|Year : 2014 | Volume
| Issue : 5 | Page : 12-16
The role of dental surgeons in combating drug resistance: A study in South India
Ravi Teja Chitturi1, Venkatesan Ramesh2, Reghunathan Priyanka3, Natarajan Senthilnathan4, Rathinam Elanagai5
1 Department of Oral Pathology, SIBAR Institute of Dental Sciences, Guntur, Andhra Pradesh, India
2 Department of Pedodontics and Preventive Dentistry, Indira Gandhi Institute of Dental Sciences, Puducherry, India
3 Department of Prosthodontics and Crown & Bridge, Rajah Muthiah Dental College and Hospital, Annamalai Nagar, Tamil Nadu, India
4 Department of Conservative Dentistry and Endodontics, SRM Institute of Dental Sciences, Chennai, India
5 Department of Oral Pathology, Rajah Muthiah Dental College and Hospital, Annamalai Nagar, Tamil Nadu, India
|Date of Web Publication||19-Dec-2014|
Ravi Teja Chitturi
Department of Oral Pathology, SIBAR Institute of Dental Sciences, Takkellapadu, Guntur - 522 509, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: One of the reasons for an important global concern i.e., antibiotic resistance is the pattern of antibiotic prescription by doctors. Knowledge regarding essential medicines and the rational use of medicines by doctors is important to combat drug resistance. This study was designed to study the knowledge of dental surgeons in south India regarding antibiotics required for various dental infections and also to assess the various factors that affect their prescription. Materials and Methods: A total 700 private dentists were randomly selected and questionnaires were sent by post or electronic media. The replies were collected and the response to each question was analyzed and expressed as absolute frequencies. Results: Over 80% of the dental surgeons correctly recognized the need to prescribe antibiotics when there was evidence of systemic spread, but over half of the dentists prescribed antibiotics even when a localized fluctuant swelling, for which antibiotics are not required. Also, 20-30% of dentists prescribed antibiotics unnecessarily for conditions such as chronic marginal gingivitis and acute pulpitis. Very importantly we found that there were many dentists' prescriptions that were affected by non-clinical factors, such as, patients' expectation of a prescription, work pressure, lack of time, and uncertainty in diagnosis to name a few. Conclusion: The results show that knowledge and antibiotic prescription pattern among dental surgeons is suboptimal. It is very important to provide continuing dental education in this aspect, to combat the threat of drug resistance.
Keywords: Antibiotic resistance, dental surgeons, dentists, essential medicine, India, knowledge, rational use of medicines
|How to cite this article:|
Chitturi RT, Ramesh V, Priyanka R, Senthilnathan N, Elanagai R. The role of dental surgeons in combating drug resistance: A study in South India. Int J Nutr Pharmacol Neurol Dis 2014;4, Suppl S1:12-6
|How to cite this URL:|
Chitturi RT, Ramesh V, Priyanka R, Senthilnathan N, Elanagai R. The role of dental surgeons in combating drug resistance: A study in South India. Int J Nutr Pharmacol Neurol Dis [serial online] 2014 [cited 2022 Dec 8];4, Suppl S1:12-6. Available from: https://www.ijnpnd.com/text.asp?2014/4/5/12/147457
| Introduction|| |
The advent of antibiotics was one of the landmark achievements by the human race to combat the threat by microorganisms. The battle between human beings and microorganisms still continues and the little bugs have not let this battle go easy, by showing their ability to develop antibiotic resistance.  This ability of the microorganisms to overcome and become resistant to drugs poses a big challenge, and therefore, can be considered no less than a battle. Unfortunately this battle has sometimes been fought on the wrong side by doctors themselves. Although the problem of antibiotic resistance is global, it is a particular pressing concern in developing countries like India due to various reasons, such as, inappropriate use of antibiotics. The problem of antibiotic resistance remained unknown in India until 2009, when New Delhi metallo-ß-lactamase-1 (NDM-1) was first reported. 
