|Year : 2019 | Volume
| Issue : 3 | Page : 141-147
Knowledge, attitude, and practice of dental practitioners regarding antibiotic prescribing for aggressive periodontitis in Morocco
Radia Hamdoun1, Sanaa Chala2, Oum Keltoum Ennibi1
1 Department of Periodontology, Laboratory of Biotechnology and Oral Biology, Center of Biotechnology and Innovative Technology, Faculty of Dental Medicine, Mohammed V University in Rabat, Morocco
2 Department of Endodontics and Restorative, Faculty of Dental Medicine, Laboratory of Clinical and Epidemiological Research, Mohammed V University in Rabat, Morocco
|Date of Web Publication||25-Jun-2019|
Dr. Radia Hamdoun
Department of Periodontology, Faculty of Dental Medicine, Mohammed V University, Institute Rabat, Rabat
Source of Support: None, Conflict of Interest: None
Background: The use of systemic antibiotics in complement of the periodontal debridement in the treatment of aggressive periodontitis is supported by evidence published in the literature. The appropriate use of antibiotics allow to avoid practices that may enhance microbial resistance. Aims: The objective of this study is to evaluate the knowledge, attitudes, and practices of a population of dental practitioners in Morocco regarding antibiotics prescribing for patients with aggressive periodontitis. Materials and Methods: This cross-sectional study was carried among practitioners from cities of Casablanca, Rabat, Sale, Fez, Kenitra, and Temara from January to April 2016. The data collected were analyzed through the Statistical Package for Social Sciences software (SPSS version 13.0). Results: A total of 750 replies were received giving a response rate of 75%. Nearly 63.7% of the participants were female and 68% had <10 years' practice experience. The present study showed that dental practitioners had good knowledge regarding antibiotic use. The median score of knowledge was 3 (maximum possible score of 4). The results of attitudes and practices toward prescribing antibiotics were poor. Four hundred and twenty-two (67.5%) choose inappropriate dose of systemic metronidazole combined with amoxicillin. Gender, age, duration of practice, graduation, and continuing education in periodontology were significantly associated with the prescription of correct dose and duration of antibiotic treatment. Conclusion: This study lends support that scientific basis for prescribing antibiotics for aggressive periodontitis was not respected by the majority of the participants in this Moroccan population of dental practitioners. The attitude towards the prescription of antibiotics should therefore be modified. Also, it adds to the evidence the needed to designing periodontal national guidelines for studied dental practitioners.
Keywords: Antibiotics, Attitudes, Knowledge, Practice
|How to cite this article:|
Hamdoun R, Chala S, Ennibi OK. Knowledge, attitude, and practice of dental practitioners regarding antibiotic prescribing for aggressive periodontitis in Morocco. J Int Oral Health 2019;11:141-7
|How to cite this URL:|
Hamdoun R, Chala S, Ennibi OK. Knowledge, attitude, and practice of dental practitioners regarding antibiotic prescribing for aggressive periodontitis in Morocco. J Int Oral Health [serial online] 2019 [cited 2020 Apr 8];11:141-7. Available from: http://www.jioh.org/text.asp?2019/11/3/141/261267
| Introduction|| |
Aggressive periodontitis is a rapidly progressing periodontal disease that arises in young healthy controls. Its pathogenesis is very complex, including bacterial and immunogenetic susceptibility. The treatment of these entities is based on periodontal debridement. However, because of the specific microbiological profile, the disease responds less well to conventional mechanical periodontal therapy than chronic periodontitis., Accurate and appropriate use of antibiotics is crucial for a safe and effective treatment.,
Antibiotic resistance has been real threats to international public health.,, Previous studies suggest that the overprescription of antibiotics by dentists is a global fact. Indeed, many practitioners prescribe antibiotics for the treatment of acute dental conditions even if a local measure is the main attitude to remove the source of inflammation or infection.,,
In Morocco, aggressive periodontitis seems to be highly prevalent,, and a strong association was shown with the presence of Aggregatibacter actinomycetemcomitans notably the highly leukotoxic clone JP2 either in teenagers or young adults., Other bacteria belonging to the red complex were also isolated in this disease. Therefore, prescribing antibiotics as adjunctive to mechanical debridement should be useful to control the highly periopathogenic bacteria-associated aggressive periodontitis. This prescription is still empiric because of the lack of laboratories dealing with oral bacteria in this country. Many studies had shown variations in antibiotics prescribing practices among dental practitioners worldwide.,,,,,,,
The aim of the study was to evaluate the knowledge, attitudes, and practices (KAPs) of a population of dental practitioners in Morocco regarding antibiotics prescribing for patients with aggressive periodontitis. Furthermore, this study also explores the influence of professional and demographic profile on dental practitioners' KAP of antibiotics use.
