Study of ntibiotic prescribing mong dentl prctitioners in Shirz, Islmic Republic of Irn G. Vessl, 1 A. Khbiri, 2 H. Mirkhni, 3 B.D. Cookson 4 nd M. Askrin 2 دراسة حول وصف املضادات احليوية بني أطباء األسنان يف شرياز يف مجهورية إيران اإلسالمية غزال وصال أتوسا خبريي حسني مري خاين بري كوكسون مهرداد عسكريان اخلالصة: يثري الوصف غري املناسب للمضادات احليوية من ق ب ل العاملني يف الرعاية الصحية قلقا عامليا. وتقي م هذه الدراسة املعارف واملامرسات لدى أطباء األسنان يف مدينة شرياز يف مجهورية إيران اإلسالمية من حيث استخدامهم العالجي للمضادات احليوية يف املرىض املصابني بالعدوى يف أسناخ األسنان. فمن بني )%48.6( 219 من أطباء األسنان الذين أجابوا عىل االستبيان و ص ف أكثر من %40 منهم املضادات احليوية للتور م املوضعي املتموج وملشاكل ال تستدعي املعاجلة باملضادات احليوية وفقا للدالئل اإلرشادية للمامرسات اجليدة )مثل: التهاب اللب احلاد والعدوى املزمنة يف ذروة السن وخ راج دواعم السن والتهاب اللثة املزمن والتهاب دواعم السن املزمن والتهاب حوائط التاج والسنخ اجلاف(. ووصفت الغالبية من أطباء األسنان املضادات احليوية عىل نحو صحيح ملعاجلة العدوى احلادة يف حوائط الذروة )%77.2( والتهاب اله ل ل )%75.3( والتهاب اللثة احلاد املتقرح )%63.0(. وكان األموكسيسلني هو أكثر املضادات احليوية املوصوفة يف مجيع احلاالت الرسيرية ولكن تباينت جرعة مجيع املضادات احليوية وتكرارها ومدة استخدامها عىل نحو كبري. وتدل هذه الدراسة عىل احلاجة إىل دالئل إرشادية ألطباء األسنان حول االستخدام الرشيد للمضادات احليوية يف مجهورية إيران اإلسالمية. ABSTRACT Inpproprite prescribing of ntibiotics by helth cre professionls is worldwide concern. This study evluted the knowledge nd prctices of dentl prctitioners in the city of Shirz, Islmic Republic of Irn regrding their therpeutic use of ntibiotics for ptients with dentolveolr infections. Of 219 (48.6%) dentists responding to the questionnire more thn 40% would prescribe ntibiotics for loclized fluctunt swelling nd for problems for which ntibiotics re not required ccording to good prctice guidelines (cute pulpitis, chronic picl infection, periodontl bscess, chronic gingivitis, chronic periodontitis, pericoronitis nd dry socket). A mjority correctly prescribed ntibiotics for cute peripicl infection (77.2%), cellulitis (75.3%) nd cute ulcerted gingivitis (63.0%). Amoxicillin ws the most frequently prescribed ntibiotic for ll clinicl conditions but there ws wide vrition in dosge, frequency nd durtion for ll ntibiotics used. Guidelines on rtionl ntibiotic use re needed for dentl prctitioners in the Islmic Republic of Irn. Étude de l prescription d ntibiotiques pr des dentistes à Chirz (République islmique d Irn) RÉSUMÉ L prescription indptée d ntibiotiques pr les professionnels de l snté est un sujet de préoccuption mondil. L présente étude évlué les connissnces et les prtiques de dentistes dns l ville de Chirz (République islmique d Irn) concernnt leur utilistion thérpeutique des ntibiotiques pour les ptients tteints d infections dento-lvéolires. Sur 219 dentistes (48,6 %) ynt répondu u questionnire, plus de 40 % prescririent des ntibiotiques pour un œdème fluctunt loclisé et d utres problèmes pour lesquels les ntibiotiques ne sont ps nécessires selon les directives sur les bonnes prtiques (pulpite iguë, pthologie picle chronique, bcès périodontl, gingivite chronique, périodontite chronique, péricoronrite et lvéolite sèche). L mjorité d entre eux prescrivent à bon escient des ntibiotiques pour une infection péripicle iguë (77,2 %), un phlegmon (75,3 %) et une gingivite ulcéreuse iguë (63,0 %). L moxicilline est l ntibiotique le plus fréquemment prescrit pour toutes les ffections cliniques. En revnche, l posologie, l fréquence et l durée de l ensemble des tritements ntibiotiques vrient considérblement. Des directives sur l utilistion rtionnelle des ntibiotiques sont nécessires pour les dentistes en République islmique d Irn. 1 Deprtment of Clinicl Phrmcy, Fculty of Phrmcy; 2 Deprtment of Community Medicine; 3 Deprtment of Phrmcology, Shirz University of Medicl Sciences, Shirz, Islmic Republic of Irn (Correspondence to M. Askrin: mehrddskrin@gmil.com). 4 Lbortory of Helth Cre Associted Infection, Helth Protection Agency, London, United Kingdom. Received: 06/11/09; ccepted: 18/03/10 763
