In general practice, the cure of any disease is reliant on the use of drugs.1 Since the accidental discovery of penicillin by Alexander Fleming in 1928, antibioticshave been widely used in medical practice. Antibiotics are currently predominantly utilized in the obliteration of bacterial infections, either by killing them or slowing down their growth.2 However, according to one study, up to 50% of antibiotics are deemed unnecessary, and resistance is one of
the most serious challenges confronting medical practitioners.3
Antibiotic resistance occurs when microorganisms develop
a mechanism to protect themselves from antibiotics in order
to survive, rendering the antibiotic useless when used against
that microorganism.4
Antibiotic resistance is spreading alarmingly throughout the world, including developed countries.5 In recent years, it has been identified as one of the primary causes of a high frequency of hospitalization, morbidity, and mortality.6 According to current data, the World Health Organization (WHO) estimates that 700,000 people die each year as a result of antibiotic resistance, and predicts that by 2050, antimicrobial resistance will be responsible for ten million deaths per year.7 Multiple studies from the USA reported that at least 500,000 patients infected with C. difficile need to be admitted in hospital and <14,000 people died.8 Antimicrobial resistance data in middle- and low-income countries are limited because of the challenges in conducting antimicrobial resistance surveillance.9
The common causes of antibiotic resistance include over prescription, incomplete treatment and inappropriate selfmedication.10 Among different causes of antimicrobial resistance, irrational use of antibiotic is the most prominent one.11 Irrational antibiotics can take many forms, including the use of too many medicines per patient (polypharmacy), the inappropriate use of self-medication (often with prescription-only medicines), in non-bacterial infections, outside clinical guidelines, or with inadequate dosage or inappropriate route of administration such as overuse of injections when oral formulations would be more appropriate.12 The irrational drug has many bad consequences including treatment failure, compromise in patient health, and increased cost.13
Even in dentistry, antibiotic prescription for dental infection is a common practice. A study evealed that 12% of dentists adequately prescribed antibiotics as a prophylactic intervention and treatment.14 A study conducted in Australia revealed that antibiotics are not used vigilantly for various dental infections which has led to development of resistance.15 A study conducted in Karachi revealed that antibiotic
prescription has been increased to 65% in past ten years in low middle-income countries like Pakistan. 1 6 The World health Organization defines rational drug
prescription as the use of fewest number of drugs to achieve the best potential impact in the shortest time and at the lowest possible cost.17 It is fact that appropriate antibiotic selection, dose and duration of treatment could prevent or slow down the emergence of antimicrobial resistance.18 The change in doctors’ attitude have impact on the practice of their antibiotic prescription. Furthermore, if the doctors are aware of their practices regarding antibiotics prescription, they will grasp the guideline accordingly.19
To highlight the awareness about antibiotics use and to combat its resistance numerous agencies are in operation.20,21 Moreover, the World Health Organization (WHO) has recently focused on educating health care providers about proper prescription with step-by-step guideline.22
Antibiotic stewardship is a key intervention to improve prescribing practices at individual as well as combined professional level.23 Infectious Disease Society of America (IDSA) defined ‘antimicrobial stewardship’ as that optimizes the indication, selection, dosing, routes of administration and duration of antimicrobial therapy to maximize clinical cure or prevention of infection while limits the collateral damage of antimicrobial use, including toxicity, selection of pathogenic organism and emerge of resistance. Antimicrobial stewardship program helps the clinician to improve quality of care and patient safety through increase rate of infection cure, reduce treatment failure and increase appropriate prescribing.24
Large number of studies are conducted to assess the awareness & attitude of medical students on antibiotic resistance as well as stewardship, but few studies are there to measure the same in dental students.25-27 Keeping this lacuna in mind this study is initiated to assess the awareness and approach regarding antibiotic prescription in different level of dental students.

METHODOLOGY
The cross-sectional study was conducted at Ziauddin University and teaching hospital; Karachi from 1st april, 2020 to 30th july,2020 and enrolled third and final year
dental students as well as house officers.28 Because firstand second-year dental students are not in clinical practice at this level, they were excluded from the study. After approved by the Institutional Ethics Committee of Ziauddin University, the sample size was calculated using Open Epi calculator. The computed sample size was 133 to which 5% non-response rate was added. Out of 139 students seventy- two were dental students and sixty- four were house officers. Non-probability convenience sampling technique was used.
All students in the study understood simple English, and, hence, it is selected as interview language in questionnaire. A self- designed, self-administered questionnaire29-32 was prepared to collect the demographic data and information regarding the prescription pattern of antibiotics amongst study subjects. All questions in the questionnaire were close ended. The questionnaire’s reliability was verified by calculating the alpha-coefficient, Cronbach’s which was found to be satisfactory. The questionnaire comprised information pertaining to Demographic characteristics, standard guideline for antibiotic prescriptions, antibiotic stewardship and resistance, improper prescription and its consequences. The questionnaire was filled by third and final year BDS students during class sessions by their teachers, to reduce information and selection bias. Data was obtained from house officers during their clinical rotations The dental students were briefed about the purpose of the study and the significance of participation and a written informed consent was obtained from them.
The data were analyzed by using SPSS version 22 and descriptive statistics were computed. The results were presented as means and standard deviations, frequencies,
and percentages. The R software version 3.1.1 (GNU General Public License) was used for computing. The frequency and percentage (percentage) of individuals who answered correctly for the various questions relating to socio-demographic variables, awareness regarding antibiotic usage were displayed using descriptive statistics. The Chi-square test of independence was used to evaluate the frequency of accurate responses across dental students and house officer.