| Materials And Methods|| |
A cross-sectional survey was conducted from January to April 2016 among 1000 practitioners from the cities of Casablanca, Rabat, Sale, Fez, Kenitra, and Temara of Morocco. These localities were chosen because of the high concentration of practitioners. The practice addresses of all dentists were obtained from the north and south regional boards. Convenience sampling technique was used, and all dentists who were willing to participate from the selected cities were included in the study. Practitioners included in the survey were those who work either in private or public practice and who prescribe antibiotics for periodontal indications. They were given a cover letter explaining the goal of the study and requested for voluntary participation. Patients with orthodontic treatment were excluded in the presented study.
The study was observational, anonymous, and respected the standards of the Helsinki Declaration governing ethical principles in medical research on human beings. All participants gave signed informed consent before enrollment into the study.
A standardized questionnaire was designed in French. Before starting the main survey and to evaluate the questionnaire, a scale pilot study was performed on 50 dental practitioners. Based on that, the questionnaire was adjusted and improved. The final questionnaire consisted of 17 questions subdivided into three items [Annexure 1].
Item 1: demographic data, education (practitioners' final degree, general practice, or specialist), when and where the dentist was graduated, and any continuing education and training on antibiotics or periodontology recently (past 3 years).
Item 2: knowledge about adjunctive antibiotic use in aggressive periodontitis treatment, split into four questions: What is the initial treatment of aggressive periodontitis? When? Why? and What antibiotics were prescribed for aggressive periodontitis?
Item 3: the dentist's current practice and attitude toward antibiotic prescription in aggressive periodontitis: in this section, questions were related to the dose, frequency, and duration of treatment.
We have defined as a reference attitude as follows:
- The initial treatment of aggressive periodontitis must include mechanical instrumentation and antimicrobial therapy
- The administration of antimicrobial therapy must be after root planning
- The prescription: association of amoxicillin (500 mg three times a day) and metronidazole (250 mg three times a day) for 7 days.
The final questionnaire was handed out to 1000 dental practitioners. Two procedures were followed for data collection; either the practitioner is interviewed using structured questionnaires when possible or the questionnaire is lefted to the assistant to be filled by the practitioner. The professionals should fill the form anonymously.
Evaluation of responses regarding the use of antibiotics was based on evidence-based guidelines and standards in selected published literature.,,,,
Ethical consent declaration
The study was observational, anonymous, and respected the standards of the Helsinki Declaration governing ethical principles in medical research on human beings. All participants gave signed informed consent before enrollment into the study (Ref No. 400/7 Apr).
A common grading was used for each question in all three categories. We graded the answers as “right” or “wrong” for the single answer. Score 1 or 0 was assigned to “right” or “wrong” answers, respectively. For items with multiple answer questions, we assigned score 1 for each “right” answer and score 0 for the “wrong” one. The score of correct answers was calculated by adding scores of right answers, i.e., Score KAP.
The data collected were analyzed through the Statistical Package for Social Sciences software version 13.0 (SPSS, IBM, and Chicago, IL, USA). The qualitative variables were expressed in effective and percentage. The quantitative variables were expressed in the median and quartiles. The comparisons between the qualitative variables were performed using the Chi-squared test. Linear regression analysis was performed to assess associated factors of score KAP. The level of statistical significance of all tests was P < 0.05.
| Results|| |
Seven hundred and fifty (75%) replies were received of the 1000 questionnaires distributed initially. Of these, 125 (25%) incomplete questionnaires were excluded, which in 625 useable replies. Participants' characteristics are shown in [Table 1]. Nearly 52.8% (n = 330) of respondents were aged 30 years or less. In relation to gender, 63.7% were female. Nearly 84.3% of the practitioners were graduated from Moroccan Dental Schools. Sixty-eight percent had <10 years' practice experience, and 33.6% of them had attended a continuing education program on periodontology. The median score of correct responses was 5.,,
Referring to the questionnaire, the median score of knowledge was 3 (maximum possible score of 4). More than 80% of the respondents answered correctly to the question about instrumentation must precede antimicrobial therapy to reduce the subgingival bacterial load. Fifty-eight percent of them prescribe antibiotics after root planning. Gender, age, duration of practice, and graduation were significantly associated with increased knowledge scores. Adequate timing for prescription was significantly higher among young practitioners with <10 years' practice experience and having obtained their diploma in Morocco [Table 2]. The choice of the antibiotic was influenced by the following criteria: spectrum of action (84.8%), resistance (36.8%), concentration in crevicular fluid (35.5%), economic status of patient (25%), and medical condition (24.7%).