EMHJ Vol. 17 No. 10 2011 Estern Mediterrnen Helth Journl L Revue de Snté de l Méditerrnée orientle Introduction Dentl prctitioners regulrly prescribe ntibiotics for therpeutic or prophylctic purposes to mnge orl nd dentl infections. However, inpproprite prescribing nd excessive use of ntibiotics hve been identified s mjor fctors in the emergence of ntibiotic resistnce, which is n ongoing chllenge ever since the discovery of ntimicrobil gents [1]. There re other issues too, such s possible dverse events nd dditionl costs of prescribing. Consequently, surveillnce of ntimicrobil resistnce, monitoring of ntibiotic usge nd ttempts to improve prescribing ttitudes hve become crucil [2]. In 1997 more thn 3.5 million prescriptions for ntibiotics were dispensed by generl dentl prctitioners in Englnd t net ingredient cost of 5.2 million. Antibiotic prescribing by dentists my therefore ply mjor role in the emergence of resistnt bcteril strins, prticulrly when there is evidence of misuse [3]. Currently there re no specific guidelines in Islmic Republic of Irn for prophylctic or therpeutic prescribing of ntibiotics in dentistry. In ddition, there re no dt describing the indictions for which ntibiotics re prescribed, whether these hve ny scientific bsis, or whether the ntibiotic gents, their dose, frequency nd durtion, re bsed on published guidelines or stndrds. We therefore conducted this study to evlute the knowledge nd ttitude of dentl prctitioners in the city of Shirz (the cpitl of Frs province) regrding their therpeutic use of ntibiotics for ptients with dentolveolr infections. Methods Smple We estimted the smple size of 197 using d = 0.3, stndrd devition = 1.5, α = 0.05 nd β = 0.2. We miled questionnires to ll dentists in the study re (n = 450), which ccording to our previous studies would enble us to rech the clculted smple size. Questionnire The questionnire ws modifiction of tht described by Plmer et l. [3] nd imed to investigte the knowledge of dentl prctitioners bout therpeutic prescribing of ntibiotics. To ensure its vlidity the questionnire ws piloted nd discussed with 12 dentl specilists from ech deprtment of the School of Dentistry in Shirz. In order to evlute the relibility of the questionnire, n extended pilot study ws performed on 50 dentl prctitioners. The Kuder Richrdson coefficient of relibility ws high (r = 0.86). Thus no chnges were mde to the questionnire. The questionnires were miled out to the selected dentl prctitioners in the city of Shirz over 3-week period in 2006, nd collected 1 week lter from their offices. It recorded the ge, sex, prctitioners finl degree (generl or specilist), when nd where it ws obtined, whether the prctitioner ws ffilited to the university nd ny prticiption in the lst 2 yers in continuing eduction progrmmes relted to the rtionl use of ntibiotics. Respondents nswered nonymously nd were requested to void use of ny reference mterils while nswering the questionnire. The questionnire lso explored the number of ptients treted per week nd for which clinicl signs the prctitioner would prescribe ntibiotics for ptients presenting with dentl infection. The clinicl signs chosen were: elevted temperture nd evidence of systemic spred; loclized fluctunt swelling; gross or diffuse swelling; restricted mouth opening; difficulty in swllowing; nd closure of the eye due to swelling. We lso explored whether ptients expecttions of n ntibiotic prescription would be reson for prescribing ntibiotics. Another prt of the questionnire investigted the use of ntibiotics for common clinicl conditions. If positive response ws given, the prctitioners