KNOWLEDGE OF ANTIMICROBIAL RESISTANCE AND ANTIMICROBIAL PRESCRIPTION AMONG DENTAL PRACTITIONERS IN CHENNAI CITY- A CROSS-SECTIONAL STUDY

KNOWLEDGE OF ANTIMICROBIAL RESISTANCE AND ANTIMICROBIAL PRESCRIPTION AMONG DENTAL PRACTITIONERS IN CHENNAI CITY- A CROSS-SECTIONAL STUDY

Rajkumar *, P. Iyapparaja, Parangimalai Diwakar Madankumar and Swetha Gadde

Department of Public Health Dentistry, Ragas Dental College and Hospital, 2/102, East Coast Road, Uthandi, Chennai, Tamil Nadu, India.

ABSTRACT: Introduction: Most human oro-facial infections originate from odontogenic infections, and prescribing antimicrobial has become a ubiquitous phenomenon. The World Health Organization (WHO) has recognized the inappropriate, indiscriminate and irrational use of antimicrobials leading to antimicrobial resistance. Aim & Objective: To assess the knowledge of antimicrobial resistance and antimicrobial prescription among dental practitioners in Chennai city. Materials and Methods: A total of 110 registered dental practitioners participated in this cross-sectional study. A pre-validated and self-administered questionnaire was prepared and distributed to the registered dental practitioners in Chennai city to collect the demographic details and the information regarding knowledge and practice towards antimicrobial resistance and an antimicrobial prescription for the most common oral conditions and commonly prescribed antimicrobials for their patients were obtained. Statistical analysis. The data were statistically analyzed by using the Statistical Package for the Social Science version 20.0. Descriptive statistics were performed, and a Chi-square test was done to assess the association between knowledge and practice of BDS and MDS participants. Results: 79.66% of BDS and 92.16% of MDS practitioners recommended amoxicillin as their first choice antibiotic drug. 77.96% of BDS and 52.94% of MDS were used to calculate the drug dosage based on the age and weight of the patients. During the pregnancy period, 76.27% of BDS and 60.78% of MDS practitioners were considered, amoxicillin is the safest antibiotic for oral infections. Conclusion: Based on this cross-sectional survey, the overall knowledge of antimicrobial prescription and antimicrobial resistance among dental practitioners was lower.

Keywords: Awareness of antimicrobial resistance, Antibiotic prescription, Dental practitioners, Over-prescription, Antibiotic prophylaxis, Chennai

INTRODUCTION: Throughout our history, the discovery of antimicrobial drugs has been a boon to us. Antimicrobial drugs can be called “Life-saving drugs”. However, the antimicrobial prescription may be associated with unfavorable side effects ranging from gastrointestinal disturbances to fatal anaphylactic shock.

Additionally, inappropriate, indiscriminate, and irrational use of antimicrobials has led to antimicrobial resistance ^{1, 2}. This growing problem has contributed significantly to the morbidity and mortality of infectious diseases, with death rates of communicable illnesses rising again ^{3, 4}.

The World Health Organization has recognized this growing global problem announcing their theme for the year 2011 as “Antibiotic resistance: No action today, no cure tomorrow” and has pressed for an international action ⁵. India is one of the largest consumers of antimicrobial drugs worldwide. Overall, 80% of physicians and 7-11% of dentists prescribe antimicrobial drugs. Although judicious use of antimicrobial agents is strongly encouraged, their overuse or misuse has become entrenched globally in various settings. In acute care hospitals, it is estimated that approximately 20%–50% of all antimicrobials prescribed are either unnecessary or inappropriately used. Some of the factors influencing this irrational prescription use include socio-economic status, physician and dentist’s knowledge, and training, patient load, diagnostic ambiguity, availability of treatment guidelines and pharmaceutical marketing ⁵.

Further rampant antimicrobial use has contributed to adverse clinical outcomes, increasing healthcare costs, and the emergence of multidrug-resistant organisms, which poses a significant threat to public health. The dentistry-based antimicrobial prescription has emerged as a major potential driver of the global phenomenon of antimicrobial resistance. Approximately 2.4 million people get antimicrobial resistance infection which accounts for 50000 deaths/year (World Health Organization, 2019) ⁶.