Regarding the questions about attitudes and practices on antibiotic use for aggressive periodontitis, the median score was 2 (maximum possible score of 6). The most commonly prescribed antibiotics families were penicillins (77%) and nitroimidazole (56.1%). Of 474 respondents who prescribe a combination of amoxicillin and metronidazole for aggressive periodontitis, 422 (67.5%) choose amoxicillin (3000 mg/day), and (1500 mg/day) of metronidazole for a median duration of 10 days and 3% of dentists choose amoxicillin (1500 mg/day) and metronidazole (750 mg/day) for a median duration of 10 days. A combination of amoxicillin, clavulanic acid, and metronidazole was prescribed among 3.8% of practitioners.
Gender, age, duration of practice, graduation, and continuing education in periodontology were significantly associated with the prescription of correct dose and duration of antibiotic treatment [Table 3].
The results of the multivariate analysis revealed that age (95% confidence interval [CI] −0.52; −0.005 P = 0.04), graduation (from Morocco) (95% CI-0.53; −0.31 P < 0.001), and continuing education in periodontology (95% CI − 0.67; −0.21 P < 0.001) were associated with correct score of KAP [Table 4].
|Table 4: Factors associated with knowledge toward antibiotics prescribing in aggressive periodontitis|
Click here to view
| Discussion|| |
This study was the first effort to describe the current KAPs of a population of dental practitioners in Morocco regarding antibiotics prescribing for patients with aggressive periodontitis.
The present study showed that dental practitioners had good knowledge regarding antibiotic use. However, the results of attitudes and practices toward prescribing antibiotics were poor. Indeed, type, moment of prescription, dose, frequency, and duration of prescribed antibiotic differed among the practitioners. Indeed, only 52.6% of practitioners estimated that mechanical instrumentation must precede antimicrobial therapy to reduce the subgingival bacterial load. Previous studies had shown that mechanical instrumentation, which disrupts the structured bacterial aggregates, must always precede antimicrobial therapy.,, The present study revealed that many practitioners prescribed the association of amoxicillin and metronidazole. According to the literature,,,,, the combination of amoxicillin and metronidazole seems to be widely used as an adjunctive treatment of aggressive periodontitis, because of its benefits on eradication of A. actinomycetemcomitans., A meta-analysis regarding the effectiveness of the use of amoxicillin and metronidazole in patients with generalized aggressive periodontitis clearly showed an adjunctive effect of the amoxicillin and metronidazole in patients with generalized aggressive periodontitis. Akincibay et al., 2008 compared the clinical outcome of systemic doxycycline vs. systemic metronidazole combined with amoxicillin during scaling and root planing. They found that both groups showed significant improvements in plaque index, gingivitis index, periodontal probing depth and clinical attachment level values. However, the metronidazole plus amoxicillin group showed significantly more improvement in plaque index and gingivitis index. The authors added that even no statistically significant differences in probing pocket depths and attachment levels between both groups at the end of the study was shown, the improvement in the metronidazole plus amoxicillin group was better. Other studies had also suggested that amoxicillin combined with metronidazole presents a great impact in the management of patients with aggressive periodontitis.,
In the present study, some inappropriate practices were noticed regarding the prescriptions (dose and duration). Nearly, 67.5% of practitioners chose an overdose of systemic metronidazole combined with amoxicillin (1000 mg dose of amoxicillin three times per day and 500 mg dose of metronidazole three times per day for a median duration of 10 days). A combination of amoxicillin, clavulanic acid, and metronidazole was prescribed among 3.8% of practitioners. This association can be harmful for patients' health and cause bacterial resistance.
