ORIGINAL Tanwir ARTICLE et al
Diagnosis and Prescribing Pattern of Antibiotics and Painkillers Among Dentists Farzeen Tanwira/Gaetano Marroneb/Amna Tariqc/Cecilia Stålsby Lundborgd Purpose: To examine the pattern of antibiotic and painkiller prescriptions per diagnosis by dentists. Materials and Methods: A cross-sectional study was conducted in Karachi, Pakistan. Dentists in the outpatient departments of the Dr. Isharat-ul-Ebad Khan Institute of Oral Health Sciences (DIKIOHS) filled out a form for each patient visiting during a two-week period. The form included: personal history of the patient, i.e. name, age, sex and education, patient’s complaint(s), medical history, dental history, full examination of the teeth and oral cavity, treatment need as far as different specialties are concerned, investigations, provisional diagnosis and treatment given. The WHO ATC system for drug classification was used. The number of prescriptions and defined daily doses (DDD) were recorded. Results: A total of 709 patient forms (355 for male patients and 354 for female patients) were collected and included in the analysis. Of these, 123 (17%) included antibiotics and 455 (64%) painkillers. Caries/pulpitis was the most common diagnosis (n = 222; 31% of cases), of which 48 (21%) were prescribed antibiotics. Amoxicillin and metronidazole were the most common antibiotics prescribed for this diagnosis (n = 25); for caries/pulpitis diagnosis, 44 DDD/100 patients were prescribed. This was also the diagnosis for which painkiller prescription was most common (n = 191; 86%), with 102 DDD/100 patients. Conclusion: Our study shows the prescription pattern of antibiotics and painkillers by dentists in Pakistan for the first time. There is a clear need to emphasise correct diagnostic methods and develop contextualised prescription guidelines and educational initiatives, so that the optimum effect of antibiotics and painkillers will be achieved without compromising patients’ health. Keywords: antibiotics, DDD, dentists, diagnosis, painkillers, prescription Oral Health Prev Dent 2015;13:75-83 doi: 10.3290/j.ohpd.a32341
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esistance to antibacterials is increasing globally and antibiotic use, whether rational or irrational, contributes to this (Cars et al, 2008; English and Gaur 2010; Tanwir and Khiyani 2011). We are facing not only epidemics but pandemics of antibiotic re-
a
Associate Professor and Head, Department of Periodontology, Ziauddin College of Dentistry, Ziauddin University, Karachi, Pakistan; Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
b
Statistician, Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
c
Lecturer, Department of Periodontology, Ziauddin College of Dentistry, Ziauddin University, Karachi, Pakistan.
d
Professor, Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
Correspondence: Dr. Farzeen Tanwir, Department of Periodontology, Ziauddin University, 4/B, Shahrah-e-Ghalib, Clifton, Karachi-75600, Pakistan. Tel:+92-21-3586-2937-9 Ext: 475, Fax: +92-3586-2940. Email:
[email protected] or Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A , Solna Campus, SE-171 77, Stockholm, Sweden. Tel: +46524-833-66, Fax: +46-311-590. Email:
[email protected]
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Submitted for publication: 13.05.12; accepted for publication: 18.04.13
sistance (Cars et al, 2008). Extensive measures need to be taken worldwide as well as in individual countries to curb this trend (Mevius et al, 1999; Lundborg et al, 2002; Dar-Odeh et al, 2010; English and Gaur 2010). One way is to develop clinical practice guidelines and contextualised educational material (Mevius et al, 1999; Lundborg et al, 2002; Dar-Odeh et al, 2010; English and Gaur 2010). To this end, it is necessary to have information about current prescribing practices among the target group (Demirbas et al, 2006; Dar-Odeh et al, 2010). Although such information is available for doctors, very little has been published world-wide for dentists, despite the fact that dentists are quite frequent prescribers of antibiotics (Demirbas et al, 2006; Tanwir and Khan, 2011). Dentists traditionally encounter patients with a variety of infectious diseases. Treatment of infections such as caries and periodontal diseases are best managed by operative intervention and oral hygiene measures.