were sked to stte the ntibiotic they would prescribe, its dose, intervl nd durtion, for ptients who were not llergic to penicillin. The prctitioner ws lso sked wht ntibiotic s/he would choose if the ptient ws llergic to penicillin. The clinicl conditions were cute pulpitis, cute peripicl infection, chronic picl infection, periodontl bscess, cute ulcertive gingivitis, chronic gingivitis, chronic periodontitis, pericoronitis, dry socket, nd cellulitis. In reviewing the literture, systemtic serch for literture published in English vilble vi MEDLINE for the yers 1996 through December 2007 ws conducted. The serch terms included: ntibiotic tretment nd dentistry. Identified rticles were used to select dditionl key terms for further serches. Other relevnt rticles were identified from the bibliogrphies of these ppers. A serch ws lso conducted of the US Centers for Disese Control nd Prevention nd World Helth Orgniztion published documents, which focused on ntibiotic tretment nd dentistry. We lso serched severl leding textbooks on this subject. Dt nlysis A knowledge score ws constructed for ech question sked regrding signs in which the prctitioner would prescribe ntibiotics. Ech of these 6 questions were grded s 0 (if incorrect) versus 1 (if correct). For questions regrding use of ntibiotics in common clinicl conditions, knowledge of respondents ws evluted bsed on evidence-bsed guidelines nd stndrds in selected published literture. Mens nd stndrd devitions (SD) were obtined for continuous vribles, nd compred using Student t-test. Ctegoricl vribles were reported s percentges nd compred using the chi-squred test. Non-prmetric 764
correltion ws used to determine the strength of the reltionship between demogrphic nd professionl fctors nd the knowledge score. The level of sttisticl significnce of ll tests ws 2-tiled P-vlue < 0.05. All nlyses were performed using SPSS, version 9. Results Bckground chrcteristics Of the 450 dentl prctitioners to whom the questionnires were sent, 219 (48.6%) completed the forms (64.4% mle, 35.6% femle). The mjority of the prctitioners grduted from Shirz Dentl School (66.2%). Only 5.9% of the prctitioners hd ttended continuing eduction progrmme on rtionl use of ntibiotics within the previous 2 yers. The demogrphic nd professionl chrcteristics of respondents re shown in Tble 1. Prescribing hbits Tble 2 shows the clinicl signs for which the prctitioners would prescribe ntibiotics. Over 80% would prescribe for ptients with elevted body temperture, gross or diffuse fcil swelling nd closure of the eye due to swelling. A minority of prctitioners (17.7%) would prescribe ntibiotics s result of ptient s demnd. Regrding ntibiotic prescriptions for clinicl signs, the men knowledge score ws 3.9 (rnge 0 6). There ws no sttisticl significnt difference in the men knowledge scores by sex, professionl qulifictions or hving ttended continuing eduction course (Tble 3). Prescribing for specific conditions The percentge of prctitioners prescribing for specific conditions re shown in Tble 4. The results showed tht the mjority of dentists would prescribe for cute peripicl infection (77.2%), cellulitis (75.3%) nd cute Tble 1 Demogrphic nd professionl chrcteristics of prticipting dentl prctitioners (n = 219) Vrible Sex ulcerted gingivitis (63.0%). The prctitioner s preferred choice of ntibiotics for specific conditions tht ctully need ntibiotic tretment, ssuming no llergy to penicillin, is shown in Tble 5. Amoxicillin ws the ntibiotic most frequently prescribed. The dose, frequency nd durtion of tretment with ech ntibiotic prescribed differed mong the prctitioners. Of the 126 prctitioners who would prescribe moxicillin for cute peripicl infection, the gret mjority (70.6%) chose 250 or 500 mg dose 3 dily for period of 6 10 dys. Few dentists (6.3%) chose the lower dose of 250 mg nd only 2.4% preferred shorter Vlue Mle 