Research Of Dental Antibiotic Treatment Selection By Both General Practitioners And Oral Dental Surgeons In Lebanon

To our knowledge, this study is the first to examine dental antibiotic treatment selection by both general practitioners and oral dental surgeons in Lebanon. This study is also the first to evaluate the frequency and types of antibiotics prescribed for therapeutic or prophylactic purposes, their adherence to international guidelines and all factors influencing this practice among Lebanese dentists.

Antibiotic use should be restricted to infrequent medical conditions in oral and dental medicine and should be prescribed according to the assumed risk of infection for the patient. The etiologic treatment of an infectious focus is most often a non-drug treatment. In addition, oral hygiene is essential for the prevention of infections in oral and dental medicine, and antibiotics must never be used to compensate the patient’s inadequate oral hygiene, or be a substitute for universal hygiene rules and asepsis required for all caregiving.

Despite the low rates of immunodepressed patients and those with high risk of infectious endocarditis (8. 8% and 4. 7% respectively), our findings showed that the overall rate of antibiotic prescribing was relatively high (23. 8%) compared to other studies from British Columbia, Canada (11. 3%), United States (10%), England (10%), Belgium (4. 2%) and Germany (6%). In addition, results of this study suggest that antibiotics are mostly prescribed for prophylactic purposes for invasive oral and dental procedures especially implant surgeries (36. 3%), followed by endodontic treatment and procedures (19. 0%), and dental extractions (18. 7%); these findings are consistent with results of studies from UAE, Iran, and Jordan showing a similar prescription rate in case of implant surgeries (36. 25%). However, this finding was not coherent with results from a study in India where antibiotic prescription in case of the implant was extremely low (2. 5%) whereas dental extraction had the highest frequency of antibiotic prophylactic prescription (30. 8%) (35). Furthermore, concerning the appropriateness of these indications, only 1% of these antibiotic prescriptions were compliant to the guidelines in case of implant surgery, 11. 1 % in case of endodontic treatment and procedures, and 6. 7% in case of dental extractions. These results reveal the tendency of dentists to prescribe antibiotics for unnecessary cases, where such medications are not usually required.

On the other hand, for therapeutic purposes in diseases of infectious origin, the use of antibiotic was mainly for periodontal abscesses/ abscesses (indeterminate) (22. 8%), followed by pulp diseases and periradicular complications (20. 5%). This finding is in agreement with the result of a survey conducted in India where the most common dental indication of antibiotics among dentists was posted dental extraction attributing to 30. 8%, followed by a dental abscess which was 21. 6%. In contrast, concerning the appropriateness of these indications, only 1. 7% of these antibiotic prescriptions were compliant to the guidelines in case of periodontal abscesses/ abscesses (indeterminate), and 1. 9 % in case of pulp diseases and periradicular complications. However, a 2013 systematic review and meta-analysis concluded that periapical abscesses should be drained through a pulpectomy or incision and drainage and that the use of antibiotics was of no additional benefit in terms of the outcomes of pain or infection. When it comes to antibiotics’ types, the excessive use of broad-spectrum antibiotics, such as amoxicillin and clavulanic acid, may be accompanied by an increase in the rates of resistance of respiratory germs. Inappropriate prescription leads to the selection of resistant strains, which is potentially damaging and may contribute to the global antimicrobial resistance problem.