RESULTS
The demographic data revealed that out of total 139 study participants,113(81.3%) were females, whereas 89(64%) of them were aged between 23-28 years. In our study 64(46%) of the participants were house officers. Moreover, only 18(12.9%) of them were in private practice (table 0).

of standard antibiotic prescribing guidelines most of the students were familiar (79.1%). Moreover, most students knew that amoxicillin is beta lactam antibiotic (87.8%).
Whereas half of the participants were aware that prolong use of antibiotics lead to superinfection. (54.7%); Least responses were received about antibiotic stewardship (17.3%). It was pleasingly seen that most of the participants are aware that antibiotics are not necessarily required in all dental infections (65.5%). Majority of dental students replied in favor of probability of Antibiotic abuse (92.1%). More than 2/3rd of the respondents believed that antibiotics aid in recovery of infections (84.9%). Their responses were positive towards antibiotic misuse leading to resistance (95%). While (77%) of the participants answered that they are aware that superinfection would be prevented by prescribing proper antibiotic dosage. Regarding, antibiotic stewardship ‘role in reducing its resistance, half of the participants were in favor (49.6%). Association of better efficacy of antibiotic with cost is denied by majority of participants (71.9%). While the majority believe that antibiotic should be continued even if symptoms are relieved. (64.7%). Almost equal dental students responded in favor (51.1%) and against (48.9%) of prescribing antibiotics without any senior consultation. It is encouraging to note that maximum dental students used to inquire recent antibiotic course prior to prescription (90.6%). Most of the respondents prefer to take extra precaution for prescribing antibiotic in immune compromised patients (89.9%). It is surprisingly seen that (23%) of the responders

experienced antibiotic resistance in their practice. While (10.8%) of the participants faced acute emergency due to antibiotic associated adverse effects (table 1).
Statistically a significant association between implementation of standard guidelines of antibiotic prescription with private clinical practices (p=0.011). In
addition, correlation of prolonged antibiotic use leads to super infection also significant with private clinical practice. (p value 0.001). A significant association (p value 0.023) is seen between resistance due to improper antibiotic therapy and gender. While experience of antibiotic resistance in clinical practice is significantly correlate with different level of qualification (p=0.002) (table 2).

DISCUSSION
Antibiotics have shown to be a powerful and effective arsenal against a variety of diseases during the previous five decades. Today, the development of antibiotic-resistant pathogenic bacteria and their dissemination in the human population is an increasing problem around the world, posing a serious threat to public health in the twenty-first century, especially in poor nations.33 Availability of antibiotic in Pakistan is as Over the counter (OTC). A study conducted in Pakistan supports this fact.34 An Indian study also revealed that (76%) of the Indian population purchase medicine from pharmacy based on their peer’ antibiotic experience prescribed by senior physician. This is in concordance to current study as this study revealed Almost equal dental students responded in favor (71%) and against (68%) of prescribing antibiotics without any senior consultation.
Another important issue is doctor mostly prescribe broad spectrum rather than narrow spectrum, even in scenarios where it is not needed, leading to antimicrobial resistance (AMR).35 It was pleasingly seen in present study that most of the participants were aware that antibiotics are not necessarily required in all dental infections (65.5%). In Pakistan, dentistry school lasts four years, and students in their second year of BDS complete a pharmacology course that covers prescription, pharmacology and pharmacokinetics knowledge. They begin to apply this knowledge throughout their clinical rotations in third, fourth year as well as during their house job. Dentists are free to work once they have completed their internship. In many investigations, dentists’ and dental students’ knowledge of drug prescription has been found to be insufficient.16 This shows that dental training should be enhanced throughout college years or while working as a house dentist. In order to train students and give them with the required ability to perform in a clinical setting, the medical curriculum should be well-rounded. There are gaps in the literature when it comes to evaluating
antibiotic prescription among dental students. One study compared the prescription patterns of dental students in their
last year and house officers.36 The goal of this study is to determine the level of awareness and approach to antibiotic prescription and resistance among dentistry students at various levels. In our research, we discovered that dental students had a good but not perfect understanding of several elements of antibiotics; similar findings have been reported in previous studies.29
The standard antibiotic prescribing guidelines were known by (79.1%) of the participants in our study. According to a survey done in India in 2017, (87.1%) of participants follow the rational prescription process. This could be related to dentistry school’s curriculum, which includes instruction on how to write rational prescriptions.28 Only (30%) of dental students followed WHO prescribing recommendations, according to Guzman’s research, while the remainder did not since most of them were uninformed of the guidelines.37 There was a significant correlation between the implementation of antibiotic guidelines and private practice in our research, indicating that they may have more autonomy in dealing with patients.
The results of this study revealed that (54.7%) were aware that superinfection has association with prolong antibiotic use while, a study conducted in India revealed that
(83.8%) medical students aware that superinfection is an adverse effect of prolong antibiotic use.38 In this study, we found that different levels of education were linked with the knowledge of superinfection associated with prolonged antibiotic usage. Another study revealed that higher education levels are certainly linked with better understanding.39 It’s encouraging to see that (90%) of the participants want to know about previous antibiotic courses before writing prescriptions. A study conducted in Lebanon in 2018 found that dentists follow a similar practice.40 (92.1%) of the participants believed that there is an abuse of antibiotic at present. Similar results have been showed by a study conducted in UAE.41 In our survey, 64.7 % said they would
finish their antibiotic course even if their symptoms improved, compared to 36.7 % who said they would quit taking antibiotics if their symptoms subside. On the contrary, according to a survey done in Lebanon, 48.5 % continue their antibiotic treatment even if their symptoms improve.42
In our study, antimicrobial misuse was mentioned as a source of antimicrobial resistance by (95%) of the participants. In 2017, Jamhour reported that (83%) of Lebanon’s 500
respondents were aware that antibiotic overuse can lead to microbial resistance.43 In 2020, Higuita-Gutiérrez and colleagues reported that medical students from three Medellin medical schools have low awareness of antibiotic use due to a lack of training in antibiotic use and bacterial resistance.44
In the same year, Veses and colleagues found that awareness programs are needed to promote student use of antibiotics in young generations, particularly among pre-professional health sciences students, after surveying undergraduate dental students at Universidad Cardenal Herrera.45 Due to lack of training, Tsopra in 2020 employed a game called ‘Anti-bio Game,’ in which students play the role of a doctor meeting patients in consultation, as a promising technique for
enhancing understanding in antibiotic prescription.46
Antibiotic resistance is a global public health problem and a potential threat to humanity, according to various stakeholders and health agencies, and there is utmost need
to combat this threat immediately.47 The majority of participants (90.6%) mentioned that knowing about antimicrobials and their appropriate use is crucial in their medical profession, indicating that future prescribers are concerned and aware of the extent and relevance of the issue. Aside from antibiotic prescribing, the ideas of developing antibiotic usage protocols in healthcare facilities should be taught as part of the undergraduate curriculum. Small group exercises that allow students to practice patient education skills, such as negotiating with patients about the need for antibiotics and educating them about effective antibiotic usage, should be a big element of the antibiotic curriculum for students. Only 17.3 % of the participants in our study responded about antibiotic stewardship. However, a study of medical and pharmacy students in East Africa found that pharmacy students had higher awareness of antibiotic stewardship. They believed their pharmacy degree program had covered antimicrobial stewardship concepts.48 According to these findings, the undergraduate medical/dental curriculum should include and emphasize antimicrobial stewardship and resistance principles from early years in order to enhance correct prescribing practice of future doctors. Further, policymakers should organize educational programs and workshops frequently to keep students up to date about antibiotic prescription and its associated resistance.
According to our findings, (89.9%) would take extra cautions while prescribing antibiotics for immunocompromised. Only patients in the high-risk category should be covered, according to new guidelines from the American Heart Association.49
There are certain limitations to our research. Recall bias could have influenced the responses. The students often do not practice what they tell. When the investigator is not there, their attitude may change. The outcome may not be applicable to the entire society. To validate the results on a broader population, a qualitative study should be conducted.Prescribing medication is a skill that doctors in practically every medical specialty need. Newly qualified doctors are typically exempt from having to begin high-risk practical procedures, they are frequently expected to prescribe powerful medications from the first day of clinical practice. To guide
their learning about future advancements, many graduates should require not only knowledge of today’s pharmaceuticals, but also a firm basis in therapeutic concepts, based by a scientific understanding of drug action.

