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 Table of Contents  
ORIGINAL RESEARCH
Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 71-80

Knowledge of antibiotics among dentists in Saudi Arabia


1 Department of Pharmacy, Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar
2 Dean for Post Graduates and Scientific Research, Riyadh, Saudi Arabia
3 Vice Dean of Pharmacy, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia
4 Department of Dental, Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar

Date of Web Publication13-Apr-2017

Correspondence Address:
Mansour K Assery
Dean for Post Graduates and Scientific Research, Riyadh Colleges of Dentistry and Pharmacy, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-7428.203634

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  Abstract 


Aims and Objectives: The aim of this study is to assess the pattern and knowledge of the use of antibiotics by dentists in Saudi Arabia. Furthermore, over the last decades, antibiotic resistance has become a global problem which can affect morbidity and mortality. Materials and Methods: A simple questionnaire was distributed to dental practitioners over Saudi Arabia between August and October 2015. It included questions about sociodemographic characteristics, professional profile, and antibiotic prescription in dental practice. A total of 228 dentists responded to this questionnaire, and the responses (86%) showed medium level of knowledge. The data were analyzed using Statistical Package for Social Science version 22. Results: The majority (92.5%) of respondents used penicillin as the first line in case of local infection. About 65.4% believed that completion of the antibiotics course is necessary for its effectiveness in some cases only. In addition, for patients allergic to penicillin, azithromycin was the most common antibiotic prescribed by respondents (63.2%); furthermore, the antibiotic preferred for acute periapical infections; the results showed the high percentage choose amoxicillin (77.2%), and for acute ulcerative gingivitis, the respondents prescribed metronidazole (44.7%). In addition, 44.7% of respondent's chose amoxicillin as preferred therapy for cellulitis. Furthermore, there was no statistically significant difference in the knowledge level by gender (P = 0.240). Furthermore, the level of knowledge among dentists regarding the antibiotics and place of the study showed no statistically significant relationship between government and private dental schools (P = 0.740). Furthermore, there was no statistically significant difference in the level of knowledge amid respondents who had attending antibiotic courses undergraduate and postgraduate (P = 0.325). Conclusion: Based on our findings, it was concluded that most dentists had medium knowledge in prescribing antibiotic therapy for dental infection. This study confirmed the need to further extend education of dental doctors is an important part for patient and society awareness, which will lead to a reduction in antibiotic resistance, and enhancement of the level of the dental care services by delivering high standard quality, effective and efficient health care.

Keywords: Antibiotics, dental practice, knowledge, penicillin


How to cite this article:
Al Khuzaei NM, Assery MK, Al Rahbeni T, Al Mansoori M. Knowledge of antibiotics among dentists in Saudi Arabia. J Int Oral Health 2017;9:71-80

How to cite this URL:
Al Khuzaei NM, Assery MK, Al Rahbeni T, Al Mansoori M. Knowledge of antibiotics among dentists in Saudi Arabia. J Int Oral Health [serial online] 2017 [cited 2019 Nov 19];9:71-80. Available from: http://www.jioh.org/text.asp?2017/9/2/71/203634




  Introduction Top


“Antibiotic” is a Greek word, anti (“against”) and bios (“life”).[1]

Antibiotics are chemical structures that arise from special microorganisms which are formed using a fermentation process.[2] In the 20th century, the standard of antibiotic action was discovered. In 1929, Alexander Fleming discovered penicillin, the first chemical compound with antibiotic characteristics. On the other hand, Howard Florey (1898-1968) and Ernst Chain (1906-1979) developed a form of penicillin that could be used to fight bacterial infections in humans.[2]

All the antibiotics used in dental practice are listed in [Table 1].
Table 1: Antibiotics useful in dental practice

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Some bacteria are naturally resistant to some antibiotics, for example, penicillin not effective against Gram-negative bacteria; others can acquire resistance by mutation in some of their genes when they are exposed to an antimicrobial. Antibiotic resistance is global problem which can affect morbidity and mortality. Its consequence increases health cost and adverse effect.[3] In the United Kingdom, 9%-10% antibiotic prescriptions are in primary care.[4] In addition, empirical broad-spectrum antibiotic therapy used by a dentist can predispose to selection of resistance species,[5] and antibiotic resistance is rising more from odontogenic infection.[6]