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Table 1 Main topics included in the diagnosis prescribing form Patient information • Name, age, sex, patient number, address, telephone number and presenting complaint • Medical history • Taking any medication (drugs), allergy to drugs, smoking, betel nut chewing • Heart problems (yes/no), bleeding disorder (yes/no), diabetes (yes/no), HIV/aids (yes/no), pregnancy (yes/no), if yes, which trimester Dental History • Oral abscess, oral ulcer, bleeding gums, food impaction, sensitivity, halitosis, special concerns regarding dental treatment (time, money and fear) • Oral examination: dentition status • Table with codes* • Treatment need according to various dental departments** Treatment record • Investigations (blood tests, radiography), diagnosis, dental procedure, medications, referral * D = caries, M = missing, F = filling, T = traumatised tooth, S = mobile tooth, C = crowned tooth.; ** Operative dentistry, oral surgery, periodontology, prosthodontics and orthodontics.
However, the prescription of antibiotics is also common (Demirbas et al, 2006; Dar-Odeh et al, 2010). For example, in the US, dentists account for 7% of antimicrobials prescribed (Anderson et al, 2000), and national prescription data from Wales shows that antibiotics accounted for 7% of drugs prescribed by dentists (Anderson et al, 2000). In the dental community, there has also been a trend towards the use of prophylactic antibiotics as a cautionary measure (Epstein et al, 2000; Palmer et al, 2000; Dar-Odeh et al, 2010). Antibiotic prescription is almost invariably combined with the prescription of non-steroidal anti-inflammatory drugs (NSAIDs) (Poveda Roda et al, 2007). A study from Pakistan shows that 91% of antimicrobial agents used in Karachi were taken on the advice of a physician or surgeon and only 9% as self-medication (Sturm et al, 1997). In 1999, the Federation Dentaire International (World Dental Federation) commission issued guidelines for appropriate use of antimicrobial agents (Samaranayake and Johnson 1999; Al-Haroni and Skaug 2006), which may lead to a change in prescribing practices that could reduce development of antibiotic resistance (Samaranayake and Johnson 1999; Larrabee, 2002; Siddiqi et al, 2002; Al-Haroni and Skaug 2006; Dar-Odeh et al, 2010). Our recently published paper in Pakistan shows an increase in antibiotic prescription by dentists of Pakistan over the years and also that antibiotic prescription habits vary in different cities of Pakistan (Tanwir and Khan, 2011). However, in general, very little information is available from Pakistan on prescribing (Zafar et al, 2008), and so far, no study has been published on dentists’ prescribing related to individual diagnosis in Pakistan.
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Hence, this study was conducted to investigate the pattern of antibiotic and painkiller prescriptions per diagnosis among the dentists of Dow University of Health Sciences (DUHS), Karachi, as an example of Pakistani dentists.
MATERIALS AND METHODS This cross-sectional study was conducted in Karachi, Pakistan, at Dr. Isharat-ul-Ebad Khan Institute of Oral Health Sciences (DIKIOHS), part of Dow University Health Sciences (DUHS). The dental hospital opened in 2006, is affiliated with an academic institution and as of 2011 has provided dental treatment to more than 30,000 patients free of charge. It is a public-sector hospital run by a grant from the government for the treatment of poor patients.
Data collection instrument and analysis The study was approved by the Ethics Review Board of Ishratul Ibad Khan Institute of Dow University of Health Sciences. The diagnostic form used by the dentists in the oral medicine/diagnosis department at the outpatient department (OPD) of DUHS was used for this study. The form included the personal history of the patient, including name, age, sex and education and the presenting complaint of the patient. It also included medical history, dental history, full examination of the teeth and oral cavity, treatment need as far as different specialties are concerned, and lastly investigations, provisional diagnosis and treatment given (Table 1).
