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 Table of Contents  
ORIGINAL RESEARCH
Year : 2019  |  Volume : 11  |  Issue : 3  |  Page : 141-147

Knowledge, attitude, and practice of dental practitioners regarding antibiotic prescribing for aggressive periodontitis in Morocco


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 Publication25-Jun-2019

Correspondence Address:
Dr. Radia Hamdoun
Department of Periodontology, Faculty of Dental Medicine, Mohammed V University, Institute Rabat, Rabat
Morocco
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_73_19

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  Abstract 

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 2019 Nov 13];11:141-7. Available from: http://www.jioh.org/text.asp?2019/11/3/141/261267


  Introduction Top


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.[1],[2] Accurate and appropriate use of antibiotics is crucial for a safe and effective treatment.[3],[4]

Antibiotic resistance has been real threats to international public health.[4],[5],[6] 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.[7],[8],[9]

In Morocco, aggressive periodontitis seems to be highly prevalent,[10],[11] and a strong association was shown with the presence of Aggregatibacter actinomycetemcomitans notably the highly leukotoxic clone JP2 either in teenagers or young adults.[10],[12] Other bacteria belonging to the red complex were also isolated in this disease.[13] 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.[8],[14],[15],[16],[17],[18],[19],[20]

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 Top


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.[21],[22],[23],[24],[25]

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).

Statistical analysis

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 Top


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.[4],[5],[6]
Table 1: Dental practitioners' characteristics

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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%).
Table 2: Association between sociodemographic data and knowledge

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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].
Table 3: Association between sociodemographic data and attitude

Click here to view


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

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  Discussion Top


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.[3],[24],[25] The present study revealed that many practitioners prescribed the association of amoxicillin and metronidazole. According to the literature,[21],[22],[23],[24],[25] 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.[2],[26] 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.[25] Akincibay et al., 2008[27] 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.[27] Other studies had also suggested that amoxicillin combined with metronidazole presents a great impact in the management of patients with aggressive periodontitis.[28],[29]

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.[30]

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.[9],[21],[22],[23],[24],[25]

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.[2],[9],[24],[31],[32] No definitive protocol has been defined in the literature regarding the best time for administration of antimicrobial therapy and the most appropriate dosage.[33] It has been shown that there is a clear clinical benefit of using antibiotics at the initial therapy compared with using them at retreatment.[2],[21],[33]

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.[14],[15],[16],[17],[18],[19],[20] 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.[16],[31],[32] This finding points out that dental practitioners need expert advice on what dosage and when and the molecule to prescribe.[14],[20],[34],[35],[36],[37],[38]

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 Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.

Annexure 1: Questionnaire

Dental Practitioners' Characteristics

1. City:…………………………………………………….

2. Practitioners Gender:

Male ◻ Female ◻

3. Age:……………………………………………….

4. Graduation Year:…………………………………

5. Duration of practice:…………………………….

6. Degree:

• General Practitioners ◻

• Specialist in periodontology ◻

7. Graduation

• 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 ◻

• Others…………………………………………….

17. Which treatment regimen do you use most often in the treatment of aggressive periodontitis?

……………………………………………………………………………………………….

 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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