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Vol. 32 No. 02 Apr – Jun 2023 Archives - JPDA

Factors Influencing the Emergence of Antimicrobial Drug Resistance in Clinical Dental Practice

Resham Hafeez1                 BDS, MCPS
Hina Mahmood2                  BDS, MDS
Fahad Raza3                        BDS
Wajeeha Jabeen4                BDS, MCPS
Pakiza Raza Hyder5            BDS, M.Phil

 

OBJECTIVE: To investigate the perception of general dentists regarding the over-prescription of antibiotics leading to
Antimicrobial drug resistance in their clinical practice.
METHODOLOGY: A cross-sectional study encompassing a personalized Likert scale questionnaire on factors influencing
anti-microbial resistance in dental general practices was conducted on 196 practitioners. The questionnaire inquired about
different factors which tend to affect the over-prescription of antibiotics and influence anti-microbial resistance. It was piloted
on 30 participants before dissemination.
RESULTS: Factors showing the highest level of agreement were "lack of patient awareness regarding use of antibiotics"
(96.9%), "over-the-counter availability" (95.4%), and self-medication" (95.4%). General dental practitioners were overprescribing
in their clinical setup due to improper guidelines (24.4%), for their patient's satisfaction (21.2%), and lack of knowledge (19.2%).
33.5% of them stated that patients reporting to them were self-medicating and 27.2% found that their patients had a lack of
awareness.
CONCLUSIONS: This study concluded that all the factors were responsible for the Antimicrobial Drug Resistance phenomenon
in clinical dental practice. However, the majority of the dentists were over-prescribing antibiotics due to improper guidelines,
lack of knowledge, and for the patient's satisfaction.
KEYWORDS: Antimicrobial Drug Resistance; Awareness; Antibiotics; Dental General Practices; Over-the-Counter Drugs.
HOW TO CITE: Hafeez R, Mahmood H, Raza F, Jabeen W, Hyder PR. Factors influencing the emergence of antimicrobial
drug resistance in clinical dental practice. J Pak Dent Assoc 2023;32(2):60-65.
DOI: https://doi.org/10.25301/JPDA.322.60
Received: 21 December 2022, Accepted: 03 June 2023

INTRODUCTION

I did not invent penicillin. Nature did that. I only discovered it by accident” Alexander Fleming. The invaluable discovery of penicillin in 1928 proved to be one of the most outstanding scientific discoveries inmedicine, successfully treating various infections. Since  then, hundreds of natural, semisynthetic, and synthetic antibiotics have been identified.1
However, the prevalent and extensive use of antibiotics over the past 80 years has led to the emergence of microorganisms or superbugs which are tolerant to certain antibiotics, leading to failure in treating infectious diseases, including life-threatening conditions.2 Globally, between 2000 and 2015, a 91% rise in the consumption of critically important antibiotics was documented and this trend has not ceased.3
Although Antimicrobial drug resistance (AMR) is a natural phenomenon that was first observed in the early 1940s4 , nevertheless it has only intensified by the misuse of antimicrobials over the years. AMR has now been identified as one of the greatest threats to human life globally, and an even bigger menace for developing countries resulting in daunting treatment failures of basic infections, financial loss, prolonged treatment, and even death.5,6
In dentistry, prescribing antibiotics is typically empirical, since culture and susceptibility tests are not routinely  conducted, therefore broad-spectrum antibiotics are widely
prescribed.7 Even though, undergraduate dental students are taught, that most oral infections may be treated operatively or surgically. Nevertheless, dentists worldwide
are prescribing millions worth of antibiotics every year. The literature suggests a significant contributing factor in the selection of resistance may be the unnecessary use of antibiotics in dentistry.8
Therefore, it does not come as a surprise that resistance is present in the oral flora.9 Evidence demonstrates that the presence of resistance in oral flora is a global problem. In Pakistan, bacterial resistance has been well documented in several studies conducted over a decade. An increasing trend of Gram-negative organisms’ resistance was recognized with extended-spectrum beta-lactamases (ESBLs) being a major concern.10 Oral commensals associated with specific dental infections such as α-hemolytic streptococci and gram-negative anaerobes, such as members of the genus Prevotella, appeared in the majority of studies reviewed, show strains resistant to a range of antibiotics used commonly in dentistry.9 Several qualitative studies have revealed multi-layered aspects linked to non-rational and irresponsible antibiotic prescribing.3 Broadly, the factors responsible for injudicious prescribing practice stem from doctors’ knowledge and perception, demographics of the patient, malpractice by pharmacies, misleading advertisements, economic benefits offered by pharmaceutical representatives, or the regulatory environment in the country.11,12,5,10
Enforcing regulations, and addressing prescribing and dispensing practices have been principal points of strategies to decrease antimicrobial usage for many years.10 Although several small-scale studies have been conducted in Pakistan suggesting gaps in awareness of appropriate antibiotic use10 , however, there is a lack of data on the current status of dental professionals’ understanding of the factors that influence antimicrobial resistance in their clinical practice.13

METHODOLOGY
A cross-sectional study was conducted from January 2022 to March 2022 for a period of 3 months and approval was sought from Institutional Review Board (IRB) (Ref# IMDC/DS/IRB/217). Surveyed dental practitioners included registered consultants, demonstrators, and postgraduate residents. Non-practicing dentists and those with less than 1 year of experience were excluded from the study.
A personalized electronic Likert scale questionnaire was self-constructed on google forms, and content validity was assessed by five panelists including 2 medical educationists and three senior dental consultants. After the panelists’ assessment and responses were received, changes were made to the questionnaire. The items which were repetitive, ambiguous, or showed less relevance were excluded from the questionnaire. It was then piloted on 30 general dentists and Cronbach’s alpha coefficient was calculated as 0.79.
A sample size of 186 was calculated by taking 86% of the population proportion of dental practitioners who agreed that antimicrobial drug resistance is a global threat with absolute precision of 0.1 at a 95% confidence level.14 To compensate for any incomplete/incorrectly filled  the sample size was increased to 20% and the questionnaire was distributed to 223 dental practitioners via email and WhatsApp. The response rate was n=207. After excluding the incomplete responses, the final analysis was performed on 196 questionnaires. Informed consent was taken from each participant.
The first section of the questionnaire comprised of biodata including age, gender, designation, and years of experience. The second section encompassed major factors related to
doctors, patients, pharmaceuticals, and law and legislature and was labeled as “domain”. These domains included related to the knowledge and prescription of antibiotics by dental practitioners, patients’ misuse of antibiotics, pharmaceutical endorsements/ incentives, insufficiencies in law, and overthe-counter (OTC) sales. At the end of each domain, the participants were inquired about the most contributing factor which affected the clinical practice of dentists via an openended question.
Data from complete questionnaires were entered in the statistical software SPSS v-22 and descriptive analysis was carried out. The quantitative variable such as age was reported as mean ± standard deviation. The qualitative variables like the perception of antimicrobial resistance and the opinion of the dental practitioners about the most affecting factor in their clinical setup were reported as frequencies and percentages. Further, the extended bar chart, table, and infographics were used to report the findings.

RESULTS
The study included a total of 196 dental practitioners, out of which 66 (33.7%) were males and 130 (66.3%) were females. The age was distributed as mean ± standard deviation=29.41 ± 5.43, min=21, and max=52 years. The perception of the dental practitioners regarding the factors affecting the over-prescription of antibiotics was recorded on a 5-point Likert scale ranging from strongly agree to strongly disagree. The participant’s clinical experience ranged from 1-10 years and its further distribution is shown in fig.1.

For the overall evaluation of the agreement level of the participants, the responses strongly agreed and agreed were merged into one category “agreed”. Similarly, strongly disagreed and disagreed were merged into “disagreed”. The factors in each domain, based on the participants’ response i.e., agreed are listed in descending order (Figure 2). The factors showing the highest percentage of agreement were

In the doctors’ domain, improper guidelines for antibiotic prescription n=38/196(19.4%) followed by patient satisfaction n=33/196(16.8%), and lack of knowledge n=30/196 (15%) tops the list of factors. However, in the patient’s domain, most participants agreed that self-medication n=53/196(27%) and lack of awareness n=43/196(21.9%) were influencing factors. In the pharmaceutical domain, increase brand endorsement n=64/196(32.7%) and incentive/pressure from pharmaceutical companies n=58/196(29.6%) were considered important factors in over-prescription. Lastly, in the law and legislature domain, the majority of the participants believed that the lack of public awareness programs in the country n=76/196(38.8%) is mostly responsible for over-prescription of antibiotics.

