|Year : 2016 | Volume
| Issue : 2 | Page : 145-151
Antibiotic overusage and resistance: A cross-sectional survey among pediatric dentists
Sapna Konde, Lalitha S Jairam, Preetha Peethambar, Sunil Raj Noojady, Narayan Chandra Kumar
Department of Pedodontics and Preventive Dentistry, AECS Maaruti College of Dental Sciences and Research Centre, Bangalore, Karnataka, India
|Date of Web Publication||14-Apr-2016|
Dr. Sapna Konde
Department of Pedodontics and Preventive Dentistry, AECS Maaruti College of Dental Sciences and Research Centre, Bangalore, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Most human orofacial infections originate from odontogenic infections and prescribing antibiotics has become a ubiquitous phenomenon. The World Health Organization (WHO) has recognized the inappropriate, indiscriminate, and irrational use of antibiotics leading to antibiotic resistance as a global problem. Objective: The objective of this survey is to compare the antibiotic prescription pattern and the awareness of antibiotic resistance among Bachelor of Dental Surgery (BDS) practitioners and pediatric dentists. Materials and methods: A hundred BDS practitioners and 100 pediatric dentists included in the study were given a questionnaire containing both open-ended and closed-ended questions. The questionnaire comprised information pertaining to antibiotic prescription for most common oral conditions, commonly prescribed antibiotics, their dosage, etc. Results: The majority of the practitioners prescribed antibiotics for managing oral diseases. On comparing the prescription patterns between the BDS practitioners and pediatric dentists, there was an overprescription in the BDS group for many conditions, which was statistically significant. Amoxicillin was the most commonly prescribed drug in both the groups. In the presence of an anaerobic infection, the most preferred drug was a combination of amoxicillin and clavulanic acid with metronidazole. With regard to the duration of antibiotic prescription, 74% BDS practitioners prescribed antibiotics as a 3-day course and 60% pediatric dentists resorted to a 5-day course, which was statistically significant. The awareness regarding antibiotic prophylaxis and antibiotic resistance was found to be adequate in both the groups. However, there was a general lack of awareness with regard to the guidelines for antibiotic prescribing in both the groups. Conclusion: Practitioners should prescribe antibiotics in accordance with the guidelines to curb antibiotic resistance, an emerging public health problem.
Keywords: Antibiotic prescription, antibiotic resistance, overprescription
|How to cite this article:|
Konde S, Jairam LS, Peethambar P, Noojady SR, Kumar NC. Antibiotic overusage and resistance: A cross-sectional survey among pediatric dentists. J Indian Soc Pedod Prev Dent 2016;34:145-51
|How to cite this URL:|
Konde S, Jairam LS, Peethambar P, Noojady SR, Kumar NC. Antibiotic overusage and resistance: A cross-sectional survey among pediatric dentists. J Indian Soc Pedod Prev Dent [serial online] 2016 [cited 2019 Jun 25];34:145-51. Available from: http://www.jisppd.com/text.asp?2016/34/2/145/180444
| Introduction|| |
In recognition of the growing problem of antibiotic resistance, professional organizations of health care practitioners have developed guidelines regarding the appropriate use of antibiotics. It has been found that dentists prescribe between 7% and 11% of all common antibiotics.  The American Academy of Pediatric Dentistry (AAPD) has published guidelines for antibiotic use, recognizing the increasing prevalence of antibiotic-resistant microorganisms. The guidelines are intended to provide guidance for the proper and judicious use of antibiotic therapy in the treatment of oral conditions in children.  Pediatric patients require special dosing that is adjusted for their body weight. A number of formulas have been used throughout the years to determine the best dose for pediatric patients but the most commonly used method is stated as mg/kg of body weight.
Antibiotic prescribing may be associated with unfavorable side effects, which range from gastrointestinal disturbances to fatal anaphylactic shock. It has been reported that the overprescription of antibiotics in children is leading to increased fatal diarrheal cases and a drastic change in the sensitiveness of gut flora. The increasing resistance problems of recent years are probably related to overuse or misuse of broad-spectrum agents.  This growing problem has contributed significantly to the morbidity and mortality due to infectious diseases, with rising death rates for communicable diseases. , The World Health Organization (WHO) recognized this global problem and announced the theme for the year 2011 as "Antibiotic resistance: No action today, No cure tomorrow." 