The Food and Drug Administration (FDA) in America classifies medications into five different pregnancy risk categories [Table 2]. Drugs are set in different risk categories depend on available studies in humans and animals. There are four characteristics to evaluate in drug selection; these characteristics are based on the high molecular weight, unionized and highly lipophilic; the more protein bound (a drug are less likely to cross the placenta).[7],[8]
Table 2: United States Food and Drug Administration (pregnancy risk categories)

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Penicillins and cephalosporins are safe to use throughout pregnancy; tetracyclines should not be used in pregnancy, which will affect the bone and teeth in the fetus. The erythromycin - not known to be harmful and metronidazole - manufacturer advises avoidance of high-dose regimens (Empirical Antimicrobial Guidelines for Forth Valley Hospitals 2013-2015).[9] Penicillins and cephalosporins are the drugs of choice in breastfeeding.

One study in exploring health professionals' experiences of medication error in the Kingdom of Saudi Arabia found that 68.6% of errors were related to medication error.[10]

There are no specific dental guidelines for the treatment of infections, and every association and ministry of health have their own guidelines and nothing is international standard. Furthermore, there is no clear published guideline available in saudi arabia. So it is mandatory to publish one [Table 3].
Table 3: Different dental guidelines

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A graduate dentist acquires solid foundation in the principle therapeutic and up-to-date knowledge. Little information is available on knowledge and understanding of antibiotic prescribing patterns in dentists in Saudi Arabia; hence, the aim of the study is to assess the knowledge of antibiotic among dentists.


  Materials and Methods Top


A cross-sectional prospective survey in Saudi Arabia was conducted among dentists in Riyadh College of Dentistry and Pharmacy and members of Saudi Dental Society at Riyadh College of Dentistry and Pharmacy website from August to October 2015 in the Kingdom of Saudi Arabia. The Ethics Committee in Riyadh Colleges of Dentistry and Pharmacy approved the protocol for this study of knowledge of antibiotics among dentists on April 9, 2015; Registration Number: FPGRP/43439003/109 on April 9, 2015.

The questionnaire required consent to participate in the study. Confidentiality and anonymity were confirmed so that responses cannot be linked to individual participants.

The questionnaire was developed after reviewing several of previous relevant literature [11],[12],[13],14] using Google forms. The questionnaire included 25 questions and was divided into sections by demographic data which included, age, gender, qualification, specialization, years of experience, place of studying dentistry, university from which the dental degree was acquired, any antibiotic course attended, and current occupation. Another part is to measure the aim to identify the level of knowledge of dentists about antibiotics. It consists of 17 questions; respondent takes one degree in the case of correct answer and takes zero in the case of wrong answer [Table 4] represents the level of knowledge and degree.
Table 4: Levels of knowledge

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It was posted online on August 30, 2015, through Riyadh College of Dentistry and Pharmacy website and was briefly explained, and enquiry was answered. The invitation letter and questionnaire were provided in the English language to all dental practitioners and dentists at Riyadh College of Dentistry and Pharmacy [Appendix 1[Additional file 1]]. On the 5th week, a final reminder was sent to participants and the participants were thanked for their assistance.

Inclusion criteria

  • Dentists in their internship year
  • Postgraduate dentists
  • Practicing dentists.


Exclusion criteria

  • Any person outside the dental practice
  • Dental students.


Data analysis

The data were analyzed using Statistical Package for Social Science (IBM SPSS version 22, USA). The appropriate statistical models and analyses were used based on the type of data from question. Descriptive analysis was used to present an overview of findings from this population, and Chi-square test was used to test difference between groups. The level of significance was set at P≤ 0.05.


  Results Top


This study sought to identify the knowledge of antibiotics among dentists in Saudi Arabia. A total 228 dental practitioners responded to this survey.