The basic step that can be taken towards building up antimicrobial resistance could be awareness. This also includes knowledge about the right drug to be prescribed at the right time with the appropriate dosage. Many approaches are being made to control the spread. One of these approaches is to undertake various institutional and educational programs among the public and medical sectors about antimicrobial resistance and its complications regarding the steps that can prevent its development and spread. The Indian Council of Medical Research has initiated an antimicrobial stewardship program that aims to restrict inappropriate use of antimicrobials, optimize selection, dose, route, and duration of the treatment for best outcomes, minimizing detrimental adverse events, high costs and the emergence of resistance ⁷.

The World Health Assembly adopted a global action plan on antimicrobial resistance, which gives five specific objectives (WHO global action plan for AMR 2015). These objectives underscore the need for an effective “one health” approach involving coordination among numerous international sectors. Literature evidence shows that dentists are prescribing more common antimicrobial drugs for many dental diseases. Exploration of the same revealed very limited studies in India assessing the antimicrobial prescription pattern among dentists. As per the National Center for Disease Control and Prevention, approximately one-third of all outpatient antimicrobial prescriptions are unnecessary. According to The Indian Council of Medical Research (2017), antimicrobial overprescribing is common in dentistry and major contributor to antimicrobial resistance ⁸. Also, the lack of awareness observed emphasizes the need for developing national guidelines for antimicrobial use in dental conditions. Practicing such guidelines will go a long way in controlling antimicrobial resistance. Hence, this study was conducted to assess the dental practitioner’s knowledge and practice regarding antimicrobial prescription and resistance in Chennai city.

MATERIALS AND METHODS: This cross-sectional study was approved by the Institutional Review Board of Ragas Dental College and Hospital (IEC Number-20191207). A pre-validated and self-administered questionnaire was prepared and distributed to the registered dental practitioners in Chennai city to collect the demographic details regarding age, gender, designation, year of clinical experience, type of dental practice with the information regarding knowledge and practice towards antimicrobial resistance and an antimicrobial prescription for the most common oral conditions and commonly prescribed antimicrobials for their patients were obtained.

The questionnaire contained both close-ended and open-ended questions to make it flexible for the participants. This questionnaire contains 14 knowledge questions and 10 attitude questions. Written informed consent was obtained from all the study participants. A total of 110 registered dental practitioners participated in this cross-sectional study.

Sample Size Calculation: Sample size calculation was performed according to a study conducted by Puranik p et al., (2018) ⁹ considering a study with an 80% power and α = 0.05. The minimum sample size should be 96 individuals using G-Power software version 3.1.

Inclusion and Exclusion Criteria: Dentists who were registered in the Dental Council of India and had more than one year of clinical experience were included in this study. Dental students and non-registered dental practitioners were excluded. Participants who failed to return filled-in forms within the data collection period were excluded from this study.

Statistical Analysis: The data were entered into Microsoft Excel 2010 version and the statistical analyzed by using the Statistical Package for the Social Science version 20.0 (IBM Corp, Armonk, New York, United States).

Descriptive statistics were performed and a Chi-square test was done to assess the association between knowledge and practice of BDS and MDS participants. For analysis, responses regarding knowledge and practice were dichotomized as correct and incorrect. P < 0.05 (confidence interval of 95%) was considered as statistically significant.

RESULTS: In this cross-sectional study, a total number of 110 registered dental practitioners participated, of which 71 (64.6%) were males, and 39 (35.4%) were females with a mean age of 31.0 ± 2 years.

The majority of participants were qualified as BDS (53.64%), and others were MDS (46.36 %). Out of 110 registered dental practitioners, 59 (53.64%) were doing clinical practice individually and 51 (46.36%) practitioners were doing group practice. Most of them had working experience of up to 5 years Table 1.

TABLE 1: DEMOGRAPHIC CHARACTERISTICS AND WORK EXPERIENCE OF STUDY PARTICIPANTS

Table 2 denotes common antibiotics, and antibiotic courses prescribed by dental practitioners: BDS (79.66%) and MDS (92.16 MDS) practitioners recommended amoxicillin as their first choice antibiotic drug, followed by the combination of amoxicillin with clavulanic acid (20.34% BDS and 3.92% MDS). Antimicrobial prescriptions of 42.37% of BDS and 45.09% of MDS practitioners were prescribed for 3 days and 45.76 percent of BDS and 49.01 percent of MDS practitioners were prescribed antimicrobials for 5 days.

