An Evaluation of Antibiotic Prescribing Practices among Dentists in Lahore: A Cross-sectional Study

The appropriate use of antibiotics has become a major concern in healthcare. The over prescription and misuse of antibiotics has contributed to antibiotic resistance which has emerged as a major public health issue. Objective: The current study is conducted to investigate the antibiotic use by the dentists and to assess the conformity with evidence-based guidelines. Methods: A convenience sample of 216 dental practitioners were included in the study. A self-structured questionnaire was administered after getting consent from the participants. The questionnaire consisted of demographic details, self-reported usage of antibiotics in different clinical situations and questions exploring the practices regarding the use of antibiotics. Data were analyzed using SPSS version 24.0. Results: 87% of the participants prescribed antibiotics in irreversible pulpitis, 53.7% in dry socket and 78.7% in localized periapical abscess. Regarding their practice of antibiotic prescription, 77.8% participants reported the prescription of antibiotics in addition to the dental treatment for early resolution of the symptoms. 73.2 % reported that they fear the spread of infection if they have not prescribed antibiotics and 66.7% reported the use of antibiotics to defer the patient if the provision of treatment was not possible at the time. 68.9% participants reported that they would resort to some different antibiotic in case of persistent dental pain at the follow-up visit. Conclusions: The study shows indiscriminate and inappropriate use of antibiotics by the dentists. A lack of knowledge among the dental practitioners regarding the evidence-based clinical indications for antibiotics was evident.


I N T R O D U C T I O N
The appropriate use of antibiotics has become a major concern in healthcare. The over prescription and misuse of antibiotics has contributed to antibiotic resistance which has emerged as a major public health issue. Objective: The current study is conducted to investigate the antibiotic use by the dentists and to assess the conformity with evidence-based guidelines. Methods: A convenience sample of 216 dental practitioners were included in the study. A self-structured questionnaire was administered after getting consent from the participants. The questionnaire consisted of demographic details, self-reported usage of antibiotics in different clinical situations and questions exploring the practices regarding the use of antibiotics. Data were analyzed using SPSS version 24.0. Results: 87% of the participants prescribed antibiotics in irreversible pulpitis, 53.7% in dry socket and 78.7% in localized periapical abscess. Regarding their practice of antibiotic prescription, 77.8% participants reported the prescription of antibiotics in addition to the dental treatment for early resolution of the symptoms. 73.2 % reported that they fear the spread of infection if they have not prescribed antibiotics and 66.7% reported the use of antibiotics to defer the patient if the provision of treatment was not possible at the time. 68.9% participants reported that they would resort to some different antibiotic in case of persistent dental pain at the follow-up visit. Conclusions: The study shows indiscriminate and inappropriate use of antibiotics by the dentists. A lack of knowledge among the dental practitioners regarding the evidence-based clinical indications for antibiotics was evident.
The participants were also given clinical scenarios to assess their use of antibiotics in different clinical conditions. The results are summarized in Table 2. Exploring the commonly used antibiotics in their prescription, 76.8% participants commonly prescribe Coa m o x i c l a v, 4 5 . 4 % g i ve A m o x i c i l l i n, 4 3 . 1 % g i ve metronidazole, 41.2% give Cephalosporin and 50.9 % chose ' others'. 35.2% (n=76) of the participants reported that they were aware of the guidelines regarding antibiotic prescription. Regarding their practice of antibiotic prescription, 77.8% (n=168) participants reported the use of antibiotics in addition to the dental treatment for early resolution of the symptoms. 73.2 % (n=158) participants reported that they feared the spread of infection if they have not prescribed antibiotics. 66.7% (n=144) reported the use of antibiotics to defer the patient if the provision of treatment was not possible at the time. 68.9% (n=149) participants reported that they would resort to some different antibiotic in case of persistent dental pain at the follow-up visit.
annually 23,000 deaths and 2 million illnesses have been attributed to antibiotic resistant strains [5]. A retrospective cohort study conducted in UK revealed that antibiotics were prescribed in majority of the dental consultations [6]. In order to address this emerging issue, various organizations have developed guidelines to help the dental practitioners for decision making regarding the use of antibiotics including American Dental Association (ADA) [7], American Association of Endodontics (AAE) [8] and American Academy of Pediatric Dentistry (AAPD) [1]. However, poor adherence to these guidelines has been reported. It has also been observed that developing countries with weaker healthcare systems are more likely to be affected owing to easy availability of over-thecounter antibiotics and lack of access to professional healthcare [9,10]. This gives us an insight to the potential damage, an erroneous prescription of antibiotic can cause. This also warrants monitoring and control of antibiotic usage. With this backdrop, it is imperative to explore the a n t i b i o t i c p r e s c r i b i n g p r a c t i c e s a m o n g d e n t a l practitioners. The current study is conducted to investigate the antibiotic use by the dentists and to assess the conformity with evidence-based guidelines.
The study was approved by institutional Ethical Review Board, University College of Dentistry, The University of Lahore (UCD/ERCA/21/11de). A convenience sample of 216 dental practitioners were included in the study consisting of both academic and non-academic dentists. Dentists who were not into clinical practice were excluded. A selfstructured questionnaire was administered after getting consent from the participants. The questionnaire consisted of demographic details of the participants, selfreported usage of antibiotics in different clinical conditions and questions exploring the practices regarding the use of antibiotics in different clinical scenarios. The data was collected and analyzed by SPSS version 24.0.

