the available antibiotics judiciously by considering appropriate indication and dosage. One factor reported to cause this antibiotic resistance is the overuse or misuse of broad spectrum agents.  It has been reported that 20-50% of the total medication used are antibiotics in the United States.  In our present study, dentists (37%) were of the opinion that antibiotics shall be prescribed and are effective for viral infections as well. This further emphasizes the overuse and misuse of antibiotics leading to its resistance. Dentists prescribe antibiotics mainly for the following reasons: As adjunctive therapy in oro facial infections; as a preventive measure to prevent local infection after dental procedures; to prevent the systemic spread of oral micro-organisms.  Additional considerations that shall define the antibiotic use in an individual patient are the severity of the infection, status of the immune system, and presence of systemic symptoms like fever. ,
Another important finding in the present study was that 76% preferred to prescribe broad spectrum antibiotics. Odontogenic infections are usually polymicrobial in nature (aerobic and anaerobic micro-organisms) and are mostly community-acquired (chances of being multi-drug resistant is relatively low as compared to nosocomial infections). However, it was reported that the anaerobic population is three to four times more than the aerobes.  Organisms predominating in specific odontogenic infection are mentioned in [Table 2]. , Antibiotics which are effective against odontogenic infections caused by the above-mentioned organisms include penicillin, clindamycin, erythromycin, cefadroxil, metronidazole, and tetracyclines. , In the present study, amoxicillin was the most commonly prescribed antibiotic followed by metronidazole and combination of amoxicillin and clavulanic acid. This explains that the majority of dentist used particular antibiotics to treat specific infections. However, 0.8% used a broader spectrum of antibiotics like vancomycin though the indication was not mentioned. Also that 75% preferred broad spectrum instead of the narrow spectrum which is in contradiction to the above-mentioned result which stated amoxicillin was the commonly prescribed antibiotic. This infers that many dentists did not know the spectrum of activity of various antibiotics highlighting the importance of continuous medical education regarding the antimicrobial use in dentistry. Constitution of a hospital antibiotic committee that establishes practice guidelines for antibiotic use, monitors antibiotic resistance, and antibiotic prescription behavior has also been shown to be an effective measure for curtailing irrational antimicrobial use and its inherent antibiotic resistance.  Recently, a cluster randomized controlled trial infers small educational seminars regarding the antimicrobial use for general dental practitioners in Germany has been quite promising in terms of promoting rational antibiotic use. 
| Conclusion|| |
We found poor KAP regarding antimicrobial use in dentistry thereby conferring increasing potential for the development of serious antimicrobial resistance. Immediate constitution of hospital antibiotic committee and scrutinizing the prescription of antibiotics are mandatory in dental hospitals.
| References|| |
Lambrecht JT. Antibiotic prophylaxis and therapy in dental surgery. Schweiz Monatsschr Zahnmed 2004;114:601-13.
Jaunay T, Sambrook P, Goss A. Antibiotic prescribing practices by South Australian general dental practitioners. Aust Dent J 2000;45:179-86.
Cope AL, Wood F, Francis NA, Chestnutt IG. General dental practitioners′ perceptions of antimicrobial use and resistance: A qualitative interview study. Br Dent J 2014;217:E9.
Epstein JB, Chong S, Le ND. A survey of antibiotic use in dentistry. J Am Dent Assoc 2000;131:1600-9.
Rodriguez-Núñez A, Cisneros-Cabello R, Velasco-Ortega E, Llamas-Carreras JM, Tórres-Lagares D, Segura-Egea JJ. Antibiotic use by members of the Spanish Endodontic Society. J Endod 2009;35:1198-203.
Jain MK, Oswal S. Antibiotics in dentistry-An art and science. Ann Dent Speciality 2013;1:20-5.
Flynn TR, Halpern LR. Antibiotic selection in head and neck infections. Oral Maxillofac Surg Clin North Am 2003;15:17-38.
Woods RG. A Guide to the Use of Drugs in Dentistry. 12 th
ed. Sydney: Australian Dental Association; 1996.
Piecuch JF, Arzadon J, Lieblich SE. Prophylactic antibiotics for third molar surgery: A supportive opinion. J Oral Maxillofac Surg 1995;53:53-60.
Choudhury M, Needleman I, Gillam D, Moles DR. Systemic and local antimicrobial use in periodontal therapy in England and Wales. J Clin Periodontol 2001;28:833-9.
Lindhe J. Necrotising periodontal disease. In: Lindhe J, Karring T, Lang NP, editors. Clinical Periodontology and Implant Dentistry. 3 rd
ed. Copenhagen: Munksgaard, Copenhagen; 1997.
López-Píriz R, Aguilar L, Giménez MJ. Management of odontogenic infection of pulpal and periodontal origin. Med Oral Patol Oral Cir Bucal 2007;12:E154-9.
Dodson TB, Perrott DH, Kaban LB. Pediatric maxillofacial infections: A retrospective study of 113 patients. J Oral Maxillofac Surg 1989;47:327-30.
Oberoi SS, Dhingra C, Sharma G, Sardana D. Antibiotics in dental practice: How justified are we. Int Dent J 2015;65:4-10.
Pestotnik SL, Classen DC, Evans RS, Burke JP. Implementing antibiotic practice guidelines through computer-assisted decision support: Clinical and financial outcomes. Ann Intern Med 1996;124:884-90.
Sandor GK, Low DE, Judd PL, Davidson RJ. Antimicrobial treatment options in the management of odontogenic infections. J Can Dent Assoc 1998;64:508-14.
Peterson L. Principles of management and prevention of odontogenic infections. In: Peterson L, Ellis E, Hupp JR, Tucker MR, editors. Contemporary Oral and Maxillofacial Surgery. 3 rd
ed. St. Louis, Missouri: Mosby-Year Book, Inc.; 1998.
Sae-Lim V, Wang CY, Trope M. Effect of systemic tetracycline and amoxicillin on inflammatory root resorption of replanted dogs′ teeth. Endod Dent Traumatol 1998;14:216-20.
Baker KA, Fotos PG. The management of odontogenic infections. A rationale for appropriate chemotherapy. Dent Clin North Am 1994;38:689-706.
Walker C. Antimicrobial agents and chemotherapy. In: Slots J, Taubman MA, editors. Contemporary Oral Microbiology and Immunology. St. Louis, Missouri: Mosby Year Book; 1992.
Shlaes DM, Gerding DN, John JF, Craig WA, Bornstein DL, Duncan RA, et al
. Society for healthcare epidemiology of America and Infectious Disease Society of America joint committee on the prevention of antimicrobial resistance: Guidelines for the prevention of antimicrobial resistance in hospitals. Infec Control Hosp Epidemiol 1997;18:275-91.
Loffler C, Bohmer F, Hornung A, Lang H, Burmeister U, Podbielski A, et al
. Dental care resistance prevention and antibiotic prescribing modification-the cluster-randomized controlled DREAM trial. Implement Sci 2014;9:27.
[Table 1], [Table 2]