141 64.4 Femle 78 35.6 Degree Generl prctitioner 186 84.9 Specilist 33 15.1 Acdemic position Yes 14 6.5 No 205 93.5 Men (SD) Rnge Age (yers) 36.5 (7.8) 24 72 Durtion of prctice (yers) 9.6 (7.0) 0.5 37 No. of ptients/week 35.7 (27.5) 5 200 SD = stndrd devition. durtion of 2 3 dys. Some prctitioners (10.3%) even chose durtion of 4 weeks. Of those 37 prctitioners who prescribed penicillin V for cute peripicl infection, more thn 81.1% chose 250 or 500 mg dose 4 dily for 6 10 dys but only 8.1% chose the lower dose. For cute ulcertive gingivitis, more thn hlf of the 61 prctitioners who prescribed moxicillin (52.5%) chose 500 mg dose 3 dily for period of 6 10 dys; only 3.3% chose shorter durtion of 2 3 dys nd 16.4% even chose durtion of 4 weeks. Of 38 prctitioners who chose metronidzole to tret cute ulcertive gingivitis, 50.0% chose 250 Tble 2 Prescribing of ntibiotics by dentl prctitioners for selected clinicl signs nd ptient expecttions (n = 219) Clinicl sign Would prescribe Gross diffuse swelling 193 88.3 Elevted temperture nd evidence of systemic spred 185 84.4 Closure of the eye becuse of swelling 178 81.4 Difficulty in swllowing 103 46.9 Loclized fluctunt swelling 101 46.0 Restricted mouth opening 94 42.7 Ptient s expecttion for prescription 39 17.7 Clinicl signs tht tht need ntibiotic tretment. 765
EMHJ Vol. 17 No. 10 2011 Estern Mediterrnen Helth Journl L Revue de Snté de l Méditerrnée orientle Tble 3 Knowledge score by professionl nd demogrphic vribles for clinicl signs tht need ntibiotics Vrible No. Men (SD) score b Sex mg dose 3 dily for 6 10 dys, 34.2% incorrectly chose 4 dily intervl for this drug nd only bout 7.9% would tret for 2 3 dys. Prctitioners who chose tetrcycline for the tretment of this condition used vriety of different dosges, durtions nd intervls. For the tretment of cellulitis, mjority of the 85 prctitioners who prescribed moxicillin (64.7%) chose 500mg dose 3 dily for 6 10 dys nd 21.2% chose n even higher durtion of tretment (4 weeks). Most of the 21 prctitioners who chose penicillin V P-vlue Mle 139 3.9 (1.2) 0.76 Femle 77 3.9 (1.2) Degree Generl 180 3.9 (1.2) 0.53 Specilist 32 3.8 (1.4) Acdemic 14 3.9 (1.6) 0.98 Non-cdemic 203 3.9 (1.2) Continuing eduction course Yes 13 4.4 (1.1) 0.18 No 197 3.9 (1.2) Totl 219 3.9 (1.3) Attended continuing eduction progrmme on rtionl use of ntibiotics within the previous 2 yers. b Rnge: 0 6. SD = stndrd devition. to tret this condition chose 500 mg dose 4 dily for 7 10 dys (57.1%), while 19.0% preferred 4 weeks of tretment. A considerble proportion of the prctitioners surveyed preferred n injection of penicillin to tret this condition; however, there ws considerble disgreement regrding the dosge nd the number of injections. For ptients llergic to penicillin, erythromycin ws the most common ntibiotic prescribed by the respondents (70.0%), followed by clindmycin (15.7%) nd cephlexin (7.6%). Of Tble 4 Prescribing of ntibiotics by dentl prctitioners for selected dentl dignoses (n = 219) Dignosis Would prescribe Acute peripicl infection 169 77.2 Cellulitis 165 75.3 Pericoronitis 147 67.1 Acute ulcertive gingivitis 138 63.0 Periodontl bscess 134 61.2 Chronic picl infection 72 32.9 Acute pulpitis 55 25.1 Chronic periodontitis 45 20.5 Dry socket 45 20.5 Chronic gingivitis 30 13.7 Dignoses tht need ntibiotic tretment. those prctitioners who preferred erythromycin more thn hlf chose 400 mg dose 4 dily for 6 10 dys. Others incorrectly prescribed 3 dily dose, or longer durtion of tretment of up to 4 weeks. Discussion Within the lst few decdes ntimicrobil resistnce hs become worldwide problem nd constitutes mjor thret to public helth. The unsystemtic prescribing of ntibiotics by helth cre professionls is mjor fctor to be considered. Evidence of the inpproprite use of ntibiotics in dentistry hs incresed nd this could led to the problem of ntimicrobil resistnce [3 