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Original Article Knowledge regarding antibiotic drug action and prescription practices among dentist in Jaipur city, Rajasthan Dushyant Pal Singh, Naganandini Sampath, Amit Vasant Mahuli, Himani Yadav, Simpy Amit Mahuli, Roma Yadav ABSTRACT Department of Public Health Dentistry, NIMS Dental College, Jaipur, Rajasthan, India
Address for correspondence: Dr. Dushyant Pal Singh, E‑mail: dushyantsinghjadoun @gmail.com
Introduction: Dentists prescribe antibiotics routinely to manage oral and dental infections. Unscrupulous antibiotic prescriptions can be associated with unfavorable side effects and the development of resistance. Thus, the aim of this study was to assess the level of knowledge regarding antibiotic prescription use among dentists in Jaipur City, Rajasthan. Materials and Methods: A questionnaire survey was conducted among 300 dentists in Jaipur city. A validated, self‑designed, 21‑item, closed‑ended questionnaire was used to collect data on knowledge regarding antibiotic prescription. Descriptive statistics were calculated. Results: A total of 300 dental practitioners were included in the study. The majority of the respondents seem to prescribe antibiotics that are broad spectrum or the ones that are commonly used. A considerable percentage of the respondents were not aware of the pregnancy drug risk categories by Food and Drug Administration. The most of the respondents said that they prescribe antibiotics on the basis of the diagnosis, whereas more than two‑thirds of the respondents said that they never advise culture sensitivity test before prescribing the antibiotics. Conclusion: Our findings suggest the knowledge of dentists regarding antibiotic prescription is inadequate and more focus should be given to the ongoing training regarding the pharmacological aspects, pertinent medical conditions, and prophylactic use of antibiotics in dentistry. KEY WORDS: Antibiotics, dentists, microbial resistance
Introduction
A
ntibiotics play a vital role in dental practice for prevention of disease and therapeutic use. Antibiotics prevent diseases caused by various microorganisms at host sites in the oral cavity or distant sites due to spread of infection. In most cases, therapeutic antibiotics are prescribed to treat diseases of oral cavity (hard and soft tissue) after local treatment has failed. Endodontic, oral surgical, and periodontal infections call for the use of antibiotics. Rational of use of antibiotics in dental practice needs reasoning and knowledge regarding the selection of right antibiotics for the cause.[1,2] In dentistry, antibiotics are used for the prevention of life‑threatening disease and to cease postoperative infections. Penicillin is the first line of drug in treating odontogenic Access this article online Quick Response Code:
Website: www.jdrr.org DOI: 10.4103/2348-2915.169827
infections as they are sensitive to Gram‑positive aerobes, intraoral anaerobes, organisms found in alveolar abscess, periodontal abscess, and necrotic pulps. Aerobic and anaerobic microorganisms are sensitive to penicillin.[3] The prescription of antibiotics by the majority of the dentists is vastly on empirical basis without the need for antibiotics many times just to prevent unpleasant complications and prophylactic purpose. Belief that most of the oral diseases are infectious stimulates dentists for prescribing of antibiotics.[4] The right choice of antibiotic during anaerobic or aerobic infections is another major cause of concern in general practice. There is evidence that antibiotics are prescribed inappropriately in general dental practice with the increasing worldwide problem This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact:
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How to cite this article: Singh DP, Sampath N, Mahuli AV, Yadav H, Mahuli SA, Yadav R. Knowledge regarding antibiotic drug action and prescription practices among dentist in Jaipur city, Rajasthan. J Dent Res Rev 2015;2:127-9.
© 2015 Journal of Dental Research and Review | Published by Wolters Kluwer ‑ Medknow
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of antimicrobial resistance, and the threat to public health, there is a need to rationalize the prescribing of antibiotics.[5] The understanding of rational for the use of antibiotics in pregnant females is important for the safety of the fetus.[5,6] This study was carried out to assess the knowledge regarding antibiotic prescription use among dental practitioners in Jaipur city, Rajasthan.
Materials and Methods A cross‑sectional study was conducted to assess the knowledge regarding antibiotic drug action and prescription practices among dentist in Jaipur city, Rajasthan. A total sample size of 300 was calculated based on the pilot study conducted. A pilot study was conducted on a sample size of 20 subjects to check the feasibility of the study. Convenient sampling technique was used. Practicing dentist in Jaipur city registered with Indian Dental Association and dentists in the academic institution were considered as study samples. Incomplete questionnaires were excluded from the study sample. A closed‑ended questionnaire with 21‑item including the demographic details of the study subjects was designed. The self‑designed questionnaire was checked for face, content, and construct validity (Cronbach’s alpha value 0.91). There was a single investigator. Ethical clearance for the study was obtained by the Institutional ethical committee. The study took place approximately for a period of 3 months. Voluntary informed written consent was obtained from participant dentist after explanation of the nature of the study. Descriptive statistics were used to assess the knowledge of the respondents.