DISCUSSION Change in the era from focal infection to periodontal medicine has inclined dentists towards prescribing antibiotics in oral infections lately. Chairside management of most of these lesions usually renders antibiotic intervention
unnecessary and it is pivotal for general dentists to understand the dynamics and impact of antibiotic resistance. To initiate a change, it is important to first know the perception of the practicing dentists about factors responsible for antibiotic misuse as well as identify which factors are most contributory to their clinical practice. This survey provides insight into general dentists’ understanding of the overprescription of antibiotics with a specific focus on the factors contributing to antibiotic resistance in their clinical practice.
The perception of the general dentists in this survey leading to AMR is multifactorial. The most agreed-upon factors leading to AMR were a lack of patient awareness regarding the overuse of antibiotics, OTC availability, and self-medication.
Data from developing and underdeveloped countries highlight poor management of community-based programs and implementation of national drug policies regarding OTC medication.17
In the present study, most of the general dental practitioners agreed, that overall factors leading to AMR were patient-related, of which the highest agreement was seen for lack of patients’ awareness and self-medication. Extensive literature has reinforced that these two are significant factors in the escalation of the AMR phenomenon.15,16
Lack of dentists knowledge regarding AMR and improper guidelines for antibiotic prescription was agreed upon by 74-78% of dentists, which is consistent with studies done in multiple cities across the country.18,19 According to a recent survey, it was concluded that the increasing AMR crisis is a result of antibiotic-seeking behavior owing to the financial constraints of patients. Although the sale of un-prescribed antibiotics is prohibited by the national drug policy of Pakistan, on the contrary, every individual in the country has convenient access to antibiotics that are sold as OTC medicines.17
A few studies originating from the UK have found ‘Patient’s influence’ as one of the main factors resulting in the overuse of antibiotics. In an umbrella review, W.Thompsan et al concluded that antibiotic-seeking behaviors, patient’s attitude and knowledge towards antibiotics, and will to accept operative dental procedure influences over-prescription.16
The participants were also inquired about the leading factors influencing the over-prescription of antibiotics in their private clinics. The majority of the clinicians were drawn towards prescribing antibiotics due to improper antibiotic guidelines, their lack of knowledge, and patients’ satisfaction. Only 3% (n= 3/156) of the practitioners claimed that none of the factors influence their prescription practice. A study done in Lahore, one of the cosmopolitan cities, found that general physicians lacked the knowledge regarding basic epidemiology of AMR, anti-microbial stewardship, or any national or foreign guidelines while prescribing antibiotics.18 In this study, a high percentage of dentists felt that patients reporting to their clinics lacked awareness regarding the overuse of antibiotics and tend to self-medicate. A systematic review reported an overall prevalence of 42.64% for self-medication in the WHO Southeast Asian region. One of the main reasons for self-medication among communities was the belief, that they can successfully manage their illnesses. Other reasons reported were inadequate health facilities and economic instability in this region.20 One important aspect leading to the self-medication of antibiotics is the misconceptions related to their use. David. A et al in a study observed that both patients and clinicians were under the perception that antibiotics can mitigate strong symptoms of a disease and pose a minimal health risk.21
In the Pharmaceutical domain, both brand endorsement and incentives from pharmaceutical companies were considered to influence the antibiotic prescription pattern of
the majority of dentists. Chantal M Morel et al in a recent study identified that brand endorsements and incentives offered by pharmaceutical companies are one of the major
obstacles in the rationale prescription of antibiotics.22 The alarming statistics in 2017 of AMR National action plan of Pakistan reveals, that majority of the pharmaceutical brand advertisements are misleading, and only nearly 15% of promotional brochures meet the WHO criteria. Furthermore,
in this survey, the majority of the dentists were of the view that there is a lack of public awareness programs for antibiotic resistance and a lack of a regulatory body overseeing antibiotic use. Some dentists also believed that there is a lack of strict laws against antibiotic dispensation.
A survey in 2021 reports, that even though the sale of non-prescribed antibiotics in Pakistan is prohibited by the national drug policy (NDP), the incidence of dispensing of non-prescribed antibiotics in community pharmacies of Pakistan is very high. This owes to insufficient knowledge of legislation, and a lack of awareness of regulations/ policies regarding OTC sales.17

LIMITATIONS AND FUTURE RECOMMENDATIONS
The study carried out had some limitations, as the data was collected only from general dentists of Islamabad and Rawalpindi. A country-wide study may give a holistic perception regarding the factors leading to AMR in dentistry. The study relied on self-reported practices, and participants may have provided more professionally desirable answers, resulting in an underestimation of the true picture. In the current era of digitalization, employing Artificial Intelligence to tackle AMR through predictive algorithms can substantially reduce antibiotic abuse and improve
prescription practices. Similarly, an up-to-date guideline regarding the rational use of antibiotics in a mobile application
may also be explored for dental professionals helping in judicious clinical decisions.
Awareness programs and antibiotic stewardship is the need of the hour. Making AMR part of a professional dental education curriculum, training dental practitioners in public & private setups, and encouraging the use of hospital antibiograms can aid in curtailing antibiotic resistance.

CONCLUSION
This study concluded that dentists agreed that all factors were responsible for escalating the AMR phenomenon. In their clinical practice, the majority of dentists were drawn towards prescribing antibiotics due to improper antibiotic guidelines, lack of knowledge, and patient satisfaction. They also reported that patients who come for dental treatment lack awareness regarding the overuse of antibiotics and tend to self-medicate. Dentists also accepted that both brand endorsement and incentives from pharmaceutical companies tend to influence their antibiotic prescription practice.

CONFLICT OF INTEREST
None declared

REFERENCES
1. Mohr KI. History of Antibiotics Research. Curr Top Microbiol Immunol [Internet]. 2016 Dec 1 [cited 2022 Feb 11];398:237-72.  Available from: https://pubmed.ncbi.nlm.nih.gov/27738915/

2. WHO’s first global report on antibiotic resistance reveals serious, worldwide threat to public health [Internet]. [cited 2022 Feb 16]. Available from: https://www.who.int/southeastasia/news/detail/30-04- 2014-who-s-first-global-report-on-antibiotic-resistance-reveals-seriousworldwide-threat-to-public-health

3. Böhmer F, Hornung A, Burmeister U, Köchling A, Altiner A, Lang H, et al. Factors, perceptions and beliefs associated with inappropriate antibiotic prescribing in German primary dental care: A qualitative study. Antibiotics. 2021;10.

4. Barber M, Rozwadowska-Dowzenko M. Infection by penicillinresistant Staphylococci. Lancet. 1948 Oct 23;252(6530):641-4.

5. Bilal H, Khan MN, Rehman T, Hameed MF, Yang X. Antibioti resistance in Pakistan: a systematic review of past decade. BMC Infect Dis [Internet]. 2021 Dec 1 [cited 2022 Feb 21];21:1-19. Available
from: https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-021-05906-1

6. Sekyere JO, Asante J. Emerging mechanisms of antimicrobial resistance in bacteria and fungi: advances in the era of genomics. Future Microbiol [Internet]. 2018 [cited 2022 Feb 15];13:241-62. Available from: https://pubmed.ncbi.nlm.nih.gov/29319341/

7. Yu J, Nie E-M, Jiang R, Zhang C-Y, Li X. Analgesic and Antibiotic Prescription Pattern among Dentists in Guangzhou: A Cross-Sectional Study. 2020; Available from: https://doi.org/10.1155/2020/6636575

8. G R Barker AJQ. An investigation into antibiotic prescribing at a dental teaching hospital. Br Dent J – Nat. 2000;188(12).

