Knowledge and Practices of Patients Regarding Antibiotics Used For Dental Problems

Amna Sohail               BDS, BSc

Azka Yaseen               BDS, BSc, PDAGD

Samir Riaz Qazi        BDS, FFDRCSI, M.Phil

OBJECTIVES: The objective of this survey was to assess the level of common knowledge and practices concerning usage of antibiotics among dental patients.
METHODOLOGY: A descriptive questionnaire-based survey was done consisting of fifteen questions at the Institute of Dentistry, CMH Lahore Medical College.
RESULTS: Sample included 500 dental patients, 237 males (48.2%) and 255 females (51.8%). Participants were divided into various groups; less educated (up to matriculation level), more educated (above matriculation level), low-income (<25000 PKR monthly) and high-income (25000 PKR and above monthly).
Majority (61.8%) of the sample thought antibiotics have antiviral effects. Three-fourth (75.5%) of the sample thought antibiotics have an analgesic effect while (67.3%) thought antibiotics should be prescribed post-extraction.
Thirty-eight percent thought that antibiotics should be taken before any dental work while more than half (54.7%) knew that antibiotics have side effects. Majority (74.5%) knew that unnecessary use of antibiotics make them ineffective leading to antibiotic resistance. In the sample, (90.7%) believed it was important to complete the course of antibiotics prescribed by dentist but (43%) used to discontinue antibiotics on feeling better. Twenty six percent of the sample considered homeopathic medicine more effective than antibiotics for treatment of infections.
Self-medication was reported by (42.3%) and (41.1%) used antibiotics prescribed by pharmacists at some point in their lives.
CONCLUSION: Patients’ knowledge about antibiotics was inadequate, antibiotics misuse was widespread and high selfmedication rates were reported.
KEYWORDS: Antibiotics, Self-medication, Antimicrobial resistance, Patient, Knowledge, Dentistry.
HOW TO CITE: Sohail A, Yaseen A, Qazi SR. Knowledge and practices of patients regarding antibiotics used for dental problems. J Pak Dent Assoc 2020;29(2):71-76.
Received: 29 June 2019, Accepted: 28 February 2020


Antibiotics are commonly used as well as misused drugs in the world, particularly in developing countries.1
In dentistry, there is evidence to suggest over-prescription of antibiotics by dental practitioners in the management of acute dental conditions, despite contrary clinical guidelines.2 This might be due to uncertainty about diagnosis, demand and expectations of patients, and because of the pressure of time on the clinician.3 Patient expectations increase the possibility of receiving a particular prescription by three times.4 Inappropriate antibiotic prescribing habits lead to the development of resistant bacterial strains.5 Centers for Disease Control US (CDC) estimates that at least 30% of oral antibiotic courses prescribed in the outpatient setting during 2010-11 were unnecessary.6
In an English study, general dental practitioners (GDPs) reported that their decisions in antibiotic prescribing were compelled by both clinical related pressures and wider responsibilities towards public health.7

Over the years, misuse of antibiotics has resulted in the emergence of antibiotic-resistant bacterial strains which are
intensifying with time8 and caused death of around 23,000 people in US.9 Dentists in primary care make up approximately one in ten of all therapeutic antibiotic prescriptions, hence contributing to the problem of bacterial resistance.10
In addition to these inappropriate prescribing habits of doctors, self-medication or the use of un-prescribed drugs is common practice around the globe.11 Factors that lead to self-medication include high cost of medicines, inaccessibility to health facilities12, having minor illness, high health care costs, lack of adequate time to visit a physician, prior experience in using a drug, and long waiting time to visit a qualified practitioner.13,14
Self-medication with antibiotics ranges from 2% to 92% in different countries, with the most frequent self-medicated prescription-only medicine being antibiotics.15
In Pakistan, little research has been carried out in the past regarding antibiotics misuse by patients. By evidence the proportion of self-medicating individuals is alarmingly high.24 This problem has been related to illiteracy, ignorance, lack of legislation regarding the use of prescribed drugs, poor socioeconomic status, dental phobia, no health insurance, unavailability of quality dental clinics, and availability of homeopathic drugs.24 Prescription of medicines by nondoctors also contributes to the misuse of antibiotics.25 This study was aimed at examining common knowledge and practices concerning usage of antibiotics among dental patients. The findings of this study may, thus, help initiate effective interventions to decrease misconceptions about the antibiotics use in the region.


