Amna Sohail BDS, BSc
Azka Yaseen BDS, BSc, PDAGD
Samir Riaz Qazi BDS, FFDRCSI, M.Phil
OBJECTIVES: The objective of this survey was to assess the level of common knowledge and practices concerning usage of antibiotics among dental patients.
METHODOLOGY: A descriptive questionnaire-based survey was done consisting of fifteen questions at the Institute of Dentistry, CMH Lahore Medical College.
RESULTS: Sample included 500 dental patients, 237 males (48.2%) and 255 females (51.8%). Participants were divided into various groups; less educated (up to matriculation level), more educated (above matriculation level), low-income (<25000 PKR monthly) and high-income (25000 PKR and above monthly).
Majority (61.8%) of the sample thought antibiotics have antiviral effects. Three-fourth (75.5%) of the sample thought antibiotics have an analgesic effect while (67.3%) thought antibiotics should be prescribed post-extraction.
Thirty-eight percent thought that antibiotics should be taken before any dental work while more than half (54.7%) knew that antibiotics have side effects. Majority (74.5%) knew that unnecessary use of antibiotics make them ineffective leading to antibiotic resistance. In the sample, (90.7%) believed it was important to complete the course of antibiotics prescribed by dentist but (43%) used to discontinue antibiotics on feeling better. Twenty six percent of the sample considered homeopathic medicine more effective than antibiotics for treatment of infections.
Self-medication was reported by (42.3%) and (41.1%) used antibiotics prescribed by pharmacists at some point in their lives.
CONCLUSION: Patients’ knowledge about antibiotics was inadequate, antibiotics misuse was widespread and high selfmedication rates were reported.
KEYWORDS: Antibiotics, Self-medication, Antimicrobial resistance, Patient, Knowledge, Dentistry.
HOW TO CITE: Sohail A, Yaseen A, Qazi SR. Knowledge and practices of patients regarding antibiotics used for dental problems. J Pak Dent Assoc 2020;29(2):71-76.
DOI: https://doi.org/10.25301/JPDA.292.71
Received: 29 June 2019, Accepted: 28 February 2020
INTRODUCTION
Antibiotics are commonly used as well as misused drugs in the world, particularly in developing countries.1
In dentistry, there is evidence to suggest over-prescription of antibiotics by dental practitioners in the management of acute dental conditions, despite contrary clinical guidelines.2 This might be due to uncertainty about diagnosis, demand and expectations of patients, and because of the pressure of time on the clinician.3 Patient expectations increase the possibility of receiving a particular prescription by three times.4 Inappropriate antibiotic prescribing habits lead to the development of resistant bacterial strains.5 Centers for Disease Control US (CDC) estimates that at least 30% of oral antibiotic courses prescribed in the outpatient setting during 2010-11 were unnecessary.6
In an English study, general dental practitioners (GDPs) reported that their decisions in antibiotic prescribing were compelled by both clinical related pressures and wider responsibilities towards public health.7
Over the years, misuse of antibiotics has resulted in the emergence of antibiotic-resistant bacterial strains which are
intensifying with time8 and caused death of around 23,000 people in US.9 Dentists in primary care make up approximately one in ten of all therapeutic antibiotic prescriptions, hence contributing to the problem of bacterial resistance.10
In addition to these inappropriate prescribing habits of doctors, self-medication or the use of un-prescribed drugs is common practice around the globe.11 Factors that lead to self-medication include high cost of medicines, inaccessibility to health facilities12, having minor illness, high health care costs, lack of adequate time to visit a physician, prior experience in using a drug, and long waiting time to visit a qualified practitioner.13,14
Self-medication with antibiotics ranges from 2% to 92% in different countries, with the most frequent self-medicated prescription-only medicine being antibiotics.15
In Pakistan, little research has been carried out in the past regarding antibiotics misuse by patients. By evidence the proportion of self-medicating individuals is alarmingly high.24 This problem has been related to illiteracy, ignorance, lack of legislation regarding the use of prescribed drugs, poor socioeconomic status, dental phobia, no health insurance, unavailability of quality dental clinics, and availability of homeopathic drugs.24 Prescription of medicines by nondoctors also contributes to the misuse of antibiotics.25 This study was aimed at examining common knowledge and practices concerning usage of antibiotics among dental patients. The findings of this study may, thus, help initiate effective interventions to decrease misconceptions about the antibiotics use in the region.
METHODOLOGY
A descriptive cross-sectional questionnaire-based survey was conducted among patients presenting in Out-patient
Department (OPD) of Institute of Dentistry, CMH Lahore Medical College in order to assess their knowledge and practices concerning antibiotics and its resistance. Permission was sought from the IRB (4187/IOD/CMH) before carrying out the survey.