[Table 5] shows the distribution of the study sample according to age; the results reflect that the highest proportion of the study sample was at the age range of 21-30 (36.4%) years, compared to 29.8% of the study sample aged between 31 and 35 years, and the study sample individuals who were between the ages of 36 and 40 years accounted for a percentage of 18.0%, while a proportion (14.9%) were aged above 45 years.
Table 5: Demographic profile of the sample popoulation

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Furthermore, the results showed that most of the study samples were males at a rate of 67.5%, while female rate was 31.6%. In addition, the results showed that most of the dentists were government dental school graduates at a rate of 66.2%, compared to 32.9% of the study sample was private dental school graduates. According to [Table 5], the Kingdom of Saudi Arabia has the highest rate in locations where the dental degree was obtained at a rate of 77.2%, while Arab country graduates at rate of 14.5%, compared to Europe at a rate of 3.1%, followed by North America graduates at a rate of 2.6%, and the least percentage (1.8%) for the Indian subcontinent. [Table 5] also shows the distribution of the study sample according to years of experience. The results reflected that the highest percentage of the study sample for the years of experience was <10 years at a rate of 62.7%, followed by experience of 10-20 years at a rate of 17.5%, and the least percentage for the years of experience was 20-30 years at a rate of 7.9%.

The results also showed that the highest percentage of dentists who acquired their drug knowledge was for both “before and after graduation courses” at a rate of 43.9% and 43%, respectively, and the least percentage was for after graduated at a rate of 9.2%. The majority of the participants were graduate dentists at a rate of 96%, followed by interns at a 0.9%.

[Table 6] shows the distribution of the study sample according to the specialization. It was evident from the results that the highest percentage of the study sample was prosthodontics at a rate of 27.2%, followed by endodontics and conservative dentistry at a rate of 25.4%, as a percentage of periodontics (12.7%) with equal percentage for pediatric dentistry, orthodontics and dentofacial orthopedics, and oral and maxillofacial surgery reached 8.3%, and the least percentage was for dental public health at a rate of 3.9%.
Table 6: The distribution of the study sample according to area of specialization

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[Table 7] demonstrates what type of drug dentist prefer to prescribe in localized infection or to those patients who are non allergic to penicillin, penicillin in 92.5 % while 2.2% chose metronidazole. Azithromycin and cephalexin were the drugs of choice for 1.3% of sample.
Table 7: In case of localized infection and penicillin nonallergic patient, what antibiotic will be the first line to begin

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[Table 8] shows that with the case of localized infection and patient is allergic to penicillin, the majority of study sample chose doxycycline at a dose 100 mg every 12 h (80.7%), followed by amoxicillin/clavulanate 875 mg every 12 h at rate of 7.9% and amoxicillin 875 mg every 12 h (7%).
Table 8: The first.line antibiotic selection for localized infection in penicillin.allergic patients

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[Table 9] shows that the highest percentage of the doctors considered that amoxicillin/clavulanate 875 mg every 12 h at a rate of 77.6% is the drug of choice in the treatment of spreading infection in a nonallergic patient, while amoxicillin 875 mg every 12 h has a rate of 14.5%, and the least percentage for doxycycline 100 mg every 12 h at a rate of 4.8%.
Table 9: The first line antibiotic selection for spreading infection in penicillin nonallergic patient

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[Figure 1] shows that most dentists in case of penicillin allergy of the study sample considered that azithromycin is most suitable in case of spreading infection by rate of 63.2%, while 25.4% consider that doxycycline is most suitable, and the least percentage is for amoxicillin/clavulanate at a rate of 8.3%.
Figure 1: Antibiotic selection in case of spreading infection in penicillin-allergic patients

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[Table 10] shows that the highest percentage of the study sample reported that the requirement for azithromycin 250 mg to improve the patient compliance is 2 tablets for the 1st day and then once daily for 5 days at a rate of 46.5%, while 32.5% consider that 1 tablet every day for 3 days, and the least percentage estimate that 1 tablet every day for 7 days at a rate of 17.5%.
Table 10: Dosing for azithromycin to improve the patient compliance

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[Table 11] shows that the majority percentage of the doctors chose clindamycin at a rate of76.3%, followed by metronidazole at a rate of 14.9%, while the least percentage for amoxicillin/clavulanate at a rate of 5.3% in the case of a patient with spreading oral infection and cannot tolerate penicillin.
Table 11: The alternative antibiotics prescribed by dentist in case the patient with spreading oral infection who cannot tolerate penicillin.related to the side effects