A descriptive cross-sectional questionnaire-based survey was conducted among patients presenting in Out-patient
Department (OPD) of Institute of Dentistry, CMH Lahore Medical College in order to assess their knowledge and practices concerning antibiotics and its resistance. Permission was sought from the IRB (4187/IOD/CMH) before carrying out the survey.
The questionnaire was translated into Urdu and retranslated back into English and modified as required. It was then piloted on 10 patients and revised again. The purpose of this study was discussed with participants, any ambiguities
cleared, and verbal consent was taken. Filled forms were collected immediately. The study included 500 respondents. All patients, age 13 and above, presenting in the OPD were included in the study. The mean age of respondents was 35.3 years (minimum age=13, maximum age=85, Table 1). There were 237 (48.2%) males and 255 (51.8%) females in the study (8 missing). The participants were divided into various groups such as; Less educated (up to matriculation level, 36.8%), More educated (above matriculation level, 63.2%), Low-income (<25000 PKR monthly, 40.1%) and Highincome (25000 PKR and above monthly, 59.5%) groups (Table 1). Data collected in this study was analyzed using IBM SPSS v23 (IBM Corp, USA, 2017). The level of statistical significance was set at P < 0.05.


There were 500 respondents in this study. The mean age of respondents was 35.3 years (SD=13.3, median age=32, minimum age=13, maximum age=85, Table 1). There were 237 (48.2%) males and 255 (51.8%) females in the sample (8 missing). Participants were divided into various groups; Less educated (36.8%), More educated (63.2%), Low-income (40.1%) and High-income (59.5%) (Table 1). The most

Table 1: Demographics of study participants (missing: 8)

frequent occupation was housewife (36.2%) followed by private job (17.2%), and self-employed (9.2%).
In the study, a vast number (82.7%) of respondents were aware of the fact that antibiotics can kill bacteria. But majority (61.8%) of the sample thought antibiotics have antiviral effects despite of any gender, education or income group (P=0.050, Table 2). Three-fourth (75.5%) of the sample thought antibiotics have an analgesic effect. Significantly more of the less educated participants had this thought than more educated ones (81.8% vs. 71.8%, P=0.049, Table 2). Augmentin (32%) and Amoxil (24%) were the most commonly misused antibiotics for pain relief.
A large number (67.3%) of the respondents were of the view that dentists should prescribe antibiotics post-extraction
where majority of the respondents were from low income group (78.3%) and seem to be unaware about the role of
antibiotics after extraction of tooth/teeth (Table 2). Comparatively lesser number of respondents (38%) were of
the opinion that antibiotics should be taken before going for any dental work which included significantly high number of females as compared to males (43.2% vs 32.3%, P=0.048) and low income group as compared to high income group (43% vs 30.2%, P=0.021) (Table 2).
More than half (52.8%) of the sample thought that antibiotics can cause allergic reactions including (54.2%) of more educated people (Table 2). While (54.7%) thought that antibiotics can have side effects such as diarrhea. Significantly high difference was seen among more educated people with high income as compared to less educated people with low income (58.8% vs 47.5%, P=0.052 and 59.8% vs 47.1%, P=0.021 respectively, Table 2).

