|Year : 2020 | Volume
| Issue : 3 | Page : 213-220
Knowledge and practice of antibiotic prescription by dentists for management of oral diseases in Eastern Province, Saudi Arabia: A cross-sectional study
Sukinah Sameer Alzouri1, Essra Aldawood2, Batool Hassan Aljuzair3, Mohammed Alsaeed4, M Nazargi Mahabob5
1 College of Dentistry, King Faisal University, Al-Ahsa, Saudi Arabia
2 College of Public Health, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
3 Ministry of Health, Al Qurayyat, Saudi Arabia
4 Consultant Periodontist, Qatif Central Hospital, Qatif, Saudi Arabia
5 Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, King Faisal University, Al-Ahsa, Saudi Arabia
|Date of Submission||17-May-2019|
|Date of Decision||23-Dec-2019|
|Date of Acceptance||24-Dec-2019|
|Date of Web Publication||02-Jun-2020|
Dr. M Nazargi Mahabob
Department of Oral Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, King Faisal University, AL AHASA-31982.
Source of Support: None, Conflict of Interest: None
Aim: Dentists routinely prescribe antibiotics to treat oral and maxillofacial infections prophylactically for those patients with immunocompromised conditions or as an adjunctive with the definitive treatment. Inappropriate prescription or excessive use can lead to bacterial resistance. The aim of this study was to assess the knowledge and awareness of dentists on antibiotics prescriptions, and to determine whether the dentists follow the rational of antibiotics use. Materials and Methods: A self-administered multiple-choice questionnaire regarding dentists’ knowledge and practice about antibiotics prescriptions was distributed among government and private dental clinics in Eastern Province of Saudi Arabia. Data were analyzed by using the Statistical Package for the Social Sciences (SPSS) software, version 22.0, and P value was fixed at ≤0.05. Results: The response rate was 57.29% and 33.3% of dentists’ knowledge of antibiotics and their prescriptions were obtained through university. All dentists agreed that it is important to be updated. Results show that there was no significant difference between the mean total scores of knowledge with most of demographic variables (P > 0.05), whereas significant difference was found regarding specialty and years of practice (P < 0.05). Finally, there was significant difference between the nationality and type of practice regarding the mean total score of practice (P < 0.05). Conclusion: From all participants, 50% of dentists have acceptable knowledge regarding antibiotics prescription in all aspects, whereas less than 30% were able to show acceptable level of clinical practice regarding antibiotics prescription. Regular update to dentists’ knowledge accumulated by continuous education courses and formulation of national guidelines need to be followed as a standard for the dentists.
Keywords: Antibiotics, Infections, Knowledge, Prescription
|How to cite this article:|
Alzouri SS, Aldawood E, Aljuzair BH, Alsaeed M, Mahabob M N. Knowledge and practice of antibiotic prescription by dentists for management of oral diseases in Eastern Province, Saudi Arabia: A cross-sectional study. J Int Oral Health 2020;12:213-20
|How to cite this URL:|
Alzouri SS, Aldawood E, Aljuzair BH, Alsaeed M, Mahabob M N. Knowledge and practice of antibiotic prescription by dentists for management of oral diseases in Eastern Province, Saudi Arabia: A cross-sectional study. J Int Oral Health [serial online] 2020 [cited 2020 Aug 5];12:213-20. Available from: http://www.jioh.org/text.asp?2020/12/3/213/285563
| Introduction|| |
The word “antibiotic” derived from a Greek word, anti (against) and bios (life),, means that the process by which life could be used to destroy life. In the twentieth century, the standard of antibiotic (AB) action was discovered. In 1929, Alexander Fleming discovered penicillin, the first chemical compound with AB characteristics, and Howard Florey and Ernst Chain produced the usable form of penicillin that could be used in treatment of bacterial infections in humans., ABs are used in the treatment of infections caused by bacteria, and they act on bacteria by either killing or inhibiting their growth. ABs can shorten infection duration and reduce the risk of the spread of infection to adjacent anatomical spaces or systemic spread., AB prescription in dentistry is generally empiric, that is, the clinician does not know the exact responsible organisms. As a result, broad-spectrum ABs are commonly used in dental practice, which increase the risk of oral bacterial resistance., Inappropriate prescription or excessive use can lead to “bacterial resistance,” which means the bacterial ability to withstand the effect of ABs. In the field of dentistry, majority of infections originate from or are related to endodontic, gingival, or periodontal infections. However, there is no need of recommending ABs in all these situations. According to recent research literatures, most of these can be managed with local interventions by removing or relieving the foci of sepsis. This can be carried out by incision and drainage, root canal treatment, or tooth extractions., Recently, the World Health Organization in its Guide to Good Prescribing has given details about educating healthcare providers for prescribing with real-life examples and issued a broad guideline.