6]. This fct nd the increse in the number of ntibiotic prescriptions written by dentists ech yer [4] shows the importnce of exmining the role of dentists in prescribing ntibiotics in everydy prctice. The present study showed evidence of poor prescribing of ntibiotics by dentists in Shirz. The indictions for ntibiotics in cute dentolveolr infections hve been defined s: signs of spreding infection, ptient mlise, temperture elevtion nd lymphdenitis [3,4]. Generlly the survey showed tht dentl prctitioners re wre of these indictions nd mostly used ntibiotics wisely for cute infections. However, more thn 40% would prescribe ntibiotics for loclized fluctunt swelling. Therefore, considerble proportion of prctitioners prescribed ntibiotics for ll swellings where locl tretment would hve been sufficient. This ws similr finding to studies performed in Kuwit [6], nd Yemen [5], where 55% nd 68% of the prctitioners respectively prescribed ntibiotics for locl swelling. With men score of 3.9 out of mximum possible score of 6, we could sy tht our dentl prctitioners hd n intermedite knowledge regrding clinicl signs tht require ntibiotic tretment, score 766
Tble 5 Antibiotics preferred by dentl prctitioners for clinicl conditions tht need ntibiotic therpy Clinicl condition Acute peripicl infection (n = 169) similr to the Yemeni generl dentists (men score of 3.7) [5]. It is grtifying to note tht only minority of the respondents (17.7%) would prescribe ntibiotics for n unscientific reson such s ptients expecttions, which is irrtionl nd n buse of ntibiotic usge. This figure ws found to be only 4% for dentl prctitioners in Kuwit [6], nd 10% for the dentists in Englnd [3], but ws similr to dentl prctitioners prctising in Yemen (15%) [5]. The proportion of prctitioners who would routinely prescribe ntibiotics for specific conditions vried gret del mong the presenting diseses. More thn 70% of those surveyed would correctly prescribe ntibiotics for cellulitis nd cute peripicl infections, while only 63% would prescribe ntibiotics for cute ulcertive gingivitis, which is recommended s prt of the initil therpy [4]. The mjority of uncomplicted infected swellings of dentl origin cn be successfully treted by removing the source of infection by dringe of bscesses, removl of infected pulp contents or tooth extrction. Antibiotics re not effective in the mngement of Would prescribe Amoxicillin 126 74. 5 Penicillin V 37 21.9 Other b 6 3.5 Acute ulcertive gingivitis (n = 138) Amoxicillin 61 44.2 Metronidzole 38 27.5 Tetrcycline 18 13.0 Other c 21 15.2 Cellulitis (n = 165) Amoxicillin 85 51.5 Penicillin 40 24.2 Penicillin V 21 12.7 Other d 19 11.5 Number of dentists who would prescribe n ntibiotic for this condition. b Penicillin V + metronidzole, metronidzole, cephlexin; c Penicillin V, mpicillin, cephlexin, erythromycin, doxycycline; d Cephlexin, mpicillin, metronidzole, comoxiclv, gentmicin. pin ssocited with irreversible pulpitis [4,7]. However, 25.0% of our dentl prctitioners surveyed believed in the use of ntibiotics in ptients presenting with cute pulpitis. This ws similr to the study performed in Yemen nd Kuwit in which 32% nd 20% of dentists respectively would prescribe ntibiotics for this condition [5,6]. However, lower percentge (13%) of dentl prctitioners in Englnd prescribed ntibiotics for this cute pulpitis. Chronic picl infections rrely need ntibiotics unless there is evidence of gross locl spred; extrction or root cnl therpy re the definitive tretment options. In this survey bout one-third of the prctitioners would prescribe ntibiotics for chronic picl infections, similr to the studies in Kuwit nd Englnd [3,6]. However, our prctitioners knowledge in this regrd ws much higher thn the Yemeni dentl prctitioners in whom 72% would prescribe for chronic picl infections. Chronic dentolveolr infections rrely require ntibiotics, unless there