The questionnaire was translated into Urdu and retranslated back into English and modified as required. It was then piloted on 10 patients and revised again. The purpose of this study was discussed with participants, any ambiguities
cleared, and verbal consent was taken. Filled forms were collected immediately. The study included 500 respondents. All patients, age 13 and above, presenting in the OPD were included in the study. The mean age of respondents was 35.3 years (minimum age=13, maximum age=85, Table 1). There were 237 (48.2%) males and 255 (51.8%) females in the study (8 missing). The participants were divided into various groups such as; Less educated (up to matriculation level, 36.8%), More educated (above matriculation level, 63.2%), Low-income (<25000 PKR monthly, 40.1%) and Highincome (25000 PKR and above monthly, 59.5%) groups (Table 1). Data collected in this study was analyzed using IBM SPSS v23 (IBM Corp, USA, 2017). The level of statistical significance was set at P < 0.05.
RESULTS
There were 500 respondents in this study. The mean age of respondents was 35.3 years (SD=13.3, median age=32, minimum age=13, maximum age=85, Table 1). There were 237 (48.2%) males and 255 (51.8%) females in the sample (8 missing). Participants were divided into various groups; Less educated (36.8%), More educated (63.2%), Low-income (40.1%) and High-income (59.5%) (Table 1). The most
Table 1: Demographics of study participants (missing: 8)
frequent occupation was housewife (36.2%) followed by private job (17.2%), and self-employed (9.2%).
In the study, a vast number (82.7%) of respondents were aware of the fact that antibiotics can kill bacteria. But majority (61.8%) of the sample thought antibiotics have antiviral effects despite of any gender, education or income group (P=0.050, Table 2). Three-fourth (75.5%) of the sample thought antibiotics have an analgesic effect. Significantly more of the less educated participants had this thought than more educated ones (81.8% vs. 71.8%, P=0.049, Table 2). Augmentin (32%) and Amoxil (24%) were the most commonly misused antibiotics for pain relief.
A large number (67.3%) of the respondents were of the view that dentists should prescribe antibiotics post-extraction
where majority of the respondents were from low income group (78.3%) and seem to be unaware about the role of
antibiotics after extraction of tooth/teeth (Table 2). Comparatively lesser number of respondents (38%) were of
the opinion that antibiotics should be taken before going for any dental work which included significantly high number of females as compared to males (43.2% vs 32.3%, P=0.048) and low income group as compared to high income group (43% vs 30.2%, P=0.021) (Table 2).
More than half (52.8%) of the sample thought that antibiotics can cause allergic reactions including (54.2%) of more educated people (Table 2). While (54.7%) thought that antibiotics can have side effects such as diarrhea. Significantly high difference was seen among more educated people with high income as compared to less educated people with low income (58.8% vs 47.5%, P=0.052 and 59.8% vs 47.1%, P=0.021 respectively, Table 2).
Majority (74.5%) of the sample knew that unnecessary use of antibiotics can make them ineffective leading to antibiotic resistance. Significantly high frequency of the more educated and high income groups were aware of this phenomenon as compared to less educated and low income groups (79.7% vs 65.4%, P=0.002 and 79.8% vs 69.2%,
p=0.028 respectively, Table 2).
In the sample, a vast number (90.7%) of respondents, despite of any gender, education or income group, were aware about the importance of completing the course of antibiotics prescribed by dentist (Table 2). But (43%) of the sample used to discontinue further antibiotics on feeling better before completion of course (Table 3). Twenty six percent of the sample considered homeopathic medicine to be more effective than antibiotics for treatment of infections, with significantly more participants of less
educated and low income groups as compared to the
participants of more educated and more income groups
(34.4% vs 21.3%, P=0.004 and 30.5% vs 13.6%, P=0.000
respectively, (Table 2). This depicts the low level of awareness
among low socio-economic groups.
In the sample, (41.0%) of respondents told that they
used to give the leftover antibiotics to their friends, roommates
or family members if they were ever asked for (Table 3).
This practice led to self-medication which was reported by
(42.3%) of the total respondents (Table 3).
In the study, (41.1%) of participants had used antibiotics
prescribed by pharmacists at some point in their lives,
including significantly high number of males as compared
to females (46.4% vs 35.9%, P=0.016), as well as more
Table 2: Frequency of respondents agreeing with research statements related to knowledge about antibiotics.
* indicates significant differences amongst groups.
Table 3: Frequency of respondents agreeing with research statements related to practices about antibiotics.
* indicates significant differences amongst groups.
educated and high income groups as compared to less
educated and low income groups (44.2% vs 35.5%, P=0.000
and 46.7% vs 38.3% respectively, Table 3).