The Scottish Dental Clinical Effectiveness Programme (SDCEP) and the Faculty of General Dental Practice in the United Kingdom (FGDP UK) clinical guidelines have also stated that in healthy individuals with nonspreading infections originating from teeth and alveolar bone (dentoalveolar infections), ABs are not recommended., Even though recent medical literatures show evidences about increasing antimicrobial resistance, studies conducted in the United Kingdom and India evaluating the knowledge and perception of dentists and dental students toward the prescription and indications of ABs show that the dental community is not having adequate knowledge in this area., In Saudi Arabia, there are no specific dental guidelines for the treatment of infections, and every association and ministry of health has their own guidelines and nothing is of international standard., Furthermore, there is no clear published guideline available in Saudi Arabia. One study exploring health professionals’ experiences of medication error in Saudi Arabia found that 68.6% errors were related to medication error.
In Saudi Arabia, there were not enough studies related to the knowledge or the awareness regarding AB prescription among dental practitioners. Therefore, the objectives of our study were follows:
To assess the knowledge and awareness of dentists about AB prescription.
To determine whether the dentists follow the rational use of AB prescription.
| Materials and Methods|| |
A cross‑sectional prospective survey was conducted among dentists of government and private dental clinics in Eastern Province of Saudi Arabia. The questionnaire was developed after reviewing several of previous relevant literature using Google Forms. The questionnaire required consent to participate in the study. This questionnaire-based anonymous and observational study was ethical approved (Ref no. 2154/18). Confidentiality and anonymity were confirmed so that responses cannot be linked to individual participants. Study was conducted only after getting consent from participants.
The survey was questionnaire-based and the questionnaire was designed to fulfill two objectives: to get an overview of the dentists’ understanding of ABs, and to evaluate the prescribing practice. Before the main survey, a small primary pilot study was conducted with preliminary manuscript in a group of 15 dental practitioners covering basic questions of ABs and their usage. On the basis of the pilot study, the questionnaire was modified and validated with the help of relevant experts from the field of statistics and epidemiology. As the primary language of study in dental institutions of Saudi Arabia is English, the questionnaire did not require translation.
A self-administered questionnaire and an electronic one (Google Forms) were distributed from October 2018 to December 2018 (3 months), containing multiple-choice questions, including three parts: the first part was related to demographic data (gender, types of practice, years in practice, and their specialty). The second part consisted of questions to assess the dentists’ knowledge about AB prescription (importance to take medical history and the meaning of AB resistance). The third part consisted of questions to evaluate the prescribing practice (the most common AB prescribed, informing the patients about the pattern of usage, clinical conditions that require AB prescription, and when to prescribe AB as a prophylaxis).
The results were analyzed using descriptive statistics. Chi-square test of independence was carried out to check the significance of the study, and analysis of variance and t-test were used to determine differences among groups. A P value of ≤0.05 was considered to be statistically significant. The software used for statistical analysis in this study was Statistical Package for the Social Sciences (SPSS), version 22.0 (IBM, Armonk, NY).
| Result|| |
A total of 185 questionnaires were distributed and 106 were received, which gives a response rate of 57.29%. The sample included 54 general dental practitioners (GDPs), 39 specialists, and 13 consultants; 69 were men and 37 were women; and 77 were Saudis and 29 were non-Saudis [Table 1]. The graphs below show the sector of practice and years of experience. The majority of participants were from government hospitals (81.9%), 17.1% were from private clinics, and 1% from other sectors. In addition, the majority of those participants were dentists with less than 5 years (38.5%) or with more than 10 years (37.5%) of professional experience.
