|Year : 2016 | Volume
| Issue : 4 | Page : 348-353
Dental students' compliance with antibiotic prescribing guidelines for dental infections in children
Yee Chen Wong, Mandakini Mohan, Allan Pau
School of Dentistry, International Medical University, Kuala Lumpur, Malaysia
|Date of Web Publication||29-Sep-2016|
International Medical University, 126 Jalan Jalil Perkasa 19, Bukit Jalil, Kuala Lumpur 57000
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: To investigate the antibiotic prescribing training received by dental students, clinical experience in treating child patients, awareness of antibiotic prescribing guidelines, preparedness in antibiotic prescribing, and compliance with antibiotic prescribing guidelines for the management of dental infections in children. Methods: This was a cross-sectional study involving final year dentals students from Malaysian and Asian dental schools. A self-administered questionnaire consisting of five clinical case scenarios was e-mailed to all final year students at selected dental schools. Students' responses were compared for each clinical case scenario with the prescribing guidelines of the American Academy of Pediatric Dentistry and the American Dental Association. Compliance in each scenario was tested for association with their preparedness in antibiotic prescribing, previous training on antibiotic prescribing and awareness of antibiotic prescribing guidelines using Chi-square test. Data collected were analyzed using SPSS statistics version 20. Results: A total of 108 completed responses were received. About 74 (69%) students were from Malaysian dental schools. The compliance rate with prescribing guidelines ranged from 15.7% to 43.5%. Those attending Malaysian dental schools (47.3%) and those who had treated child patient more often (46.3%) were more likely (P < 0.05) to be aware of the guidelines. Those who had received antibiotic prescribing training (21.3%) were more likely to think they were well prepared in antibiotic prescribing (P < 0.05). Conclusions: Final year dental students had low awareness and compliance with antibiotic prescribing guidelines. Further research is needed to investigate how compliance with the guidelines may be enhanced.
Keywords: Antibiotic prescribing, dental education, dental students
|How to cite this article:|
Wong YC, Mohan M, Pau A. Dental students' compliance with antibiotic prescribing guidelines for dental infections in children. J Indian Soc Pedod Prev Dent 2016;34:348-53
|How to cite this URL:|
Wong YC, Mohan M, Pau A. Dental students' compliance with antibiotic prescribing guidelines for dental infections in children. J Indian Soc Pedod Prev Dent [serial online] 2016 [cited 2021 Apr 20];34:348-53. Available from: https://www.jisppd.com/text.asp?2016/34/4/348/191415
| Introduction|| |
The increasing incidence of antibiotic resistance has been widely reported to pose an overwhelming threat to worldwide public health , at the community, country, and regional levels, resulting in harm to individual patients.  Primary care patients prescribed antibiotics for certain infections have been reported to develop bacterial resistance to those antibiotics in the month immediately after treatment, but may persist for up to 12 months.  This effect not only increases the population carriage of organisms resistant to first line antibiotics, but also creates the conditions for increased use of second line antibiotics. Although clinicians in general believe that antibiotic resistance is a public health problem, many believe that it is caused by others. 
Factors contributing to the antibiotic resistance phenomenon have been reported to include the routine use of antibiotics in agriculture resulting in potential direct infection with resistant bacteria from an animal source  and over-consumption of antibiotics in healthcare settings.  It is generally acknowledged that the dentists have a role in helping to reduce antimicrobial resistance development by prescribing the correct drug, at the standard dosage and appropriate regimen when necessary, , and evidence-based guidance on sensible protocols for antimicrobials prescribing has been set out. 
Systemic antibiotics are not routinely used in dentistry as most dental and periodontal diseases are best managed by surgical interventions and oral hygiene measures, but over-prescribing practices by dentists is reportedly prevalent.  Surveys of antibiotics prescribing among general dental practitioners in the UK, , Australia,  and Belgium,  among others, have concluded that therapeutic prescribing of antibiotics varied widely and was suboptimal. Over-prescribing  and low adherence to professional guidelines  in antibiotics prescribing for dental infections in children have also been reported.
Recent research has focused on preparing health professions students for appropriate antibiotic prescribing. ,,, A survey of 37 medical schools in 13 European countries has reported wide variations in exposure of students to important principles of prudent antibiotic use among countries and within the same country.  Among dental vocational practitioners in the UK, wide variations in the therapeutic antibiotic regimens used have been reported, with most not conforming to the guidelines available.  Some researchers have suggested that it is crucial to develop appropriate curricula for teaching healthcare (pharmacy, dentistry, nursing, veterinary medicine, and midwifery) undergraduate students about judicious antibiotic prescribing. , Little is known about antibiotic prescribing among dental students. This paper aims to report on antibiotic prescribing training received by dental students, clinical experience in treating child patients, awareness of antibiotic prescribing guidelines, preparedness in antibiotic prescribing, and compliance with antibiotic prescribing guidelines for the management of dental infections in children.
| Methods|| |
A cross-sectional survey was conducted on final year dental students using a self-administered questionnaire. Opportunistic sampling was carried out to recruit students from a sample Malaysian and Asian dental schools, selected through personal contacts. The survey was approved by the Institutional Review Board.