9. Louise C. Sweeney1, Jayshree Dave1,2 PAC and JH. Antibiotic resistance in general dental practice-a cause for concern? 2004; Available from: https://academic.oup.com/jac/article/53/4/567/782420

10. National AMR Action Plan for Pakistan Antimicrobial Resistance National Action Plan Pakistan Ministry of National Health Services Regulations & Coordination Government of Pakistan. 2017;

11. Ping Wong LI, Alias HI, Amir Husin S, Brukan Ali Z, Sim B, Sri La Sri Ponnampalavanar S. Factors influencing inappropriate use of antibiotics: Findings from a nationwide survey of the general public in Malaysia. 2021.
https://doi.org/10.1371/journal.pone.0258698

12. Nahar P, Unicomb L, Lucas PJ, Uddin MR, Islam MA, Nizame FA, et al. What contributes to inappropriate antibiotic dispensing among qualified and unqualified healthcare providers in Bangladesh? A qualitative study. BMC Health Serv Res [Internet]. 2020 Jul 15 [cited 2022 Feb 21];20:1-11. Available from:
https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913- 020-05512-y

13. Maddy. Antibiotic prescribing and resistance: Views from lowand middle-income prescribing and dispensing professionals Report to the World Health Organization, researched and compiled by students and staff of the Antimicrobial Resistance Centre at the London Sc. [cited 2022 Feb 9]; Available from: http://www.who.int/antimicrobialresistance/LSHTM

14. Anka Cori, Svjetlana Grgic, Sandra Kostic, Katarina Vukojevic,Ruzica Zovko, Natasa Radica, et al. Attitudes of dental practitioners towards antimicrobial therapy in Croatia and Bosnia and Herzegovina | Enhanced Reader. Eur J Dent. 2020;

15. Anwen L. Cope1, Nick A. Francis2 FWIGC. Antibiotic prescribing in UK general dental practice: a cross-sectional study. 2015;

16. Thompson W, Tonkin-Crine S, Pavitt SH, Mceachan RRC, Douglas GVA, Aggarwal VR, et al. Factors associated with antibiotic prescribing for adults with acute conditions: an umbrella reviewa cross primary care and a systematic review focusing on primary dental care. Available
from: https://academic.oup.com/jac/article/74/8/2139/5475276

17. Majid Aziz M, Haider F, Rasool MF, Hashmi FK, Bahsir S, Li P, et al. antibiotics Dispensing of Non-Prescribed Antibiotics from Community Pharmacies of Pakistan: A Cross-Sectional Survey of Pharmacy Staff’s Opinion. 2021.
https://doi.org/10.3390/antibiotics10050482

18. Saleem Z, Hassali MA, Godman B, Hashmi FK, Saleem F. Antimicrobial prescribing and determinants of antimicrobial resistance: a qualitative study among physicians in Pakistan. Int J Clin Pharm. 2019;41:1348-58.
https://doi.org/10.1007/s11096-019-00875-7

19. Farzeen Tanwir SK. Antibiotic Prescription Habits of Dentists in Major Cities of Pakistan | Journal of the Pakistan Dental Association. J Pak Dent Assoc [Internet]. [cited 2022 Aug 16]; Available from:
http://archive.jpda.com.pk/volume-20-issue-3/antibiotic-prescriptionhabits-of-dentists-in-major-cities-of-pakistan/

20. Nepal G, Bhatta S. Self-medication with Antibiotics in WHO Southeast Asian Region: A Systematic Review. 2018;

21. Broniatowski DA, Klein EY, May L, Martinez EM, Ware C, Reyna VF. Patients’ and clinicians’ perceptions of antibiotic prescribing for upper respiratory infections in the acute care setting HHS Public Access Background and rationale for study. Med Decis Mak. 2018;38:547-61.

22. Morel CM, Lindahl O, Harbarth S, Marlieke o, De Kraker EA, Edwards S, et al. Industry incentives and antibiotic resistance: an introduction to the antibiotic susceptibility bonus. J Antibiot (Tokyo) [Internet]. 2020;73:421-8.
https://doi.org/10.1038/s41429-020-0300-y

Factors Influencing the Emergence of Antimicrobial Drug Resistance in Clinical Dental Practice

Resham Hafeez1                 BDS, MCPS
Hina Mahmood2                  BDS, MDS
Fahad Raza3                        BDS
Wajeeha Jabeen4                BDS, MCPS
Pakiza Raza Hyder5            BDS, M.Phil

 

OBJECTIVE: To investigate the perception of general dentists regarding the over-prescription of antibiotics leading to
Antimicrobial drug resistance in their clinical practice.
METHODOLOGY: A cross-sectional study encompassing a personalized Likert scale questionnaire on factors influencing
anti-microbial resistance in dental general practices was conducted on 196 practitioners. The questionnaire inquired about
different factors which tend to affect the over-prescription of antibiotics and influence anti-microbial resistance. It was piloted
on 30 participants before dissemination.
RESULTS: Factors showing the highest level of agreement were "lack of patient awareness regarding use of antibiotics"
(96.9%), "over-the-counter availability" (95.4%), and self-medication" (95.4%). General dental practitioners were overprescribing
in their clinical setup due to improper guidelines (24.4%), for their patient's satisfaction (21.2%), and lack of knowledge (19.2%).
33.5% of them stated that patients reporting to them were self-medicating and 27.2% found that their patients had a lack of
awareness.
CONCLUSIONS: This study concluded that all the factors were responsible for the Antimicrobial Drug Resistance phenomenon
in clinical dental practice. However, the majority of the dentists were over-prescribing antibiotics due to improper guidelines,
lack of knowledge, and for the patient's satisfaction.
KEYWORDS: Antimicrobial Drug Resistance; Awareness; Antibiotics; Dental General Practices; Over-the-Counter Drugs.
HOW TO CITE: Hafeez R, Mahmood H, Raza F, Jabeen W, Hyder PR. Factors influencing the emergence of antimicrobial
drug resistance in clinical dental practice. J Pak Dent Assoc 2023;32(2):60-65.
DOI: https://doi.org/10.25301/JPDA.322.60
Received: 21 December 2022, Accepted: 03 June 2023

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Assessment of Awareness and Approach Regarding Antibiotic Prescription and Resistance among Different Level of Dental Students in a Tertiary Care Dental College, Karachi

Saba Hanif 1                             BDS
Syeda Nadia Firdous2             BDS, MPH
Kauser Ismail3                         BDS, M.Phil
Zoeen Fatima4                         BDS
Angabeen Anjum5                   BDS, M.Phil

 

OBJECTIVE: To evaluate the awareness and approach of dental students regarding antibiotic prescription and its resistance
due to irrational use of antibiotics. Antibiotic resistance is spreading alarmingly throughout the world, including developed
countries. The common causes of antibiotic resistance include over prescription, incomplete treatment and inappropriate selfmedication. Among different causes of antimicrobial resistance, irrational use of antibiotic is the most prominent one.
METHODOLOGY: After approved by the Institutional Ethics Committee of Ziauddin University this cross-sectional study
was conducted from 1st April, 2020 to 30th July,2020 at Ziauddin University. Third and final year dental students as well as
house officers were enrolled and the computed sample size was 133 to which 5% non-response rate was added, therefore total
139 dental students were approached. Non-probability convenience sampling technique was used. A self- designed, selfadministered questionnaire 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 comprised
information pertaining to demographic characteristics, standard guideline for antibiotic prescriptions, antibiotic stewardship
and resistance, improper prescription and its consequences. 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 awareness of dental students
regarding antibiotics was the outcome factor. The data was analyzed by using SPSS version 22.
RESULTS: Out of total 139 dental students majority (79.1%)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). 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%).
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.
KEYWORDS: Awareness. Antibiotics, Resistance, Prescription, Dental Students.
HOW TO CITE: Hanif S, Firdous SN, Ismail K, Fatima Z, Anjum A. Assessment of awareness and approach regarding antibiotic
prescription and resistance among different level of dental students in a tertiary care dental college, Karachi. J Pak Dent Assoc
2023;32(2):66-73.
DOI: https://doi.org/10.25301/JPDA.322.66
Received: 22 August 2022, Accepted: 07 July 2023

INTRODUCTION

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

REFERENCES
1. Jain A, Bhaskar DJ, Gupta D, Yadav P, Dalai DR, Jhingala V, Garg Y, Kalra M. Drug prescription awareness among the 3 rd year and final year dental students: A cross-sectional survey. J Indian Assoc Public Health Dent. 2015;13:73.
https://doi.org/10.4103/2319-5932.153598

2. Iqbal A. The attitudes of dentists towards the prescription of antibiotics during endodontic treatment in north of Saudi Arabia. J Clin Diagn Res. 2015;9:ZC82.
https://doi.org/10.7860/JCDR/2015/13718.5964

3. He P, Sun Q, Shi L, Meng Q. Rational use of antibiotics in the context of China’s health system reform. Br Med J. 2019;365.
https://doi.org/10.1136/bmj.l4016