Knowledge regarding antibiotics prescription
Dentists’ knowledge about ABs and their prescription were obtained through different methods; some participants reported the main method was education from university (33.3%), whereas others reported different methods, including books (23%), professional experience (22.5%), and literature (21.2%), Almost all dentists (99.1%) prescribed ABs to treat bacterial infection. All of them agreed about the importance of being updated about ABs. Not just that, but 98.1% thought that it also was of great significance to take the medical history for each patient before prescribing ABs. Almost all the dentists (97.2%) have already heard about AB resistance and 91.5% of them are aware about its meaning [Table 2]. The majority of dentists (55.3%) prescribed ABs based on guidelines and 37.9% based on symptoms. These numbers show a great discrepancy from those of the dentists who prescribed ABs based on patient’s preference (0.8%), the cost of the drugs (1%), and the availability of the drugs (5%) [Figure 1].,
Practice regarding antibiotics prescription
The majority of dentists (65.1 %) prescribed ABs for therapeutic purposes, whereas others (20.8%) as adjunctive and some (13.3%) for prophylaxis purposes [Figure 2]. Also, most dentists (68.3%) prescribed ABs for 5 days, whereas some (28.8%) for 7 days and very few (2.9%) for 10 days. The amoxicillin was the most commonly used AB (70.7%) by the dentists as shown in [Figure 3]. For patients with penicillin allergy, clindamycin and azithromycin were the most frequently prescribed alternative (63.8%), as shown in [Figure 4].,
|Figure 3: Percentage of the most common antibiotics prescribed by dentists|
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[Table 3] shows the number of dentists asking their patients about AB allergy, adverse reaction, drugs interaction, and AB usage. [Table 4] shows that the most common clinical cases that indicate AB prescriptions were cellulitis (77.1%), following surgical extraction (53.3%), and following acute periapical infection (47.6%). However, few dentists prescribed ABs in cases of toothache (1%), where patients requested the prescription (1.9%), and when the diagnosis was not certain (1%). Many participants prescribed ABs as prophylaxis in cases with history of infective endocarditis (84.6%), prosthetic heart valve (84.6%), and rheumatic heart diseases (69.2%), whereas no one prescribed ABs for patients with hypertension [Table 5]. Mean score of knowledge and mean score of practice regarding prescription of ABs are shown in [Table 6].
, , ,
|Table 3: Numbers of dentists asking their patients about antibiotic allergy, adverse reaction, drugs interaction, and AB usage|
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|Table 6: Mean scores of knowledge and practice regarding demographic variables|
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The maximum score of knowledge was 6 and that of practice was 46. From all participants, 50% of dentists have acceptable knowledge regarding AB prescription in all aspects, whereas less than 30% were able to show acceptable level of clinical practice regarding AB prescription.
[Table 7] shows no significant difference between the mean total scores of knowledge with most of demographic variables (P > 0.05), whereas significant difference was found regarding specialty and years of practice (P < 0.05). Finally, significant difference was observed between the nationality and type of practice regarding the mean total score of practice (P < 0.05). [Table 8] and [Table 9] show that there is a significant relationship between specialization and knowledge about ABs. Specialists are having more knowledge about the ABs than the GDPs. [Table 10] and [Table 11] show that there is a significant relationship between nationality and the knowledge about AB usage. According to this study, Saudis are having more awareness about ABs than the non-Saudis. [Table 12] and [Table 13] show that there is no significant co-relationship between knowledge and gender.
|Table 7: Mean scores of knowledge and practice regarding demographic variables|
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|Table 8: Comparison Between knowledge and the years of the practice (significant)|
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|Table 10: Significant t-test between Saudi and non-Saudi dentist knowledge about ABs|
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|Table 12: Group statistics between gender and knowledge (nonsignificant)|
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| Discussion|| |
Dentists routinely prescribe ABs therapeutically to patients with oral and maxillofacial infections, and prophylactically for those with immunocompromised conditions or adjunctive with the definitive treatment. Inappropriate or excessive prescription of ABs will lead to microbial resistance., Therefore, there is a need to assess the knowledge and practice of the dentists on the AB prescription.