The survey instrument consisted of four main parts which included sample characteristics, clinical case scenarios involving antibiotic prescribing decisions,  perceptions on antibiotic resistance,  and confidence in prescribing antibiotics for dental infections.  [Table 1] presents the five clinical cases on antibiotic prescribing for dental infections in children. Four scenarios are offered for case 1-4, and three for case 5. Students were asked to indicate for each scenario whether they would prescribe antibiotics or not. Students were deemed compliant with the guidelines if they answered all scenarios correctly in each case. They were considered noncompliant if they answered wrongly in any one scenario. The proportion of participants who complied with the guidelines in each scenario was calculated.
|Table 1: Clinical cases on antibiotic prescribing for dental infections in children|
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Students were also asked for the number of child patients they treated in a week, whether they had antibiotic training in the past 12 months, their awareness of any antibiotic prescribing guidelines and how well prepared they felt in antibiotic prescribing for children.
An e-mail was sent to selected dental schools in Malaysia, Hong Kong, and Taiwan, seeking for approval to conduct the survey on their students. Following this, an e-mail containing a link to the online questionnaire was sent to the deans and student representatives of the dental schools for them to cascade down to their final year students from September to December 2014. One further e-mail was sent 1 month later to remind those who had not responded.
The data collected were analyzed using SPSS statistics version 20 (IBM, Armonk, New York). The proportions of participants who complied with antibiotic prescribing guidelines in each case were calculated. Compliance in each scenario was tested for association with their preparedness in antibiotic prescribing, previous training on antibiotic prescribing, and awareness of antibiotic prescribing guidelines using the Chi-square test.
| Results|| |
A total of 108 complete questionnaires were received from final year dental students. [Table 2] shows the distribution of students by sex, nationality of dental school, training in antibiotic prescribing, and number of child patients treated. Most were female (63.0%) and from Malaysian dental schools (68.5%). Most reported having had training in antibiotic prescribing in the last 12 months (69.4%) and treated at least one child patient per week (62.0%).
|Table 2: Distribution of subjects by sex, dental school, training in antibiotic prescribing, and number of child patients treated (n = 108)|
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Only 37.0% students reported the awareness of antibiotic prescribing guidelines for dental infections in children [Table 3]. Those attending Malaysian dental schools (47.3%) were more likely to report awareness compared to those attending non-Malaysian dental schools (14.7%). Students who treated on average one child patient or more per week (46.3%) were statistically significantly more likely to be aware of antibiotic prescribing guidelines compared to those who treated fewer than one child patient per week (22.0%). Awareness of antibiotic guidelines was not associated with sex or antibiotic prescribing training.
Only 16.7% of students thought that they were well prepared for antibiotic prescribing for children [Table 4]. Students who had received antibiotic prescribing training (21.3%) were statistically significantly more likely to think they were well prepared in antibiotic prescribing compared to those who had not received training (6.1%). Those who treated on average one child patient or more per week (22.4%) were statistically significantly more likely to be aware of antibiotic prescribing guidelines compared to those who treated fewer than one child patient per week (7.3%). Preparedness in antibiotic prescribing for children was not associated with sex or school nationality.
|Table 3: Awareness of antibiotic prescribing guidelines and association with sex, school nationality, training in antibiotic prescribing and average number of child patients treated per week|
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|Table 4: Preparedness in antibiotic prescribing for children and association with sex, school nationality, training in antibiotic prescribing and average number of child patients treated per week|
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The compliance rate with prescribing guidelines in each of the clinical case ranged from 15.7% to 43.5% [Table 5]. For case 1, 43.5% would prescribe antibiotics only for pain and facial swelling with radiographic evidence of pathology, which is consistent with the AAPD guidelines. For case 2, when fever was added to the scenario, the compliance rate was 15.7%. For case 3, when fever was absent, but draining fistula was added to the signs and symptoms, the compliance was 34.3%. For cases 4 and 5, which were nonworking day cases, the compliance rates were 28.7% and 25.9%, respectively.