TABLE 2:  COMMON ANTIBIOTIC & DURATION OF ANTIBIOTIC COURSE

Table 3 denotes the knowledge about antimicrobial prescriptions of dental practitioners, most of the dental practitioners (77.96% BDS and 52.94% MDS) were used to calculate the drug dosage based on the age and weight of their patients. So, the difference between BDS and MDS dental practitioners was statistically significant (P=0.005). The undergraduate (81.36 %) and postgraduate (60.78%) dental practitioners were given antibiotic prophylaxis for dental procedures like flap surgery, Dental implant placement & reimplantation of teeth, Endodontic instrumentation, or surgery beyond the tooth apex. But the conditions like the shedding of deciduous teeth, bleeding from trauma to the lips, or oral mucosa for these two dental conditions both the group of dental practitioners (BDS-67.80% and MDS-37.25%) were not prescribed antibiotic prophylaxis before the treatment was statistically significant (P=0.005). Following cardiac conditions like Infective endocarditis and compromised immunity, patients with shunts, indwelling vascular catheters & medical devices, and patients with prosthetic joints, both the group of dental practitioners (BDS-59.32% and MDS-43.14%) gave antibiotic prophylaxis before any dental procedures. 76.27% of BDS and 60.78% of MDS practitioners were considered during the pregnancy period; amoxicillin is the safest antibiotic for oral infections Table 3.

TABLE 3: KNOWLEDGE ABOUT ANTIMICROBIAL PRESCRIPTION

For viral infections in the Oro-facial region, both BDS (79.66%) and MDS (64.71%), dental practitioners preferred Acyclovir as the drug of choice, and the difference between BDS and MDS dental practitioners were statistically significant (P=0.024). Pericoronitis infection both BDS (67.79%) and MDS (54.90%) dental practitioners were prescribed metronidazole - 400mg & Amoxicillin - 500mg. The severe dental infections did not respond to 1st line antibiotic drugs in this situation, 38.90% of BDS and 47.06% of MDS dental practitioners checked the diagnosis & refer the patient to the specialist before go to higher antibiotics, but 45.76% of BDS & 35.29% of MDS dental practitioners were going for the culture sensitivity test. The patients had a severe dental abscess, and who had allergic to the penicillin group of drugs in this condition BDS (57.63%) and MDS (31.37%) dental practitioners were prescribed alternative drug Clindamycin, but 33.90% of BDS and 39.22% of MDS dental practitioners were preferred metronidazole. The difference between both BDS and MDS groups was statistically significant (P=0.006) Table 3.

Table 4 denotes practice about antimicrobial prescriptions of dental practitioners, the undergraduate (35.59%) and postgraduate (62.75%) dental practitioners told that culture-sensitivity test was necessary for all the oral infections before prescribing antimicrobial drugs, but 54.24 % of BDS and 56.86 % of MDS participants were told that culture sensitivity test was not necessary for all the oral infections. The BDS and MDS dental practitioners prescribed systemic antimicrobials for common dental conditions like tooth sensitivity (P=0.00), Dento-alveolar abscess (P=0.009), tooth fracture (P=0.029), and halitosis (P=0.003) were statistically significant. Apart from that, the following dental conditions like dental caries, aphthous ulcers, gingival bleeding, and surgical removal of the impacted tooth were not statistically significant (P=≥0.05). Periodontal conditions like Periodontal pockets, Gingival abscess, Pericoronitis, ANUG, Endo-perio lesion, Generalized periodontitis, Gingivitis, Flap surgery, Aggressive periodontitis, Implant placement, Root planing, Operculectomy. There was no statistically significant difference between BDS and MDS (P=≥0.05), but Periodontal abscess (P=0.001) was statistically significant. Both groups of dental practitioners had prescribed systemic anti-microbials for periapical pathological conditions like acute periapical abscess with no signs of fever, Periapical abscess with fever, Periapical pathology progressed into cellulitis, discharge from endodontically treated teeth, avulsion and replantation was not statistically significant (P=≥0.05). Asymptomatic chronic periapical pathology was statistically significant (P=0.049) Table 4.

