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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 67-72

The compliance of dentists toward prescribing prophylaxis antibiotic for special care patients at risk of having infective endocarditis


1 Department of Pharmacology and Toxicology, Pharmacy College, Umm Al-Qura University, Makkah, Saudi Arabia
2 Department of Preventive Dentistry, Faculty of Dentistry, Umm Al-Qura University, Makkah, Saudi Arabia
3 Department of Dentistry, King Faisal Hospital, Makkah, Saudi Arabia
4 Department of Diagnostic Oral Medicine, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
5 Department of Basic and Clinical Oral Sciences, Faculty of Dentistry, Umm Al-Qura University, Makkah, Saudi Arabia

Date of Submission07-Apr-2022
Date of Decision28-May-2022
Date of Acceptance07-Jul-2022
Date of Web Publication27-Jul-2022

Correspondence Address:
Dr. Hassan Abed
Department of Basic and Clinical Oral Sciences, Faculty of Dentistry, Umm Al-Qura University, Makkah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/KKUJHS.KKUJHS_19_22

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  Abstract 

Background: Prescribing antibiotics (Abs) as a prophylactic before dental procedures is recommended by the American Academy of Pediatric Dentistry (AAPD) in patients with cardiac diseases to prevent a potentially life-threatening infection of the cardiac valves or endocardium called “infective endocarditis (IE).” Aim: This study aimed to assess the compliance of dentists in Makkah city with the AAPD recommendations of prescribing prophylaxis Abs for special care pediatric patients at risk of having IE. Materials and Methods: This was an observational cross-sectional study among dentists who are working at the major hospitals in Makkah city, Saudi Arabia. Participants' perception regarding the prescription of prophylactic Abs was measured using validated and reliable questions. The reliability analysis was used with a model of alpha (Cronbach) to study the properties of measurement scales and the items that compose the scales and the average inter-item correlation. Results: One hundred and thirty-two dental practitioners were participated. Dental care providers would prescribe Abs with dental extraction (92.4%), periodontal surgery (89.4%), nonsurgical root canal treatment beyond apex (77.3%), supragingival scaling (67.4%), and retraction cord placement (46.2%). On the other hand, dental practitioners would not prescribe Abs for orthodontic appliance (87.9%), intraoral radiograph (87.1%), primary teeth shedding (81.8%), tooth preparation when taking an oral impression (76.5%), local anesthesia infiltration (68.2%), and restoration of Class II caries with matrix and wedge (56.8%). A significantly lower knowledge score was obtained by general dental practitioners when compared with consultant and specialists (P = 0.044). Consultants and specialists recorded significantly lower knowledge on the prescription of prophylaxis Abs for Class II caries with matrix and wedge (P < 0.001) when compared with general dental practitioners. Conclusions: Most dentists followed the AAPD recommendations of prophylactic Abs for children who have a high risk of developing IE. However, Class II dental restorations with matrix and wedge and placement of retraction cord have recorded more invalid responses. General dental practitioners had lower knowledge when compared with consultants and specialists when prescribing Abs for children who have a high risk of developing IE.

Keywords: Antibiotics, dental infection, infective endocarditis, special care dentistry


How to cite this article:
Maghrabi L, Algarni A, Abuljadayel J, Aljabri M, Aljohani K, Abed H. The compliance of dentists toward prescribing prophylaxis antibiotic for special care patients at risk of having infective endocarditis. King Khalid Univ J Health Sci 2022;7:67-72

How to cite this URL:
Maghrabi L, Algarni A, Abuljadayel J, Aljabri M, Aljohani K, Abed H. The compliance of dentists toward prescribing prophylaxis antibiotic for special care patients at risk of having infective endocarditis. King Khalid Univ J Health Sci [serial online] 2022 [cited 2022 Nov 28];7:67-72. Available from: https://www.kkujhs.org/text.asp?2022/7/1/67/352521