4. Kanneppady SS, Oo AM, Lwin OM, Al-Abed AA, Kanneppady SK. Knowledge, attitude, and awareness of antibiotic resistance among medical students. Archiv Medi Health Sci. 2019;7:57.
https://doi.org/10.4103/amhs.amhs_104_18

5. Aslam B, Wang W, Arshad MI, Khurshid M, Muzammil S, Rasool MH, Nisar MA, Alvi RF, Aslam MA, Qamar MU, Salamat MK. Antibiotic resistance: a rundown of a global crisis. Infect Drug Resis. 2018;11:1645.
https://doi.org/10.2147/IDR.S173867

6. Ramchurren K, Balakrishna Y, Mahomed S. Patients’ knowledge, attitudes and practices regarding antibiotic use at a regional hospital
in KwaZulu-Natal, South Africa 2017. Southern African J Infectious Dise. 2018;33:1-6.
https://doi.org/10.4102/sajid.v33i5.146

7. Farley E, Stewart A, Davies MA, Govind M, Van den Bergh D, Boyles TH. Antibiotic use and resistance: Knowledge, attitudes and perceptions among primary care prescribers in South Africa. South Afr Medi J. 2018;108.
https://doi.org/10.7196/SAMJ.2018.v108i9.12933

8. Roos NA, Bakar MA, Haque M. Knowledge, attitude and practice among Malaysian medical students, doctors, other health professionals and common people regarding antibiotic use, prescribing and resistance: A systematic review. Adv Human Biology. 2019;9:179.
https://doi.org/10.4103/AIHB.AIHB_42_19

9. Gandra S, Alvarez-Uria G, Turner P, Joshi J, Limmathurotsakul D, van Doorn HR. Antimicrobial resistance surveillance in low-and middle-income countries: progress and challenges in eight South Asian and Southeast Asian countries. Clin Microbiology Reviews. 2020;33:e00048-19.
https://doi.org/10.1128/CMR.00048-19

10. Sarraf DP, Rai D, Rauniar GP. Knowledge, attitude and practices on antibiotic use and resistance among doctors in bp koirala institute
of health sciences. J Drug Deli Therapeut. 2018;8:170-5.
https://doi.org/10.22270/jddt.v8i4.1753

11. Hashemi S, Nasrollah A, Rajabi M. Irrational antibiotic prescribing: a local issue or global concern? EXCLI J. 2013;12:384.

12. Mboya EA, Sanga LA, Ngocho JS. Irrational use of antibiotics in the Moshi Municipality Northern Tanzania: a cross sectional study. Pan Afr Medi J. 2018;31.
https://doi.org/10.11604/pamj.2018.31.165.15991

13. Umar LW, Isah A, Musa S, Umar B. Prescribing pattern and antibiotic use for hospitalized children in a Northern Nigerian Teaching Hospital. Ann Afri Medi. 2018;17:26.
https://doi.org/10.4103/aam.aam_44_17

14. Koyuncuoglu CZ, Aydin M, Kirmizi NI, Aydin V, Aksoy M, Isli F, Akici A. Rational use of medicine in dentistry: do dentists prescribe
antibiotics in appropriate indications?. Eur J Clin Pharmacol. 2017;73:1027-32.
https://doi.org/10.1007/s00228-017-2258-7

15. Teoh L, Stewart K, Marino R, McCullough M. Antibiotic resistance and relevance to general dental practice in Australia. Aus Dent J. 2018;63:414-21.
https://doi.org/10.1111/adj.12643

16. Ahsan S, Hydrie MZ, Hyder Naqvi SM, Shaikh MA, Shah MZ, Jafry SI. Antibiotic prescription patterns for treating dental infections in children among general and pediatric dentists in teaching institutions of Karachi, Pakistan. PloS one. 2020;15:e0235671
https://doi.org/10.1371/journal.pone.0235671

17. Amaha ND, Weldemariam DG, Abdu N, Tesfamariam EH. Prescribing practices using WHO prescribing indicators and factors associated with antibiotic prescribing in six community pharmacies in Asmara, Eritrea: a cross-sectional study. Antimicro Resist Infect Cont. 2019;8:1-7
https://doi.org/10.1186/s13756-019-0620-5

18. Firouzabadi D, Mahmoudi L. Knowledge, attitude, and practice of health care workers towards antibiotic resistance and antimicrobial stewardship programmes: A cross-sectional study. J Evaluat Clin Pract. 2020;26:190-6.
https://doi.org/10.1111/jep.13177

19. Wong YC, Mohan M, Pau A. Dental students’ compliance with antibiotic prescribing guidelines for dental infections in children. J Indian Soci Pedodon Prevent Dent. 2016;34:348.
https://doi.org/10.4103/0970-4388.191415

20. Global action plan on antimicrobial resistance;
http://www.who.int/antimicrobial-resistance/global-action-plan/en

21. Ghafur A, Mathai D, Muruganathan A, Jayalal JA, Kant R, Chaudhary D, Prabhash K, Abraham OC, Gopalakrishnan R, Ramasubramanian V, Shah SN. The Chennai Declaration: a roadmap to tackle the challenge of antimicrobial resistance. Indian J Cancer. 2013;50:71
https://doi.org/10.4103/0019-509X.104065

22. De Vries TP, Henning RH, Hogerzeil HV, Fresle DA, Policy M, World Health Organization. Guide to good prescribing: a practical manual. World Health Organization; 1994.

23. Wasserman S, Potgieter S, Shoul E, Constant D, Stewart A, Mendelson M, Boyles TH. South African medical students’ perceptions and knowledge about antibiotic resistance and appropriate prescribing: are we providing adequate training to future prescribers?. South Afri Med J. 2017;107:405-10.
https://doi.org/10.7196/SAMJ.2017.v107i5.12370

24. Ferdoush J, Parveen K, Ata M, Reza FH, Rahman MS. Knowledge, perception and preparedness of future prescribers about antimicrobial stewardship. Bangladesh J Pharmacol. 2016;11:928-34.

25. Shrestha R. Knowledge, attitude and practice on antibiotics use and its resistance among medical students in a tertiary care hospital. J Nepal Med Assoc. 2019;57(216):74.
https://doi.org/10.31729/jnma.4224

26. Jairoun A, Hassan N, Ali A, Jairoun O, Shahwan M, Hassali M. University students’ knowledge, attitudes, and practice regarding antibiotic use and associated factors: a cross-sectional study in the United Arab Emirates. Int J General Medicine. 2019;12:235.
https://doi.org/10.2147/IJGM.S200641

27. Shah S, Abbas G, Chauhdary Z, Aslam A, ur Rehman A, Khurram H, Noreen S, Chand UR, Younis MH, Zulfiqar U. Antibiotic use: A cross-sectional survey assessing the knowledge, attitudes, and practices amongst students of Punjab, Pakistan. J Am College Health. 2020:1-6.

28. Doshi A, Asawa K, Bhat N, Tak M, Dutta P, Bansal TK, Gupta R. Knowledge and practices of Indian dental students regarding the prescription of antibiotics and analgesics. Clujul Med. 2017;90:431.
https://doi.org/10.15386/cjmed-768

29. Konde S, Jairam LS, Peethambar P, Noojady SR, Kumar NC. Antibiotic overusage and resistance: A cross-sectional survey among pediatric dentists. J Indian Soci Pedodont Prevent Dent. 2016;34:145.
https://doi.org/10.4103/0970-4388.180444

30. Shaik T, Meher BR. A questionnaire based study to assess the knowledge, attitude and practice (KAP) of rationale use of antibiotics among undergraduate dental students in a tertiary care dental hospital of South India. Int J Basic Clin Pharmacol. 2017;6:312-5.
https://doi.org/10.18203/2319-2003.ijbcp20170321

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
https://doi.org/10.1186/s12889-019-6878-y

32. Huang Y, Gu J, Zhang M, Ren Z, Yang W, Chen Y, Fu Y, Chen X, Cals JW, Zhang F. Knowledge, attitude and practice of antibiotics: a questionnaire study among 2500 Chinese students. BMC Med Educ. 2013;13:1-9.
https://doi.org/10.1186/1472-6920-13-163

33. Sakr S, Ghaddar A, Hamam B, Sheet I. Antibiotic use and resistance: An unprecedented assessment of university students’ knowledge, attitude and practices (KAP) in Lebanon. BMC Public Health. 2020;20:1-9.
https://doi.org/10.1186/s12889-020-08676-8

34. Khan FU, Khan FU, Hayat K, Chang J, Saeed A, Khan Z, Ashraf M, Rasheed UM, Atif N, Ji W, Aziz MM. Knowledge, attitude and practices among consumers toward antibiotics use and antibiotic resistance in Swat, Khyber-Pakhtunkhwa, Pakistan. Expert review of anti-infective therapy. 2020;18:937-46.
https://doi.org/10.1080/14787210.2020.1769477

35. Krockow EM, Colman AM, Chattoe-Brown E, Jenkins DR, Perera N, Mehtar S, Tarrant C. Balancing the risks to individual and society: a systematic review and synthesis of qualitative research on antibiotic prescribing behaviour in hospitals. J Hospital Infection. 2019;101:428-39.
https://doi.org/10.1016/j.jhin.2018.08.007

 

36. Humayun A, Kadri W. A study comparing drug choices and prescription patterns amongst final year students and house officers in Karachi. Pak Oral Dent J. 2019;39:345-8.

