Introduction:
Endodontic pain is caused by inflammatory process, which is most commonly related to microbial, mechanical or chemical factors. When the infection spreads the inflammation will occur, in such a case the host responses do not appear to be capable of controlling these microbial factors. Therefore, prescription of antibiotic in addition to the local treatment is used to augment host response mechanisms (Ashraf. 2002).
Antibiotics are common drugs used either for prophylaxis or as a part of the management of orofacial infection (Longmana et al. 2000, Kakoei et al . 2006). Several studies have shown that the knowledge of general practitioner dentist toward the prescription of antibiotic for prophylactic and therapeutic needs is inadequate (Palmer et al. 2000,Kakoei et al. 2006, Nabavizadeh et al .2011). This will effect
the bacteria by progressive loss of there sensitivity to these drugs and the spreading of resistant strains of bacteria, which will have more of a risk to the patient than the infection being treated or prevented. (Azevedo et al. 2009).
Various adverse effects can be occur duo to Antibiotics consumption, including drug interactions, overgrowth of resistant microorganisms, nausea, gastrointestinal upsets, potentially fatal allergic reactions and antibiotic associated colitis (Longmana et al .
2000). Antibiotics may become resistant by Bacteria, which is a serious public health problem. Evidence exists that the resistance of oral micro flora to antibiotics has increased during the past decades (Palmer et al. 2000,Epstein et al. 2000, Azevedo et al. 2009, Segura-Egea et al. 2010,Suaifan et al. 2012).
The aim of this study was to evaluate the current knowledge of antibiotic prescription in endodontic practice among general practitioner dentists in Riyadh city, Saudi Arabia.
Materials and Methods
The Study-Target Population:
The target study objects were general dental practitioners who are practicing in the dental field not more than 5 years in Riyadh, Saudi Arabia.
After evaluating the validity and reliability of the questionnaire, one-page questionnaire was distributed manually among 372 active general dentists in both private and governmental sectors to investigate their behavior of prescribing antibiotics therapeutically and prophylactically, participant were asked to give some answers to some clinical signs and conditions required antibiotics and their choice of medicine. Other electronic questionnaire (developed on Survey Monkey Website) was mailed to 11,284 dentist (4500 were sent to all general dental practitioners attended conferences in Riyadh Colleges of Dentistry and Pharmacy and Members in Suadi
Dental Society, 6744 were sent to dental general practitioners on their social network accounts and 40 were sent to all dental general practitioners working at King Abdulaziz Medical City).
The Study Tool: The Questionnaire
A structured English written questionnaire was developed and modified from a previous study (Nabavizadeh, 2011). The participant consent was the first choice to be selected in the questioner. The questionnaire consists of 26 questions divided into three sections.
The first section covered the demographic characteristics; Gender, qualification source (Saudi Arabia or other countries), Employee (Governmental sector or Privet sector) and Working experience since graduation (1yr, 2yrs, 3yrs, 4yrs, 5yrs).
The second section of the questionnaire composed of thirteen questions that investigate the practitioners’ knowledge of the indications for prescribing antibiotics to an adult patient with no allergies, in a number of systemic clinical signs that may be associated with a dental infection. The clinical signs chosen were; fever, malaise, diffused swelling, and difficulty on swallowing. GDPs were also asked about the preferred antibiotic of choice if they were to use it in clinical conditions that require the use. These clinical conditions were (Symptomatic Irreversible Pulpitis, Symptomatic Apical Periodontitis, Acute Apical Abscess, Chronic Apical Abscess with Sinus Tract, Chronic Apical Periodontitis). Also investigated practitioners’ knowledge of prescribing suitable antibiotics on two session’s root canal treatment,
one long session root canal treatment, after all root canal treatment, if the patients insist and in retreatment cases.
The third section composed of nine questions assessed knowledge of the medical conditions and dental procedures that may require antibiotics as prophylactic treatment. The dental procedures were (before all root canal treatments and only before endodontic surgeries), the medical conditions included (HIV+, HBS+, non- controlled Diabetes, Congenital Heart diseases, Mitral valve prolapse and prosthetic joint in the past 2 years and those with a history of cancer and Radiotherapy). Antibiotic choices were (Penicillin Vk, Clindamycin, Amoxicillin, Amoxicillin with clavulanic acid and one of the choices was others).
Data analysis:
Data were analyzed and tabulated using IBM SPSS Statics version 21
Results
A total of 372 paper replies were received, only 222 useable replies fulfilled the acceptance criteria giving a response rate of 59.6%, also a total of 230 replies were received through email, twitter, and facebook only 95 fulfilled the acceptance criteria resulting in an overall total 317 replies. Few GDPs (n=22 ,6.9%) had full knowledge of section 2(correct answers to all 13 questions) of antibiotic prescription protocols. Figure 1 show the breakdown of responses. The maximum possible score for the questionnaire was 22, with respondents achieving a range of 6-21 (mean 13.73, S.D.
4.09). Table 1 shows the range of scores, means and standard deviations for demographic comparison. The total mean scores for gender, place of previous
education, working sector and working experience were compared. T-Tests showed no significant difference between genders (t_ 5.804; P > 0.05). A separate T-test, however, showed a significant difference between GDPs who have taken their bachelor degree in Saudi Arabia from GDPs who studied in other countries. Also a separate T-test revealed a significant difference between private sector and government sector differences were significant at (t_ 6.569;p<0.001).