There are several human reasons why microorganisms develop resistance to drugs. Some of the important reasons are use of sub therapeutic dose of antibiotics and unnecessary usage of antibiotics.  Dentists prescribe antibiotics for a number of reasons, such as, odontogenic and other orofacial infections.  There are studies that show a large number of dentists prescribe antibiotics in conditions where it is not indicated.  There are various factors that affect this adverse act by dentists, which include clinical factors such as lack of knowledge and numerous non-clinical factors, such as, patient's expectations, lack of time, and excess workload to name a few.  The Global Antibiotic Resistance Partnership (GARP) claims that the menace of antibiotic resistance and studying the factors related to it are more important in countries like India than in the developed nations.  This study is the first among dentists in India and has been done with a view to provide an insight into studying the various factors involved in reducing the overprescription of antibiotics. The aim of this study is to assess the knowledge regarding essential antibiotics required for various dental conditions and factors that affect the prescription of private dental practitioners.
| Materials and Methods|| |
This study was carried out between February and May 2014, in south India, after approval from the Institutional Review Board and the Ethical Committee of the University. A total of 700 private dental practitioners, whose contact details were available at the local office were sent questionnaires either in paper form or by electronic media. This questionnaire was designed to examine the dental practitioners' prescribing patterns. It was a modified version of the one prescribed by Palmer et al.  The questionnaire was anonymous and consisted of four parts. The first part was related to their demographic data such as age, sex, and a question to know whether they had attended any courses/seminars/continuing dental education (CDE) programs on antibiotics over the past two years.
The second part of the questionnaire was to test their knowledge with regard to the use of antibiotics. The practitioners were given few clinical signs and asked whether it was necessary to prescribe antibiotics for them when present along with a dental infection. The clinical signs suggested were elevated body temperature, lymphadenopathy, localized fluctuant swelling, gross diffuse swelling, restricted mouth opening, difficulty in swallowing, and closure of the eye because of swelling. These conditions were selected according to the study done by Palmer et al.,  Information regarding their knowledge of requirement of an antibiotic for common dental infections, which presented without any systemic sign, was also sought. The dental infections chosen were acute pulpitis, acute periapical infection, chronic periapical abscess, chronic marginal gingivitis, pericoronitis, reimplantation, cellulitis, and dry socket.
The third part of the questionnaire was designed to obtain knowledge about the common antibiotics prescribed by dental practitioners. The dental infections selected were the same as chosen in the second part. The last part of the questionnaire was designed to know if any non-clinical factors such as patients expectation of a prescription, work pressure, lack of time, uncertainty in diagnosis, patients' social status, prevention of postoperative infection, or improper aseptic measures in their clinic or cases where treatment had to be delayed, affected their prescription.
The data obtained from the questionnaires were entered into the Statistical Product and Service Solutions (SPSS) v. 17.0 software for Windows 7. From this database the overall response rates were calculated along with the percentage of response for each question.
| Results|| |
Out of the 700 questionnaires sent, 423 that were received gave a response rate of 60.42%. Of these, 37 questionnaires were incomplete, and thus, 386 of them were usable. Out of the total of 386 respondents, 306 (79.27%) were males and the remaining 80 (20.73%) were females. Among all those who had responded only 19 (4.92%) of them had attended a CDE program on antibiotics over the past two years.
Choice of antibiotics for systemic conditions
Over 94% preferred to prescribe antibiotics when there was an elevated body temperature (94.04%), a gross diffuse swelling (94.56%) or there was closure of the eyes due to a swelling (95.85%) when present along with a dental infection. Over 83% of them felt that conditions such as lymphadenopathy (83.42%), restricted mouth opening (88.34%), and also difficulty in swallowing (88.86%) required antibiotics. Interestingly 54.4% of the dentists thought antibiotics were required when a patient presented with a localized fluctuant swelling [all data in [Table 1].
|Table 1: Percentage of practitioners prescribing antibiotics for clinical conditions with any dental infection |
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Choice of antibiotics for various clinical conditions
[Table 2] shows the data on use of antibiotics by dentists in various clinical conditions without association of systemic signs. Majority of dentists, that is, more than 80% prescribed antibiotics for chronic periapical abscess (83.16%), pericoronitis (89.64%), and cellulitis (90.93%). Over half of the dentists surveyed prescribed antibiotics for conditions such as dry socket (50.78%), reimplantation of teeth (53.37%), and acute periapical infection (60.62%). Also there were dentists who prescribed antibiotics for conditions such as chronic marginal gingivitis (20.98%) and acute pulpitis (30.57%). The antibiotics prescribed by dentists for various clinical conditions have been shown in [Table 3].