In the current study, amoxicillin combined with clavulanic acid appears to be the most prescribed medication for both therapeutic and prophylactic antibiotherapies (57. 6% and 55. 9% respectively). The combination of metronidazole and spiramycin came in second in the curative group and third in the prophylaxis group. This result differed from the findings of Mainjot et al (22. 1% of all prescriptions were for, amoxicillin-clavulanic acid) and Gowri et al where the commonly prescribed antibiotics were amoxicillin 71. 7%, metronidazole 33. 3%, and amoxicillin with clavulanic acid 26. 6%. This infers that many dentists in our study did not know the spectrum of activity of various antibiotics, knowing that monotherapy is usually the gold standard for first-line treatment, and, second-line treatment is considered in case of first-line treatment failure, highlighting the importance of continuing medical education regarding antimicrobial use in dentistry. Antibiotics conformity with guidelines was found to be low in our study for both therapeutic and prophylactic purposes (17. 4% and 21. 8% respectively). Also, the dose and duration of the antibiotic was rarely appropriate in prophylactic prescriptions (7. 1% and 7. 3% respectively) because, dentists in the present study did not follow the recommended regimen for prophylactic antibiotherapy (single dose: 2g Amoxicillin and in case of allergy or of intolerance to b-lactams, 600 mg clindamycin for adults within the hour before the invasive procedure).

In the multiple regression model, conformity significantly increased among younger and males patients, cardiac patients with a high risk of infectious Endocarditis, and among oral surgeons in comparison to their counterparts. Whereas, it has decreased with the regular participation of dentists in national conferences. Except for patients with high risk of infectious Endocarditis, this indication was not correlated with the risk of infection for the patient and his oral hygiene nor with the invasive oral and dental procedures and/or the diseases of infectious origin which took place. However, previous research has shown that practitioner gender, postgraduate qualification status, number of years since qualification or attendance on postgraduate education courses about antimicrobial prescribing cannot be reliably used to predict patterns of inappropriate antibiotic use. It may be more likely that compliance with clinical guidelines on antibiotic use is determined by practitioners’ knowledge, attitudes and the environment in which they work.

This study showed an evidence for overuse of antibiotics among Lebanese dentists, that might be explained by the lack of national guidelines endorsed by the Lebanese health authorities as opposed to other countries, or the lack of awareness or familiarity with guidelines. Even if practitioners are familiar with a clinical guideline, if they do not agree with the way it was devised or if their personal interpretation of the evidence differs from that of the guideline developers, it can severely limit the likelihood that they will implement the recommendations. A qualitative study of GDPs has highlighted instances where dentists have expressed reservations in relation to the evidence base on which guidelines are developed or where uncertainty has arisen due to the existence of conflicting recommendations. Practitioners may still encounter barriers that limit their ability to perform the recommended behavior due to the patient or healthcare-system related factors. In a large clinical audit of antibiotic prescribing among GDPs in England, 3. 5% of prescriptions were reported to be written because of perceived patient expectation. Diagnostic and prognostic uncertainties may be other explanations. In a questionnaire study of English GDPs, investigators found that 47. 3% of practitioners reported that they may prescribe an antibiotic in instances wherethey were uncertain of a diagnosis. Other important factors include failure of previous operative treatment, shortage of clinical time, use of antibiotics as a substitute for surgery, aging populations, and patient pressure. In addition, a few studies done in developing countries reported that abuse of prophylactic antibiotics was to prevent postoperative infection following surgical dental manipulations or to cover either a defect in aseptic clinical technique or improperly sterilized equipment. Although prevention of infection is important, it must be balanced against the expanding problem of antibiotic resistance and allergy. Moreover, the availability of these drugs to the public with or without a prescription cause dentist to prescribe more and more antibiotics to patients whether they are necessary or not. Possibly pressure from pharmaceutical companies through their medical representatives. On the other hand, Patients presenting at dental surgeries also need to be educated about the importance of restricting the use of antibiotics to only cases of severe infection. Unfortunately, dental patients not only pressure their dentist to get an antibiotic prescription, but they also self-medicate. Self-medication was found to be high in some developing countries, also in Europe. In addition, the majority of the people are unaware of the relationship between oral hygiene and systemic diseases or disorders. According to the World Health Organization (WHO), "Promotion of oral health is a cost-effective strategy to reduce the burden of oral disease and maintain oral health and quality of life.

In conclusion, antibiotic prescribing guideline compliance of dentists can be improved by increasing awareness among dental practitioners of the recommended guidelines through a combination of audit, education and feedback intervention. Furthermore, the importance of initiating awareness programs among the general public should not be overlooked.