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[Figure 2] shows that the distribution of the study sample according to the source of information during prescription. The results reflect that the highest percentage of the dentists go for textbooks and guidelines for information at a rate of 50.9%, while relay on their background knowledge from pharmacology course at a rate of 42.5%, and the least percentage go for colleague for information at a rate of 3.1%.
Figure 2: The distribution of the doctors according to their source of information during prescription

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[Table 12] shows that most of the dentists decided that no prophylactic therapy is needed in case of stable angina at a rate of 78.5%, followed by congenital heart disease at a rate of 11.4%, prosthetic cardiac valve at the rate of 4.8%, and the least percentage for cardiac transplant at a rate of 1.3%.
Table 12: Dentists response to in which cardiac case, the patient will not need prophylaxis with antibiotics

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[Figure 3] shows that the majority of the respondents chose amoxicillin at a rate of 77.2%, while penicillin V at a rate of 12.7%, and the least percentage for tetracycline at a rate of 5.7% to treat acute periodical.
Figure 3: Responses to acute periapical infection

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[Table 13] shows that the highest percentage of the respondents chose metronidazole at a rate of 44.7%, while tetracycline at a rate of 35.1%, and the least percentage for amoxicillin at a rate of 15.8% for the management of ulcerative gingivitis.
Table 13: Antibiotic preferred by dentists for acute ulcerative gingivitis

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[Figure 4] shows the distribution of the dentists according to which antibiotics preferred for cellulites. The results reflect that most of the dentists chose amoxicillin at a rate of 44.7%, followed by penicillin V at a rate of 32.5%, and the least percentage for penicillin at a rate of 19.3%.
Figure 4: Antibiotic of choice for treating cellulitis

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[Table 14] shows that the percentage of the dental practitioners asking the patient about allergic or any disease history before prescription at a rate of 95.2%, while not asking the patient about having allergy or any related disease before prescription came back at a rate of 1.3%.
Table 14: The dentist ask the patient about any allergic or any disease history before prescription

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[Figure 5] shows that the highest percentage of the dentist did not prescribe antibiotics before considering surgical procedure at a rate of 55.3%, while 40.8% from the study sample prescribe antibiotics before considering surgical procedure.
Figure 5: Prescription of preoperative prophylactic antibiotic

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[Table 15] shows the relationship between the level of knowledge for dentists about antibiotics and place acquiring their dental degree; there is no statistically significant association between the level of knowledge and location of acquiring the dental degree (P ≤ 0.05).
Table 15: The relationship between the level of knowledge for dentists about antibiotics and place acquiring their dental degree

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  Discussion Top


Prescribing medicine is a challenging skill that requires a physician to understand the principle of clinical pharmacology to make the clinical decision to prescribe drug safely and effectively.[15],[16] Antibiotics are common drugs used by the dental practitioners to treat infections that affect orofacial region. Nevertheless, there is an increased evidence in the dental literature regarding their inappropriate or sometimes unnecessary use of these medications that may lead to antibiotic resistance, adverse body reactions, and an increase in health-care cost.[14],[17]

The objective of this study was to investigate the knowledge of antibiotics among dentists in the Kingdom of Saudi Arabia. In this study, the majority (92.5%) of respondents used penicillin as the first line in case of local infection. Although penicillins have a narrow antibiotic spectrum, it covers most bacteria involved in oral infections.[18] For patients allergic to penicillin, azithromycin was the most common (63.2%) antibiotic prescribed by respondents, followed by doxycycline (25.4%) and amoxicillin/clavulanate potassium (8.3%). This finding is consistent with the earlier findings of Abdulkader et al.[13] and Vessal et al.,[12] who found that erythromycin was the most common antibiotic prescribed by 21.2% and 70% of the practitioners in Malaysia and Iran, respectively. On the other hand, Mainjot et al.[19] found that macrolides were the most commonly (57.1%) prescribed antibiotics in Belgium, followed by clindamycin (16.3%). Erythromycin is a bacteriostatic antibiotic that is weakly active for most infection and resistance may occur during the courses.[20] Furthermore, it has an increased resistance with new macrolides.[21] Therefore, in penicillin-allergic patients, it is recommended to use clindamycin which is highly effective against Gram-positive, anaerobic, and some Gram-negative bacteria.[22] Erythromycin and tetracycline are not recommended due to the increasing resistance developed by some strains of streptococci and their deficiency of optimal anaerobic coverage.[23],[24]

Antibiotics should continue until the local inflammation is cured completely which typically occurs after 7-14 days depending on the severity of infection. Noncompliance with antibiotics treatment would lead to treatment failure, and the prolongation of treatment will cause adverse effects or resistance.[25],[26] The majority of respondents in this study believed that completion of the antibiotics course is necessary to maximize its therapeutic effect only in some case (65.4%), while 23.7% responded that completion of the antibiotics is essential in its effectiveness. Interestingly, it was found that 8.3% of dentists believed that completion of the course is not essential for its effectiveness.