is evidence of gross locl spred [4], nd the mjority of ptients with the commonly encountered forms of chronic periodontitis usully respond well to conventionl therpies [8]. Adjunctive ntibiotics should be prescribed only for very limited group of ptients e.g. those with specific clinicl fetures or ggressive forms of periodontl disese in order to prevent ntibiotic resistnce due to periodontl therpy [9]. Nevertheless bout 14% nd 20% respectively of our dentl prctitioners surveyed would prescribe ntibiotics routinely for chronic gingivitis nd chronic periodontitis. These results were similr to those obtined from dentl prctitioners in Kuwit [6]. Our dentl prctitioners were more knowledgeble in this regrd compred with the dentl prctitioners in Yemen, where 54% nd 66% respectively would routinely prescribe ntibiotics for these infections [5]. A lower percentge (3% nd 13% respectively) of dentl prctitioners in Englnd would prescribe ntibiotics in the bove conditions [3]. Pericoronitis, periodontl bscesses nd dry sockets re treted by locl mesures, nd ntibiotics re only indicted for lrge spreding infections or systemic involvement [4,10]. The use of systemic ntibiotics in the tretment of periodontl disese is controversil. It is cceptble not to use ntibiotics routinely for the tretment of dult periodontl disese. Mechnicl debridement methods, including dringe of pus for cute periodontl bscesses, should be considered the first-line tretment for most periodontl diseses. Systemic ntimicrobils should be considered s djuncts to such methods, nd never used lone in this chronic disese, s they cn predispose to bscess formtion. Adjunctive systemic ntimicrobils my be considered in cute disese where debridement or dringe of pus is difficult, or there is locl spred or systemic upset. There is lso evidence tht systemic ntibiotics cn be used in juvenile periodontitis [4,11]. Initil tretment of pericoronitis is usully imed t debridement of the 767
EMHJ Vol. 17 No. 10 2011 Estern Mediterrnen Helth Journl L Revue de Snté de l Méditerrnée orientle periodontl pocket by irrigtion or by mechnicl mens, disinfection of the pocket with n irrigtion solution such s hydrogen peroxide or chlorhexidine, nd surgicl mngement by extrction of the opposing mxillry third molr, nd occsionlly, of the offending mndibulr third molr. Severe cses of pericoronitis with systemic symptoms my wrrnt ntibiotic therpy [12]. Such exceptionl situtions were not covered in our questionnire, nd unfortuntely more thn 60% of our dentl prctitioners surveyed would prescribe ntibiotics routinely for periodontl bscess nd pericoronitis. In the study performed in Englnd nd Yemen more thn 80% of the prctitioners, would prescribe for these two conditions [3], while this percentge ws more thn 70% in Kuwit [6]. The percentge of our prctitioners prescribing ntibiotics for dry socket ws 20%, much lower compred with the studies performed in Kuwit, Yemen nd Englnd (> 50%) [3,5,6]. Amoxicillin ws the most frequently prescribed ntibiotic for cute dentolveolr infections requiring ntibiotics, which is similr to other studies [3,6,13]. This ws followed by penicillin V for cute peripicl infections, metronidzole for cute ulcertive gingivitis nd penicillin injection for cellulitis (Tble 3). The dt reveled tht the dentists surveyed prescribed wide spectrum of ntibiotics. The use of penicillin V is bsed on old studies tht hve isolted minly streptococci nd stphylococci from dentl bscesses, while more recent studies hve shown tht the min isoltes from dentl bscesses re complex mixtures of fculttive nd nerobic bcteri, some of which re penicillin resistnt [14,15]. Bsed on review of the evidence nd good prctice for prescribing therpeutic ntibiotics in dentistry [4], moxicillin 250 mg 3 dily for mximum of 5 dys nd metronidzole 200 mg 3 dily for 3 dys hve been recommended s first nd second choice