Article Type : Research Article
Authors : Yamina E, Chayma BA, Sawssen B, Fatma M, Ahlem B, Fethi M and Hichem G
Keywords : Child; Antibiotic; Prescriptions; Pediatric dentistry
Context: Prescribing is not an insignificant act and the knowledge that recommendations exist does not mean that they are integrated by practitioners. Exceptionally in pediatric dentistry, prescribing is never systemic and requires special attention. Indeed, vigilance must be redoubled because children’s bodies are not as mature as those of adults. Aims: Evaluate the degree of knowledge of the recommendations and the quality of prescribing for children in a population of Tunisian free practice dentists.
Setting and design: A descriptive study involving 154 free practice Tunisian dentists was conducted.
Methods: It was performed using a questionnaire composed of 57 questions. Statistical analyses: SPSS 24.0 and Microsoft Excel 2010 software. Significance was considered for p<0.05.
Results: This study showed that 90.9% of the participants were used to update their knowledge. The most prescribed antibiotic for curative antibiotic therapy with no known risk of beta-lactam allergy was amoxicillin with 89,9% of responses and spiramycin with 51.94% in beta-lactam allergic children. To alleviate pain, the molecule of choice was paracetamol with 72.1% of the responses, with dentists who are accustomed to updating their having the most adequate management (p=0.042) With regard to sedation per os, 64.9% of the practitioners surveyed correctly answered the optimal dosage of antihistamines and it was the dentists specializing in this area who have the most adequate management (p=0.005).
Conclusion: This study revealed a lack of knowledge on the part of dentists: the molecules prescribed are not always adapted.
In
dentistry, the majority of etiological treatments for oral diseases are not
medicinal, but there are still situations where prescription is necessary .The
act of prescription must be part of a therapeutic strategy. In fact, the
prescriptions must be preceded by a rigorous interrogation of the patient in
order to know his surgical and medical history, his current treatments in order
to detect a possible drug interaction or a contraindication to a prescription
and whether or not he has allergies.1 In the particular case of pediatric
dentistry, prescribing is never systematic and needs special attention as a
matter of fact that children’s bodies are not as mature as those of adults.2
This study aimed to focus on evaluating the degree of knowledge of the recommendations
and the quality of prescribing for children in a population of Tunisian free
practice dentists.
Methods
Study design and sample
It
was a cross-sectional survey to assess the prescribing practices of general and
pediatric dentists in Tunisia, through a questionnaire. The sample consisted of
154 dentists.
Inclusion criteria
Dentist
who agreed to participate in the study and completed the entire questionnaire.
Non-inclusion criteria
Non-qualified
dentist and those who did not answer all the questions.
Conduct of the study
A
Survey sheet was shouted on the Google forms software, guaranteeing the storage
of data on the server and the anonymity of the
respondents, and sent via dentist groups on social networks.
Data collection
Data
were collected using a questionnaire composed of 57 questions that included two main domains: demographic
questions pertaining to respondents personal characteristics, as well as to
their practice characteristics and a set of questions concerning prescribing in children divided into
sub-parts : antibiotics; analgesic; sedation; fluoride, antifungal and
prescription for patients at risk.
Statistical analysis
Statistical
analyses were performed using SPSS 24.0 and Microsoft Excel 2010 software.
Significance was considered for p<0.05. Pearson chi-square test and Fisher
test were used to compare the different variables.
Results
The sample included 154 dentists who agreed to participate and answered all the questions.
Table 1
presents dentists’ demographic and practice characteristics. The sample
consisted of 59.70% males and 40.30% females. Most of them were alumni of the
Dental Faculty of Monastir Tunisia. The most represented age group was between
30 and 45 years. A professional experience of less than 5 years was noted in
57.1% of practitioners .Nearly 90% of the respondents were general dentists and
5% were pediatric dentists. The majority of dentists worked in a private
practice in urban areas. Findings showed that 90.9% of dentists had the habit
to update their knowledge about drug prescription. Among the 154 dentists who
answered the questions, only 33% completed an internship in a Pediatric
Dentistry Department. Regarding the percentage of children in daily practice, 51.3
% of them met between 10 to 30% of children during their practice. Most of
these children (90, 3%) were aged between 4 and 10 years.
