Prescription pattern of antibiotic and analgesic in endodontic treatment in Kuwaiti population: A self administered Survey

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1 Original Article Prescription pattern of antibiotic and analgesic in endodontic treatment in Kuwaiti population: A self administered Survey Manal J. Al Maslamani, Faraj A. Sedeqi, Alex J. Moule Department of Restorative Sciences, Faculty of Dentistry, Kuwait University, Kuwait Key words: Antibiotics, analgesics, endodontic, pain management, root canal treatment Address for correspondence: Dr. Manal J. Al Maslamani, Department of Restorative Sciences, Faculty of Dentistry, Kuwait University, P.O. Box: Safat 13110, Kuwait. E mail: mmaslamani@hsc.edu.kw ABSTRACT Introduction: Surgical and non surgical endodontic treatment of involved teeth can necessitate prescription of analgesics and antimicrobials. The literature suggests confusion amongst practitioners regarding the need for adjunctive medication, mainly during non surgical endodontic treatment, often leading to over prescription. Aim: The aim of this study was to determine the current clinical practice of dentists participated in this study with respect to antibiotic and analgesic prescription patterns in their endodontic treatment management in Kuwait. Materials and Methods: Prescription patterns for antibiotics and analgesics were analyzed based on the responses to self administered questionnaire (n = 169). Information was collected based on different clinical endodontic diagnostic scenarios. Statistical analysis was performed with SPSS software version 17.0 to determine relationships between prescription patterns, age, gender, and dental qualification (specialists and general dentists). Results: Ninety two percent of dentists prescribed analgesics for the management of endodontic pain. While 16% prescribed antibiotics for severe dental pain; 62% prescribed antibiotics for acute apical abscesses. Significantly more male dentists prescribed antibiotics for dental pain than female dentists. No significant difference was found between general dental practitioners and specialists attitude toward drug prescriptions. Amoxicillin and ibuprofen were the most commonly prescribed medications. Conclusion: While the majority of dentists appeared to prescribe antibiotics and analgesics appropriately, some did not. This research confirmed previous studies and established a need for imparting information of evidence based prescriptions protocols for the dentists surveyed in this study in Kuwait. INTRODUCTION Many people suffer from dental diseases, like dental caries, periodontal disease, and root canal infection. Some of the conditions warrant conventional management e.g. fillings, scaling, and non surgical endodontic treatment. However, others need surgical management Quick Response Code: Access this article online Website: DOI: / like crown lengthening and apical microsurgery. Beside conventional and surgical procedures, some conditions warrant antibiotics and analgesics prescription. Regarding the therapeutic aspect, to the best of our knowledge, there are no standardized protocol for antibiotics and analgesics before, during, and after non surgical endodontic treatment. However, the drugs most commonly used are amoxicillin and ibuprofen. Based on our experience and on recent literature search reports, we found that there is irregularity amongst practitioners with respect to the appropriate need, timing, and type of medication. [1] 128

2 [Downloaded free from on Thursday, August 07, 2014, IP: ] Click here to download free Android application for this jou The most frequent symptom of patients presenting for endodontic treatment is pain. [2,3] Pre treatment analgesia may decrease the incidence of post operative endodontic pain. [4 6] A number of studies have investigated the appropriateness of different analgesic compounds on the management of endodontic pain. [2,7] To our knowledge, only one study has, however, surveyed endodontists analgesic prescription preferences [8] and general practitioners endodontic pain management strategies have not been formulated. Many practitioners confuse the need for analgesics with the prescription of antibiotics. [9] Since their introduction, antibiotics have been used extensively in dentistry for the treatment of dental infections. Diseases of the dental pulp and periapical tissues are mainly caused by microorganisms; however, to our knowledge, not all endodontically involved teeth require administration of systemic antibacterial medication. Successful management can be achieved by pulp extirpation and mechanical and chemical cleaning of the root canal. In general, antibiotic prescriptions