The response rate of this study was 57.29%, which is lower than that found in other similar studies., It could be due to distribution of the questionnaires to the dentists during the duty hours and some dentists have full-day schedule so there is no time to fill out the questionnaires. In our study, 50% of dentists had acceptable level of knowledge regarding AB prescription, which is similar to that found in a study conducted by Salako et al. However, a study conducted by Al Khuzaei et al. showed a higher percentage of dentists with acceptable level of knowledge (61%) but still suboptimal. This may be due to the lack of continuing educational lectures to update the dentists’ knowledge about the most recent guidelines. Also, the overload of clinical work could be a reason for not reading articles and attending lectures. The studies conducted in Saudi Arabia to check the knowledge and attitudes of dental practitioners regarding AB prescription have found that most of the dental practitioners are not having sufficient knowledge in this matter., However, according to this study, Saudis are having more awareness about AB usage than the non-Saudis.
Only 55.3% of participants depend on guidelines to select the appropriate ABs in contrast to those who have 5 or more years of experience (61.5%), who may rely on their clinical experience to select ABs instead of guidelines. Amoxicillin was the most commonly used AB followed by amoxicillin with clavulanic acid, which is comparable to the result of a study conducted in Kuwait. This is because amoxicillin is a wide-spectrum AB, whereas clindamycin was the first choice in case of penicillin allergy.
Most of dentists (90.5%) claimed that they ask their patients if they take any medications, which might interact with prescribed ABs. Our data also reported that the therapeutic purpose was the main indication for prescribing ABs in cases of cellulitis and following surgical extraction, whereas they neglected other, important clinical cases as elevated temperature with evidence of systemic involvement and aggressive periodontitis.
The use of ABs following surgical extraction should be reduced because the complications that happened after extraction could be minimized by using aseptic techniques and better instrumentation. In addition, an upsetting finding was that only 40% dentists prescribe ABs for aggressive periodontitis, which may lead to serious complications such as heart diseases and diabetes., Unfortunately, 47% of participants prescribed ABs in case of acute periapical infection, which can be treated by removing the cause of infection by either extraction or appropriate root canal treatment.
Most of the dentists (84.6%) prescribed ABs as prophylaxis for patients with history of infective endocarditis and prosthetic heart valve, which is similar to previous studies., However, less than 50% of dentists prescribed ABs as prophylaxis for uncontrolled diabetes, whereas it should be given more to prevent infections during dental treatment.,
On the contrary, 69.2% of dentists prescribed ABs as prophylaxis to patients with rheumatic heart diseases, which should not be given according to the recent AHA 2007 Guidelines. Fifty percent of dentists prescribed ABs as prophylaxis for angioplasty within 6 months, but still suboptimal.
Dentists who have 5 or more years of experience tended to have a higher level of knowledge about AB prescription. This is in contrast to the result found in a study conducted in Riyadh, which reported that there was no relation between years of practice and knowledge. Consultants tended to have a higher mean of knowledge than the others. There was a statistically significant difference between Saudi and non-Saudi dentists: Saudi dentists tended to have a higher mean of good practice. Furthermore, dentists who work in government hospitals showed higher qualities of practicing than those who work in private clinics.
| Conclusion|| |
Even though the participants were fewer in this study, it clearly indicates that the periodical updates about the ABs and new trends are needed. This can be achieved by making it mandatory for all practitioners to attend the continuous dental education programs and conferences.
Data availability statement
Study conducted among dentists in part of eastern province of Saudi Arabia.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[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]