|Table 2: Percentage of private practitioners prescribing antibiotics for clinical conditions without any systemic signs |
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|Table 3: Data showing clinical signs and the percentage of different antibiotics prescribed by private practitioners |
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Non-clinical factors affecting the prescription
The results of the last part of the questionnaire, where the dentists were asked to select the non-clinical factors that affect their prescription, are summarized in [Table 4]. A majority of the dentists gave reasons such as to prevent postoperative infection (55.96%) and patient's expectation of a prescription (46.89%). The other reasons included, improper aseptic measures in their clinic (33.42%), treatment had to be delayed (24.61%), there was uncertainty in the diagnosis (15.80%), due to work pressure and lack of time (10.36%), or due to patient's social status (4.66%).
|Table 4: Percentage of various non-clinical factors affecting a private practitioners prescription |
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| Discussion|| |
This survey was designed to test the knowledge of private dental practitioners and to acquire knowledge regarding their antibiotic prescription. Out of the 700 dentists, only 423 responded, which gave an overall response rate of 60.42%. Although we expected a higher response rate, it seemed that the practitioners were too busy to respond to questionnaires or sometimes the paper work got lost in their pile of documents or they simply did not care, as observed in other studies. 
In our study we observed that a majority of the dentists knew exactly when to prescribe antibiotics, that is, they prescribed them in conditions where a dental infection was associated with signs such as elevated body temperature, lymphadenopathy, gross diffuse swelling, restricted mouth opening, difficulty in swallowing, and closure of the eye because of swelling. However, more than half of the dentists prescribed antibiotics for a localized fluctuant swelling where a local treatment would have sufficed and antibiotics were not necessary. The reason could be lack of knowledge or due to some non-clinical factors, as observed by some authors. , The response about the knowledge of dental practitioners with regard to the requirement of antibiotics for clinical conditions where there were no signs of systemic spread was alarming. There were many dentists who prescribed antibiotics for conditions such as acute pulpitis, acute periapical infection, chronic marginal gingivitis, pericoronitis, and dry socket, where such a prescription was not required. These results were similar to other ones observed by Addy et al. and Weber et al. ,, These results also showed lack of knowledge of a major portion of dental practitioners regarding the requirements of antibiotics. Although there are several non-clinical factors involved, some dental practitioners' prescriptions showing an overuse of antibiotics, as described later, is unwarranted. One of the factors associated with such a practice, as suggested by a few authors' is a lack of practitioner's interest and proper knowledge.  We strongly feel that regular CDE programs must be conducted to make dentists aware of the menace of antibiotic resistance and dental practitioners should also take the necessary steps to prevent misuse of antibiotics.
Regarding the choice of antibiotics, the majority of dentists prescribed amoxicillin along with metronidazole for many of the dental infections, as shown in [Table 3]. This concurs with the results obtained by various authors. ,, For conditions such as chronic periapical abscess, the drugs of choice according to the British National Formulary (BNF) are amoxicillin and metronidazole.  A main portion of dentists prescribe these, but the majority use either cephalosporins in combination with metronidazole or a combination of amoxicillin and clavulanic acid. This may be due to the opinion of dental surgeons that microbes have become resistant to amoxicillin as suggested by few authors. ,, The management of cellulitis has also brought up interesting findings. A large portion of the practitioners have felt the necessity to use cephalosporins along with metronidazole for the same. Although literature suggests that the use of amoxicillin along with metronidazole would have sufficed. ,, This finding is in concurrence with the study by Kotwani et al., where the authors have suggested a possible overuse of cephalosporins by practitioners in India. 
Analysing the final part of the survey was quite interesting. We surveyed the non-clinical factors that affected a dental practitioner's prescription. A majority of the dentists prescribed antibiotics either due to patient's expectation of a prescription or due to the inappropriate setup in their clinic or an interesting 'just-in-case' attitude, to prevent postoperative infection. This finding was similar to a study performed in Kuwait, where dentists preferred to prescribe antibiotics either due to the fact that they felt the setup in their clinics was not aseptic enough or even to make sure that there were no postoperative complications.  Other non-clinical factors that affected a dentist's prescription was lack of time, work load, and for reasons where treatment had to be delayed. These findings were similar to the results obtained by Palmer et al.  Thus, it could be stated that time, workload, and other patient factors also affected a dental surgeons antibiotic prescription.