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Table 2 Reported dental diagnosis according to age and sex among 709 patients attending the public hospital of Dow University of Health Sciences, Karachi, Pakistan Reported diagnosis
Abscess/ Infection
Caries/pulpitis
Calculus/plaque/stains/ sensitivity/gingivitis/ periodontitis
BDR*/impaction
Mobility
Missing teeth
Calculus and caries
Caries and missing teeth
Caries and mobility
Others
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Age categories (years) 2–6 7–18 19–30 31–60 >60 Total 2–6 7–18 19–30 31–60 >60 Total 2–6 7–18 19–30 31–60 >60 Total 2–6 7–18 19–30 31–60 >60 Total 2–6 7–18 19–30 31–60 >60 Total 2–6 7–18 19–30 31–60 >60 Total 2–6 7–18 19–30 31–60 >60 Total 2–6 7–18 19–30 31–60 >60 Total 2–6 7–18 19–30 31–60 >60 Total 2–6 7–18 19–30 31–60 >60 Total
Total (n = 709)
0 2 0 7 1 10 13 56 73 70 10 222 2 13 71 71 3 160 1 8 21 22 9 61 0 1 3 26 12 42 0 0 1 6 1 8 0 9 68 90 5 172 0 0 1 3 2 6 0 0 1 1 1 3 0 6 10 8 1 25 *BDR: broken-down root.
Male (n = 355)
Female (n = 354)
0 2 0 6 1 9 9 29 30 26 7 101 1 10 34 35 2 82 0 5 9 12 6 32 0 1 3 13 7 24 0 0 1 3 1 5 0 8 33 43 4 88 0 0 1 2 1 4 0 0 0 1 1 2 0 1 2 4 1 8
0 0 0 1 0 1 4 27 43 44 3 121 1 3 37 36 1 78 1 3 12 10 3 29 0 0 0 13 5 18 0 0 0 3 0 3 0 1 35 47 1 84 0 0 0 1 1 2 0 0 1 0 0 1 0 5 8 4 0 17
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Table 3 Prescription of antibiotics for 709 patients attending the public hospital of Dow University of Health Sciences in Karachi, Pakistan
Reported diagnosis
Total no. of cases n (%)
Number of patients treated with antibiotics n (%)
Abscess and infection
10 (1.4)
7 (70)
6
1
0
Caries/pulpitis
222 (31.3)
48 (21.6)
25
14
Calculus/ plaque/stains/ sensitivity/ gingivitis/ periodontitis
160 (22.6)
9 (5.6)
5
BDR*/ impaction
61 (8.6)
18 (29.5)
Mobility
42 (5.9)
3 (7.1)
Missing teeth
8 (1.1)
0 (0)
Calculus and caries
172 (24.3)
Caries and missing teeth
Amoxicillin with Amoxicillin clavulanic and metro- Amoxicillin acid Cefadroxil nidazole J01CA04 J01CR02 J01DB05 n n n n
Clindamycin J01FF01 n
Ampicillin combination J01CA51 n
Total DDD/100 patients/ diagnosis
0
0
0
8.32
9
0
0
0
44.34
1
2
0
1
0
9.05
16
1
1
0
0
0
21.28
2
0
0
1
0
0
2.89
33 (19.2)
23
6
4
0
0
0
36.25
6 (0.8)
1 (16.7)
1
0
0
0
0
0
1.27
Caries and mobility
3 (0.4)
0 (0)
Others
25 (3.5)
4 (16)
2
1
0
0
0
1
3.38
Total
709 (100)
123 (17.3)
80
24
16
1
1
1
97.14
Each antibiotic prescribed per dental diagnosis and DDD/100 patients/diagnosis.