Exploration of scientific literature has revealed a scarcity of literature with overprescription of antibiotics in the pediatric population, which provided an impetus to conduct this survey, the objective of which was to compare the antibiotic prescription pattern (based on AAPD guidelines) and the awareness of antibiotic resistance between Bachelor of Dental Surgery (BDS) practitioners and pediatric dentists.
| Materials and Methods|| |
This study was a cross-sectional survey. A validated, self-designed questionnaire [Table 1] was prepared to collect demographic data and information regarding the prescription pattern of antibiotics among dentists. The questionnaire contained both open-ended and close-ended questions. A hundred BDS practitioners and 100 pediatric dentists were included in the survey. A written informed consent was obtained from all the participants. The questionnaire comprised information pertaining to the following: Demographic details, qualification and work experience, number of pediatric patients treated, most common antibiotic prescribed, duration and dosage, clinical conditions for which antibiotics were prescribed, awareness about antibiotic prophylaxis, and awareness about antibiotic resistance. The data obtained were compiled, tabulated, and subjected to statistical analysis. The R software version 3.1.1 (GNU General Public License) was used for computing. For the comparison of prescription pattern between BDS and Master of Dental Surgery (MDS) practitioners, the chi-square test was used.
| Results|| |
The responses given by the participants regarding antibiotic prescriptions for commonly encountered oral conditions are compiled and presented in [Table 2]. When comparisons were made between BDS practitioners and pediatric dentists, it was found that there was a significant increase in the prescription of antibiotics among the BDS practitioners than the pediatric dentists (MDS) for most of the oral conditions except for a few conditions such as localized intra oral swelling (P = 0. 3994), acute facial swelling (P = 0. 122), extraction by open method (P = 0. 1175), and congenital cardiac abnormalities (P = 0. 6985), which were not statistically significant according to the chi-square test.
|Table 2: Comparison of responses between BDS practitioners and pediatric dentists for various oral conditions |
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For the management of oral conditions, it was found that the majority of dentists prescribed amoxicillin (86% BDS and 70% MDS) as their first choice followed by ofloxacin with ornidazole (6% BDS and 13% MDS), cephalexin (2% BDS and 12% MDS), and clindamycin (6% BDS and 5% MDS) [Table 3] (a). In the presence of an anaerobic infection, the most common antibiotics prescribed were amoxicillin and clavulanic acid with metronidazole (97% BDS and 90% MDS); cephalexin was the next preferred choice (2% BDS and 6% MDS) followed by ofloxacin with ornidazole (1% BDS and 4% MDS) as given in [Table 3]b. With regard to the duration of antibiotic prescription 74% BDS practitioners prescribed for 3 days, whereas 40% pediatric dentists prescribed for 3 days, which was statistically significant given as in [Table 3]c. In situations of an oral facial infection, the majority of the pediatric dentists (90%) performed incision and drainage followed by antibiotic coverage in contrast to only 22% BDS practitioners. With respect to the awareness of the guidelines for antibiotic prescription, only 17% BDS practitioners were aware as compared to 56% pediatric dentists, which was statistically significant given in [Table 3]d. Around 88% BDS practitioners and 99% pediatric dentists were aware of "antibiotic resistance" and a majority of them knew that self-medication and injudicious use of antibiotics were contributing to the development of antibiotic resistance.
| Discussion|| |
Most oral diseases presented to dentists are primarily inflammatory conditions. A considerable percentage of dental pain originates from acute and chronic infections of pulpal origin, which necessitates operative intervention  rather than antibiotics. Nonindicated clinical cases for antibiotic use include acute periapical infection, dry socket, and pulpitis.  Chronic inflammatory periodontal conditions are also not indicated for antibiotics; systemic antimicrobials should only be used in acute periodontal conditions where drainage or debridement is impossible, where there is local spread of the infection, or where systemic upset has occurred.  In our study, 88% BDS practitioners and 66% pediatric dentists prescribed antibiotics for pediatric periodontal conditions, which was not routinely required, showing a statistical significant difference. According to the AAPD guidelines, some pediatric periodontal diseases such as neutropenias, Papillon-Lefèrve syndrome, and leukocyte adhesion deficiency may require antibiotic coverage as the immune system is unable to control the growth of the periodontal pathogens. It has also been stated that culture and susceptibility testings of isolates from involved sites could be helpful in drug selection. 