Table 2
presents dentists responses concerning prescribing in children:
Antibiotics
More
than half of the participants (56, 5%) answered that they took vocational
training or read a recent article on the proper use of antibiotics. The most
prescribed antibiotic as part of first-line curative antibiotic therapy with no
known risk of beta-lactamin allergy was Amoxicillin with 89.9% of responses and
only 11.56% of dentists indicated the correct dosage as recommended by the
National Agency for the Safety of Medicines and Health Products
(ANSM).Regarding antibiotic therapy in children allergic to beta-lactamin, the
molecule of choice was spiramycin with a percentage equal to 51.94% .The
association amoxicillin - clavulanic acid as part of the second-line curative
antibiotic therapy was used with a percentage equal to 79.2%. Only 11% used
Cycline in patients diagnosed with aggressive periodontitis.
Prescription for patients at risk
The
molecule of choice for prophylaxis in patients at risk was amoxicillin for
68.8% of practitioners and 73.4% of them prescribed the exact dose.
Analgesic
To
relieve pain, the molecule of choice was Paracetamol with 72, 1% of the
responses of which 31, 2% mentioned the correct dose.
Sedation
With
regard to sedation, only 10 % of the participants surveyed declared that they
have used it. For oral sedative premedication the most prescribed molecule was Benzodiazepine
(39%). For those who prescribed benzodiazepines, 63.3% of them prescribed the
correct dosage, while for antihistamines 64.9% prescribed the exact dosage.
Fluoride
55,
8% of the participants mentioned that they read latest fluoride prescription
recommendations. Of all the participants 57.8% never prescribed fluoride to
children aged 6 months to 6 years.
Antifungal
The
molecule of choice of the fungal infections was Fluconazole with a percentage
equal to 32, 5%. Table 3 presents the results of the bivariate analyses in
which factors associated with dentists’ practices and the correct dosage of the
molecule prescribed were examined. For Antibiotics, the adequate posology of
Amoxicillin and Spiramycin was influenced by the practice type (P = 0.004) and
Clindamycin by dental school attended (P = 0.001). In addition, for Analgesic,
dentists who completed some type of professional training after graduation were
more likely to prescribe Paracetamol in accordance with the professional
guidelines (P =0.042). For the Sedation, prescribing the correct dosage of
Antihistamine was impacted by the practice type (P = 0.005).
Discussion
The
participation was predominantly male with 59.7% and it was the youngest
practitioners who participated the most in this study. In fact the most
represented age group was that of 30 to 45 years old with 53.9% of
practitioners, which was similar to a study carried out within the UFR Nantes
[3]. These results showed that young people are more inclined to question their
professional knowledge .Although 90.9% of practitioners said that they were in
the habit of updating their knowledge and 56.6% of them indicated that they
underwent professional training or read a recent article concerning the correct
use of antibiotics in the last year during the prescription of antibiotics;
they relied on clinical sense and experience when prescribing antibiotics.
Similar results for the use of specific recommendations were observed in the US
national study [4,5] this clearly indicates the increased likelihood of misuse
and unwarranted use of antibiotics that may contribute to the world of
antimicrobial resistance. Amoxicillin was the most prescribed antibiotic in the
First-line curative antibiotic therapy with no risk known of beta-lactamin
allergy (89,6%) which was similar to the other studies carried out in other
parts of the world [3-12]. Only 11,59% of dentists mentioned the correct
posology as recommended by the ANSM6 it was the practitioners specialists who
prescribed the adequate dosage with a
significant association (p = 0.038) .Regarding antibiotic therapy in children
allergic to Beta-lactamin, the molecule of choice was Spiramycin for 51.94%
practitioners. The adequate dosage was influenced by the professional status of
the practitioners: specialist dentists prescribed it more than general
practitioners. The association was statically significant (p = 0.004) .These results
can be explained by the fact that general practitioners have little contact
with children in their practice so the interest of continuing education which
aims to develop medical knowledge and adapt practices to the permanent
evolution of knowledge. When the first line curative antibiotic therapy is
judged ineffective, the molecule of choice for second-line antibiotic therapy
was the Amoxicillin combination with Clavulanic acid for 79.2% of the
answers.Similar results were found in the study of the UFR of Nantes [3]. As
for the prescription of Cyclines, the majority of practitioners did not
prescribe it: this can be explained by their interest in avoiding the risk of
dental Dyscromia or enamel Hypoplasia during systemic administration in young