37. Guzmán-Álvarez R, Medeiros M, Lagunes LR, Campos-Sepúlveda A. Knowledge of drug prescription in dentistry students. Drug Health Patient Saf. 2012;4:55-59.
https://doi.org/10.2147/DHPS.S30984

38. Dawnji SR, Nair MK. Knowledge, attitude and practice of antibiotic use and resistance among second year medical students in a teaching hospital. J Med Sci Clin Res. 2018;6:198-203.
https://doi.org/10.18535/jmscr/v6i8.32

39. Vallin M, Polyzoi M, Marrone G, Rosales-Klintz S, Tegmark Wisell K, Stålsby Lundborg C. Knowledge and attitudes towards antibiotic use and resistance-a latent class analysis of a Swedish populationbased sample. PloS one. 2016;11:e0152160.
https://doi.org/10.1371/journal.pone.0152160

40. Mansour H, Feghali M, Saleh N, Zeitouny M. Knowledge, practice and attitudes regarding antibiotics use among Lebanese dentists. Pharmacy Practice (Granada). 2018;16(3).
https://doi.org/10.18549/PharmPract.2018.03.1272

41. 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.
https://doi.org/10.1186/s12889-019-6878-y

42. Mouhieddine TH, Olleik Z, Itani MM, Kawtharani S, Nassar H, Hassoun R, et al. Assessing the Lebanese population for their knowledge, attitudes and practices of antibiotic usage. J Infect Public Health. 2015;8:20-31.
https://doi.org/10.1016/j.jiph.2014.07.010

43. Jamhour A, El-Kheir A, Salameh P, Abi Hanna P, Mansour H. Antibiotic knowledge and self-medication practices in a developing country: a cross-sectional study. Am J Infect Control. 2017;45:384-8.
https://doi.org/10.1016/j.ajic.2016.11.026

44. Higuita-Gutiérrez LF, Molina-Garcia V, Acevedo Guiral J, Gómez Cadena L, et al. Knowledge regarding antibiotic use among students of three medical schools in Medellin, Colombia: a cross-sectional study. BMC Med Educ. 2020;20:22.
https://doi.org/10.1186/s12909-020-1934-y

45. Veses V, Del Mar J-SM, González-Martínez R, Cortell-Ballester I, Sheth CC. Raising awareness about microbial antibiotic resistance in undergraduate dental students: a research-based strategy for teaching non-laboratory elements of a microbiology curriculum. BMC Med Educ. 2020;20:47.
https://doi.org/10.1186/s12909-020-1958-3

46. Tsopra R, Courtine M, Sedki K, Eap D, Cabal M, et al. AntibioGame®: a serious game for teaching medical students about antibiotic use. Int J Med Inform. 2020;136:104074.
https://doi.org/10.1016/j.ijmedinf.2020.104074

47. Nadimpalli M, Delarocque-Astagneau E, Love DC, Price LB, Huynh BT, Collard JM, Lay KS, Borand L, Ndir A, Walsh TR, Guillemot D. Combating global antibiotic resistance: emerging one health concerns in lower-and middle-income countries. Clin Infect Diseases. 2018;66:963-9.
https://doi.org/10.1093/cid/cix879

48. Lubwama M, Onyuka J, Ayazika KT, Ssetaba LJ, Siboko J, Daniel O, Mushi MF. Knowledge, attitudes, and perceptions about antibiotic use and antimicrobial resistance among final year undergraduate medical and pharmacy students at three universities in East Africa. Plos one. 2021;16:e0251301.
https://doi.org/10.1371/journal.pone.0251301

49. Suda KJ, Calip GS, Zhou J, Rowan S, Gross AE, Hershow RC, Perez RI, McGregor JC, Evans CT. Assessment of the appropriateness of antibiotic prescriptions for infection prophylaxis before dental procedures, 2011 to 2015. JAMA network open. 2019;2:e193909-.
https://doi.org/10.1001/jamanetworkopen.2019.3909

Assessment of Awareness and Approach Regarding Antibiotic Prescription and Resistance among Different Level of Dental Students in a Tertiary Care Dental College, Karachi

Saba Hanif 1                             BDS
Syeda Nadia Firdous2             BDS, MPH
Kauser Ismail3                         BDS, M.Phil
Zoeen Fatima4                         BDS
Angabeen Anjum5                   BDS, M.Phil

 

OBJECTIVE: To evaluate the awareness and approach of dental students regarding antibiotic prescription and its resistance
due to irrational use of antibiotics. Antibiotic resistance is spreading alarmingly throughout the world, including developed
countries. The common causes of antibiotic resistance include over prescription, incomplete treatment and inappropriate selfmedication. Among different causes of antimicrobial resistance, irrational use of antibiotic is the most prominent one.
METHODOLOGY: After approved by the Institutional Ethics Committee of Ziauddin University this cross-sectional study
was conducted from 1st April, 2020 to 30th July,2020 at Ziauddin University. Third and final year dental students as well as
house officers were enrolled and the computed sample size was 133 to which 5% non-response rate was added, therefore total
139 dental students were approached. Non-probability convenience sampling technique was used. A self- designed, selfadministered questionnaire 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 comprised
information pertaining to demographic characteristics, standard guideline for antibiotic prescriptions, antibiotic stewardship
and resistance, improper prescription and its consequences. 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 awareness of dental students
regarding antibiotics was the outcome factor. The data was analyzed by using SPSS version 22.
RESULTS: Out of total 139 dental students majority (79.1%)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). 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%).
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.
KEYWORDS: Awareness. Antibiotics, Resistance, Prescription, Dental Students.
HOW TO CITE: Hanif S, Firdous SN, Ismail K, Fatima Z, Anjum A. Assessment of awareness and approach regarding antibiotic
prescription and resistance among different level of dental students in a tertiary care dental college, Karachi. J Pak Dent Assoc
2023;32(2):66-73.
DOI: https://doi.org/10.25301/JPDA.322.66
Received: 22 August 2022, Accepted: 07 July 2023

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knowledge-regarding-prescription-of-antibiotic-for-endodontic-treatment-among-house-officers-of-multan-2

Muhammad Ali1                                  BDS, MCPS
Dil Rasheed2                                       BDS, FCPS
Hafiza Hina Irshad3                            BDS
Muhammad Jamil4                             BDS, FDSRCS
Muhammad Mohsin Javaid5             BDS, MSPH
Mustafa Sajid6                                   BDS, FCPS

 

OBJECTIVE: To evaluate the knowledge regarding the prescription of antibiotic for treatment of endodontic disease and errors
made by the house officers at Multan Dental College.
Since the discovery of antibiotics, they have been in use broadly for the treatment of odontogenic infections. Prescription is a
dynamic, customized clinical process, which is set owing to the necessities of patient & the acquaintance of the practitioner.
METHODOLOGY: This survey-based study was conducted among 40 house officers working at Multan Dental College. A
survey form was designed, about the pattern of antibiotics prescription and the situations for which they were recommended
by the House officers.
RESULTS: The medication of choice was mostly Amoxicillin + clavulanic acid (52.6%) and Amoxicillin alone (47.3%). 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%). Chronic apical abscess with sinus tract (58%). Overall, 12% of part takers were used to suggest
p antibiotics for root canal treatment.
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. Curriculum & syllabus should offer great emphasis on prescribing.
KEYWORDS: Antibiotics, Endodontics, Prescription, prophylaxis, Root canal treatment (RCT)
HOW TO CITE: Ali M, Rasheed D, Irshad HH, Jamil M, Javaid MM, Sajid M. Knowledge regarding prescription of antibiotic
for endodontic treatment among house officers of multan. J Pak Dent Assoc 2023;32(2):54-59.
DOI: https://doi.org/10.25301/JPDA.322.54
Received: 28 Novemebr 2022, Accepted: 07 July 2023