tretments respectively. For ptients llergic to penicillin, erythromycin 250 mg 4 dily or 500 mg 2 dily up to 4 dys hve been recommended [4]. In greement with previous studies [13,16,17], there ws considerble vrition from the recommended frequencies, doses nd durtion of ntibiotic therpy. There is incresing evidence tht short courses of ntibiotics together with locl surgicl mesures re dequte for treting dentolveolr infections [4,18,19]. Prolonged courses of ntibiotics, which were recommended by most of the prctitioners in our survey for periods up to 10 dys, could be hrmful, due to the fct tht the dose nd durtion of therpy re key fctors in developing ntibiotic resistnce. The fct tht considerble number of our prctitioners surveyed chose durtion of tretment of up to 4 weeks is of gret concern. Acute orofcil infections hve rpid onset nd reltively short durtion of 2 to 7 dys, prticulrly if the offending cuse is treted nd/or eliminted [20]. If clinicl experience nd the nture of the infection demonstrte tht its predicted course my be 3 dys, then 3 dys of ntibiotic therpy is enough. When clinicl evidence indictes tht the infection is expected to resolve or is resolved, the ntibiotic therpy should be terminted [4,19,20]. Unfortuntely the optiml durtion of ntibiotic therpy for mny dentl infections hs never been defined by rndomized controlled trils. Current guidelines re bsed on expert opinion, which is considered to be the lowest level of evidence. There is n urgent need for rndomized controlled trils with the objective of providing scientific bsis for best prctice recommendtions. Until such dt exist, the ntibiotics should be pplied for short durtion. It is believed tht lrge doses of moxicillin (500 mg), which ws prescribed by mjority of our prctitioners, re not necessry in cute dentolveolr infections, s the bsorption of this ntibiotic in stndrd 250 mg mounts is good enough to be therpeuticlly effective [3,4]. The dose of metronidzole prescribed by our dentl prctitioners ws 250 mg (in contrst with the recommended dose of 200 mg [4]), due to the fct tht in the Islmic Republic of Irn the tblets re formulted t this higher dosge level. Our findings indicte tht the scientific bsis for prescribing ntimicrobil gents ws neglected by the mjority of the respondents. Most of those surveyed used ntibiotics routinely for conditions where locl tretment would be sufficient. This is not surprising s similr findings were reported mong other helth professionls in Islmic Republic of Irn [21 23], nd by dentl prctitioners in other countries [3,5,6]. It is cler tht our dentl prctitioners need expert dvice on when nd wht to prescribe, for how long nd in wht dosge. Qulittive reserch is required to see if we cn find out directly from prctitioners why this problem of inpproprite ntibiotic prescribing is so intrctble, s well s the prctitioners ttitude towrds chnging their prescribing behviour. Audit of clinicl ntibiotic prescribing in dentistry hs been reported to improve generl dentl prctitioners ttitudes to prescribing ntimicrobils, reducing the number of prescriptions following the introduction of guidelines [24,25]. It is importnt to inform the dentl community bout the ccepted current ntibiotic prescription guidelines nd the relted evidence-bsed clinicl prctice nd this pper dds to the evidence needed for designing ntionl guidelines for our dentl prctitioners. There is lso need to improve undergrdute eduction nd to increse postgrdute courses nd other eductionl ctivities on ntibiotic prescribing, especilly since there ws no difference in prescribing between those prctitioners who hd completed continuing eduction progrmme nd those who hd not. This study lends support to the hypothesis tht ntibiotics re being inppropritely 768