Majority (74.5%) of the sample knew that unnecessary use of antibiotics can make them ineffective leading to antibiotic resistance. Significantly high frequency of the more educated and high income groups were aware of this phenomenon as compared to less educated and low income groups (79.7% vs 65.4%, P=0.002 and 79.8% vs 69.2%,
p=0.028 respectively, Table 2).
In the sample, a vast number (90.7%) of respondents, despite of any gender, education or income group, were aware about the importance of completing the course of antibiotics prescribed by dentist (Table 2). But (43%) of the sample used to discontinue further antibiotics on feeling better before completion of course (Table 3). Twenty six percent of the sample considered homeopathic medicine to be more effective than antibiotics for treatment of infections, with significantly more participants of less
educated and low income groups as compared to the
participants of more educated and more income groups
(34.4% vs 21.3%, P=0.004 and 30.5% vs 13.6%, P=0.000
respectively, (Table 2). This depicts the low level of awareness
among low socio-economic groups.
In the sample, (41.0%) of respondents told that they
used to give the leftover antibiotics to their friends, roommates
or family members if they were ever asked for (Table 3).
This practice led to self-medication which was reported by
(42.3%) of the total respondents (Table 3).
In the study, (41.1%) of participants had used antibiotics
prescribed by pharmacists at some point in their lives,
including significantly high number of males as compared
to females (46.4% vs 35.9%, P=0.016), as well as more

Table 2: Frequency of respondents agreeing with research statements related to knowledge about antibiotics.
* indicates significant differences amongst groups.

Table 3: Frequency of respondents agreeing with research statements related to practices about antibiotics.
* indicates significant differences amongst groups.

educated and high income groups as compared to less
educated and low income groups (44.2% vs 35.5%, P=0.000

and 46.7% vs 38.3% respectively, Table 3).
Antibiotic misuse was prevalent in the sample evidenced
by the high self-medication rates (42.3%) and the use of
pharmacist-prescribed antibiotics (41.1%). The
misconceptions that antibiotics had antiviral (61.8%) and
analgesic effect (75.5%), should be taken before any dental
work (38%), and should be prescribed post-extraction
(67.3%) were widespread. This might be due to inadequate
knowledge regarding appropriate antibiotic usage and due
to the unregulated dispensation of these drugs by pharmacies.
Self-medication rates (42.3%) in the study were
comparatively lower than those in the region: 92% in
Kuwait18, (51%) in India19, (53%) in Iran20 and (48%) in
Sudan, where (76%) antibiotics were pharmacist-prescribed
and (24%) were obtained from friends, family, or at home.21
In the US, however, the rate of self-medication is considerably
lower (5%).22
Misconception about antiviral effects of antibiotics was
(61.8%) in the study and most (75.5%) of the respondents
thought antibiotics had analgesic effect. A Swedish study
showed that (19.1%) agreed that common colds are cured
with antibiotics23, (6.5%) in Netherlands24 and (7.4%) in
Australia25 had similar views, but considerably lower than
what has been reported from Britain (38%)26, and the USA
(55%).27,28 A Jordanian study showed (28.1%) individuals
misused antibiotics as analgesics.29 According to a systemic
review in 2015, (50%) of the sample were not aware that
antibiotics were not therapeutic for viral infections (such as
flu and common cold), pain, and inflammation.30
Majority of patients did not know that antibiotics can
only treat bacterial infections and that they are not useful
against viruses.31 Thus leaving them unaware about the fact
that misuse of antibiotics can lead to the problem of
developing bacterial resistance.32 In developed parts of the
world, such as Europe, attitudes towards antibiotics were
found to be influenced by country and level of education.33
It was also found that awareness about antibiotic resistance
was lagging in countries with higher prevalence of
resistance.33 In China, public, in general, was not aware of
the causes of antibiotic resistance, or their role and capability
in causing or preventing resistance.34
The perception that homeopathic medicine is superior
to antibiotics is of concern and indicates lack of trust in
allopathic medicine as (26%) of the study sample considered
homeopathic medicines were more effective than antibiotics
for treatment of infections.
Although the study had socioeconomically diverse
respondents but this may not represent the overall population
of Lahore. Because the limitation of this study was sample
size that comprised of patients from single private hospital
only. Respondents may also have denied self-medication or
using pharmacy-prescribed antibiotics, especially if aware
that this was inappropriate behavior.
Further research needs to be done on the misuse of
antibiotics in the region especially by dental patients and
their expectations from dentists for an antibiotic course
prescription possibly leading to inappropriate antibiotic
prescriptions by GDPs. A cohesive approach involving
policymakers, prescribers and the general public is needed,
using both educational and regulatory measures. Such
measures should be embedded in the general policy by the
government to change the culture of antibiotic use by
improving awareness among the general public and
professionals about the risks associated with antibiotic
misuse, as well as reducing public misconception about the
analgesic and antiviral effects of antibiotics.
Previous interventions that have successfully improved
prescribing behavior among GDPs include clinical audits35,36
and pharmacist-delivered academic detailing.37 GDPs need
to accurately and extensively inform their patients with the
intention of making them aware of the importance of correct
behavior regarding antibiotic intake.
High self-medication rates were reported in the sample
despite reasonable knowledge about antibiotic resistance
and its side effects. Antibiotic misuse was widespread in
the sample and may be linked to the misconception that
antibiotics have an antiviral and analgesic effect.
None declared
1. Ocan M, Obuku EA, Bwanga F, Akena D, Richard S, Ogwal-Okeng
J, Obua C. Household antimicrobial self-medication: a systematic
review and meta-analysis of the burden, risk factors and outcomes in
developing countries. BMC public health. 2015;15:742.
2. Cope AL, Chestnutt IG. Inappropriate prescribing of antibiotics in
primary dental care: reasons and resolutions. Prim Dent J. 2014;3:
3. Butler CC, Rollnick S, Pill R, Maggs-Rapport F, Stott N.
Understanding the culture of prescribing: qualitative study of general
practitioners’ and patients’ perceptions of antibiotics for sore throats.