|Table 5: Compliance rates to antibiotic guidelines for each of the clinical cases|
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For most of the cases, compliance with antibiotic guidelines did not appear to be associated with school nationality, training in antibiotic prescribing in the last 12 months, child patients treated per week, awareness of antibiotic prescribing guidelines, or preparedness in antibiotic prescribing. The exceptions were for case 2, in which students who had received antibiotic prescribing training (21.3%) were more likely to be compliant when compared to students who had not (3.0%). For nonworking day case 5, students who treated one or more child patient per week (52.2%) were more likely to be compliant when compared to students who treated fewer than one child patient per week (31.7%).
| Discussion|| |
This study investigated the prevalence dental students' training in antibiotic prescribing, clinical experience in treating child patients, awareness of antibiotic prescribing guidelines for dental infections in children, and preparedness in antibiotic prescribing, and their association with compliance with existing guidelines. The key findings were that most students had received training on antibiotic prescribing and had treated one or more child patients per week, but most were not aware of any guidelines on antibiotic prescribing or felt well prepared in antibiotic prescribing. Compliance with guidelines was generally low and was not associated with training, clinical experience, awareness, or preparedness.
Only a third of participants in the present study reported the awareness of any antibiotic prescribing guidelines, with variations observed between countries and those with different degrees of clinical experience in treating child patients. Awareness was surprisingly not associated with training in antibiotic prescribing. Health professions students' knowledge on antibiotic prescribing has consistently been reported to be poor ,, and most felt that more learning was needed. ,,
The majority of the students in the present study did not feel well prepared in antibiotic prescribing for children. Those who had received training and those with more clinical experience were more likely to feel well prepared. Consistent with the literature, lack of prepared has been reported for medical students in the USA  and lack of confidence for medical students in Europe. 
Compliance with antibiotic guidelines in the case scenarios presented in the present study was low. Similar lack of concordance between guidelines and the antibiotic prescribing practices of dentists has been reported.  Compliance did not appear to be associated with training in antibiotic prescribing, clinical experience, awareness of guidelines or preparedness for practice, although in two of the case scenarios training and clinical experience were associated with compliance. Dissonance between knowledge and behaviors, however, may be explained by contextual influences decisions, such as patient and system factors, diagnostic uncertainty, and the habits of, and relationship with, supervisors. 
The findings of the present study should be viewed in the context of its limitations. Recruiting students to the study was challenging, even though the survey was approved and supported by the deans of dental schools that were approached. Consequently, the sample size was small. However, within these limitations, the findings are consistent with other studies and highlight the need to improve education in antibiotic prescribing around the world, including Asia. Dissemination of antibiotic prescribing guidelines is also important, including the treatment of dental infections in children.
Antibiotic prescribing education may be in the form of lectures, workshops, informal education in clinical practice, and self-directed learning. Besides clinical education, there are a number of intervention programs, such as patient education, delayed prescriptions, audit and feedback, clinician reminder and decision support system, and financial and regulatory incentives or disincentives that may be implemented to promote judicious antibiotic prescribing.  The use of delayed prescriptions for infections for which antibiotics are not immediately indicated effectively reduce antibiotic use by patients and does not result in excess morbidity.  Such education will instill greater self-confidence in reducing antibiotic prescribing, and at least some change in consultation style and antibiotic prescribing behavior. 
| Conclusion|| |
Final year dental students are future dentists who will be serving the community. Yet, the findings of this survey suggest that there was low awareness of professional guidelines and compliance with the guidelines was low. Much more coordinated efforts within a country and between countries are needed to educate dental students in judicious antibiotic prescribing, and to better prepare them for their practice as future dentists.
Financial support and sponsorship
This study was sponsored by an IMU internal grant (BDS I1/2011(03)2014).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Caron WP, Mousa SA. Prevention strategies for antimicrobial resistance: A systematic review of the literature. Infect Drug Resist 2010;3:25-33.
Levy SB. Antibiotic resistance-the problem intensifies. Adv Drug Deliv Rev 2005;57:1446-50.
Bell BG, Schellevis F, Stobberingh E, Goossens H, Pringle M. A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistance. BMC Infect Dis 2014;14:13.
Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: Systematic review and meta-analysis. BMJ 2010;340:C2096.
McCullough AR, Rathbone J, Parekh S, Hoffmann TC, Del Mar CB. Not in my backyard: A systematic review of clinicians′ knowledge and beliefs about antibiotic resistance. J Antimicrob Chemother 2015;70:2465-73.
Chang Q, Wang W, Regev-Yochay G, Lipsitch M, Hanage WP. Antibiotics in agriculture and the risk to human health: How worried should we be? Evol Appl 2015;8:240-7.
Oberoi SS, Dhingra C, Sharma G, Sardana D. Antibiotics in dental practice: How justified are we. Int Dent J 2015;65:4-10.
Johnson TM, Hawkes J. Awareness of antibiotic prescribing and resistance in primary dental care. Prim Dent J 2014;3:44-7.