children. Eleven percent of practitioners indicated it in the patients
diagnosed with aggressive periodontitis, which is in line with the
recommendations of the ANSM [13] the attitude of practitioners concerning the
management of patients at risk of infection seems mostly inadequate. The
attitude closest to recommendations is “an exceptional referral to a
specialist” since the majority of patients at risk of infection can be treated
by dental office, with respect for the precautions specific to each case. More
worryingly, 43.5% of practitioners did not take specific precautions to
patients at risk of infection. They said to respect only the precautions
hygiene standards, which are strictly aimed at preventing the transmission of
germs patient-to-patient, patient-to-caregiver, and caregiver-to-patient. Regarding prophylactic antibiotic therapy,
66.2% of practitioners indicated it only for invasive procedures, this goes in
the direction of ANSM recommendations [13] for prophylactic antibiotic therapy
in children without allergic risk, 73.4% of practitioners declared prescribing
amoxicillin. For children allergic to Beta-lactams, 63.6% of practitioners
prescribed Clindamycin, this response was influenced by the original faculty:
the dentists who performed them initial training at the Faculty of Dental
Medicine of Monastir prescribed it less correctly than other practitioners, the
association was statistically significant (p=0.001), which means that there is
still information work to be done with practitioners in order to better guide
them in their prescription. To reduce pain, the molecule of choice was
Paracetamol (72.1% of responses) unlike studies conducted in British Columbia
and Canada [1] where ibuprofen being the most commonly prescribed non-opioid
analgesics. For the rest of the answers, some (1.2% of practitioners)
prescribed Codeine, which is not in line with the recommendations: In 2017, the
Food and Drug Administration (FDA) issued its warning on stronger, a
"contraindication" to codeine in children under 12 years, due to the
serious risks, including slowed or difficult breathing and death, which appear
to be a higher risk in children under 12 years [14]. Regarding the optimal
dosage of Paracetamol for children less than 12 years, 31.2% of practitioners
answered correctly. These are the doctors dentists accustomed to updating their
knowledge of the correct use of drugs that had the most adequate prescription,
with a significant association (p=0.042).
With regard to sedation per os, 64, 9% of the practitioners surveyed,
correctly answered the optimal dosage of Antihistamine and it was the dentists
specializing in this area who have the most adequate management (p = 0.005).
The knowledge that the recommendations exist does not however mean that they
are well known and/or integrated by the practitioners. .In fact, 55% of
practitioners declared that they had taken note of the recommendations of the
ASNM of 2008, but they were more numerous (91.6%) those who did not make the
fluoride balance, the realization of which, must be carried out before any
medical prescription in many countries in order to avoid overconsumption in the
face of the multitude of sources of intake [14-18]. This can be explained by
the difficulty in carrying out the fluoride balance [15]. In pediatric
dentistry, antifungals are mainly used in cases of oral candidiasis [19,20]. In
this study 40.3% of practitioners prescribed antifungals for oral thrush. The
molecule of choice of the fungal infections was Fluconazole with a percentage
equal to 32, 5% followed by Amphotericin B with 18, 8% which was similarly
observed in the literature [21,22].
Conclusion
This
study revealed a poor mastery of the recommendations and a lack of knowledge on
the part of the dentists: the molecules prescribed are not always adapted.
Appropriate prescriptions were noted with specialist dentists. A strategy must
be implemented to improve the quality of prescription.
3.
Benoit B. La
prescription medicamenteuse en odontologie pediatrique: enquete pilote realisee
au sein de la faculte dodontologie de Nantes. Dis; 2017.
11.
Peterson LJ.
Antibiotics for oral and maxillofacial infections. In Newman MG, Kornman KS,
editors. Antibiotic/Antimicrobial Use in Dental Practice. St. Louis, MO: Mosby;
1990: 159-71.
13.
De Securite
SAnitaire, Agence Française. De Produits de Sante. Prescription des
antibiotiques en pratique bucco-dentaire. Recommandations de bonne pratique.
Med Mal Infect. 2011; 42:193-212.
14.
US Food and Drug
Administration FDA Drug Safety Communication: FDA restricts use of prescription
codeine pain and cough medicines and tramadol pain medicines in children;
recommends against use in breastfeeding women. 2017.
15.
Droz D, C.
Karmann. Le bilan fluore: un prealable a toute prescription de fluor chez l
enfant. Inf. Dent. 1997; 1249-1253.
17.
EUROPEAN ACADEMY
OF PEDIATRIC DENTISTRY (EAPD). Guidelines on the use of fluoride in children:
an EAPD policy document. Eur Arch Paediatr Dent. 2009; 10: 129- 135