The knowledge of dentists regarding the prescription of antibiotics varied as shown in various studies. In studies conducted in England, Kuwait, and Turkey, it was found that many of the dentists prescribed antibiotics for dry socket which is not indicated as per the AAPD guidelines. Antibiotics were also prescribed for localized intraoral swelling in many studies conducted in Kuwait,  Norway,  England,  and South Australia  which is not warranted. Both these conditions are not indicated for antibiotic prescription as per the AAPD guidelines. In our study, 96% and 45% of the BDS and MDS practitioners, respectively, prescribed antibiotics for dry socket, which is not indicated as per the guidelines.
The most common dental infections present in the form of pulpitis and periapical periodontitis require only operative measures such as fillings, root canal therapy, or extraction if the tooth is not restorable as per the AAPD guidelines on antibiotic therapy for pediatric dental patients. Unfortunately, dentists still prescribe antibiotics for these condition. ,,,,,,, In our study, 28% of the BDS practitioners and 2% of the pediatric dentists prescribed antibiotics for reversible pulpitis and 84% of the BDS practitioners and 36% of the pediatric dentists prescribed antibiotics for irreversible pulpitis. Whether this pulpal and periapical pathosis is a true infection (an invasion of tissues by pathogenic bacteria) is debatable; most bacteria recovered from these lesions are common facultative and obligate anaerobic oral bacteria that are relatively nonpathogenic, which have not been shown to proliferate readily in the host tissues. Rather, they seem to be able to survive best in necrotic tissues. Therefore, the damage they cause may be secondary. Furthermore, there is good evidence that these lesions are actually caused by immune mechanisms reacting to toxins and histolytic enzymes produced by the bacteria. The pulpal circulation is compromised in these cases and systemic antibiotic will not reach therapeutic concentrations in the pulp. Removing the source of the infection by performing thorough nonsurgical root canal therapy will usually allow healing of periradicular lesion. 
Another distressing finding was that a number of dentists prescribe antibiotics for viral infections such as herpes simplex virus-1 infections.  In our survey, 86% of the BDS practitioners prescribed antibiotics for viral infections as opposed to 12% of the pediatric dentists. Clinical situations that require antibiotic therapy on an empirical basis are limited, and they include oral infection accompanied by elevated body temperature and evidence of systemic spread such as lymphadenopathy and trismus. 
The most commonly used antibiotic in dental practice is penicillin. The most popular antibiotic is amoxicillin followed by penicillin V, metronidazole, amoxicillin, and clavulanate.  In our study, it was found that 86% of the BDS practitioners and 70% of the pediatric dentists relied on amoxicillin as the first choice, which was similar to studies conducted by Karibasappa,  Montgomery,  Gonul,  and Gregoire.  In comparison between the two groups, it was found that there was a statistically significant difference in the prescription of amoxicillin and cephalexin with the latter being prescribed more by the pediatric dentists. In the presence of an anaerobic infection, the prescription pattern varied; 97% and 90% of the BDS practitioners and pediatric dentists, respectively, relied on the combination of amoxicillin and clavulanic acid with metronidazole. Similar findings were reported by Karibasappa  and Gonul.  Cephalexin was the next choice (2% BDS and 6% MDS) followed by ofloxacin with ornidazole (1% BDS and 4% MDS). Results from a study by Karibasappa GN suggest that oflaxacin, ornidazole, and cephalexin were preferred after metronidazole.  There was a statistical significant difference in the prescription of the combination of amoxicillin and clavulanic acid with metronidazole between the two groups. This could be attributed to the lesser exposure of BDS practitioners to the extensive literature regarding the newer antibiotics.