DISCUSSION
Antibiotic misuse was prevalent in the sample evidenced
by the high self-medication rates (42.3%) and the use of
pharmacist-prescribed antibiotics (41.1%). The
misconceptions that antibiotics had antiviral (61.8%) and
analgesic effect (75.5%), should be taken before any dental
work (38%), and should be prescribed post-extraction
(67.3%) were widespread. This might be due to inadequate
knowledge regarding appropriate antibiotic usage and due
to the unregulated dispensation of these drugs by pharmacies.
Self-medication rates (42.3%) in the study were
comparatively lower than those in the region: 92% in
Kuwait18, (51%) in India19, (53%) in Iran20 and (48%) in
Sudan, where (76%) antibiotics were pharmacist-prescribed
and (24%) were obtained from friends, family, or at home.21
In the US, however, the rate of self-medication is considerably
lower (5%).22
Misconception about antiviral effects of antibiotics was
(61.8%) in the study and most (75.5%) of the respondents
thought antibiotics had analgesic effect. A Swedish study
showed that (19.1%) agreed that common colds are cured
with antibiotics23, (6.5%) in Netherlands24 and (7.4%) in
Australia25 had similar views, but considerably lower than
what has been reported from Britain (38%)26, and the USA
(55%).27,28 A Jordanian study showed (28.1%) individuals
misused antibiotics as analgesics.29 According to a systemic
review in 2015, (50%) of the sample were not aware that
antibiotics were not therapeutic for viral infections (such as
flu and common cold), pain, and inflammation.30
Majority of patients did not know that antibiotics can
only treat bacterial infections and that they are not useful
against viruses.31 Thus leaving them unaware about the fact
that misuse of antibiotics can lead to the problem of
developing bacterial resistance.32 In developed parts of the
world, such as Europe, attitudes towards antibiotics were
found to be influenced by country and level of education.33
It was also found that awareness about antibiotic resistance
was lagging in countries with higher prevalence of
resistance.33 In China, public, in general, was not aware of
the causes of antibiotic resistance, or their role and capability
in causing or preventing resistance.34
The perception that homeopathic medicine is superior
to antibiotics is of concern and indicates lack of trust in
allopathic medicine as (26%) of the study sample considered
homeopathic medicines were more effective than antibiotics
for treatment of infections.
Although the study had socioeconomically diverse
respondents but this may not represent the overall population
of Lahore. Because the limitation of this study was sample
size that comprised of patients from single private hospital
only. Respondents may also have denied self-medication or
using pharmacy-prescribed antibiotics, especially if aware
that this was inappropriate behavior.
Further research needs to be done on the misuse of
antibiotics in the region especially by dental patients and
their expectations from dentists for an antibiotic course
prescription possibly leading to inappropriate antibiotic
prescriptions by GDPs. A cohesive approach involving
policymakers, prescribers and the general public is needed,
using both educational and regulatory measures. Such
measures should be embedded in the general policy by the
government to change the culture of antibiotic use by
improving awareness among the general public and
professionals about the risks associated with antibiotic
misuse, as well as reducing public misconception about the
analgesic and antiviral effects of antibiotics.
Previous interventions that have successfully improved
prescribing behavior among GDPs include clinical audits35,36
and pharmacist-delivered academic detailing.37 GDPs need
to accurately and extensively inform their patients with the
intention of making them aware of the importance of correct
behavior regarding antibiotic intake.
CONCLUSION
High self-medication rates were reported in the sample
despite reasonable knowledge about antibiotic resistance
and its side effects. Antibiotic misuse was widespread in
the sample and may be linked to the misconception that
antibiotics have an antiviral and analgesic effect.
CONFLICT OF INTEREST
None declared
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- Demonstrator, Department of Prosthodontics, Institute of Dentistry, CMH Lahore Medical College.
- General Dentist, Institute of Dentistry, CMH Lahore Medical College.
- Oral Surgeon, , Institute of Dentistry, CMH Lahore Medical College.
Corresponding author: “Dr. Azka Yaseen” < dentalresearch2016@gmail.com >
Fig 1: Intra oral view
Fig 2: Design pattern drawn for lab instructions
Fig 4: Maxillary obturator inserted
Fig 5: Front occlusal view
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Table 1: Describes Demographic details of the respondents
Table 2: Association of age group with Knowledge regarding LCU
Table 3: Association of Gender with Knowledge regarding LCU
Figure 1: Mean Age of the Patients
Table 1: Gender of the Patients
Table 2: Mean values for Cfu before & Cfu after the provision of Complete Dentures. Cfu; Colony Forming Units
Table 3: Comparison between Colony Forming Units (CFU) before and after provision of Complete Dentures