Our results are different from those reported by Abazi and Mihani 2018. The study aimed to evaluate the aspects related to the pattern of prescription of antibiotics among dentists in Tirana region for periodontitis. It showed that dentists in the Tirana region tend to prescribe amoxicillin alone (32.5%) and its combination with metronidazole (12.1%) or with clavulanic acid is prescribed in the management of patients with aggressive periodontitis, in both localized and generalized forms.
Regarding the moment of prescribing, 58% of dental practitioner use antibiotics at the initial therapy after root planning, whereas 2.4% have suggested that for patients with aggressive periodontitis, systemic antimicrobial therapy should be postponed until re-evaluation and only refractory cases should benefit from antibiotics as adjunctive to re-instrumentation. Many studies were carried out on the effect of systemic antibiotics as an adjunct to mechanical debridement in aggressive periodontitis.,,,,,
Along with different periodontal debridement protocols, different dosages for both antibiotics (range 750 mg to 1500 mg/day) and a different length of treatment (range 7–14 days) were performed.,,,, No definitive protocol has been defined in the literature regarding the best time for administration of antimicrobial therapy and the most appropriate dosage. It has been shown that there is a clear clinical benefit of using antibiotics at the initial therapy compared with using them at retreatment.,,
When studying factors associated with KAP toward antibiotics use, younger dentist obtained better scores than older ones. The continuing education in periodontology was also an independent factor associated with KAP of antibiotics use [Table 2] and [Table 3]. Indeed, practitioners who had achieved a continuing education program had better prescription knowledge and practice than those who had not. This observation highlights the importance of reinforcing education and the necessity to sensitize dentists to undergo periodic training, postgraduate courses, and other educational activities on antibiotic prescribing in periodontology.
Many studies worldwide showed that important consumption of antibiotics in the management of acute dental conditions is a universal concern.,,,,,, The majority of dentists in the world were aware of the contribution of dentistry-based antibiotic prescribing to the problem of antibiotic resistance, and the vast majority of them acknowledged either over, extended, or misuse prescription as causes of this resistance.,, This finding points out that dental practitioners need expert advice on what dosage and when and the molecule to prescribe.,,,,,,
In limitations, this study was conducted using convenience sampling. However, our results may provide baseline data about the KAPs of a population of dental practitioners in Morocco regarding antibiotics prescribing for patients with aggressive periodontitis. Furthermore, the absence of published national treatment guidelines of aggressive periodontitis and the use of international guidelines to assess conformity may create some underestimation of the results.
Within the limits of the current cross-sectional study, this article adds to evidence that attitude toward prescribing antibiotics behaviors should be changed and the dental community should be aware about the accepted antibiotic prescription guidelines in periodontology and the evidence based on the clinical practice.
| Conclusion|| |
The present study lends support that scientific basis for prescribing antibiotics for aggressive periodontitis was not respected by the majority of the participants in this Moroccan population of dental practitioners. That supports the hypothesis that antibiotics are being inappropriately prescribed by the dental profession and raises the need for improving the KAPs of dentists toward using antibiotic as adjunctive treatment in aggressive periodontitis. Judicious use of antibiotics is essential to counter the significant threat of microbial resistance.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Annexure 1: Questionnaire
Dental Practitioners' Characteristics
2. Practitioners Gender:
Male ◻ Female ◻
4. Graduation Year:…………………………………
5. Duration of practice:…………………………….
• General Practitioners ◻
• Specialist in periodontology ◻
• Morocco◻• The Eastern countries ◻• Other (SenegalTunisia) ◻
8. Exercise sector:……………………………………
9. Continuing education:
Yes ◻ NO ◻
If yes which ones:……………………………………………………………………
10. Continuing education in periodontology
Yes ◻ NO ◻
If yes which ones:……………………………………………………………………
Knowledge and Attitude
11. What is the initial treatment of aggressive periodontitis?
• Mechanical instrumentation ◻
• Mechanical instrumentation + antimicrobial therapy ◻
• Mechanical instrumentation + antimicrobial therapy + surgery ◻
• I do not know ◻
12. In case of prescription of antibiotic, when do you prescribe antibiotic on aggressive periodontitis?
• At the first consultation and before the first descaling session ◻
• After the first descaling session ◻
• After blind root planning ◻
• After surgery ◻
• I do not know ◻
13. How do you justify the timing of prescription…………………………………………
14. In case of prescription of antibiotic you opt for
Monotherapy ◻ Associations ◻
15. What are the families of antibiotics that do you choose most often in the treatment of aggressive periodontitis?
◻Azithromycin ◻Penicillin ◻Nitroimidazole
◻Cyclin ◻Related macrolides ◻Others:………………….