The data were collected for two weeks in 2009 from five OPD/DIKIOHS departments: operative dentistry, periodontology, surgery, prosthodontics and orthodontics. The patient forms were collected at the end of the day and photocopied for the purpose of this study. The data were entered and analysed using SPSS software version 18.0, (SPSS; Chicago, IL, USA). Descriptive statistics for all the principal variables were calculated. Age in years was categorised as follows: 2–6, 7–18, 19–30, 31–60 and > 60. The first two categories were chosen according to the eruption pattern of teeth, i.e. in the age group of 2–6 years only deciduous teeth are present, while in the 7–18 age group all permanent teeth have erupted. Frequencies and percentages were used for the categorical variables. A multivariable logistic re-
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gression model was created for the binary outcome ‘antibiotic prescription’ (no = 0, yes = 1). The independent variables tested in the model were (i) age group (see above), (ii) gender and (iii) diagnosis (abscess/infection, broken-down root (BDR)/impaction, calculus/plaque/stains/sensitivity/gingivits/ periodontitis and caries/pulpitis). All nine different types of diagnoses included in the form were tested in the model and the four mentioned above were found to be significant. Because of the small sample size of the first age group, we decided to pool the first two age categories in the logistic model. Covariates found significant in bivariate analysis (chi-square test) at a level of P < 0.20 were included in the model and removed if not significant, except for gender, which was kept in the model in order to adjust for its effect (Wald test was performed
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Table 4 Prescription of painkillers for 709 patients attending the public hospital of Dow University of Health Sciences in Karachi, Pakistan
Reported diagnosis
Number of Naproxen Paraceta- FlurbiproTotal Total no. patients treated Ibuprofen sodium Diclofenac mol fen DDD/100 of cases with painkillers M01AE01 M01AE02 M01AB05 N02BE01 M01AE09 patients/ n (%) n (%) n n n n n diagnosis
Abscess and infection
10 (1.4)
8 (80.0)
3
4
0
0
1
6.06
Caries/pulpitis
222 (31.3)
191 (86.0)
105
40
14
18
14
102.94
Calculus/plaque/ stains/sensitivity/ gingivitis/periodontitis
160 (22.6)
32 (20.0)
11
13
2
2
4
21.21
BDR*/ impaction
61 (8.6)
59 (96.7)
15
24
8
7
5
45.44
Mobility
42 (5.9)
37 (88.1)
15
4
9
2
7
29.26
Missing teeth
8 (1.1)
3 (37.5)
1
1
1
0
0
1.72
Calculus and caries
172 (24.3)
107 (62.2)
52
26
14
6
9
72.47
Caries and missing teeth
6 (0.8)
3 (50)
2
1
0
0
0
1.59
Caries and mobility
3 (0.4)
3 (100)
0
2
1
0
0
2.92
Others
25 (3.5)
12 (48)
4
4
1
1
2
9.32
Total
709 (100)
455 (64.2)
208
119
50
36
42
292.93
* BDR: broken-down root. Each painkiller prescribed per dental diagnosis and DDD/100 patients/ diagnosis.
for the significance of the regression parameters). Odd ratios (OR) and their 95% confidence intervals (CI) were also computed. A value of P < 0.05 was considered statistically significant in the final models. The test of significance was two-sided.