  Introduction Top


Antibiotics (Abs) are prescribed in dentistry for the treatment of oral and dental infection.[1] They also are used as a prophylactic agent to minimize the risk of systemic involvement caused by the spread of orofacial infection and control the periods of infection caused by oral flora introduced to distant sites in a host at risk.[2],[3] For example, Abs prescribed as a prophylactic in patients with high risk of cardiac disease, immunosuppression, and immunodeficiencies, who may not tolerate a simple infection.[4],[5] Infection in the compromised patients might lead to serious events; hence prophylactic Abs would be helpful to eliminate transient bacteremia and ultimately prevent further adverse effects.[6] It is worth mentioning that a definitive treatment by removing the source of infection is the proper method for managing oral infections to prevent claims of negligence of overusing Abs.[2] For example, dental extraction, surgical and nonsurgical root canal, and periodontal therapy are the most common options for the treatment of the infected tooth.[7]

However, prescribing Abs as a prophylactic before dental procedures are recommended by the American Heart Association (AHA) in some patients with cardiac diseases to prevent a potentially life-threatening infection of the cardiac valves or endocardium called “infective endocarditis (IE).[8] IE has high morbidity and mortality rates; hence, prevention is crucial.[9] Besides, the AHA also recommended the importance of maintaining good oral hygiene and minimizing oral diseases in a high-risk patient for having IE, and not only focusing on prescribing the Abs as a prophylactic alone.[10] This is because dental procedures develop less bacteremia when compared to other daily habits such as toothbrushing, chewing, and flossing.[8]

In fact, it has been reported that dental care providers are prescribing relatively more Abs than in the past.[11] This was justified by dentists' intention to prevent unpleasant complications associated with oral infection and to make their patients feel well. Abuse of Abs such as prescribing them for longer duration and inappropriate conditions by dental care providers have been reported.[12] This indeed led to the development of microbial resistance to a variety of Abs.[13]

The number of evidence-based studies supporting the efficacy of prescribing Abs as prophylaxis in the pediatric population have been limited until now. Most of the indications are based on consensus. Despite extensive research regarding the appropriate use of Abs and its resistance worldwide, the use and misuse of Abs by dentists in Makkah city among pediatric patients who have a high risk of developing IE have not been yet reported. Therefore, this study aimed to assess the compliance of dentists in Makkah city with the American Academy of Pediatric Dentistry (AAPD) recommendations of prescribing prophylaxis Abs for special care pediatric patients at risk of having IE.


  Materials and Methods Top


Ethical approval

This study was approved by the Institutional Review Board at Umm Al-Qura University, Makkah city, Saudi Arabia (reference number: LJBQ041020).

Study design and setting

This was an observational cross-sectional study based on data collection that has been collected through utilizing a standardized questionnaire. The questionnaire aimed to assess if the dentists are following the AAPD recommendations[4],[8] regarding Abs prescriptions for special care pediatric patients at risk of having IE. Eligible participants were invited through E-mail to fill in an online survey.

Inclusion and exclusion criteria

Qualified dental care providers who treat dental pediatric patients and work in any of the major four hospitals in Makkah city (i.e., Al-Noor specialist Hospital, Heraa General Hospital, King Faisal Hospital, and King Abdul-Aziz Hospital) were invited to fill in an online survey. For example, consultants, specialists, residents (i.e., master and Saudi board postgraduate dental students), and dental interns were included in the study. Undergraduate dental students were excluded from the study.

Measures

Demographic data were collected from the participants. Eligible participants were asked if they would prescribe Abs for the following domains: restoration of Class II caries with matrix and wedge, supragingival scaling, nonsurgical root canal treatment beyond apex, periodontal surgery, intraoral radiograph, tooth extraction, shedding of primary teeth, local anesthesia infiltration, placement of retraction cord, placement of orthodontic appliances, not bands, and tooth preparation when taking oral impressions.

Data analysis

A simple descriptive statistic was used to define the characteristics of the study variables through a form of counts and percentages for the categorical variables, while mean and standard deviations were used to present continuous variables. To establish a relationship between categorical variables, Chi-square test was used. While comparing more than two groups, a one-way analysis of variance, with Games-Howell as a post hoc test, was used. Each participant's knowledge regarding the prescription of Abs was measured by giving a score to each domain that he/she would prescribe Abs. For example, the valid and invalid answers were coded as score 1 and score 0, respectively. The correlation analysis was used with a model of alpha (Cronbach) to study the properties of measurement scales and the items that compose the scales and the average inter-item correlation. A simple additive method was used to calculate the total score and convert it to a 100-point scale. The data were visually presented using GraphPad Prism version 8 (GraphPad Software, Inc., San Diego, CA, USA). IBM SPSS version 23 (IBM Corp., Armonk, N. Y., USA) was used to analyze the study data. A conventional P < 0.05 was the criteria to reject the null hypothesis.