| Conclusion|| |
The importance of knowledge regarding antibiotic resistance is very essential for a doctor, to prepare mankind for a fight against the increasing ability of microbes to evade the efficacy of antibiotics. A strict evaluation of teaching in dental schools and periodic updates to practicing dentists regarding antibiotic resistance, through CDE programs, is very essential to obtain optimum results from antibiotics. Although doctors should not always be blamed for growing antibiotic resistance, as a lot of non-clinical factors also play an important role in antibiotic prescription by dental surgeons, it is our duty to overcome all these factors, to provide quality care toward patients, with utmost care not to increase the threat of antibiotic resistance.
| Acknowledgment|| |
The authors would like to thank all the dental surgeons who were willing to participate in this study.
| References|| |
Berkowitz FE. Antibiotic resistance in bacteria. South Med J 1995;88:797-804.
Ganguly NK, Arora NK, Chandy SJ, Fairoze MN, Gill JP, Gupta U, et al
.; Global Antibiotic Resistance Partnership (GARP)-India Working Group. Rationalizing antibiotic use to limit antibiotic resistance in India. Indian J Med Res 2011;134:281-94.
Levy SB, Marshall B. Antibacterial resistance worldwide: Causes, challenges and responses. Nat Med 2004;10(Suppl 12):S122-9.
Lewis MA. Why we must reduce dental prescription of antibiotics: European Union Antibiotic Awareness Day. Br Dent J 2008;205:537-8.
Epstein JB, Chong S, Le ND. A survey of antibiotic use in dentistry. J Am Dent Assoc 2000;131:1600-9.
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 NO, Ireland RS, Palmer SE. Antibiotic prescribing patterns of a group of general dental practitioners: Results of a pilot study. Prim Dent Care 1998;5:137-41.
Kaner EF, Haighton CA, McAvoy BR. ′So much post, so busy with practice--so, no time!′: A telephone survey of general practitioners′ reasons for not participating in postal questionnaire surveys. Br J Gen Pract 1998;48:1067-9.
Patel S, Barnes JJ. The Principles of Endodontics. 2 nd
ed. Oxford: Oxford University Press; 2013. p. 43.
Addy M, Coulthard P, Crighton A, Lewis MA, Meechan JG, Robb ND, et al
. Infections. In: Martin J, editor. British National Formulary 61. London: BMJ Group and the Royal Pharmaceutical Society of Great Britain; 2011. p. 257.
Weber JT, Courvalin P. An emptying quiver: Antimicrobial drugs and resistance. Emerg Infect Dis 2005;11:791-3.
Kumar KP, Kaushik M, Kumar PU, Reddy MS, Prashar N. Antibiotic prescribing habits of dental surgeons in Hyderabad city, India, for pulpal and periapical pathologies: A survey. Adv Pharmacol Sci 2013;2013:537385.
Vessal G, Khabiri A, Mirkhani H, Cookson BD, Askarian M. Study of antibiotic prescribing among dental practitioners in Shiraz, Islamic Republic of Iran. East Mediterr Health J 2011;17:763-9.
Mainjot A, D′Hoore W, Vanheusden A, Van Nieuwenhuysen JP. Antibiotic prescribing in dental practice in Belgium. Int Endod J 2009;42:1112-7.
Garg AK, Agrawal N, Tewari RK, Kumar A, Chandra A. Antibiotic prescription pattern among Indian oral healthcare providers: A cross-sectional survey. J Antimicrob Chemother 2014;69:526-8.
Tanwir F, Marrone G, Lundborg CS. Knowledge and reported practice of antibiotic prescription by dentists for common oral problems. J Coll Physicians Surg Pak 2013;23:276-81.
Al-Huwayrini L, Al-Furiji S, Al-Dhurgham R, Al-Shawaf M, Al-Muhaiza M. Knowledge of antibiotics among dentists in Riyadh private clinics. Saudi Dent J 2013;25:119-24.
Demirbas F, Gjermo PE, Preus HR. Antibiotic prescribing practices among Norwegian dentists. Acta Odontol Scand 2006;64:355-9.
Kotwani A, Holloway K, Roy Chaudhury R. Methodology for surveillance of antimicrobials use among out-patients in Delhi. Indian J Med Res 2009;129:555-60.
Salako NO, Rotimi VO, Adib SM, Al-Mutawa S. Pattern of antibiotic prescription in the management of oral diseases among dentists in Kuwait. J Dent 2004;32:503-9.
[Table 1], [Table 2], [Table 3], [Table 4]