should only be used for the control of infection and in patients with systematic manifestations. Their use has no proven benefit in the immediate relief of pain acute pulpitis. [9] Inappropriate use of antibiotics has to be discouraged, as overuse and misuse can have a negative impact on the general population [10] leading to adverse drug reactions, emergence and resistance species, increased drug resistant microbial infections, and economic burden. [11,12] As culturing is seldom carried out, prescriptions are often based on presumption from clinical and bacterial epidemiological data. [13] As endodontic infections are usually poly microbial, involving a combination of gram positive and gram negative facultative and/or strict anaerobic bacteria, [14,15] broad spectrum antibiotics is typically prescribed. Amoxicillin is the most frequently prescribed antibiotic [3] during endodontic treatment. It has been reported that in some countries, dentists prescription of antibiotics in endodontic management can be inappropriate and unnecessary, even where infections are present. [1,3,8,9] However, reliable worldwide data is not readily available, and Kuwait lacks such data. In view of this, it is considered important from a public health perspective to ascertain whether the unnecessary prescription of drugs alluded to in the literature is reflected in the practice of dental community in Kuwait. It is also considered that knowledge regarding prescription practices should be available before determining whether there is a need for educational initiatives aimed at rational approaches to prescribing analgesics and antibiotics before these could be developed. Based on our search of the latest literature, we did not find any published research about the prescription pattern in Kuwait and to ascertain the practice modalities in Kuwait. Hence, the aim of this study was to determine the current clinical practice of dentists participated in this study with respect to antibiotic and analgesic prescription patterns in their endodontic treatment management in Kuwait. MATERIALS AND METHODS A self administered questionnaire was developed by the first author to investigate antibiotic and analgesic prescription patterns for pain of endodontic origin and infection management. Kuwait has 78 dental clinics at the primary health care level run by the Ministry of Health in [16] For the purpose of this study, six clinics were selected to ensure that each of the six Governorates of Kuwait was represented. The principal investigator visited the selected clinics on random days over a period of 16 weeks. All dentists who were present in the clinic on those days were given the questionnaire to complete. The completed questionnaire was collected back the same day. In the six clinics, a total of 169 dentists were given the questionnaire and all of them filled it. Hence, all the dentists who were requested to participate in the study did so. Data were collected during 16 weeks from September 2012 to December The data collection spanned over a period of 12 weeks. The questionnaire collected demographic data relating to age, gender, years of experience, and dental qualification (general or specialist); specialists were of different specialties i.e., endodontists, prosthodontits, periodontists, oral surgeons, operative dentists, and advanced general dental specialists (AGD). Information regarding prescribing patterns of practitioners of antibiotics and analgesics for a number of clinical scenarios associated with endodontic management was collected. Participants were asked whether they considered some clinical conditions required antibiotics or analgesics (the participant can choose more than 129

3 n one answer form the clinical scenarios e.g. acute and chronic apical abscess). The questions were separate for prescription of antibiotic and analgesics and to describe their choice of these medicines, if any. They were also asked specifically if they prescribed only analgesics or only antibiotic for cases with severe pain The clinical conditions represented in the questionnaire for pulpal diagnosis were reversible pulpitis, irreversible pulpitis, and necrotic pulp. The respondents were asked to report whether they always prescribe antibiotics or never prescribe antibiotics for the above conditions. For periapical diagnoses, the clinical situations were: Normal periapical area, symptomatic apical periodontitis, asymptomatic apical periodontitis, acute abscess, chronic abscess (presence of sinus tract). Their choice regarding the type, dose, and duration of antibiotic as well as analgesics was recorded. Responses were analyzed using Statistical Package for Social Sciences (SPSS) software