CONCLUSION
This study concluded that Majority of the dental students had good awareness regarding antibiotics and factors related to it as participants responded positively to the 70% of awareness based questions.More than 2/3rd 79.1% responded they were familiar to standard antibiotic prescription guidelines, 87.8% responded Amoxicillin is beta lactam; for probability of Antibiotic abuse and antibiotics aid in recovery of infections majority showed awareness (92.1% and 84.9% respectively). 95% of them were aware about the improper use of Antibiotic and its associated resistance. 77% were in favor that super infection prevented by prescribing proper antibiotic dosage. Almost equal students inquire recent antibiotic course prior to prescription (90.6%) as well as take extra caution prescribing antibiotic in immune compromised patients (89.9%).
Our study gives the insight of awareness of antibiotic prescription among dental students, which guides the concerns to know the pattern and will help to narrow down the gap between academic knowledge and professional practice. Our study also stimulates the requirement for introduction of some strategies, for example, clinical case-based and problem-based learning from early years of undergraduate training with precise emphasis on the both short-and long-term perilous effects of illogical prescriptions of antimicrobials.

CONFLICT OF INTEREST
None declared

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31. Jairoun A, Hassan N, Ali A, Jairoun O, Shahwan M. Knowledge, attitude and practice of antibiotic use among university students: a cross sectional study in UAE. BMC Public Health. 2019;19:1-8
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Anti-microbials have been commonly used in the treatment of odontogenic diseases since their discovery. Anti-infection medication were
introduced, which led to a dramatic drop in the occurrence of dangerous contaminations and foreshadowing a remarkable phase in the treatment of incurable diseases.1 Medication treatment has been the primary tool applied by medical care professionals to enhance the patient’s wellbeing. Prescribing a drug is a dynamic & individualized clinical process.2,3 Since last decade, micro-organism’s evolutionary responses to the particular pressure wielded  by the antibiotics have led to resistant of microbial species against nearly each identified antibiotic agent. Antibiotic abuse and overuse have been implicated as major contributors to the emergence of multidrug-resistant strains.4,5 Antibiotic resistance is increasing in obligatory anaerobic bacteria, with clindamycin, cephalosporin, and penicillin resistance discovered in both major and  small hospitals6. Before administering antibiotics, the benefit-to-risk ratio should always be considered. Certain patients will benefit from antibiotics, particularly those delivered systemically. In endodontic clinical therapy, antibiotics should be administered conservatively and judiciously; nonetheless, indiscriminate use (patients with pulpitis but no infection) is against basic medical practices. This could lead to a selective pressure and an increase of naturally hardy bacteria, exposing people to super and secondary infections and rendering therapies ineffective against potentially fatal infectious diseases.7,1
Prescription is a dynamic, customized clinical process, which is set owing to the necessities of patient & the acquaintance of the practitioner.8 Prescription writing is considered as necessary determinant of a medical or dental practitioner and has been part of the syllabus during their graduation.9 It is also an obligatory skill for doctors of all specialities.10
Dentists prescribe various drugs for a number of situations. If these medications are not recommended accordingly, they might cause damage to patient. Adverse medication events are stated to have been linked withmistake or incorrect writing of the prescription.11,12 Even if none of these instances end in death, they may induce morbidity in a certain individual. The act of suggesting has gotten increasingly difficult in recent years for a variety of reasons.
Prescription mistakes are classified into two types: prescription writing errors and decision-making errors. While the latter may consist of errors, such as overprescribing, under prescribing, inappropriate prescribingand irrational prescribingwhilethe formeremphases on errors made during writing of a prescription.13,14 Several studies have found poor prescription by students and junior practitioners, with some of the blame being assigned to knowledge or information-based errors.15,16 The goal of this study was to assess and evaluate house officers’ expertise of providing antibiotics for root canal therapy, as well as the errors they made.