R E S U L T S
Of the 216 participants of the study, 46.7% (n=101) were males and 53.3% (n=115) were females. 23.6 % (n=51) had clinical experience of less than 5 years, 66.7 % (n=144) between 5-10 years and 9.7% (n=21) had greater than 10 years of clinical experience. 81.1% (n=175) of the participants were general dentists while 18.9% (n=41) were specialists. The self-reported response by the participants regarding use of antibiotics in various clinical conditions has been summarized in Table 1.

D I S C U S S I O N
Over-prescription and misuse of the antibiotics was evident among the participants as the majority of the practitioners prescribe antibiotics where they are not indicated. An overuse of antibiotics was observed for acute DOI: https://doi.org/10.54393/pjhs.v3i04.84 inappropriate use of antibiotics by the dentists. A lack of knowledge among the dental practitioners regarding the evidence-based clinical indications for antibiotics is evident. There is a need to increase awareness regarding the prescription of antibiotics according to the updated guidelines through continuing education programs and it should be well emphasized in the undergraduate dental curriculum.

PJHS VOL. 3 Issue. 4 September 2022
Copyright ( irreversible pulpitis, localized periapical abscess, Pericronitis, dry socket and simple extractions. The most over-prescription of antibiotics was reported for facial swelling without systemic involvement (91.2%), followed by acute-irreversible pulpitis (87%) and localized periapical abscess (78.7%). Similar misuse of the antibiotics by the dentists has been reported in the literature worldwide even though most dentists self-report adherence to guidelines [11][12][13]. An erroneous prescription of antibiotics has been reported by A. Agnihotry et al. and A. Cope in their extensive literature reviews where dentists prescribe antibiotics in situations when they are not indicated [14][15]. A survey reported that as much as 37% of the US endodontists unnecessarily prescribed antibiotics mainly because of patient expectations [16]. The use of antibiotics is neither indicated nor effective for odontogenic infections like pulpitis/apical periodontitis/draining sinus tract/localized intra-oral swelling unless there is evidence of septicemia [3]. These conditions should be addressed by prompt dental treatment to eliminate the source of infection [17][18]. Antibiotics are ineffective in such conditions as there is lack of circulation in a necrotic pulp so they fail to reach the source of infection. Antibiotics are only indicated in such patients with systemic involvement such as pyrexia, lymphadenopathy, etc [19]. The results in Table 2 highlight the indiscriminate use of antibiotics by our dental practitioners whereby participants showed lack of adherence to the guidelines. 77.8% of the participants reported adjunct use of antibiotics along with the endodontic treatment to ensure early resolution of symptoms while 73.2% fear the spread of the infection if the antibiotics were not prescribed. Similarly, a crosssectional study conducted in Wales, UK reported the use of 70.6% of antibiotics without any dental intervention [4]. The common reasons for prescribing antibiotics include patient expectations, patient preferences, time constraints and non-compliance of patients with the dental treatment [20]. WM Walton advocated that it is the moral and ethical duty of the dentist to warn the patients regarding the misuse of antibiotics and not to comply to their requests for antibiotic prescription [21]. The study also shows injudicious use of antibiotics for traumatic dental injuries. [3] [4] [5] [6] [7] [8] The authors declare no con ict of interest.