RESULTS A total of 709 patient forms were collected and included in the analysis. Of the patients, 355 (50.1%) were males and 354 (49.9%) were females. The age group for which the highest number of forms was collected was 30–60 years (n = 304; 42.9%). The nine most common reported diagnoses are presented separately, while less frequent diagnoses were categorised together as ‘others’ (Table 2). The highest number of visits was made for a reported combined caries/pulpitis diagnosis
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(n = 222) followed by periodontal diagnosis including calculus/plaque/stains/sensitivity, gingivitis, periodontitis (n = 160). The diagnosis of calculus and caries was made for 172 patients (Table 2). Of the patients with a caries/pulpitis diagnosis, 48 (22%) were prescribed antibiotics. Amoxicillin and metronidazole were the most commonly prescribed antibiotic for this diagnosis (n = 25) (Table 3). The total number of DDD/100 patients for the caries/ pulpitis diagnosis was 44.3. The total number of patients treated with antibiotics was 123 (17.3%) (Table 3) and 455 (64.2%) were treated with painkillers (Table 4). The diagnosis for which painkiller prescription was highest was caries/pulpitis (n = 191; 86%) followed by calculus and caries (n = 107; 62.2%) (Table 4). The highest number of prescriptions for antibiotics (n = 99; 19.6%) and painkillers (n = 368; 72.7%) was by the Operative Dentistry department (Ta-
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Table 5 Prescription of antibiotics, painkillers and both by the five dental departments for 709 patients attending the public hospital of Dow University of Health Sciences, Karachi, Pakistan Total number of patients treated with painkillers n (%)
Total number of patients treated with both antibiotics and painkillers n (%)
Department
Total Number of patients (n)
Total number of patients treated with antibiotics n (%)
Operative dentistry
506
99 (19.6)
368 (72.7)
97 (19.2)
Periodontology
466
75 (16.1)
262 (56.2)
73 (15.7)
Oral surgery
186
35 (18.8)
160 (86.0)
35 (18.8)
Prosthetics
189
27 (14.3)
147 (77.8)
25 (13.2)
Orthodontics
13
0 (0)
7 (53.8)
0 (0)
Table 6 Simple logistic regression: age groups, sex and diagnosis associated with antibiotic prescriptions (with or without pain killers) Independent variables
Odds ratio
[95% CI]
P-value
2–18 years
ref
ref
ref
18–30 years
2.387
[1.245, 4.579]
0.009
30–60 years
1.495
[0.773, 2.893]
0.232
≥ 60 years
0.710
[0.230, 2.187]
0.551
M
0.846
[0.560, 1.278]
0.427
F
ref
ref
ref
Abscess/infection
15.049
[3.631, 62.371]
0.000
BDR/impaction
2.366
[1.225, 4.568]
0.010
Calculus/plaque/stains/sensitivity /gingivitis/periodontitis
0.285
[0.134, 0.607]
0.001
Caries/pulpitis
1.566
[0.963, 2.545]
0.70
ble 5). The same pattern of prescribing was seen for all patients treated with both antibiotics and painkillers, with the operative department having the highest prescription rate (n = 97; 19.2%) and prosthodontics having the lowest (n = 25; 13.2%). No prescribing was done by the orthodontics department (Table 5). Out of 709 patients, 75 chewed betel nuts; of these, 11 (15%) were treated with antibiotics and 48 (64%) were prescribed painkillers. Seventy-five out of 709 patients smoked or chewed tobacco; of these, 10 (13%) were treated with antibiotics and 51 (68%) were prescribed painkillers. Ten out of 75 patients who smoked or chewed tobacco and also chewed betel nuts were treated with both antibiotics and painkillers 10 (13%). The variables significantly associated with antibiotic prescription in the logistic regression are age and diagnosis, with patients in the age category
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18–30 years having more than double odds to be prescribed antibiotics (OR 2.4, 95% CI 1.2–4.6; P = 0.009) compared to the patients in the age group 2–18. Patients with abscesses are 15 times more likely (P < 0.001) than others to be prescribed an antibiotic. The results are adjusted by sex in Table 6.