16. What are the associations of antibiotics that do you choose most often in the treatment of aggressive periodontitis?
• Amoxicillin + metronidazole ◻
• Amoxicillin + clavulanic acid ◻
• Metronidazole + ciprofloxacin ◻
• Amoxicillin + clavulanic acid + metronidazole ◻
17. Which treatment regimen do you use most often in the treatment of aggressive periodontitis?
| References|| |
Heitz-Mayfield LJ. Systemic antibiotics in periodontal therapy. Aust Dent J 2009;54 Suppl 1:S96-101.
Teughels W, Dhondt R, Dekeyser C, Quirynen M. Treatment of aggressive periodontitis. Periodontol 2000 2014;65:107-33.
Silva MP, Feres M, Sirotto TA, Soares GM, Mendes JA, Faveri M, et al.
Clinical and microbiological benefits of metronidazole alone or with amoxicillin as adjuncts in the treatment of chronic periodontitis: A randomized placebo-controlled clinical trial. J Clin Periodontol 2011;38:828-37.
Laxminarayan R, Duse A, Wattal C, Zaidi AK, Wertheim HF, Sumpradit N, et al.
Antibiotic resistance-the need for global solutions. Lancet Infect Dis 2013;13:1057-98.
The Lancet Infectious Diseases. Antibiotic resistance: Long-term solutions require action now. Lancet Infect Dis 2013;13:995.
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;6:301-6.
Pipalova R, Vlcek J, Slezak R. The trends in antibiotic use by general dental practitioners in the Czech republic (2006-2012). Int Dent J 2014;64:138-43.
Palmer NO, Longman L, Randall C, Pankhurst CL. Antimicrobial Prescribing for General Dental Practitioners. 2nd
ed.. London: Faculty of General Dental Practitioners (UK); 2012.
Haubek D, Ennibi OK, Poulsen K, Vaeth M, Poulsen S, Kilian M. Risk of aggressive periodontitis in adolescent carriers of the JP2 clone of Aggregatibacter
in morocco: A prospective longitudinal cohort study. Lancet 2008;371:237-42.
Kissa J, Chemlali S, El Houari B, Amine K, Khlil N, Mikou S, et al.
Aggressive and chronic periodontitis in a population of Moroccan school students. J Clin Periodontol 2016;43:934-9.
Ennibi OK, Benrachadi L, Bouziane A, Haubek D, Poulsen K. The highly leukotoxic JP2 clone of Aggregatibacter actinomycetemcomitans
in localized and generalized forms of aggressive periodontitis. Acta Odontol Scand 2012;70:318-22.
Chahboun H, Arnau MM, Herrera D, Sanz M, Ennibi OK. Bacterial profile of aggressive periodontitis in morocco: A cross-sectional study. BMC Oral Health 2015;15:25.
Löffler C, Böhmer F, Hornung A, Lang H, Burmeister U, Podbielski A, et al.
Dental care resistance prevention and antibiotic prescribing modification-the cluster-randomised controlled DREAM trial. Implement Sci 2014;9:27.
Azodo CC, Ojehanon PI. Antibiotics prescription in Nigerian dental healthcare services. Odontostomatol Trop 2014;37:34-42.
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.
Palmer NA, Pealing R, Ireland RS, Martin MV. A study of therapeutic antibiotic prescribing in national health service general dental practice in England. Br Dent J 2000;188:554-8.
Al-Haroni M, Skaug N. Knowledge of prescribing antimicrobials among Yemeni general dentists. Acta Odontol Scand 2006;64:274-80.
Salako NO, Rotimi VO, Adib SM, Al-Mutawa S. Pattern of antibiotic prescription in the management of oral diseases among dentists in Kuwait. J Dent 2004;32:503-9.
Cope AL, Francis NA, Wood F, Chestnutt IG. Antibiotic prescribing in UK general dental practice: A cross-sectional study. Community Dent Oral Epidemiol 2016;44:145-53.
Rabelo CC, Feres M, Gonçalves C, Figueiredo LC, Faveri M, Tu YK. Systemic antibiotics in the treatment of aggressive periodontitis. A systematic review and a Bayesian network meta-analysis. J Clin Periodontol 2015;42:647-57.