METHODOLOGY
Forty Multan Dental College house officers took part in this survey-based study. A survey form was developed to collect information on the reasons for prescribing antibiotics as well as the circumstances in which House officials recommended them. To collect data, the universal sampling approach was utilized. The questionnaire assessed house officers’ understanding of antibiotic prescription indications for a wide range of clinical symptoms associated with oral cavity infections. Malaise and fever were clinical markers, as were scattered edoema, indications of systemic spread, and swallowing difficulties. Participants were also asked if they had any clinical cases in which antibiotics were required, as well as what therapy they favoured, if any. Acute apical abscess, acute pulpitis, chronic apical periodontitis, and long-term apical swelling with sinus tract were the clinical situations studied. Factors influencing antibiotic prescriptions were also explored. The questionnaire asked if the patient’s expectation of receiving an antibiotic, multiple visit root canal procedures, single visit RCT, or retreatment may be the reason for the antibiotics being prescribed. The second section of the questionnaire assessed/evaluated knowledge of medical circumstances and oral procedures that may require prophylactic antibiotics. The oral procedures were all randomized controlled trials, including pre and post endodontic surgeries; the medical conditions included hepatitis B, HIV, congenital heart diseases, mitral valve prolapsed, uncontrolled diabetes, and patients who had prosthetic joints in the previous two years or those reporting a history of radiotherapy and cancer. The data obtained was collated and examined.

RESULTS
This study included 24 females and 16 males (Table 1). The most incidence of antibiotic prescription was reported for acute abscess of periapical area of the tooth (62.8%) and patient having fever with malaise (62%). Antibiotic prescription for Chronic apical abscess and Chronic periodontitis with sinus tract is 58%. and 55% respectively

Patients with swelling & difficulty in swallowing (58%) while 33% was reported during prolong root canal treatment. Overall, 12% of partakers always suggested antibiotics for root canal treatment.
In the study mostly antibiotics were prescribed as prophylactic measures for congenital heart diseases 69.7%, and 62.8% is for poorly controlled diabetes mellitus. Participants prescribed Prosthetic joint in past 2 years 4 6.5% & Mitral valve prolapsed 34.9%. Graph 2

DISCUSSION
The majority of oral issues are inflammatory conditions that produce pain. In many cases, chronic or acute infections of the pulp produce oral pain, needing surgical surgery rather than medications. Antibiotics are not always required to treat endodontic source problems1.Amoxicillin + clavulanic acid (52.6%) and Amoxicillin alone (47.3%) were the drugs of choice in this study, which is similar to other studies in which Amoxicillin was the medicine of choice 57.6% & 46.47% 17,18. Clindamycin was usually the last choice in this study. These findings are congruent with those of Fahad et al and Jain A et al, who discovered that amoxicillin was the most often suggested antibiotic, whereas clindamycin was rarely used.19,18
Antibiotics were predominantly administered for acute apical abscess (62.8%) in our study, which differs with the findings of M Reza et al, who utilised antibiotics for apical/dental abscess (74% & 71%, respectively).17,19 This finding is similar with another study20, which found that antibiotics were given to 62.6% of participants with peri-apical abscess. Our survey found that 62% of patients with malaise and fever were given antibiotics, which is similar to another study that found that 57% of patients with fever were given antibiotics.19 In this investigation, 25.5% contributors suggested antibiotics for acute pulpal inflammation which is twofold as reported by Palmer et al where 12.5% of participants advised antibiotics for acute pulpitis21 and this is three fold as compared to another study (8.2%).20 Antibiotics may not be needed and may not help critical pulp situations when there are no symptoms of systemic or local involvement/infection22, in contrast to the current study in which antibiotics were taken for pulpal disorders by the majority of individuals.
Debridement of the root canal space is the recommended therapy for irreversible pulpitis. Non-surgical root canal treatment without antibiotics is often sufficient to treat chronic apical periodontitis, acute pulpitis, irreversible pulpitis, and draining sinus area. The pulpal circulation/flow is frequently disrupted in these situations, and systemic antibiotics may not reach the required therapeutic concentrations inside the pulp.23 A thorough non-surgical root canal treatment might eradicate the source of the infection and typically allow healing of the peri-radicular lesion. Nonetheless, analgesics are used for  peri-apical diseases and pulpitis pain.17
58% of partakers of this study specified the use of antibiotics in Chronic apical abscess with sinus tract which is two times that of reported in another study.55% of partakers of this study specified the use of antibiotics in Chronic apical abscess with periodontitis which is far greater than that reported in another study.24 Results of this study stated that 33% participants give antibiotics during the root canal treatment which is like the result of other study where 35.2% partakers wrote antibiotics during RCT.20 About 11.6% of defendants used to recommend antibiotics afterward root channel treatment. For peri-apical chronic lesions and chronic peri-apical abscess with sinus tracts, fifty eight percent & fifty five percent respondents recommendedan antibiotic respectively which is similar to the results stated by Nabavezadeh et al(58% and 73.1%) respectively.14 Our study showed that 55% subjects gave antibiotics apical abscess with periodontitis which is like the result of other study where 58% partakers wrote antibiotics as an adjunct.19
13.9% participants of this study advice medicine before RCT which is quite similar to another study which indicates 11.4%. 41.9% participants of this study advice antibiotics for HIV+ patients. This is in accordance with the other study where 58% of dentists stated prescribing antibiotics. In the current study, 25.6% of patients with a history of carcinoma and chemo/radiotherapy were prescribed antibiotics. This figure is lower than that reported by Yousufi S (40.6%).20 Our
study found that 69.7% of individuals were given preventive antibiotics for congenital heart disease, which is somewhathigher than the number reported in another study, which was 6019. 34.9% participants reported that we prescribe prophylactic
antibiotics for mitral valve prolapsed patients which is alike with the study conducted by Fahad et al who reported 35%19. 14% subjects reported that they gave antibiotics if patients insist which is less than observed by Liaquat A et al (70%).25
Prophylactic antibiotic treatment is recommended only for patients who are at high risk of developing infective endocarditis following bacteremia. The use of prophylactic
antibiotics by these patients prevents blood-borne microorganisms from colonising shunts and prostheses or
spreading within a compromised system. Prophylactic antibiotics are required for patients with prosthetic mitral valve prolapses, uncontrolled diabetes, and inherited heart conditions (AV shunt and cardiac valve replacement) during endodontic  treatment1. Although antibiotic prophylaxis prior to endodontic therapy is not routinely recommended for healthy patients following prosthetic joint replacement, it should be considered during the first three months after the joint replacement.26,27
According to our current study, house officers at Multan Dental College use antibiotics improperly, which can lead to issues such as resistant microorganisms, drug resistance, and other negative results. This examination resulted that knowledge for the use of antibiotics is far from ideal. This was also reported in the Wali A study.28
In endodontics, the routine uses of antibiotics either systemic or local, is still a debatable issue.29 According to one study, dentists must administrate the antibiotics according to the guidelines, only if therapies or treatments require it.30 Antibiotic abuse is a major worldwide issue.31 Prescriptions must be logical and supported by extensive evidence-based knowledge. Medical and dental students, as well as healthcare workers, must be aware of the various aspects of the drugs prescribed in order to effectively treat the illness for which the drug was prescribed.32 According to evidence33, antibiotics may provide both benefits and harm in certain situations. Antibiotics, particularly broad-spectrum antibiotics, are commonly used in dentistry.34 Many studies on antibiotic prescription in dentistry have found that overuse is a global problem.35 Antibiotics may be used more frequently in endodontics.36 The publication of recommending protocols and guidelines may help to achieve better results, and appropriate educational intervention may also be effective. The use of computers and clinical audits, as well as additional tools to increase antibiotic prescription knowledge and improve and increased patient care, should always be considered.