TABLE 4: PRACTICE OF ANTIMICROBIAL PRESCRIPTIONS

Dental practitioners were prescribed systemic antimicrobials for the following Oral surgical conditions, 3rd molar extraction with concurrent pericoronitis, Orthogenetic surgical procedures with a high risk of infection, Mandibular fracture without oral communication, Mandibular fracture with oral communication, Dental implants were not statistically significant (P=≥0.05), but Asymptomatic 3^rd molar extraction and major head and neck surgery were statistically significant (P=≤0.05). For oral mucosal conditions, the difference between the BDS and MDS practitioners was statistically significant.

Those conditions were Leukoplakia (P=0.030), Erythroplakia (P=0.010), Traumatic ulcers (P=0.00), Oral candidiasis (P=0.049). But the conditions like Hairy leukoplakia, Denture induced hyperplasia, Lichen planus, Fordyce granules were not statistically significant (P=≥0.05) Table 4.

Pediatric patients reported with severe spreading dental infection, 28.81 % of BDS and 50.98 % of MDS practitioners have increased the dosage of antimicrobial drugs, but 57.62% of BDS and 39.22% of MDS practitioners were not increasing dosage of antimicrobial drugs for severe spreading dental infections. For fungal infections like Pseudomembranous candidiasis BDS (71.19%) & MDS (74.51%), dental practitioners commonly prescribed fluconazole as the drug of choice. The periodontal infections like necrotizing ulcerative gingivitis, both BDS (72.88%) and MDS (56.86%) dental practitioners commonly preferred metronidazole & amoxicillin. But alcoholic patients and under warfarin medication, in these conditions, most of the dental practitioners’ BDS (50.85%) and MDS (50.98%) were not prescribed metronidazole. The difference between BDS and MDS was statistically significant (P=0.026) Table 4.

DISCUSSION: Most human oral infections originate from odontogenic infections. The prescribing of antimicrobials by dental practitioners has become an important aspect of dental practice. Dentists benefited greatly from the discovery of penicillin because it is a broad-spectrum antibiotic and covers most oral infections. On the other hand, antimicrobial use is the key driver of resistance. This is mainly due to its overuse in many parts of the world, particularly for minor infections, misuse due to lack of access to appropriate treatment.

Clinical situations that require antimicrobial therapy include infections accompanied by elevated body temperature and evidence of systemic spread like lymphadenopathy and trismus ¹⁰. Facial cellulitis is a serious disease that should be treated by antimicrobials promptly because of the possibility of infection spread via lymph and blood circulation, with the development of septicemia ². Dentists involved in this survey were prescribed antimicrobials for orofacial infections with systemic signs of involvement, which was appropriated according to scientific literature. The present study was conducted to access the knowledge of antimicrobial prescription for common oral infections and suggested the contribution of dentistry toward the development of antimicrobial resistance. The majority of participants were more than 30 years of age and male (64.6%), similar to few studies; most of them had undergraduate qualifications and up to 10 years of work experience ^{2, 11, 12}.

Amoxicillin was the most preferred antibiotic in the current study, either alone or in combination. In most previous studies, amoxicillin and its combination with clavulanic acid were found to be the most common prescription due to its wide spectrum with a low incidence of resistance with minimum adverse effects ^{11, 16, 17, 20, 21, 22}. Most of the orofacial infections resolve in 3 to 7 days ^{23, 24, 25}. In our survey majority of study, dental practitioners were prescribed antimicrobials for 5 days. This study showed that most of the dentists were prescribed systemic antimicrobial drugs for the cases of tooth sensitivity, halitosis, simple tooth fracture, dental caries and its sequels like pulpitis, apical periodontitis, periapical abscess, gingivitis, gingival abscess, simple extraction, root planing, operculectomy, and traumatic ulcers.