prescribed by the dentl profession in Islmic Republic of Irn. The response rte to the questionnire ws poor nd, s those who responded were likely to be more knowledgeble bout the issue, the ctul level of knowledge mong dentists in this re my be even lower. Introducing guidelines nd re-uditing fter few yers would be n importnt step in implementing rtionl ntibiotic use. Acknowledgements This study ws funded by the Deputy for Reserch t the Shirz University of Medicl Sciences References 1. 2. 3. 4. 5. 6. Weber JT, Courvlin P. An emptying quiver: ntimicrobil drugs nd resistnce. Emerging Infectious Diseses, 2005, 11:791 793. Al-Hroni M, Skug N. Incidence of ntibiotic prescribing in dentl prctice in Norwy nd its contribution to ntionl consumption. Journl of Antimicrobil Chemotherpy, 2007, 59:1161 1166. Plmer NAO et l. A study of therpeutic ntibiotic prescribing in Ntionl Helth Service generl dentl prctice in Englnd. British Dentl Journl, 2000, 188:554 558. Plmer NAO. Revisiting the role of dentists in prescribing ntibiotics. Dentl Updte, 2003, 30:570 574. Al-Hroni M, Skug N. Knowledge of prescribing ntimicrobils mong Yemeni generl dentists. Act Odontologic Scndinvic, 2006, 64:274 280. Slko NO et l. Pttern of ntibiotic prescription in the mngement of orl diseses mong dentists in Kuwit. Journl of Dentistry, 2004, 32:503 509. 7. Keenn JV et l. Antibiotic use for irreversible pulpitis. Cochrne Dtbse of Systemtic Reviews, 2005, CD004969. 8. Newmn MG, Tkei HH, Fermic AC, eds. Crrnz s clinicl periodontology, 9th ed. Phildelphi: Sunders, 2002 9. Wlter C. Weiger R. Antibiotics s the only therpy of untreted chronic periodontitis: criticl commentry. Journl of Clinicl Periodontology, 2006. 33:938 939. 10. Fculty of Dentl Surgery. Ntionl clinicl guidelines. London, Royl College of Surgeons of Englnd, 1997. 11. Addy M, Mrtin MV. Systemic ntimicrobils in the tretment of chronic periodontl disese: dilemm. Orl Diseses, 2003, 9(Suppl. 1):38 44. 12. Miloro M et l., eds. Peterson s principles of orl nd mxillofcil surgery, 2nd ed. Volume 1. London, BC Decker, 2002 13. Roy KM, Bgg J. Antibiotic prescribing by generl dentl prctitioners in the greter Glsgow Helth Bord, Scotlnd. British Dentl Journl, 2000, 188:674 676. 14. 15. 16. 17. Lewis MAO, McFrlne TW, McGown DA. A microbiologicl nd clinicl review of the cute dento-lveolr bscess. British Journl of Orl & Mxillofcil Surgery, 1990, 28:359 366. Lewis MA et l. Prevlence of penicillin resistnt bcteri in cute suppurtive orl infection. Journl of Antimicrobil Chemotherpy, 1995, 35:785 791. Thoms DW et l. Antibiotic prescription for cute dentl conditions in the primry cre setting. British Dentl Journl, 1996, 181:401 404. Plmer NAO, Mrtin MV. An investigtion of ntibiotic prescribing by generl dentl prctitioners: pilot study. Primry Dentl Cre, 1998, 5:11 14. 18. Slots J. Systemic ntibiotics in periodontics. Journl of Periodontology, 1996, 67:831 838. 19. 20. 21. Mrtin MV et l. Acute dentolveolr infections: n investigtion of the durtion of ntibiotic therpy. British Dentl Journl, 1997, 183:135 137. Sots J, Pllsch TJ. Dentists role in hlting ntimicrobil resistnce. Journl of Dentl Reserch, 1996, 75:1338 1341. Askrin M, Rez Morvveji A, Assdin O. Prescription of prophylctic ntibiotics for neurosurgicl procedures in teching hospitls in Irn. Americn Journl of Infection Control, 2007, 35:260 262. 22. Askrin M et l. Adherence to Americn Society of Helth- System Phrmcists surgicl ntibiotic prophylxis guidelines in Irn. Infection Control nd Hospitl Epidemiology, 2006, 27:876 878. 23. Askrin M, Morvveji AR, Etminn M. Prophylctic ntibiotic therpy in gynecologic-obstetric procedures: experience from three Irnin teching hospitls. Indin Journl of Medicl Sciences, 2006, 60:245 246. 24. Steed M, Gibson J. An udit of ntibiotic prescribing in generl dentl prctice. Primry Dentl Cre, 1997, 4:66 70. 25. Plmer NA, Dily YM, Mrtin MV. Cn udit improve ntibiotic prescribing in generl dentl prctice? British Dentl Journl, 2001, 191:293 295. 769