CONCLUSION
We conclude that here is deficiency of information & knowledge for the proper indication, kind, and antibiotics dose. Different educational activity like symposium or lectures should be practiced to teach the practitioner to prescribe antibiotics. The curriculum and syllabus should place a strong focus on prescribing, and appropriate medication prescription should be learnt through clinical rotations utilizing hypothetical or actual instances.

LIMITATIONS
Sample size is very small. Multiple institutes were not included in the study. Different institutes delivered different level of knowledge to the students. Public institutes must be included in the future studies. Level of house officers were not mentioned in the study because as experience of the house officers’ increases, level of education must increase.

CONFLICT OF INTEREST
None declared

REFERENCES
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2. Rauniar GP, Roy RK, Das BP, Bhandari G, Bhattacharya SK. Prescription Writing Skills of Pre-Clinical Medical and Dental Undergraduate Students. J Nepal Med Assoc. 2008; 47:197-200.
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3. Guzmán-Álvarez R, Medeiros M, Reyes Lagunes LI, CamposSepúlveda AE. Knowledge of drug prescription in dentistry students. Drug, Healthcare and Patient Safety. 2012; 4:55-9.
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4. Patel R: Clinical impact of vancomycin-resistant enterococci. J Antimicrob Chemother 51(Suppl 3):13, 2003.
https://doi.org/10.1093/jac/dkg272

5. Puttaswamy S, Gupta SK, Regunath H, Smith LP, Sengupta S. A comprehensive review of the present and future antibiotic susceptibility testing (AST) systems. Arch ClinMicrobiol. 2018;9.
https://doi.org/10.4172/1989-8436.100083

6. Fair RJ, Tor Y. Antibiotics and bacterial resistance in the 21st century. Perspectives in medicinal chemistry. 2014;6: PMC-S14459. 25-64
https://doi.org/10.4137/PMC.S14459

7. CDC. Antibiotic Use in the United States, 2017: Progress and Opportunities. Atlanta, GA: US Department of Health and Human Services, CDC; 2017.

8. Ashraf H, Pasha M, Nayyer M, Aslam A, Kaleem M. Drug Prescription Among Dental Students: A Survey of Current Knowledge and Awareness. Pak Oral Dent J. 2018;38:503-7

9. Parihar A, Sharma A, Malhotra P, Sharma D. Assessment of Prescription Writing Skills Among Undergraduates of a Medical College in North India. JK Science. 2018;20:67-72

10. Mahmood A, Tahir MW, Abid AN, Ullah MS, Sajjid M. Knowledge of drug prescription in dental students of Punjab Pakistan. Pakistan J Medi
Health Sci. 201812: 232- 7.

11. Tariq RA, Vashisht R, Scherbak Y. Medication errors. Stat Pearls [Internet]. 2020 Jun 15.

12. Lee BH. Minimizing prescription writing errors: Computerized prescription order entry. John Hopkins Medical Institutions 2006;1-10.

13. Alanazi MA, Tully MP, Lewis PJ. Prescribing errors by junior doctorsA comparison of errors with high risk medicines and non-high-risk medicines. PloS one. 2019;14: e0211270.
https://doi.org/10.1371/journal.pone.0211270

14. Aronson JK. Medication errors: definitions and classification. Br J Clin Phar. 2009;67:599-604.
https://doi.org/10.1111/j.1365-2125.2009.03415.x

15. Harding S, Nicky B, David B. The performance of junior doctors in applying cl inical pharmacology knowledge and prescribing skills to standardized clinical cases. Br J Clin Phar 2010;69:598-606.
https://doi.org/10.1111/j.1365-2125.2010.03645.x

16. Ross S, Bond C, Rothnie H, et al. What is the scale of prescribing errors committed by junior doctors? A systematic review. Br J Clin Phar 2008;67:629-40.
https://doi.org/10.1111/j.1365-2125.2008.03330.x

17. Nabavizadeh MR, Sahebi S, Nadian I. Antibiotic Prescription for Endodontic Treatment: General Dentist Knowledge + Practice in Shiraz. Iran Endod J 2011;6:54-59

18. Jain A, Gupta D, Singh D, Garg Y, Saxena A, Chaudhary H, et al. Knowledge regarding prescription of drugs among dental students: A descriptive study. J basic and clinical pharmacy. 2015 ;7:12.
https://doi.org/10.4103/0976-0105.170584

19. Ismail F, Qazia S, Sajjada A. Antibiotics Prescription Habits and Knowledge of Dentists in A Lahore Sample. Pak Oral Dent J. 2018;38:79- 84.

20. Yousufi S, Israr Y, Zaman S. Use of Antibiotics in Dental Teaching Hospitals of Peshawar, Pakistan: How Justified Are We. Int J Dent Oral Health. 2019; 5:68-73.