INTRODUCTION

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
1. Hargraeves KM, Cohen S, Burmen LH. Cohen’s Pathways of the Pulp 10thedition. Elsevier.2011

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.
https://doi.org/10.31729/jnma.157

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.
https://doi.org/10.2147/DHPS.S30984

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

Knowledge Regarding Prescription of Antibiotic for Endodontic Treatment among House Officers of Multan

Muhammad Ali1                                  BDS, MCPS
Dil Rasheed2                                       BDS, FCPS
Hafiza Hina Irshad3                            BDS
Muhammad Jamil4                             BDS, FDSRCS
Muhammad Mohsin Javaid5             BDS, MSPH
Mustafa Sajid6                                   BDS, FCPS

 

OBJECTIVE: To evaluate the knowledge regarding the prescription of antibiotic for treatment of endodontic disease and errors
made by the house officers at Multan Dental College.
Since the discovery of antibiotics, they have been in use broadly for the treatment of odontogenic infections. Prescription is a
dynamic, customized clinical process, which is set owing to the necessities of patient & the acquaintance of the practitioner.
METHODOLOGY: This survey-based study was conducted among 40 house officers working at Multan Dental College. A
survey form was designed, about the pattern of antibiotics prescription and the situations for which they were recommended
by the House officers.
RESULTS: The medication of choice was mostly Amoxicillin + clavulanic acid (52.6%) and Amoxicillin alone (47.3%). 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%). Chronic apical abscess with sinus tract (58%). Overall, 12% of part takers were used to suggest
p antibiotics for root canal treatment.
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. Curriculum & syllabus should offer great emphasis on prescribing.
KEYWORDS: Antibiotics, Endodontics, Prescription, prophylaxis, Root canal treatment (RCT)
HOW TO CITE: Ali M, Rasheed D, Irshad HH, Jamil M, Javaid MM, Sajid M. Knowledge regarding prescription of antibiotic
for endodontic treatment among house officers of multan. J Pak Dent Assoc 2023;32(2):54-59.
DOI: https://doi.org/10.25301/JPDA.322.54
Received: 28 Novemebr 2022, Accepted: 07 July 2023

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Association Between Palatally Impacted Maxillary Canine and Anomalous Maxillary Lateral Incisor – A Case Control Study

Rozi Afsar1                     BDS, FCPS
Umar Nasir2                   BDS, FCPS
Bibi Maryam3                 BDS
Atta Elahi4                      BDS, M.Phil
Abdus Saboor5              BDS, M.Phil
Badshah Afsar6             BDS

 

OBJECTIVE: To determine the association between palatally impacted maxillary canine (PIC) and anomalous upper lateral
incisor.
METHODOLOGY: This case control study was conducted on records of 60 participants (30 with PIC and 30 without). The
inclusion criteria were participants without syndromes, palatal canine impaction (cases only), and age range from 12 to 30 year.
Subjects with buccally impacted canine, history of previous orthodontic treatment and non-Pakistani nationals were excluded.
Cases were those having PIC and controls were without PIC. Participant's OPG and periapical X-rays were used to diagnose
PIC by horizontal parallax technique. Dental anomalies in upper lateral incisor were diagnosed by using casts and OPGs.
Logistic regression and chi-square test was applied to determine association between PIC and anomalous upper lateral incisor.
RESULTS: The mean age of the participants was 18.916±4.3 years. The frequency of missing lateral incisor was higher in
cases (n=3, 10%) than control (n=1, 3.3%). Similarly peg shape laterals was more in cases (n=4, 13.3%) than controls (n=2,
6.7%). However this association was not statistically significant (P=0.37). The odd of having anomalies in lateral incisor was
2.73 times higher in cases than controls but the results were not statistically significant (P=0.177).
CONCLUSION: Though the frequency of anomalous maxillary lateral incisors is higher in participants with PIC than controls
but this association was not statistically significant.
KEYWORDS: Palatal canine impaction, missing upper lateral incisors, peg shape upper lateral incisors, dental anomalies
HOW TO CITE: Afsar R, Nasir U, Maryam B, Elahi A, Saboor A, Afsar B. Association between palatally impacted maxillary
canine and anomalous maxillary lateral incisor - A case control study. J Pak Dent Assoc 2023;32(2):51-54.
DOI: https://doi.org/10.25301/JPDA.322.51
Received: 15 December 2021, Accepted: 17 May 2023

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Association Between Palatally Impacted Maxillary Canine and Anomalous Maxillary Lateral Incisor – A Case Control Study

Rozi Afsar1                     BDS, FCPS
Umar Nasir2                   BDS, FCPS
Bibi Maryam3                 BDS
Atta Elahi4                      BDS, M.Phil
Abdus Saboor5              BDS, M.Phil
Badshah Afsar6             BDS

 

OBJECTIVE: This study aimed to compare the the effectiveness of plaque removal between manual and powered toothbrushes
in hearing impaired children. Maintaining a good quality of life requires optimal levels of oral hygiene. In differently abled
subjects, manual dexterity may be slightly compromised, which is why powered toothbrushes were initially designed to help
overcome the slight deficit.
METHODOLOGY: A parallel arm, randomized study was conducted. Twenty two congenitally hearing-impaired participants
aged eighteen to twenty two of age were recruited from National Special Education Centre for Hearing Impaired Children,
Islamabad. They were randomly divided into two groups of eleven participants. Plaque levels were evaluated on the first day
and plaque removal effectiveness of powered toothbrushes compared with manual toothbrush was checked on the
eighth day. Plaque scores were evaluated using the simplified Oral Hygiene Index and Turesky's Modification of Quigley
Hein Plaque Index.
RESULTS: No significant difference of Mean score in effectiveness of plaque removal between manual and powered
toothbrushes was seen.
CONCLUSIONS: Manual and powered toothbrushes are equally effective at plaque . More studies highlighting cost effectiveness
and patient's perception regarding ease of use are required to confirm results.
KEYWORDS: Differently abled patients, manual toothbrushes, electric toothbrushes, oral hygiene.
HOW TO CITE: Hassan S, Zahid A, Khalil B, Hasan M, Nazami A. Comparison of powered toothbrushes and manual
toothbrushes in removing dental plaque among children with hearing disabilities: a randomized pilot study. J Pak Dent Assoc
2023;32(2):45-50.
DOI: https://doi.org/10.25301/JPDA.322.45
Received: 21 January 2023, Accepted: 01 July 2023

INTRODUCTION

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

Comparison of Powered Toothbrushes and Manual Toothbrushes in Removing Dental Plaque among Children with hearing Disabilities: A Randomized Pilot Study

Sobia Hassan1                    BDS, FCPS
Anam Zahid2                       BDS, MSc
Beenish Khalil3                   BDS, MSPH
Maryam Hasan4                  BDS
Arooba Nazami5                 BDS

 

OBJECTIVE: This study aimed to compare the the effectiveness of plaque removal between manual and powered toothbrushes
in hearing impaired children. Maintaining a good quality of life requires optimal levels of oral hygiene. In differently abled
subjects, manual dexterity may be slightly compromised, which is why powered toothbrushes were initially designed to help
overcome the slight deficit.
METHODOLOGY: A parallel arm, randomized study was conducted. Twenty two congenitally hearing-impaired participants
aged eighteen to twenty two of age were recruited from National Special Education Centre for Hearing Impaired Children,
Islamabad. They were randomly divided into two groups of eleven participants. Plaque levels were evaluated on the first day
and plaque removal effectiveness of powered toothbrushes compared with manual toothbrush was checked on the
eighth day. Plaque scores were evaluated using the simplified Oral Hygiene Index and Turesky's Modification of Quigley
Hein Plaque Index.
RESULTS: No significant difference of Mean score in effectiveness of plaque removal between manual and powered
toothbrushes was seen.
CONCLUSIONS: Manual and powered toothbrushes are equally effective at plaque . More studies highlighting cost effectiveness
and patient's perception regarding ease of use are required to confirm results.
KEYWORDS: Differently abled patients, manual toothbrushes, electric toothbrushes, oral hygiene.
HOW TO CITE: Hassan S, Zahid A, Khalil B, Hasan M, Nazami A. Comparison of powered toothbrushes and manual
toothbrushes in removing dental plaque among children with hearing disabilities: a randomized pilot study. J Pak Dent Assoc
2023;32(2):45-50.
DOI: https://doi.org/10.25301/JPDA.322.45
Received: 21 January 2023, Accepted: 01 July 2023