Results The filled questionnaires were collected with a response rate of 93%. A total of 159 (57%) of the respondents were MDS (had Master degree in Dental Specialty), 54.8% of the participants were male, 63.8% of the dental practitioners prescribed broad‑spectrum antibiotics [Table 1], amoxicillin, and metronidazole were the most commonly prescribed antibiotics. 40.5% of the practitioners preferred erythromycin when patients were allergic to amoxicillin. Doxycycline and metronidazole were the antibiotics of choice for periodontal infections. Amoxicillin and metronidazole are the preferred antibiotics for apical periodontitis [Graph 1]. 53.3% preferred amoxicillin during pregnancy as a safer antibiotic [Graph 2]. More than 40% of the practitioners were ignorant about the Food and Drug Administration (FDA) categories of safe drugs in pregnancy. Amoxicillin was the most commonly used antibiotic for prophylactic measures. Around 45.5% of practitioners reported self‑medication being done by their patients [Graph 3]. 84.2% of the dental practitioners were aware about the antibiotic drug resistance. However, the knowledge on the choice of antibiotics in Gram‑positive were 51.6% used amoxicillin + metronidazole and G r a m ‑ n e g a t i v e m i c r o o rg a n i s m s w e re 3 4 . 4 % u s e d amoxicillin + metronidazole thus the empirical line of treatment
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was followed. When asked about the prescription of antibiotics in pediatrics 81.4% responded, on the basis of weight/age. Less than 40% advised culture sensitivity [Table 2]. 53.4% of practitioners felt the patients actually compile with the instructions of taking antibiotics and report cases of adverse events. 97.8% of the dentist was aware of the drug interactions and antibiotics to be or not to be prescribe during systemic conditions.
Discussion The questionnaire investigated the dentists’ knowledge of antimicrobial usage in clinical dentistry. Al‑Huwayrini et al., have suggested that 29% of antimicrobial usage in clinical dentistry has no rational basis.[7] As indicated by Epstein et al., conscientious utilization of antibiotics is basic for all experts, particularly when considering the quick advancement of antibacterial resistance and the disturbing outcomes of this pattern.[8] The greater part of the dental practitioner utilized broad spectrum antibiotics (63.8%) in this study. There is impressive assertion that the beta‑lactam derivatives are the antibiotics agents of choice for these procedures gave there are no allergy or intolerances. However, there is a fewer consensus regarding which drug belonging this family should be prescribed. Amoxicillin + metronidazole were recommended antibiotics for apical periodontitis by the dental practitioner. Berini and Gay consider the regular and semisynthetic penicillins (amoxicillin) to be the choices of the first decision, others Maestre‑Vera lean toward the association amoxicillin‑clavulanate, because of the developing number of bacterial resistance, and additionally its broad spectrum, pharmacokinetic profile, tolerance, and dosing attributes.[7‑9] In this study, more than half of the dental specialist recommended amoxicillin antibiotic agents as a more secure medication during pregnancy. According to FDA pregnancy safety category, most antibiotic agents that are generally endorsed by dental specialists are class B drugs (amoxicillin), except for tetracycline and its subordinates (e.g., doxycycline), which are in classification D as a result of their impacts on developing teeth and bone. Ciprofloxacin, a broad spectrum Table 1: Distribution of prescribe according to antibiotics/ antibiotics regime n (%)
Antibiotics Broad spectrum Broad spectrum, commonly used Microorganism specific Commonly used Do not know Total
178 (63.8) 1 (0.4) 27 (9.7) 71 (25.4) 2 (0.7) 279 (100.0)
Table 2: Distribution of culture sensitivity test before prescribing the antibiotics n (%) Yes No Total
111 (39.8) 168 (60.2) 279 (100.0)
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actinomycetemcomitans, and Actinomyces have developed resistance to many antibiotics.[12] 54.5% patients were not self‑medicated, 84.2% of dentist were aware of antibiotic resistance.
70 58.4
60 50 40 30 20
22.2
0
10.8
6.8
10 Amoxicillin
Amoxicillin + Ciprofloxacin Ofloxacin + Metronidazole Ornidazole
1.1
0.7
Others
Don’t know
Percent
Graph 1: Commonly prescribed antibiotics for apical periodontitis 60
53.8
50 40 30.8 30 20 8.6
10 0
Amoxicillin
Doxycycline Ciprofloxcin
Self‑medication is an alarming concept. In developing country such as India where we have poor economic status, education status, as well as poor health care facilities. People have less knowledge regarding risks associated with their self‑medication.[13]
Conclusion This study emphasizes the rationale of the use of antibiotics in the dental practice, there are many areas in which the practitioners needs to be educated and have to be made aware of various guidelines. The following are the outcomes of the study: • The majority of the dentist used broad spectrum antibiotics based on the diagnosis of the condition, rather than microorganism specific antibiotics • The knowledge on the safe antibiotics to be used during pregnancy was not satisfactory • Practitioners reported a large number of patients doing self‑medication.
Financial support and sponsorship
6.8
Nil.
Other
Graph 2: Distribution of safer antibiotics which can be prescribed during pregnancy
Conflicts of interest There are no conflicts of interest.
60 50
54.5
References
45.2
1.
40
2.
30
3.
20
4.
10 0
0.4 Yes
No
Don’t know
Graph 3: Distribution of patients self‑medicating reported by dentists
5. 6.
fluoroquinolone antibiotic used to treat periodontal disease associated with Actinobacillus actinomycetemcomitans, is in class C. Its utilization in pregnancy has been limited in view of arthropathy and adverse effect in cartilage development observed in immature animals. There is insufficient information to absolutely focus its security in humans. Metronidazole is in class B. A few authors alert against its utilization in the first trimester as a result of potential harm to the embryo; recent studies show no teratogenic effects.[10,11]
7.
Investigations have revealed that many oral microbes such as Streptococcus spp., Prevotella spp., Fusobacterium spp., Haemophilus spp., Veillonella spp., Porphyromonas gingivalis, Aggregatibacter
12.
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8. 9. 10. 11.
13.
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