21. Palmer NA, Dailey YM, Martin MV. Can audit improve antibiotic prescribing in general dental practice? Br Dent J 2001; 191:253-5. https://doi.org/10.1038/sj.bdj.4801156a

22. Walton R: Endodontic Emergencies and Therapeutics. In: Torabinejad M, Walton R, editors. Endodontics principles and Practice, 4th Edition. St. louis: CV Saunders, 2009:153-4.

23. Segura-Egea JJ, Gould K, Sen BH, Jonasson P, Cotti E, Mazzoni A, et al. Antibiotics in Endodontics: a review. Int Endodontic J 2017;50:1169- 84.
https://doi.org/10.1111/iej.12741

24. Salvadori M, Audino E, Venturi G, Garo ML, Salgarello S. Antibiotic prescribing for endodontic infections: a survey of dental students in Italy. Int Endodontic J. 2019;52:1388-96.
https://doi.org/10.1111/iej.13126

25. Liaquat A, RCSI F, Tayyab TF, Saeed T. Are Dentists Prescribing the Antibiotics in Justified Conditions? An Exploratory Study. JPDA. 2020;29:120-123.
https://doi.org/10.25301/JPDA.293.120

26. Segura-Egea JJ, Gould K, Sen BH, Jonasson P, Cotti E, Mazzoni A, et al. European Society of Endodontology position statement: the use of
antibiotics in endodontics. Int Endodontic J. 2018;51:20-5.
https://doi.org/10.1111/iej.12781

27. Sollecito TP, Abt E, Lockhart PB, Truelove E, Paumier TM, Tracy SL, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: evidence-based clinical practice guideline for dental practitioners-a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2015;146:11-6.
https://doi.org/10.1016/j.adaj.2014.11.012

28. Wali A, Ali A, Siddiqui TM, Jafri H. Assessing prescription writing skills of House officers in Dental teaching hospitals of Karachi, Pakistan. World J Dent 2012;3:294 96
https://doi.org/10.5005/jp-journals-10015-1176

29. Nandakumar M, Nasim I. Use of Antibiotics in Endodontics-Clinical Practice Guidelines. Research J Pharmacy Technology. 2019;12:419-24.
https://doi.org/10.5958/0974-360X.2019.00076.3

30. Guerrini L, Monaco A, Pietropaoli D, Ortu E, Giannoni M, Marci MC. Antibiotics in dentistry: a narrative review of literature and guidelines considering antibiotic resistance. Open Dent J. 2019 ;13.
https://doi.org/10.2174/1874210601913010383

31. Iqbal MT, Ahmed MH, Omar N, Ahmed MR, Fahad M, Ali M, et al. Antibiotic Resistance: KAP Study on Medical and Non-Medical Students of Lahore, Pakistan. Pak J Public Health. 2020;10:24-31.
https://doi.org/10.32413/pjph.v10i1.504

32. Shahroom NS, Lakshmi T, Roy A. Knowledge of drug prescription among dental and medical student in India-an online survey. J Adv Pharm Educ Res|. 2017;7.

33. Lockhart, P.B., Tampi, M.P., Abt, E., Aminoshariae, A., Durkin, M.J., et al 2019. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal-and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. J Am Dent Assoc, 150(11), pp.906-921.
https://doi.org/10.1016/j.adaj.2019.08.020
34. Anjum MS, Parthasarathi P, Monica M, Yadav K, Irram A, Keerthi T, et al. Evaluating the knowledge of interns in prescribing basic drugs used in dentistry-a cross-sectional study. Webmed Central Pharmacol 2014;5: WMC004540.

35. Teoh L, Marino RJ, Stewart K, McCullough MJ. A survey of prescribing practices by general dentists in Australia. BMC Oral Health.
2019;19:1-8.
https://doi.org/10.1186/s12903-019-0882-6

36. Bansal R, Jain A, Goyal M, Singh T, Sood H, Malviya HS. Antibiotic abuse during endodontic treatment: A contributing factor to antibiotic resistance. J Family Medicine and Primary Care. 2019;8:3518-24
https://doi.org/10.4103/jfmpc.jfmpc_768_19

Maxillary impacted canine is most frequent impaction after third molar and its prevalence ranging from 1 to 2%.1 Two most common types of impaction of maxillary canine are buccal and palatal. Palatal impacted maxillary canine (85%) is more common than buccal one (15%).2 Impacted canine is more common in maxillary arch as compared to the mandibular arch. In about 8% bilateral canine impaction is found.3
Hypodontia and congenital missing teeth are the terms used for lack of development of one or more teeth in the primary or permanent dentition.4 The most common missing teeth are third molars followed by mandibular second premolars and then upper lateral incisors.5 The prevalence of tooth agenesis excluding third molar is ranging from 0.2 to 16.2%. Females are more affected by tooth agenesis.6 Lateral incisors are associated with anomalies like absence and peg shape. Two theories (guidance and genetic) explains the cause of palatally displaced maxillary canines.7 According to guidance theory canine erupt along the root of lateral incisors and when lateral incisor is missing or anomalous, the canine are unable to erupt.8
Jena and Duggal9 conducted a study and reported that there is an association between palatally impacted maxillary canine and missing or anomalous lateral incisors .Becker et al. reported that 5.5% had congenitally missing lateral incisor among cases having palatally impacted canine.10
Genetic and environmental factors have prime role in tooth anomalous. There is lack of local literature on association of palatally impacted maxillary canine and anomalous lateral incisors in our population. This study will help to know etiologic role of anomalous lateral incisors in maxillary canine impaction.
The objective of this study was to determine the association between palatally impacted maxillary canine and anomalous upper lateral incisor.