DISCUSSION To the best of our knowledge, this is the first study describing diagnosis and prescription patterns of dentists in a low/middle-income country. Of the 709 patients in our study, caries/pulpitis was the most common diagnosis and the number of patients treated with antibiotics was also highest for this diagnosis (21.6%). In contrast, the most common diagnosis for which antibiotics were prescribed
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by dentists in Belgium was periapical abscess (51.9%) with antibiotics prescribed in 63.3%, followed by pulpitis with 4.4% (Mainjot et al, 2009). According to a study by Al-Haroni, 28% of antimicrobial usage has no rational basis, but is prescribed based on the demand of patients or their social background (15% and 25%, respectively). A majority of chronic or even acute dental infections can, however, be successfully treated by eliminating the source of infection (pulp extirpation, drainage of abscess, or tooth extraction) without the need for antibiotics; exceptions are when there is systemic involvement with gross, rapid and diffuse spread of infection (Al-Haroni and Skaug 2006; Murti and Morse 2007; Mainjot et al, 2009; Dar-Odeh et al, 2010). In our study, amoxicillin and metronidazole were the most commonly prescribed antibiotics, and most of the prescribing was for the combined diagnosis of caries and pulpitis followed by calculus and caries. These findings agree with those of other studies (Epstein et al, 2000; Jaunay et al, 2000; Al-Mubarak et al, 2004; Demirbas et al, 2006; Murti and Morse 2007). A study from the USA shows that antibiotics are by far the most frequently prescribed drugs in general dental practice, with tetracycline being the preferred drug against periodontal disease (Al-Mubarak et al, 2004; Demirbas et al, 2006). In Nepal, the most commonly prescribed systemic agents were analgesics (43.7%), followed by antimicrobials (39%), with the most frequently prescribed substances being ibuprofen and amoxicillin, respectively (Sarkar et al, 2004), the same as in our study. Our study showed that broad-spectrum drugs like amoxicillin were the most prescribed medication for multiple dental problems, similar to a Belgian study where 82% of all dental prescriptions were for amoxicillin and amoxicillin-clavulanic acid (Mainjot et al, 2009). In contrast, Norwegian dentists showed a more conservative practice by prescribing narrow-spectrum phenoxymethylpenicillin as their first-choice antimicrobial drug. The broader spectrum amoxicillin has been more frequently used because of an actual or perceived increase of oral bacterial resistance to narrow-spectrum penicillin (American Dental Association Council on Scientific Affairs 2004; Salako et al, 2004; Al-Haroni and Skaug 2006). In England, 56% of prescriptions of penicillins were for amoxicillin, whereas phenoxymethylpenicillin prescriptions made up only 8.2% (Palmer et al, 2000). Management of most dental infections is based on empirical antibiotic therapy
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(Poveda et al, 2007), i.e. the clinician does not have access to results from antibacterial resistance tests and prescribes broad-spectrum instead of narrow-spectrum penicillins (Al-Haroni and Skaug 2007). In Sweden, narrow-spectrum pencillin (pencillin V) is most commonly prescribed (unpublished data), and studies done in Sweden show that phenoxymethylpencillin is considered the drug of choice for many indications in medicine (Lundborg et al, 2002; Andre et al, 2008; Molstad et al, 2008). In the present study, none of the dentists prescribed narrow-spectrum antibiotics. Our results probably reflect the assumption that antibiotic resistance is highly prevalent among oral bacterial species in Karachi. Metronidazole was the second-most prescribed antibiotic for infectious diseases such as caries/ pulpitis and calculus and caries (n = 25 and n = 23, respectively) in the present study, and the same is also seen in the other parts of the world, e.g. Norway and England (Palmer et al, 2000; Al-Haroni and Skaug 2007). It is known that it has good activity against anaerobes and should be dentists’ first choice when treating anaerobic infections. 6.3% and 6.9% of Norwegian dentists’ prescriptions in 2004 and 2005, respectively, were for metronidazole, compared with 22.2% of the total number of prescriptions issued by 10% of the dentists working in England (Palmer et al, 2000). Pain management has long been an important consideration in dental care (Sarkar et al, 2004), but there is a paucity of literature about the prescription pattern of painkillers in dentistry. It is common that patients in low/middle income countries only seek dental treatment when they are in pain. NSAIDs generally provide predictable outcomes for control of dental pain due to their analgesic and anti-inflammatory properties (Sarkar et al, 2004). In contrast to a previous study by Aldous and Engar (1996), most of the dentists in our study preferred NSAIDs over narcotic analgesics, similar to the Belgian study where the prescription rate of NSAIDs by dentists was 22.8% (Mainjot et al, 2009). Our data also show that ibuprofen was the most commonly prescribed painkiller when caries/ pulpitis was diagnosed, which is in keeping with findings of other studies (Aldous and Engar 2000; Sarkar et al, 2004; Mainjot et al, 2009). The combination of antibiotics and painkillers was most commonly prescribed by the operative department, followed by periodontology. This is probably because of the high number of patients with dental infections visiting these departments.