Doherty R. In the news: Antibiotic resistance. Br Dent J 2014;216:56.
Dar-Odeh NS, Abu-Hammad OA, Al-Omiri MK, Khraisat AS, Shehabi AA. Antibiotic prescribing practices by dentists: A review. Ther Clin Risk Manag 2010;6:301-6.
Palmer NA, Pealing R, Ireland RS, Martin MV. A study of therapeutic antibiotic prescribing in National Health Service general dental practice in England. Br Dent J 2000;188:554-8.
Kudiyirickal MG, Hollinshead F. Antimicrobial prescribing practice by dentists: A study from two primary care centres in UK. Minerva Stomatol 2011;60:495-500.
Jaunay T, Sambrook P, Goss A. Antibiotic prescribing practices by South Australian general dental practitioners. Aust Dent J 2000;45:179-86.
Mainjot A, D′Hoore W, Vanheusden A, Van Nieuwenhuysen JP. Antibiotic prescribing in dental practice in Belgium. Int Endod J 2009;42:1112-7.
Sivaraman SS, Hassan M, Pearson JM. A national survey of pediatric dentists on antibiotic use in children. Pediatr Dent 2013;35:546-9.
Cherry WR, Lee JY, Shugars DA, White RP Jr., Vann WF Jr. Antibiotic use for treating dental infections in children: A survey of dentists′ prescribing practices. J Am Dent Assoc 2012;143:31-8.
Huang Y, Gu J, Zhang M, Ren Z, Yang W, Chen Y, et al.
Knowledge, attitude and practice of antibiotics: A questionnaire study among 2500 Chinese students. BMC Med Educ 2013;13:163.
Scaioli G, Gualano MR, Gili R, Masucci S, Bert F, Siliquini R. Antibiotic use: A cross-sectional survey assessing the knowledge, attitudes and practices amongst students of a school of medicine in Italy. PLoS One 2015;10:E0122476.
Harakeh S, Almatrafi M, Ungapen H, Hammad R, Olayan F, Hakim R, et al.
Perceptions of medical students towards antibiotic prescribing for upper respiratory tract infections in Saudi Arabia. BMJ Open Respir Res 2015;2:E000078.
Minen MT, Duquaine D, Marx MA, Weiss D. A survey of knowledge, attitudes, and beliefs of medical students concerning antimicrobial use and resistance. Microb Drug Resist 2010;16:285-9.
Pulcini C, Wencker F, Frimodt-Møller N, Kern WV, Nathwani D, Rodríguez-Baño J, et al.
European survey on principles of prudent antibiotic prescribing teaching in undergraduate students. Clin Microbiol Infect 2015;21:354-61.
Palmer NO, Batchelor PA. An audit of antibiotic prescribing by vocational dental practitioners. Prim Dent Care 2004;11:77-80.
Lee CR, Lee JH, Kang LW, Jeong BC, Lee SH. Educational effectiveness, target, and content for prudent antibiotic use. Biomed Res Int 2015;2015:214021.
Ohl CA, Luther VP. Health care provider education as a tool to enhance antibiotic stewardship practices. Infect Dis Clin North Am 2014;28:177-93.
García C, Llamocca LP, García K, Jiménez A, Samalvides F, Gotuzzo E, et al.
Knowledge, attitudes and practice survey about antimicrobial resistance and prescribing among physicians in a hospital setting in Lima, Peru. BMC Clin Pharmacol 2011;11:18.
Pulcini C, Williams F, Molinari N, Davey P, Nathwani D. Junior doctors′ knowledge and perceptions of antibiotic resistance and prescribing: A survey in France and Scotland. Clin Microbiol Infect 2011;17:80-7.
Abbo LM, Cosgrove SE, Pottinger PS, Pereyra M, Sinkowitz-Cochran R, Srinivasan A, et al.
Medical students′ perceptions and knowledge about antimicrobial stewardship: How are we educating our future prescribers? Clin Infect Dis 2013;57:631-8.
Dyar OJ, Pulcini C, Howard P, Nathwani D; ESGAP (ESCMID Study Group for Antibiotic Policies). European medical students: A first multicentre study of knowledge, attitudes and perceptions of antibiotic prescribing and antibiotic resistance. J Antimicrob Chemother 2014;69:842-6.
Dallas A, van Driel M, van de Mortel T, Magin P. Antibiotic prescribing for the future: Exploring the attitudes of trainees in general practice. Br J Gen Pract 2014;64:E561-7.
Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev 2005;19:CD003539.
Bekkers MJ, Simpson SA, Dunstan F, Hood K, Hare M, Evans J, et al.
Enhancing the quality of antibiotic prescribing in primary care: Qualitative evaluation of a blended learning intervention. BMC Fam Pract 2010;11:34.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]