  Results Top


Participants' occupation and specialty characteristics

One hundred and thirty-two dental practitioners participated in this study, as shown in [Table 1]. From this number of respondents, more than half (53%) were interns, followed by general dentists (15.9%), residents (13.6%), specialists (9.8%), and consultants (7.6%). In terms of specialty, almost three out of every four participants (73.5%) were general practitioners, followed by maxillofacial specialists (7.6%), endodontics specialists (7.6%), orthodontists (3.8%), pedodontists (3%), prosthodontists (2.3%), periodontists (1.5%), and an oral surgery specialist (0.8%).
Table 1: Occupation and specialty of participants (n=132)

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Participants' knowledge on prescribing antibiotics

The participants' knowledge on prescribing prophylaxis Abs for dental treatment among pediatric patients who have a high risk of developing IE is exemplified in [Table 2]. Based on the responses, dental care providers prescribed Abs with dental extraction (92.4%), periodontal surgery (89.4%), nonsurgical root canal treatment beyond apex (77.3%), supragingival scaling (67.4), and retraction cord placement (46.2%). On the other hand, dental practitioners did not prescribe Abs among pediatric patients undergoing placement of orthodontic appliance but not bands (87.9%), intraoral radiograph (87.1%), primary teeth shedding (81.8%), tooth preparation when taking oral impression (76.5%), local anesthesia infiltration (68.2%), and restoration of Class II caries with matrix and wedge (56.8%). [Figure 1] illustrates the percentages of dental care providers who responded correctly on the prescription of prophylaxis Abs for dental treatment of pediatric patients who have a high risk of developing IE according to AAPD recommendations.
Figure 1: Percentages of dental care providers who responded correctly on prescription of prophylaxis antibiotics for dental treatment of pediatric patients who have a high risk of developing infective endocarditis

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Table 2: Participants' knowledge on prescribing prophylaxis antibiotics

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As provided in [Table 3], the Cronbach's alpha value of 0.716 revealed an acceptable internal consistency for the data set on prophylaxis prescription of Abs for dental treatment among pediatric patients who have a high risk of developing IE.
Table 3: Reliability of knowledge assessment on prescribing prophylaxis antibiotics

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Likewise, variation of knowledge scores among different groups of dental practitioners is determined in [Table 4]. A significantly lower knowledge score was obtained by general dentists when compared to other groups (P = 0.044) [Figure 2]. Mean knowledge scores of various dental practitioner groups on the prescription of prophylaxis Abs of pediatric patients who have a high risk of developing IE.
Table 4: Relationship between the type of occupation and knowledge assessment on prescribing prophylaxis antibiotics

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Figure 2: Mean knowledge scores of various dental practitioner groups on prescription of prophylaxis antibiotics of pediatric patients who have a high risk of developing infective endocarditis

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In terms of knowledge of prescription of prophylaxis Abs in selected scenarios, a significant difference was observed among several variables. For example, the consultant/specialist group recorded a significantly lower knowledge on the prescription of prophylaxis Abs among pediatric patients undergoing restoration of Class II caries with matrix and wedge (P < 0.001) as compared to other study groups. On the other hand, a significantly lower number of dental residents (i.e., master and Saudi board postgraduate dental students) correctly prescribed prophylaxis Abs (P = 0.020) in comparison to other groups. In contrast, the general dentist group had significantly lower knowledge score in terms of prescribing prophylaxis Abs for pediatric patients undergoing intraoral radiograph (P = 0.007) and shedding of primary teeth (P = 0.002).