The frequency of prescribing is usually mentioned in the known resources for antibiotic prescribing,  whereas the duration of treatment recommended in therapeutic guidelines is most commonly based on expert opinion.  In our study, it was found that 74% of the BDS practitioners and 40% of the pediatric dentists prescribed antibiotics for 3 days and 26% of the BDS practitioners and 60% of the pediatric dentists for 5 days. In comparison, there was a statistically significant difference between the two groups in which 60% of the pediatric dentists resorted to a 5-day protocol. In the recent years, more attention has been given to short courses. Rubenstein explains that the drugs advocated for a short-course antibiotic therapy should have certain characteristics such as rapid onset of action, bactericidal activity, lack of propensity to induce resistant mutants, easy penetrability into tissues, activity against nondividing bacteria, not being affected by adverse infection conditions, administration at an optimal dose, and optimal dosing regimen.  Short courses are preferred to long courses, particularly when treating children since children's compliance with conventional courses is poor.  A false conception about the use of antibiotics is that antibiotics should be used for a certain number of days to "kill the resistant strains" as the vast majority of strains acquire resistance via transposable elements that are preferentially transferred when antibiotics are used in subtherapeutic doses or for long durations. 
The awareness of guidelines for prescription of antibiotics was found to be low among the BDS practitioners (17%) in contrast to the MDS practitioners (56%). The difference was statistically significant. The knowledge regarding antibiotic resistance was found to be adequate in the MDS group (99%). However, it was 88% in the BDS group showing a statistically significant difference. Another alarming finding was that 68% of the BDS practitioners prescribed antibiotics until the required speciality treatment could be rendered. 34% of the MDS practitioners prescribed antibiotics to postpone appointments. About 35% of the BDS practitioners prescribed antibiotics on the coercion of parents, which was irrational and also contributed to the antibiotic resistance. Despite the awareness of antibiotic resistance, dentists show a lack of concern in curbing this grave problem.
The role of prophylactic antibiotics to prevent complications such as dry socket and serious systemic complications such as infective endocardiditis has been suggested. But the evidence for antibiotics acting to prevent infection from surgical wounds in the mouth is poor to nonexistent, indicating that preoperative parenteral antibiotic prophylaxis for routine third molar surgery in medically fit patients is unwarranted. , In case of bacterial endocardiditis, the absolute risk rate after dental treatment even in at-risk patients is considered very low.  The recent guidelines from the British Society for Antimicrobial Chemotherapy  and the American Heart Association  recommend that only patients in the high-risk category require coverage. The bases for this are as follows:
- The development of infective endocarditis does not require a prior intervention of any form, dental or nondental.
- The effectiveness of prescribing antibiotics prophylactically has not been proven clinically.
- Antibiotics when prescribed prophylactically prior to dental procedure present a greater risk of death through anaphylaxis than a protocol of no antibiotic prescription.
- The daily act of toothbrushing itself presents as a risk of infective endocarditis.
- Antibiotic prophylaxis is not cost-effective. 
However, in our study, it was found that 92% of the BDS practitioners and 96% in the pediatric dentist group were aware of the prophylactic regimen.
| Conclusion|| |
Our survey findings suggest that antibiotics were prescribed indiscriminately, inappropriately, and injudiciously to manage the oral diseases. In our study, for many oral conditions, there was an overprescription in the BDS practitioners' group when compared to the pediatric dentists' group. This may have probably been due to inadequate understanding of the disease, less skill, and less competency in performing operative intervention measures. It has to be understood that dental diseases are predominantly because of local factors; the mere removal of the local causative factors reduces the need for prescribing antibiotics considerably. Antibiotics should be used only as adjuncts even when there is a real need and never as first-line treatment modality.
In conclusion, the prescribing practices of dentists can be improved by increasing awareness of the recommended guidelines among dental practitioners. Furthermore, the importance of initiating awareness programs among the general public should not be overlooked. Also, emphasis should be laid on forming Indian guidelines for the prescription of antibiotics.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]