A one-way analysis of variance (ANOVA) using work experience as the grouping variable showed there were significant differences [F_10.338; P < 0.001] between work experience and knowledge. These significant differences were between 2nd,
3rd&4th-year working experience (mean total score 12.61, 11.32, 12.68) and 5-year working experience (mean total score 15.28). Therapeutic and prophylactic antibiotics that were prescribed by GDPs are summarized in Table 4 and 5.
The greatest number of antibiotic prescriptions was written for acute apical abscess (40.10%) and in-patient with diffused swelling (94%). Amoxicillin was the drug of choice in all-correct and incorrect cases for both section 2 (21.86%) and section
3(28%).
Figure 1:. Description of Respondents
Table 1: Number, Means, Standard Deviations,
P value of total score for prescription of antibiotics and prophylaxis antibiotics
Table 2: Conditions and total percentages of antibiotics prescription
Table 3: Conditions and total percentages of prophylaxis antibiotic prescription
Table 4: Conditions and percentages of antibiotic prescription
Table 5: Conditions and percentages of prophylaxis antibiotic
Discussion
This study assessed the knowledge of antibiotics among general dental practitioners who are practicing in the dental field not more than 5 years in Riyadh city; kingdom Saudi Arabia. Up to the researchers knowledge this is the first study of its kind to be performed in Riyadh city.
In case of symptomatic irreversible pulpitis and symptomatic apical periodontitis, (42%) percent and (49.5%) of the participants prescribed antibiotics for the first and second situation, respectively. While the proper treatment in these situations are debridement of the root canal space and non-surgical root canal therapy without antibiotic therapy. (Nabavizadeh et al .2011) .In case of chronic apical periodontitis in a healthy patient, there is no indication for antibiotic use and treatment should be limited to nonsurgical root canal treatment, but, in this study (40.4%) of participants prescribed antibiotics.
Interestingly, (59%) of participants still prescribed antibiotics for chronic apical abscess with sinus tract, management of uncomplicated abscesses is effective drainage and removal of the cause without prescription of antibiotic.
Also for acute apical abscess antibiotics are not indicated. Those who were prescribing antibiotics in the previous studies (Dornet al. 1977, Gatewood et al. 1990, Whitten et al. 1996, Yingling et al. 2002, Rodriguez-Nu´n˜ez et al. 2009) ranged from
87% to 99%. The percentage of dentists who were prescribing antibiotic in this situation was (86.8%). Amoxicillin is the antibiotic of choice for 40, 10% of them. ( Segura-Egea et al. 2010)
For these situations about dental infections with systemic signs like fever, malaise, cases of diffused swelling and difficulty in swallowing many of dentists answered these questions correctly. The percentages of these answers were 80.8%, 94% and
87.7 % respectively.
Various antibiotics were prescribed in these cases which were similar to reports of other studies (Seltzer et al.1985, Gatewood et al .1990) (Nabavizadeh et al .2011).
After all root canal treatment, two visit root canal treatment, retreatment cases, if patient insist and in prolonged root canal treatment no antibiotic therapy is required. While in this study the percentage of participants who were prescribed antibiotics for these cases were (27.8% 26.8%, 26.5%, 25.9% and 31.2%), respectively.
Before every root canal treatment, HIV patients, HBS patients, non-controlled diabetic patients and in cases of history of cancer and radiotherapy Antibiotics are not indicated prophylactically.
The percentages of participants who were prescribed antibiotic in these situations were (26.5%, 51.1%, 39.1%, 64% and 58.7%), respectively.
Prophylactic antibiotic is recommended before endodontic surgery, in cases of mitral valve prolapse, prosthetic joint in past 2years and congenital disease (AV shunt and cardiac valve replacement). 40.7% of dentists prescribed antibiotic before endodontic surgeries, 76% in mitral valve prolapse, 61.8% prescribed antibiotic for patients with prosthetic joint in past 2years and 88% for congenital diseases (AV shunt and cardiac valve replacement) which is the largest percentage for prescribing prophylactic antibiotics in this study, and 54,60% of them prescribed Amoxicillin. (Scott et al.
2005).
There is a significant difference in the percentages of awareness between dentists working in the private sector and others in the governmental sector. In this study we found that dentists working in governmental sector are more knowledgeable about the
appropriate use of antibiotic compared to dentists working in private sector, this might be due to lack of guidelines and regulations in the private management as well as private sector dentists are aiming to make highest possible profit.
Also we found that there is no significant difference between freshly graduated GDPs and those who have been practicing for five years in the awareness of antibiotic prescription. Dentists who have been practicing for one and five years are more knowledgeable compared to dentists with two, three and four years of experience. GDPs who earned their bachelor degree in Saudi Arabia are considered to be conservative in antibiotic prescription.
CONCLUSION
This study supports the conclusion that there is a lack of knowledge about the correct indication and type of antibiotics in dental practice among the GDPs, The prescription of antibiotics in cases of endodontic pathology tended to exceed general indications of their application and in some cases is irrational. There is also a need to improve undergraduate education curriculum and, Mandatory courses about antibiotics. Also, Strict policies must be enforced to regulate procurement of antibiotics and prohibit their purchase without a correct prescription.
ACKNOWLEDGEMENTS
We would like to thank the questionnaire respondents who kindly devoted their time to answer the questioner; we would also like to acknowledge Dr. Abdulaziz Al Shammery ‘s great efforts in collecting our needed data. Last but not least we give our thanks to Dr.Sharat Pani for his guidance in statistical analysis.