When an acute periapical infection is present in severe cases the use of antibiotics is recommended; amoxicillin is the drug of choice and it is preferred over penicillin V. In this study, the antibiotics preferred by the respondents for treating acute periapical infection were amoxicillin (77.2%), penicillin V (12.7%), and tetracycline (5.7%). This finding was similar to the findings of Vessal et al.,[12] who reported that amoxicillin was preferred over penicillin V (70.6% and 18.1%, respectively) to treat acute periapical infections.

In acute ulcerative gingivitis, a number of antibiotics have been suggested to treat this condition including metronidazole, amoxicillin-clavulanate, or ampicillin- sulbactam or clindamycin.[25],[27],[28] In this study, 44.7% preferred metronidazole, 35.1% preferred tetracycline, while only15.8% of the respondents preferred amoxicillin. This result was in agreement with the study of Jaunay et al.,[20] who found that metronidazole was the drug of choice among South Australian practitioners to treat acute ulcerative gingivitis.

In the current survey, 44.7% used amoxicillin to treat cellulitis. Other surveys reported different antibiotic regimens to treat this condition including amoxicillin,[12] combination of amoxicillin and clavulanate acid,[29] combination of amoxicillin and metronidazole,[14],[30],[31] or penicillin.[13]

In this study, the vast majority (86%) of the self-administered questionnaire by dentists had a medium level of knowledge in prescribing antibiotics. Al-Huwayrini et al.[32] showed by self-survey that 70% of dentists working in private clinics in Riyadh area had a good information level about prescribing antibiotics, while Baadani et al.[33] concluded that by self-administered questionnaire, both the dentists in public and private practices in western region of Saudi Arabia had good antimicrobial prescribing knowledge. However, it was emphasized that the dentists needed to have an effective wide understanding of the worldwide effect of unrequired antibiotic prescription and adverse effects.[20],[33]

Statistical analysis in the current study showed that the level of knowledge among dentists regarding the antibiotics was not affected by the participants' gender, type of the dental school (public or private), and timing of attending the sessions on the prescription of antibiotics. These findings were in line with the previous findings of two studies that evaluated the effect of gender [12] and timing of study [12],[34] on the level of antibiotics prescription knowledge.

Study limitation

  • Cross-sectional study design occurring only in Riyadh region
  • The sample size of the study only 228 although larger sample size would add further data results
  • Lack of the previous studies utilizing resembling questionnaire makes comparison of all features of result formidable.


Implications

  • Revise the educational content of the undergraduate and postgraduate courses to meet the appropriate therapeutic guidelines, for example, Drug Prescribing for Dentistry Dental Clinical Guidance
  • Monitor and audit the antibiotic use in dental clinical practice and make the necessary improvements where needed
  • Focus on patient education which has valuable role in lowering inappropriate use of antibiotic and at the same time restrain the antibiotic resistance
  • Further studies are needed to reassess the compliance of the current cohort of practitioners with the established guidelines, for example, Drug Prescribing for Dentistry Dental Clinical Guidance. In addition, more studies involving other areas of Saudi Arabia are needed to allow a more comprehensive evaluation of the antibiotics prescription skills while treating dental infections.



  Conclusion Top


Most of the surveyed dentists had medium knowledge by the self-administered questionnaire in prescribing antibiotic therapy for clinical dental infections. The dentists used different antibiotics and combination of antibiotics to treat the different dental infections. The level of knowledge among dentists regarding the antibiotics was not affected by the participants' gender, type of the dental school (public or private), and timing of attending the sessions on the prescription of antibiotics.

This study supported the need for continuous education to contribute to wise use of antibiotics such as establishing standard guidelines for antibiotics used in clinical dental practice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15]


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