METHODOLOGY
This case control study was conducted at department of Dental Radiology, Saidu College of Dentistry, Saidu Sharif Swat using records of 60 patients (30 controls and 30 cases) by using the non-probability consecutive sampling technique. Participants with palatally impacted canine were taken as cases and participants without impacted canine were used as controls. Ethical approval was obtained from hospital review committee(15/SCD/Swat/ethical).
The inclusion criteria were participants without syndromes, palatal canine impaction (cases only), and age range from 12 to 30 year. Subjects with buccal impacted canine, history of previous orthodontic treatment and non-Pakistani nationals were excluded. Participant’s OPG and periapical X-rays were used to diagnose PIC by horizontal parallax technique. Dental anomalies in upper lateral incisor like missing and peg shaped were further diagnosed by using casts and OPGs

The data were analyzed using SPSS 22. Mean and SD were calculated for continuous data like age and frequency and percentages for categorical data like gender and anomalies of upper lateral incisors. Chi-square /Fisher exact test was run to compare anomalies of upper lateral incisors between cases and control. To quantify the degree of association the odds ratio with 95% confident intervals was calculated by binary logistic regression between dependent variable (anomalies in lateral incisor) and independent variable (palatally impacted canine). P<0.05 was considered as significant level.

RESULTS
The mean age of the study participants was 18.916±4.3 years and ranging from 13 to 29 years. Females (n=33, 55%) were more than males (n=27, 45%). The frequency of missing lateral incisor was higher in cases (n=3, 10%) than control (n=1, 3.3%). Similarly peg shape laterals were more in cases
(n=4, 13.3%) than controls (n=2, 6.7%). However the association was not statistically significant (P=0.37).(Fig 2)

DISCUSSION
This case control study was aimed to determine the association between palatally impacted maxillary canine and anomalies in upper lateral incisor. Our findings showed that though the frequency of lateral incisor’s anomalies are higher in participants with palatally impacted canine than normal but this association was not statistically significant (P=0.37). The logistic regression analysis showed that odds of having lateral incisors anomalies were about three times higher but this was not significant statistically. Our results showed that association between anomalies in lateral incisor and palatally impacted canine was positive (OR=2.73) and not statistically significant. According to guidance theory maxillary canine erupt by taking guidance from root of lateral incisor.11 A study conducted by Laganà et al.12 in Italy on 336 subjects on association of displaced maxillary canine and anomalous lateral incisors. They found a statistically significant and positive association (OR=1.139, 95%= 1.43-4.15%). The non-significance of our results can be due to less number of participants in our study. Other studies also found evidence for association of PIC with upper laterals agenesis.13,14
In our study missing lateral incisor was 10% in controls and 13.3% in cases. A previous study conducted in Rawalpindi reported that agenesis of lateral incisor was 6.7% in controls and 13.3% in cases. These results support our findings.15 Another study by Garib et al.16 reported that there was 18.9% upper lateral incisor hypodontia in cases with unilateral palatal canine impactions. Another investigation by Zilberman et al.17 reported 5.5% congenitally absent upper laterals in cases with PIC. Peck and Peck found 3.4% missing maxillary lateral incisors in association with palatally impacted canines.18 Another study found 7.23% congenitally absent upper laterals incisors with palatally impacted canines.19
The current study showed that peg shaped laterals were more in cases (13.3%) than controls (6.7%). However the association was not statistically significant (P=0.37). Similar results were reported by previous study conducted in Pakistan.15

CONCLUSION
Within the limits of this study we can conclude that though the frequency of anomalous maxillary lateral incisors is higher in participants with palatal impacted canine than controls but this association was not statistically significant.

CONFLICT OF INTEREST
None declared

REFERENCES
1. Ngo CTT, Fishman LS, Rossouw PE, Wang H, Said O. Correlation between panoramic radiography and cone-beam computed tomography in assessing maxillary impacted canines. Angle Orthod. 2018;88:384- 9.
https://doi.org/10.2319/103117-739.1

2. Yan B, Sun Z, Fields H, Wang L. Maxillary canine impaction increases root resorption risk of adjacent teeth: a problem of physical proximity. Am J Orthod Dentofacial Orthop. 2012;142:750-7.
https://doi.org/10.1016/j.ajodo.2012.07.016

3. Dogramaci EJ, Sherriff M, Rossi-Fedele G, McDonald F. Location and severity of root resorption related to impacted maxillary canines: a cone beam computed tomography (CBCT) evaluation. Austral Orthod J. 2015;31:49-59.
https://doi.org/10.21307/aoj-2020-140

4. Cabay RJ. An overview of molecular and genetic alterations in selected benign odontogenic disorders. Archive Pathol Labor Med. 2014;138:754-8.
https://doi.org/10.5858/arpa.2013-0057-SA

5. Agrawal P, Manohar S, Thorne-Lyman AL, Angela K, Shrestha B, Klemm RD, et al. Prevalence of damaged and missing teeth among women in the southern plains of Nepal: Findings of a simplified assessment tool. PloS one. 2019;14:e0225192.
https://doi.org/10.1371/journal.pone.0225192

6. Cruz RM. Orthodontic traction of impacted canines: Concepts and clinical application. Dent Press J Orthod. 2019;24:74-87.
https://doi.org/10.1590/2177-6709.24.1.074-087.bbo

7. Alqahtani H. Management of maxillary impacted canines: A prospective study of orthodontists’ preferences. Saudi Pharmac J. 2021;29:384-90.
https://doi.org/10.1016/j.jsps.2021.03.010

8. Manne R, Gandikota C, Juvvadi SR, Rama HRM, Anche S. Impacted canines: Etiology, diagnosis, and orthodontic management. J Pharm
Bioallied Sci. 2012;4(Suppl 2):S234.
https://doi.org/10.4103/0975-7406.100216

9. Jena AK, Duggal R. The pattern of maxillary canine impaction in relation to anomalous lateral incisors. J Clin Pediatr Dent. 2010;35:37- 40.
https://doi.org/10.17796/jcpd.35.1.uh4vm67264vv4762

10. Becker A, Smith P, Behar R. The incidence of anomalous maxillary lateral incisors in relation to palatally-displaced cuspids. Angle Orthod. 1981;51:24-9.