This would be an alarming finding among the dental practitioners’ misuse of antimicrobials because the conditions mentioned above are not indicated for antimicrobial therapy. These could be managed adequately with local interventions. The prescription pattern was similar to some of the previous studies ^{13, 18}. Extractions performed in aseptic conditions do not require antimicrobials, while Pericoronitis is an inflammatory condition that could be managed with anti-inflammatory/analgesics. Similarly, endodontic conditions such as irreversible pulpitis and apical periodontitis could be managed with root canal therapy. In previous studies, Pericoronitis, surgical removal of the impacted molar, cellulitis, flap surgery, aggressive periodontitis, implant placement, Dentoalveolar abscess, discharge from endodontically treated teeth, avulsion and replantation, acute necrotizing ulcerative gingivitis, and chronic periodontitis were reported with a high rate of systemic antimicrobial prescriptions ^{2, 12, 14, 16, 17}. According to American Heart Association ¹⁹, antibiotics were routinely administered as a prophylactic measure for surgical procedures with a high infection rate and/or implantation of prosthetic devices, flap surgery, dental implant placement, and surgical removal of the impacted tooth, reimplantation of teeth, endodontic instrumentation or surgery beyond the tooth apex. In this present survey, 71.82% of dentists were found to be prescribing antibiotics prophylaxis for these conditions.

And also, 53.64% of participants were not prescribed antibiotic prophylaxis for the shedding of deciduous teeth, bleeding from trauma to the lips. In this survey, dental practitioners (51.82%) were found to be prescribing antibiotic prophylaxis as per the guidelines of (AHA) for following cardiac conditions like infective endocarditis and compromised immunity, patients with shunts, indwelling vascular catheters & medical devices and prosthetic joints indicated in risk patients in the context of any invasive procedure within the oral cavity ¹⁹. For the oral mucosal conditions like leukoplakia, Fordyce granules, hairy leukoplakia, denture-induced hyperplasia, lichen planus most of the dental practitioners had prescribed systemic antimicrobial drugs.

But conditions mentioned above are not recommended for antimicrobial therapy ²⁶. In this survey viral infection in the Oro-facial region, most of the dental practitioners were prescribed Acyclovir as the drug of choice. For fungal infections, most dental practitioners commonly prescribed fluconazole as the drug of choice, and they calculated the drug dosage based on age and weight of the patients ²⁵. For managing severe and recurrent orofacial infections, most dental practitioners preferred the antibiotic culture sensitivity test ⁹. Based on this cross-sectional survey, the overall knowledge of antimicrobial prescription and antimicrobial resistance among dental practitioners was comparatively lower than previous studies 2, 9. The antimicrobials were prescribed indiscriminately, inappropriately, and injudiciously to manage the oral diseases. Since dental diseases are predominantly due to local factors, the mere removal of the local causative factors reduces the need for prescribing antimicrobials considerably. It is, therefore, suggested that antimicrobials should be used as an adjunct and not a replacement for definite treatment. In the absence of signs and symptoms of infections, dental practitioners should abstain from prescribing antimicrobials for relieving pain. It is required to analyze the condition before prescribing antimicrobials to the patients.

CONCLUSION: At the level of dental practitioners should promote the antimicrobial prescription only when needed and also select the right drug, dose and duration while prescribing and testing to confirm when in doubt is recommended. In India, dentists are facing some of the challenges to conflict with the issue of antimicrobial resistance are the lack of surveillance systems and operating guidelines for antimicrobial prescription, over the counter sale of antimicrobials and lack of public awareness.

To overcome this growing global problem, this study strongly recommended that separate guidelines for antimicrobial prescriptions, CDE programs, and emphasis on dental pharmacology in the curriculum address the issue of antimicrobial resistance.

Funding Source: No funding source

Ethical Approval: Approved (IEC No: 20191207)

ACKNOWLEDGEMENTS: Nil

The manuscript has been read and approved by all the authors, and the requirements for authorship as stated earlier in this document have been met, and that each author believes that the manuscript represents honest work.

CONFLICTS OF INTEREST: Nil

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    How to cite this article:

    Rajkumar C, Iyapparaja P, Madankumar PD and Gadde S: Knowledge of antimicrobial resistance and antimicrobial prescription among dental practitioners in Chennai City- a cross sectional study. Int J Pharm Sci & Res 2021; 12(4): 1755-64. doi: 10.13040/IJPSR.0975-8232.12(4).1755-64.

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