Xajigeorgiou C, Sakellari D, Slini T, Baka A, Konstantinidis A. Clinical and microbiological effects of different antimicrobials on generalized aggressive periodontitis. J Clin Periodontol 2006;33:254-64.
Keestra JA, Grosjean I, Coucke W, Quirynen M, Teughels W. Non-surgical periodontal therapy with systemic antibiotics in patients with untreated aggressive periodontitis: A systematic review and meta-analysis. J Periodontal Res 2015;50:689-706.
Griffiths GS, Ayob R, Guerrero A, Nibali L, Suvan J, Moles DR, et al.
Amoxicillin and metronidazole as an adjunctive treatment in generalized aggressive periodontitis at initial therapy or re-treatment: A randomized controlled clinical trial. J Clin Periodontol 2011;38:43-9.
Sgolastra F, Petrucci A, Gatto R, Monaco A. Effectiveness of systemic amoxicillin/metronidazole as an adjunctive therapy to full-mouth scaling and root planing in the treatment of aggressive periodontitis: A systematic review and meta-analysis. J Periodontol 2012;83:731-43.
Rodrigues AS, Lourenção DS, Lima Neto LG, Pannuti CM, Hirata RD, Hirata MH, et al.
Clinical and microbiologic evaluation, by real-time polymerase chain reaction, of non-surgical treatment of aggressive periodontitis associated with amoxicillin and metronidazole. J Periodontol 2012;83:744-52.
Akincibay H, Orsal SO, Sengün D, Tözüm TF. Systemic administration of doxycycline versus metronidazole plus amoxicillin in the treatment of localized aggressive periodontitis: A clinical and microbiologic study. Quintessence Int 2008;39:e33-9.
Dabija-Wolter G, Al-Zubaydi SS, Mohammed MM, Bakken V, Bolstad AI. The effect of metronidazole plus amoxicillin or metronidazole plus penicillin V on periodontal pathogens in an in vitro
biofilm model. Clin Exp Dent Res 2018;4:6-12.
Mombelli A, Almaghlouth A, Cionca N, Cancela J, Courvoisier DS, Giannopoulou C. Microbiologic response to periodontal therapy and multivariable prediction of clinical outcome. J Periodontol 2017;88:1253-62.
Abazi B, Mihani J. Prescription of antibiotics for periodontal disease among dentists in the region of tirana. Open Access Maced J Med Sci 2018;6:1486-91.
Aimetti M, Romano F, Guzzi N, Carnevale G. Full-mouth disinfection and systemic antimicrobial therapy in generalized aggressive periodontitis: A randomized, placebo-controlled trial. J Clin Periodontol 2012;39:284-94.
Casarin RC, Peloso Ribeiro ED, Sallum EA, Nociti FH Jr., Gonçalves RB, Casati MZ. The combination of amoxicillin and metronidazole improves clinical and microbiologic results of one-stage, full-mouth, ultrasonic debridement in aggressive periodontitis treatment. J Periodontol 2012;83:988-98.
Kaner D, Christan C, Dietrich T, Bernimoulin JP, Kleber BM, Friedmann A. Timing affects the clinical outcome of adjunctive systemic antibiotic therapy for generalized aggressive periodontitis. J Periodontol 2007;78:1201-8.
Alkhabuli J, Kowash M, Shah A. Knowledge and attitude of Northern Emirates dental practitioners towards antibiotic prescription and its resistance. Int J Dent Oral Health 2016;2:177.
Mansour H, Feghali M, Saleh N, Zeitouny M. Knowledge, practice and attitudes regarding antibiotics use among Lebanese dentists. Pharm Pract (Granada) 2018;16:1272.
Koyuncuoglu CZ, Aydin M, Kirmizi NI, Aydin V, Aksoy M, Isli F, et al.
Rational use of medicine in dentistry: Do dentists prescribe antibiotics in appropriate indications? Eur J Clin Pharmacol 2017;73:1027-32.
Teoh L, Stewart K, Marino RJ, McCullough MJ. Part 1. Current prescribing trends of antibiotics by dentists in Australia from 2012 to 2016. Aust Dent J 2018;63:329-37.
Teoh L, Stewart K, Marino R, McCullough M. Antibiotic resistance and relevance to general dental practice in Australia. Aust Dent J 2018;63:414-21.
[Table 1], [Table 2], [Table 3], [Table 4]