INTRODUCTION

Adisability may be defined as a condition which may be cognitive, developmental, intellectual, mental, physical or sensory. It considerably affects a person’s day to day life and may be present at birth or occur anytime in life.1 3.28 million people were estimated to have disabilities in Pakistan according to 1998 census.  Data collected in 2015 showed that 2.49% of the population that year had disabilities.2 The 2017 census showed that 0.48% of the Pakistani population has disabilities.3 A study done to evaluate the oral hygiene status of 4732 adults with learning and developmental disabilities reported an overall prevalence of periodontitis of 80.3%. The highest prevalence occurred in those over the age of 60 (92.6%) and the lowest (55.8%) in adults of 20 to 39 years of age.4 Dental health is neglected in the disabled population, leading to poor oral hygiene. The main reasons are lack of oral health awareness of guardians/caretakers, lack of motivation and insufficient training of dental staff.
Regular and consistent mechanical removal of plaque and food debris has been shown to decrease numbers of pathogenic bacteria. Plaque control can be achieved with tooth brushing twice daily and using interdental aids. Electric toothbrushes entered the consumer market in the early 1960s. Since then, many studies have been carried out to compare their plaque removal effectiveness with manual toothbrushes.5,6 Prevention of oral diseases in differently abled individuals is a challenging problem for dental professionals. They should be encouraged in their efforts to take care of themselves. Until now, several studies have
concluded that there are deficits in balance, visual-motor skills and dynamic coordination in hearing impaired children.7
The main reason for choosing this population is because they are at a higher risk of developing tooth and gum disease. According to our hypothesis, electric toothbrushes are more effective in removing plaque as compared to manual toothbrushes in hearing impaired patients. According to our literature research conducted tover a course of 6 months, no such study was found in Pakistan. The goal of this study is to analyze the effectiveness of powered toothbrushes to manual toothbrushes in individuals with hearing disabilities.

METHODOLOGY
A parallel arm, single blind, randomized, pilot study was conducted in National Special Education Centre for Hearing Impaired Children Islamabad. The data was collected from 24th and 31st January 2019. Ethical clearance was acquired from ethical committee of Riphah International University (Ref. No. IIDC/IRC/2018/04/002). The study was performed on twenty-two participants with congenital hearing disabilities. The sample size was estimated using nMaster software for hypothesis testing for two means (equal variances), WHO sample size calculator with confidence interval of 95%, Power of study 80% and level of statistical significance P< 0.05, P1=0.70, P2 = 0.65.
Informed consent was taken from the Head of the Institute and participants. The study procedure was explained to participants, their caretakers and in-charge staff and they were ensured confidentiality of their participation. Inclusion criteria was “subjects of both genders above sixteen years of age, who could brush on their own, are not taking any regular medications, have satisfactory general and oral health with no history of any systemic diseases.” Exclusion criteria was “patients with orthodontic or prosthetic appliances, implants, using medication that would have an effect on gingival tissues, having any other oral and mucosal problems or more than four carious teeth requiring immediate treatment.”
Participants were familiarized with manual and powered toothbrushes before commencement of the study with help of demonstrations using sign language. Our research was not sponsored by any toothbrush manufacturing company. Examiners responsible for data collection were trained in the department of Periodontology, Islamic International Dental College. Turesky’s Modification of Quigley-Hein Plaque Index was talked through with subject experts in order to remove ambiguities pertaining to scoring before the calibration procedure was begun.Twenty two patients were calibrated. Study subjects were allocated randomly when being examined, using Open Clinical Randomize software. (Fig 1.1) Allocation of participants was done by the co-principal investigator and assessment was done by
the principal investigator. Oral examination was done using sterile instruments (explorer, probe, mirror, William’s periodontal probe) under adequate illumination. Plaque, debris and calculus was evaluated on six sites on each tooth (distobuccal, mid-buccal, mesio-buccal disto-lingual, mid-lingual, and mesiolingual). Third molars were excluded.
Eligible subjects were then randomized into two groups using OpenClinica Randomize software. (Fig 1.1). Oral hygiene kits containing manual toothbrushes and powered toothbrushes were coded A and B respectively, A (manual toothbrush) and B (powered toothbrush with rounded bristles and rotation oscillation action). Subject allocation and allotment of toothbrush kits was carried out by the co-principal investigator who was not involved in data collection procedure. Toothbrushes were labeled A and B and the investigator handing out toothbrushes to participants did not know whether A or B was manual or powered toothbrush. During manual brushing, the participants were instructed to use Modified Bass technique. Brushing techniques were demonstrated to participants as well as caretakers on a dental model. For powered toothbrush,

 

participants were told to brush according to the instructions provided on the instruction manual by the manufacturer, a copy of which was provided to each participant. The duty to help participants recall the brushing technique was assigned to the caretakers. The same toothpaste containing sodium fluoride was provided to all students and they were told to brush two times daily for 2-3 minutes, using the toothbrush they were provided with. At the end, study participants were asked to carry out the toothbrushing technique for the satisfaction of examiners. Participants were assessed after one week. Clinical examination and scoring was performed by the same investigators blinded to the toothbrush being used.
Clinical evaluations were performed by the investigator who didn’t know about allotment of the products and groups. Before start of follow-up examination, the
co-principal investigator advised all participants not to expose their group task to the investigators. Evaluation of plaque on the first day was done by O’Leary method
with explorer and mouth mirror according to criteria of Simplified Oral Hygiene Index (by Greene and Vermilion).8 On the eighth day the subjects were sent to the examination hall and the examiners used Turesky’s Modification of Quigley-Hein plaque index for recording plaque scores.
SPSS version 23 ( IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp) was used to perform statistical analysis. The plaque score differed between the two groups, on the 1st day and the8th day,which was compared usingan
independent sample t-test. Statistical significance was P<0.05, P1= 0.70, P2=0.65.
Oral Hygiene Index score (Appendix 1)9 was assessed at three sites per tooth by randomly selected quadrants by a single experienced and skilled examiner, who did not know the allotted groups. Presence of calculus and plaque  (Turesky’s Modification of Quigley-Hein plaque index) was evaluated in the same way. Visual inspection was done to assess the oral cavity at each visit and the students were properly trained before conducting the examination.

RESULTS
Demographics and Participants Information
The study included twenty two hearing impaired participants who were selected by a group of properly trained examiners after complete evaluation. The participants were studying in National Special Education Centre for Hearing Impaired Children, Islamabad and belonged to age bracket of 18-22 years. Majority of them belonged to the age group of 18 years (n=7) (31.8%). There were an equal number of male (n=11) and female (n=11) participants.
The participants had inadequate oral hygiene and brushed their teeth once daily prior to the study.
All subjects (n=22) successfully completed the study period of 8 days except 2 who were lost to follow up due
to non-availability on the 8th day. There was no substantial difference in the mean age of the subjects.

Score For Manual Tooth Brush
  The mean initial OHI-S value for manual toothbrush was 1.91 with a 0.2% of standard error, which reached a mean of 1.33 after the trial period of 8 days (p<0.05).
Evaluation of plaque and calculus showed a mean value of 1.27 and 0.69 at the start of the study which, after 8 days changed to 0.56 and 0.96 respectively. Mean debris index score was 1.07 at the start of the study and showed a significant decrease after 8 days (0.42). (Fig 1.2 and 1.3) Score for Powered Tooth Brush.
In the group using powered toothbrush, the mean baseline values of OHI-S and Debris index were 1.64 and 0.90 respectively, which later changed to 1.09 and 0.42 for OHI-S and Debris index. Plaque Index calculated at the start of our study showed a mean value of 1.36 and after 8 days it changed to 0.73. Whereas, calculus index showed a mean value of 0.63 at the start and 0.64 at the end of our

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

REFERENCES
1. Tanaka H, Seals DR. Invited review: dynamic exercise performance in masters athletes: insight into the effects of primary human aging on physiological functional capacity. J App Physiology. 2003;95:2152- 62.
https://doi.org/10.1152/japplphysiol.00320.2003

2. Pakistan, Canadian High Commission and WHO collaborate to collect comprehensive information on disabilities.
https://www.app.com.pk/national/disabled-constitute-just-0-48-oftotal-population/.