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Overall antibiotic prescription by dentists is lower compared to medical practitioners, as shown by other studies (Al-Haroni and Skaug 2007; Zafar et al, 2008). There are certain conditions for prescribing antimicrobials in dentistry: (i) post-therapeutic, (ii) therapeutic or (iii) prophylactic, firstly in acute or chronic infection to aid surgical treatment; secondly to treat active infectious disease, e.g. acute ulcerative gingivitis; thirdly to prevent metastatic infection, e.g. bacterial endocarditis (Palmer, 2003; Al-Haroni and Skaug 2007; Poveda et al, 2007). However, a number of studies suggest that dentists’ prescription practices and knowledge are not always optimal (Al-Haroni and Skaug 2007; DarOdeh et al, 2010) and non-clinical factors such as lack of time, work load, etc. might influence their decision to prescribe (Salako et al, 2004; Al-Haroni and Skaug 2007; Mainjot et al, 2009). Studies conducted in different countries to assess the prescription knowledge of dentists revealed a lack of uniformity in prescription and sometimes inappropriate rationale for prescribing (Salako et al, 2004; Al-Haroni and Skaug 2007; Mainjot et al, 2009). Hence, keeping in mind the globally and locally rapid rise of antibiotic resistance, it is strongly recommended that all dental prescriptions for antibiotics should be accompanied by a proper diagnosis along with careful dosage, administration and instructions for patients. Palmer et al (2003) and others have encouraged issuing guidelines that might be able to improve prescription practices and lead to a more rational and appropriate use of antibiotics in dental practice (Al-Haroni and Skaug 2007; Mainjot et al, 2009; Dar-Odeh et al, 2010). Lack of antiseptic techniques may lead to over-prescription of antibiotics by dentists based on a ‘just in case’ principle, but since this contributes to bacterial resistance, such practices cannot be recommended (Jaunay et al, 2000; Al-Haroni and Skaug 2006; Tanwir and Khan, 2011). Thus, educating clinicians, the public and colleagues in the medical field is necessary to end the misuse of antibiotics (Siddiqi et al, 2002; Mainjot et al, 2009; Dar-Odeh et al, 2010; Tanwir and Khiyani 2011). Our study has shown for the first time antibiotic and painkiller prescription habits per diagnosis by dentists in Karachi. Such information is important for the development and implementation of educational interventions to change prescription practices. All dentists employed full time in the dental hospital were asked, and they subsequently filled in the forms. The diagnostic form used in the study was the same as that used in the dental OPD of
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DUHS. The method used in the study is simple and entails only a little extra workload for the participants. It was feasible to perform this study for 2 weeks, which corresponds to other studies done earlier (Lundborg et al, 2002; Mainjot et al, 2009). One limitation of our study is that relatively few patients visited the OPD during the two-week study period. This may be due to the fact that the OPD of the dental hospital opened only 2 years prior to the study. Another limitation is that no external validation or independent evaluation of the various reported diagnoses was done. However, this is normally not done in diagnosis/prescription studies carried out in routine practice. Further evaluation and surveys of antibiotic use and reassessment of prescription practice after intervention and over time should be conducted in the future.
CONCLUSION Our study shows the prescription pattern of antibiotics and painkillers by dentists in Pakistan for the first time. There is a clear need to emphasise correct diagnostic methods and develop contextualised prescribing guidelines and educational initiatives, so that the maximum effect of antibiotics and painkillers will be achieved without compromising patients’ health.
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