version 17.0 (SPSS : Inc., Chicago, IL, USA). The analysis determined the relationships between the following independent variables: Age, dental qualification, gender, years of experience, and pulpal and pericapical diagnosis. Chi-square test was used for testing the differences among categorized groups. The level of significance was set at (P 0.05). RESULTS Participants (N = 169) were aged between 23 and 60 years, with a mean age of 33. Fifty nine percent (n = 99) were males and 41.4% (n = 70) were females; 66.3% (n = 112) were general dental practitioner (GDP) and 33.7% (n = 57) were specialists (13.3% (n = 13) endodontists, 8.9% (n = 15) prosthodontists, 3% (n = 5) oral surgeon, 3.6% (n = 6) periodontists, 3.6% (n = 6) AGD, 3.6% (n = 6) orthodontists, 2.4% (n = 4) peadodontists, 1.2% (n = 2) operative dentists). For dental pain, 92% of respondents prescribed analgesics for severe dental pain [Table 1]. No significant differences in analgesic prescription patterns were noted when gender and age were considered or between specialists and general dentists. On the other hand, 16% routinely prescribed antibiotics for severe dental pain. Male dentists prescribed antibiotics for pain management more frequently than female dentists 23% (P = 0.002). There was no significant difference in the prescribing patterns for pain between specialists and general dentists or in relation to age [Table 1]. When pulpal conditions were considered, regarding the type of analgesic, the most common prescription was for non steroidal anti inflammatory drugs (88.8%), with Ibuprofen (44.1%) and (diclofenac potassium) Cataflam (39.1%) being the most commonly prescribed. Ibuprofen was usually prescribed at the dose of 400 mg orally every 6 hours for 5 days, whereas Cataflam was usually prescribed of the dose of 50 mg three times daily for 5 days. Paracetamol was the next most commonly prescribed analgesic (12.42%), mostly prescribed as one tablet per need. Other analgesics that were prescribed were, Acetaminophen Tylenol 650 to 1000 mg every 4 to 6 hours as needed, and Ponstan forte (Mefenamic acid) 500 mg 3 times daily [Figure 1]. For antibiotics prescription in regard to the pulpal conditions only, 60% participants reported that they never prescribed antibiotics for pulpal conditions, while the remaining 40% did so [Figure 2]. There were significant differences in prescribing patterns when age and gender were considered. Significantly more practitioners 40 years old never prescribed antibiotics for pulpal conditions (P = 0.000). Male dentists prescribed antibiotics more than female dentists (23% vs. 5.7%). Particularly, in cases with pulp necrosis, dentists over 40 tended to prescribed antibiotics more often than younger dentists. No significant differences were found between Table 1: Analgesic and antibiotic prescriptions by dentists for patients complaining of severe pain, by age, gender and dental qualification (N = 169) Variables Prescription of analgesics for patients complaining of severe pain Prescription of antibiotics for patients complaining of severe pain <30 years (n=64) Age (N (%)) (n=70) >40 (n=35) P value* Male (n=99) Gender (N (%)) Female (n=70) P value* Dental qualification (N (%)) GDP (n=112) Specialist (n=57) P value* Total N (%) 58 (90.6) 64 (91.4) 34 (97.1) (89.9) 67 (95.7) (93.8) 51 (89.5) (92.3) 8 (12.5) 12 (17.1) 7 (20.0) (23.2) 4 (5.7) 0.002** 18 (16.1) 9 (15.8) (16.0) 130

4 specialist and general practitioner pattern of prescription of antibiotics [Table 2]. For periapical pathology cases, 86% participants usually prescribed antibiotics in cases with acute abscesses [Figure 3]. On the other hand, 24.8% prescribed antibiotics for chronic abscesses. No significant differences were found in relation to age and dental qualification and gender, except between male and female dentists for chronic abscesses, with male dentists prescribing antibiotics more frequently (P = 0.008) [Table 3]. About 70% of participants usually prescribed Amoxicillin; the most common dose prescribed being 500 mg 3 times daily for 5 days [Figure 4]. Dalacin C (Clindamycin) 150 mg twice daily for 5 days was the second commonly prescribed antibiotic (23%). The majority who prescribed this antibiotic prescribed a dose of 500 mg for 5 days. Other antibiotics prescribed in descending order of frequency were Metronidazole, Augmentin, Erythromycin, and Doxycycline [Figure 4]. DISCUSSION Numerous studies have shown that Ibuprofen and other NSAIDs are effective in controlling or Figure 1: Percentage of the types of analgesics prescribed during endodontic treatment Figure 2: Percentage of dentists who prescribe antibiotics for different pulpal conditions. (N = 169) Table 