3. Arsh A, Darain H. Persons with disabilities in Pakistan. Annals of Allied Health Sci. 2019;5:1-2.

4. Morgan JP, Minihan PM, Stark PC, Finkelman MD, Yantsides KE, Park A, et al. The oral health status of 4,732 adults with intellectual and developmental disabilities. J Am Dent Assoc. 2012;143:838-46.
https://doi.org/10.14219/jada.archive.2012.0288

5. Kumar S, Sharma J, Duraiswamy P, Kulkarni S. Determinants for oral hygiene and periodontal status among mentally disabled children and adolescents. J Indian Soc Pedodont Preven Dent. 2009;27:151.
https://doi.org/10.4103/0970-4388.57095

6. Deacon S, Glenny AM, Deery C, Robinson P, Heanue M, Walmsley A, et al. Different powered toothbrushes for plaque control and gingival health. Austral Dent J. 2011;56:231-3.
https://doi.org/10.1111/j.1834-7819.2011.01329.x

7. Gheysen F, Loots G, Van Waelvelde H. Motor development of deaf children with and without cochlear implants. J Deaf Stud Deaf Educ. 2008;13:215-24.
https://doi.org/10.1093/deafed/enm053

8. Greene JG, Vermillion JR. The simplified oral hygiene index. The J Am Dent Assoc. 1964;68:7-13.
https://doi.org/10.14219/jada.archive.1964.0034

9. Newman MG, Takei H, Klokkevold PR, Carranza FA. Carranza’s clinical periodontology: Elsevier Health Sci; 2011.

10. Waqar K. Disability: Situation in Pakistan, Right to Education Pakistan, Article 25A. Aga Khan University. 2014.

11. Brandes DA, Wilson S, Preisch JW, Casamassimo PS. A comparison of opinions from parents of disabled and non-disabled children on behavior management techniques used in dentistry. Spec Care Dent. 1995;15:119-23.
https://doi.org/10.1111/j.1754-4505.1995.tb00493.x

12. TESINI DA. An annotated review of the literature of dental caries and periodontal disease in mentally retarded individuals. Spec Care Dent. 1981;1:75-87.
https://doi.org/10.1111/j.1754-4505.1981.tb01232.x

13. Penick C. Power toothbrushes: a critical review. Int J Dent Hygiene. 2004;2:40-4.
https://doi.org/10.1111/j.1601-5037.2004.00048.x

14. Goyal S, Thomas BS, Bhat KM, Bhat GS. Manual toothbrushing reinforced with audiovisual instruction versus powered toothbrushin among institutionalized mentally challenged subjects-A randomized cross-over clinical trial. Med Oral Patol Oral Cir Bucal. 2011;16:e359- 64.
https://doi.org/10.4317/medoral.16.e359

15. Kulkarni P, Singh DK, Jalaluddin M. Comparison of efficacy of manual and powered toothbrushes in plaque control and gingival inflammation: A clinical study among the population of East Indian Region. J Int Soci Prevent Community Dent. 2017;7:168.

16. Cronin M, Dembling W, Conforti N, Liebman J, Cugini M, Warren P. A single-use and 3-month clinical investigation of the comparative efficacy of a battery-operated power toothbrush and a manual toothbrush. Am J Dent. 2001;14:19B-24B.

17. Robinson P, Deacon SA, Deery C, Heanue M, Walmsley AD, Worthington HV, et al. Manual versus powered toothbrushing for oral health. Cochrane Database of Systematic Reviews. 2005(2).
https://doi.org/10.1002/14651858.CD002281.pub2

18. Deacon SA, Glenny AM, Deery C, Robinson PG, Heanue M, Walmsley AD, et al. Different powered toothbrushes for plaque control and gingival health. Cochrane Database of Systematic Reviews.
2010(12).
https://doi.org/10.1002/14651858.CD004971.pub2

19. Haffajee AD, Thompson M, Torresyap G, Guerrero D, Socransky SS. Efficacy of manual and powered toothbrushes (I). Effect on clinical parameters. J Clin Periodontol. 2001;28:937-46.
https://doi.org/10.1034/j.1600-051x.2001.028010937.x

20. Parizi MT, Mohammadi TM, Afshar SK, Hajizamani A, Tayebi M. Efficacy of an electric toothbrush on plaque control compared to two manual toothbrushes. Int Dent J. 2011;61:131-5
https://doi.org/10.1111/j.1875-595X.2011.00029.x

21. Vibhute A, Vandana K. The effectiveness of manual versus powered toothbrushes for plaque removal and gingival health: A meta-analysis. J Indian Soci Periodontol. 2012;16:156.
https://doi.org/10.4103/0972-124X.99255

22. Yaacob M, Worthington HV, Deacon SA, Deery C, Walmsley AD, Robinson PG, et al. Powered versus manual toothbrushing for oral health. Cochrane Database of Systematic Reviews. 2014.
https://doi.org/10.1002/14651858.CD002281.pub3

23. Dogan MC, Alaçam A, Asici N, Odabas M, Seydaoglu G. Clinical evaluation of the plaque-removing ability of three different toothbrushes in a mentally disabled group. Acta Odontol Scandin. 2004;62:350-4.
https://doi.org/10.1080/00016350410010054

24. Neelima M, Chandrashekar BR, Goel S, Sushma R, Srilatha Y. “Is powered toothbrush better than manual toothbrush in removing dental plaque?”-A crossover randomized double-blind study among differently abled, India. J Indian Soci Periodontol. 2017;21:138.
https://doi.org/10.4103/jisp.jisp_185_17

25. Williams K, Ferrante A, Dockter K, Haun J, Biesbrock AR, Bartizek RD. One-and 3-minute plaque removal by a battery-powered versus a manual toothbrush. J Periodontol. 2004;75:1107-13.
https://doi.org/10.1902/jop.2004.75.8.1107

Comparison of Powered Toothbrushes and Manual Toothbrushes in Removing Dental Plaque among Children with hearing Disabilities: A Randomized Pilot Study

Sobia Hassan1                    BDS, FCPS
Anam Zahid2                       BDS, MSc
Beenish Khalil3                   BDS, MSPH
Maryam Hasan4                  BDS
Arooba Nazami5                 BDS

 

OBJECTIVE: This study aimed to compare the the effectiveness of plaque removal between manual and powered toothbrushes
in hearing impaired children. Maintaining a good quality of life requires optimal levels of oral hygiene. In differently abled
subjects, manual dexterity may be slightly compromised, which is why powered toothbrushes were initially designed to help
overcome the slight deficit.
METHODOLOGY: A parallel arm, randomized study was conducted. Twenty two congenitally hearing-impaired participants
aged eighteen to twenty two of age were recruited from National Special Education Centre for Hearing Impaired Children,
Islamabad. They were randomly divided into two groups of eleven participants. Plaque levels were evaluated on the first day
and plaque removal effectiveness of powered toothbrushes compared with manual toothbrush was checked on the
eighth day. Plaque scores were evaluated using the simplified Oral Hygiene Index and Turesky's Modification of Quigley
Hein Plaque Index.
RESULTS: No significant difference of Mean score in effectiveness of plaque removal between manual and powered
toothbrushes was seen.
CONCLUSIONS: Manual and powered toothbrushes are equally effective at plaque . More studies highlighting cost effectiveness
and patient's perception regarding ease of use are required to confirm results.
KEYWORDS: Differently abled patients, manual toothbrushes, electric toothbrushes, oral hygiene.
HOW TO CITE: Hassan S, Zahid A, Khalil B, Hasan M, Nazami A. Comparison of powered toothbrushes and manual
toothbrushes in removing dental plaque among children with hearing disabilities: a randomized pilot study. J Pak Dent Assoc
2023;32(2):45-50.
DOI: https://doi.org/10.25301/JPDA.322.45
Received: 21 January 2023, Accepted: 01 July 2023

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