  Discussion Top


This observational cross-sectional study aimed to assess the compliance of dentists in Makkah city with the AAPD recommendations of prescribing prophylaxis Abs for special care pediatric patients at risk of having IE. The knowledge of Middle East dentists of local and international parameters and awareness of the careful use regarding Abs are studied.[11],[14] Despite that, they are prone to prescribe Abs routinely to prevent postoperative infection which probably may not occur.[15] This will result in developing microbial resistance to a wide range of Abs.[13] A serious global health concern of Abs misuse and its resistance has been reported in children by the high number of prescriptions from dentists mainly for dental infections.[16],[17]

Like another previous study,[11] acceptable knowledge was observed in this study among the dentists who are working in Makkah city for different dental procedures. For example, a cross-sectional study aimed to scrutinize the knowledge and attitude of antimicrobial practices in Saudi Arabian dentistry found that knowledge and awareness regarding Abs use was 78% for students/interns, 80% for residents, and 95% for specialists/consultants.[11]

Moreover, in this study, different patterns were observed among the dentists for different situations, quite consistent with the 2020 AAPD scientific statement on the prevention of IE, which described prescribing prophylaxis Abs for all dental procedures that involve manipulation of gingival tissue or the periapical region of the teeth, or perforation of the oral mucosa.[8] For example, this study found that most of the participants have correctly prescribed Abs with dental extraction. Similarly, this study found that most participants would not prescribe Abs before the placement of orthodontic appliances, intraoral radiographs, and shedding of the primary teeth. These findings are indeed consistent with the recommendation of the AAPD, where Abs are not recommended before these procedures.[4] On the other hand, a lower frequency of correct responses was seen for placement of the retraction cord and restoration of class II caries with matrix and wedge; hence, more awareness regarding unnecessary Abs prescription before these procedures is needed. Therefore, there are differences in Abs prescriptions particularly as prophylactic medications by dentists in this study in various situations, as seen in other appraisals of assessing the dentists' knowledge of Abs prescription practices in other parts of the Kingdom of Saudi Arabia. For example, a cross-sectional study that aimed to assess dentists' knowledge and attitude regarding Abs use in dentistry found that 89% of the students/interns and 98% of the specialists/consultants had indiscriminate use of Abs.[11] Similarly, a national cross-sectional telephonic survey in Lebanon found that the mean knowledge score of the dentists was poor.[12] The differences in correct prophylactic prescription in various situations were attributable to better knowledge of the dentists and better compliance to evidence-based practice guidelines.

In addition, statistically significant differences were observed in this study among various variables, demonstrating the variability in the knowledge of the dentists. For example, a significantly lower knowledge score was obtained by the general dental practitioners when compared to specialists and consultants. The finding is consistent with the finding in the systematic review on the use and misuse of Abs in pediatric dentistry, which found pediatric dentists to have better knowledge when compared to general dental practitioners.[18] This is explained by the fact that general dental practitioners have low exposure to continuing dental education compared to specialists/consultants, interns, and residents, due to nearly nonexistent teaching and training opportunities enjoyed by the other groups.

Strengths and limitations

Four major hospitals in Makkah city were considered to recruit the participants. Thus, the recruited participants were expected to be representative. It would be reasonable to implement such a study only on pediatric dentists or pediatric dentistry residents; however, the number of pediatric dentistry-related practitioners was low in the four major hospitals. In addition, all the included participants are allowed to treat children in those hospitals when needed. Moreover, this study shows that almost 83% of the participants were general dental practitioners, who are the front liners, and assessment of their knowledge is crucial. General dental practitioners are responsible to treat children who show up in the emergency clinic before referring them to a pediatric dentistry specialist or seeking help from any other specialist in case there is no pediatric dentist in the hospital. Thus, the sample distribution reflects the real status in relation to the included hospitals.


  Conclusions Top


Most dentists followed the AAPD recommendations of prophylactic Abs for children who have a high risk of developing IE. However, class II dental restorations with matrix and wedge and placement of retraction cord have recorded more invalid responses. Besides, general dental practitioners had lower knowledge when compared with consultants and specialists when prescribing Abs for children who have a high risk of developing IE.

Clinical implications

Increasing prescription of prophylactic Abs by dental practitioners for special care pediatric patients who have a high risk of developing IE is an important aspect of dental practice. According to the NWational Center for Disease Control and Prevention, the prescription of Abs for outpatients is unnecessary, which approximately accounts for one-third of all prescriptions.[13] Patients' demand, convenience, and expectation of Abs prescription are the reasons for over-prescribing Abs. However, Abs prophylaxis is not risk-free, as it can result in fetal anaphylaxis reaction, gastrointestinal disturbances, and bacterial resistance.[13] Accordingly, dental care providers should avoid prescribing Abs routinely and should be updated with recent guidelines when prescribing Abs as prophylactic for special care pediatric patients who have a high risk of developing IE.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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