2: Antibiotic prescriptions by dentists and specialists to treat various pulpal clinical conditions by age, gender and dental qualification. Statistically significance relationships are shown in bold type (N = 169) Patient's presenting clinical condition N (%) of respondents that would prescribe antibiotics Age categories (year) P value Gender P value Dental qualification <30 N= N=68 >40 N=35 Female N=68 Male N=97 Specialist N=55 GDP N=110 P value Pulpal diagnosis Reversible pulpitis 3 (4.8) 6 (9.2) 5 (14.3) (4.5) 11 (11.6) (9.6) 9 (8.2) (8.3) Irreversible pulpitis 8 (12.9) 7 (10.8) 7 (20.0) (10.4) 15 (15.8) (17.3) 13 (11.8) (13.02) Necrotic pulp 9 (14.5) 19 (29.2) 16 (45.7) (11.9) 36 (37.9) (30.8) 28 (25.5) (26.04) Never prescribe 49 (79.0) 38 (58.5) 14 (40.0) (76.1) 50 (52.6) (55.8) 72 (65.5) (59.8) Always prescribed 3 (4.8) 1 (1.5) 2 (5.7) (0.0) 6 (6.3) (1.9) 5 (4.5) (3.6) Total N (%) Table 3: Prescription of antibiotics to treat various periapical clinical conditions by age, gender and dental qualification. Statistically significance relationships are shown in bold type (N = 169) Patient`s presenting clinical condition N (%) of respondents that would prescribe antibiotics Age categories (year) P value Gender P value Dental qualification <30 (N=62) (N=68) >40 (N=35) Female (N=68) Male (N=97) Specialist (N=55) GDP (N=110) P value Periapical diagnosis Normal periapical area 0 (0.0) 1 (1.5) 0 (0.0) (0.0) 1 (1.0) (0.0) 1 (0.9) (0.6) Symptomatic AP 8 (12.9) 9 (13.2)) 1 (2.9) (8.8) 12 (12.4) (9.1) 13 (11.8) (10.65) Asymptomatic AP 1 (1.6) 2 (2.9) 1 (2.9) (0.0) 4 (4.1) (0.0) 4 (3.6) (2.37) Acute abscess 57 (91.9) 56 (82.4) 33.(94.3) (92.6) 83 (85.6) (81.8) 101 (91.8) (86.4) Chronic abscess 14 (22.6) 18 (26.5) 10 (28.6) (14.7) 32 (33.0) (29.1) 26 (23.6) (25.5) AP: Apical periodontitis Total N (%) 131

5 reducing dental pain after/before endodontic treatment at various dosages, especially at doses of mg. [5,7,17 28] Studies have also shown that pre operative administration of ibuprofen suppresses post operative pain. [6,8] Therefore, it is not surprising that most dentists, in our study, prescribed NSAIDs (Ibuprofen 44.1% and Cataflam 39.1%) for pain management in endodontics. Generally, the dentists in this study of age 40 years prescribed antibiotics significantly less frequently than dentists over 40 years old. Of interest, also was the fact that, male dentists prescribed antibiotics for pain management significantly more frequently than female dentists. In cases of pulp necrosis, male dentists also tended to prescribe antibiotics more often than did than female dentists and that more male practitioners prescribed antibiotics for chronic abscesses (P = 008). While it is not possible to speculate on the reasons for this gender difference, the reasons will be investigated in a further study. It is universally accepted that antibiotics are only indicated if there is infection or signs of systemic involvement. [1] In reversible and irreversible pulpitis, infection is not present and the pulps are still vital. Prescription of antibiotics is thus not justified. However, when prescription patterns for pulpal and periapical diagnosis were considered, not all practitioners in this study followed this, with only 59.7% stating that they never prescribed antibiotics depending on a diagnosis of pulpitis alone, some did not. Indeed, 14% and 22% prescribed antibiotic for reversible and irreversible pulpitis with normal periapical status, respectively. On the other hand, when teeth with periapical diagnosis were considered, the majority of practitioners (86%), prescribed antibiotic for acute abscess cases with systemic manifestations. The use of systemic antibiotics for the control of post treatment endodontic pain has been shown to be without justification. [9] While most dentists in this study in Kuwait appeared to prescribe antibiotics when it is really indicated (86%), a large number still routinely prescribed antibiotics for severe dental pain. This finding is not surprising in the light of other studies. [9,20 24] This study supports the findings of similar studies in other countries. [17 28] Slaus and Bottenberg, [21] for example, revealed that 48% of Flemish dentists prescribed antibiotics inappropriately for acute apical periodontitis. [21] Also, Yingling et al. [22] reported that there were still many endodontists in the American Association of Endodontists (AAE) prescribed antibiotics unnecessarily during endodontic treatments. Mainjot et al. [23] reported that antibiotics were often prescribed by practitioners in Belgium in the absence of fever (92.2%) and without any local treatment (54.2%). A similar study to the current one conducted in Spain [24] showed that 40.0% of respondents prescribed antibiotics unnecessarily for cases of irreversible pulpitis, while 52.9% prescribed antibiotics for a scenario describing a necrotic pulp with a cute apical periodontitis but no swelling. Almost 21.5% prescribed antibiotics for necrotic pulps with chronic apical periodontitis and a sinus tract. Abbot et al. and Abbot PV in Australia in 1990 and 2000 described a tendency toward over prescription and demonstrated lack of knowledge of the incidence of adverse reactions. [11,12] The reasons why dental practitioners prescribed antibiotics unnecessarily warrant further investigation. Whether this is the patients demand, social, cultural or other factors involved are not yet known; however, the fact that over prescription occurs in dental practices is of concern in Kuwait and in other countries. Figure 3: Percentage of dentists who prescribe antibiotics for different periapical conditions. (N = 169) 132 Figure 4: Percentage of the types of antibiotics prescribed during endodontic treatment

6 The fact that, in this study, general dental practitioners were more likely to use antibiotics than endodontists could be interpreted due to the age of the endodontists in this survey is more than the general dentists ages, or because of the level of the practical experience and understanding of the disease process being, which is supported by Salako et al. [25] who previously examined the rationale and the pattern of antibiotic prescription for general dental management not specifically endodontic management and found a lack of uniformity in the rationale for antibiotic use among dental practitioners in Kuwait. With some notable exceptions, the type of antibiotics prescribed for dental infections do not appear to differ greatly from country to country, with broad spectrum antibiotics, namely amoxicillin, being the most commonly prescribed. [22 28,30] The most commonly prescribed antibiotic in this study was amoxicillin 500 mg 3 times daily for average duration 5 7 days, which follows the latest recommendations for the use of antibiotics. [3] Interestingly, a similar study in Kuwait found that amoxicillin was the most frequently prescribed antibiotic. [25] In recent years, single visit endodontic therapy has gained popularity. [4] Currently, there are no clear guidelines regarding the need to prescribe analgesics and/or antibiotics before or after single visit endodontics. Of the dental practitioners in Kuwait, only 18% consider pre treatment analgesia before single visit endodontics. A higher percentage prescribes analgesics after single visit endodontics (62.7%). Flat et al., [5] however, found no difference in pain scores at 7 and 24 hours after taking Flurbiprofen (NSAID) before pulpectomy as compared with administration 3 hours after pulpectomy. Another study investigated single dose ibuprofen pre treatment for post operative endodontic pain found no significant differences in pain levels between either single dose ibuprofen formulation or a placebo control group. [6] Only 4.7% prescribe antibiotic routinely after single visit endodontics with a tendency for dentists over 40 years old to prescribe antibiotics significantly more frequently that than dentists 40 years old group. In conclusion, it would appear that most dentists in Kuwait prescribe analgesics for pain management when performing endodontic treatment and antibiotics only when indicated. Ongoing problems with antibiotic prescription regimes have, however, been highlighted. This research corroborates other studies that identify problems with dentists prescription protocols. [11,12,20-30] Recommendations The dental curriculum needs to incorporate a clear protocol of therapeutic treatment during endodontic management. Further, the senior dentists, when supervising the work of residence/junior dentists, need to be vigilant in examining the prescription patterns of medicines during the management of endodontic cases. An important implication from the findings is that there is clearly a need for continuous professional education for all dentists, and for seniors, in particular, about the prescription modalities in relation to specific condition. REFERENCES 1. Keenan JV, Farman AG, Fedorowicz Z, Newton JT. Antibiotic use for irreversible pulpitis. Cochrane Database Syst Rev 2005;18:CD Rousseau WH, Clark SJ, Newcomb BE, Walker ED, Eleazer PD, Scheetz JP. A comparison of pain levels during pulpectomy, extractions, and restorative procedures. J Endod 2002;28: Keiser K, Hargreaves KM. Building effective strategies for the management of endodontic pain. Endod Top 2002;3: Sathorn C, Parashos P, Messer H. 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