11. Bertl MH, Foltin A, Lettner S, Giannis K, Gahleitner A, Bantleon H-P, et al. Association between maxillary lateral incisors’ root volume and palatally displaced canines: An instrumental variables approach to the guidance theory. Angle Orthod. 2018;88:719-25.
https://doi.org/10.2319/020818-107.1

12. Laganà G, Venza N, Lione R, Chiaramonte C, Danesi C, Cozza P. Associations between tooth agenesis and displaced maxillary canines: a cross-sectional radiographic study. Prog Orthod. 2018;19:1- 6.
https://doi.org/10.1186/s40510-018-0226-0

13. Krishnaveni S, Reddy YM, Sreekanth C, Reddy BV, Kranthi G, Raj P, et al. Nasal Integument as an Indicator of Maxillary Skeletal
Pattern. Int J Oral Health Med Res 2017;3:31-5.

14. Amit G, Pankaj B, Suchinder S, Parul B. Periodontally accelerated osteogenic orthodontics (PAOO)-a review. 2012.
https://doi.org/10.4317/jced.50822

15. Enlow DH, Hans MG. Essentials of facial growth Philadelphia: WB Saunders; 2008.

16. Scott J. The cranial base. Am J Phys Anthropol. 1958;16:319-48.
https://doi.org/10.1002/ajpa.1330160305

17. Bhushan R, Kumar S, Chauhan AK, Mohan S, Shekhar M, Narnoly A. Assessment of the relationship between maxillary rotation and nasal morphology in males. Contemp Clin Dent. 2015;6(Suppl 1):S12-S7.
https://doi.org/10.4103/0976-237X.152931

18. Peck S, Peck L, Kataja M. Prevalence of tooth agenesis and pegshaped maxillary lateral incisor associated with palatally displaced canine (PDC) anomaly. Am J Orthod Dentofac Orthop 1996;110: 441-43.
https://doi.org/10.1016/S0889-5406(96)70048-3

19. Leifert S, Jonas IE. Dental anomalies as a microsymptom of palatal canine displacement. J Orofac Orthop 2003;64:108-20.
https://doi.org/10.1007/s00056-003-0222-x

small head). The results of this 8 day trial period revealed that the toothbrushes had no significant effect on removal of debris and plaque when compared to each other but, following tooth brushing, twice daily, a significant reduction of plaque was seen.

DISCUSSION
WHO defines disability as “any restriction or lack (resulting from any impairment) of ability toperform activity in the manner or within the range considered normal for a human being”. Of the total population of the world approximately 15% (about one billion) fit the aforementioned definition with a mild, moderate or severe nature. 93 million of these are children.10
People with disabilities face alot of oral health discrepancies.11 Oral health is ignored due to other serious systemic conditions, disability or limited access to healthcare.
Furthermore, disabled people present specific challenges during oral health assessment due to their limited ability to perform certain functions and undergo oral examinations.12 Modification to the treatment plan is required to provide adequate dental health care to such patients. There is a general unanimity that powered toothbrushes are equally safe as manual toothbrushes.13 To remove plaque buildup from teeth and gums, bristles of apowered toothbrush vibrate and rotate. The vibration consists of micro-movement every time the toothbrush is moved across the teeth.14 According to a study significantly different results are seen regarding effectiveness of poweredtoothbrush for plaque removal.15 The results of our study showed that there was no
significant difference in plaque reduction between manual and powered toothbrushes (P value =0.78) which clearly indicates that manual tooth brushes are as effective as powered toothbrushes even in disabled subjects. Turesky’s modified Quigley-Hein index was utilized due to its ability to better assessplaque buildup as well as better assessment of interproximal areas for plaque.8 These results were comparable to the study done by Goyal et al, who also found there to be no significant difference in mean plaque scores in mentally disabled children (P>0.05).14 Some clinical trials proved superiority of manual toothbrushes over powered16 showing inconsistency with our results. However, another study showed that, if used properly, manual toothbrushes were able to remove plaque effectively.17 A recent amendment of the Cochrane report on this topic concluded that the only type of powered toothbrush which removes more plaque than a manual toothbrush is one with rotational oscillatory movements.18 A few studies affirmed the advantage of powered toothbrushes over manual toothbrushes while other studies reported there to be no such difference.19,20
In their systematic review, Vibhute and Vandana, statistically found no significant difference between powered and manual toothbrushes.21 Yaacob et al. in a systematic review found powered toothbrushes to be more successful in reducing plaque and decreasing gingivitis in comparison
to manual toothbrushes.22 Difference in results might be because of larger sample size, decision of records, arrangement of dental prophylaxis during the investigation and diverse dissemination in groups.23
In our study with manual and powered tooth brushes, after 8 days, mean plaque score were 0.56+ 0.72 and 0.72+ 0.78 respectively. These results were lower than
the results concluded by Neelima (1.93 ± 0.5 and 1.96 ± 0.4)24 and Williams et al (post brushing manual = 0.62 ± 0.03, post brushing powered = 0.93 ± 0.03).25 The differences in the results of our study with previous studies can be due to a number of reasons, such as; limited number of studies on subjects with disabilities, some of which are old or focused on old toothbrush technologies and have different methodologies such as choice of indices, differences in study design, selected populations and materials and methods. However, powered toothbrushes might be more beneficial in subjects who require help in brushing teeth due to limited dexterity and debilitation. Compliance was seen as acceptable with no antagonistic results reported in the current examination.
One of the limitations of this study was the small sample size and a limted duration of data collection. It is required that further research with a bigger sample size be done to have more accurate results

CONCLUSION
Based on study, we concluded that Oral health is given low importance among special need subjects. This may be because of a dearth of oral health and hygiene awareness
among parents or caregivers. We concluded that no notable difference was observed in plaque-removing effectiveness between powered and manual toothbrushes among differently abled participants in single brushing. We found a significant reduction in plaque post-brushing compared to pre-brushing in both these groups. Keeping in mind all the factors that led to insignificant results, we suggest that trials having longer durations and larger sample size are required to get a more clear outcome. Furthermore, it is prudent to design oral health awareness programs focusing on the needs of the population with disabilities. This will not only reduce the burden on our health care system but will also reduce the cost of treatment and improve the quality of life of special needs individuals.

ACKNOWLEDGEMENTS
No Grant or other financial support was taken; Authorsdeclare no commercial interests.

CONFLICT OF INTEREST
None declared

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