BMT. 1998;317:637-42.
4. Murshid MA, Murshid MA, Mohaidin Z, Mohaidin Z, Yen Nee G,
Yen Nee G. The influence patient’s characteristics “requests and
expectations” on physician prescribing behavior: A review. Int J
Pharmaceut Healthcare Market. 2016;10:390-411.
5. Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of
antibiotic prescribing in primary care on antimicrobial resistance in
individual patients: systematic review and meta-analysis. BMJ.
6. Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M, Enns EA,
File TM, et al. Prevalence of inappropriate antibiotic prescriptions
among US ambulatory care visits, 2010-2011. J Am Med Assoc.
7. Cope A, Wood F, Francis NA, Chestnutt IG. General dental
practitioners’ perceptions of antimicrobial use and resistance: a
qualitative interview study. Brit Dent J. 2014;217:E9.
8. Goossens H, Ferech M, Vander Stichele R, Elseviers M, Group EP.
Outpatient antibiotic use in Europe and association with resistance:
a cross-national database study. The Lancet. 2005;365:579-87.
9. Control center for diseases, Prevention. Antibiotic resistance threats
in the United States, 2013: Centres for Disease Control and Prevention,
US Department of Health and Human Services; 2013.
10. Johnson TM, Hawkes J. Awareness of antibiotic prescribing and
resistance in primary dental care. Prim Dent J. 2014;3:44-7.
11. Morgan DJ, Okeke IN, Laxminarayan R, Perencevich EN,
Weisenberg S. Non-prescription antimicrobial use worldwide: a
systematic review. The Lancet infectious diseases. 2011;11:692-701.
12. Silva IM, Catrib AMF, Matos VCd, Gondim APS. Self-medication
in adolescence: a challenge to health education. Ciência & Saúde
Coletiva. 2011;16:1651-60.
13. Shaghaghi A, Asadi M, Allahverdipour H. Predictors of selfmedication behavior: a systematic review. Iranian J Public Health.
14. Shankar P, Partha P, Shenoy N. Self-medication and non-doctor
prescription practices in Pokhara valley, Western Nepal: a questionnairebased study. BMC family practice. 2002;3:17.
15. Shehnaz SI, Agarwal AK, Khan N. A systematic review of selfmedication practices among adolescents. J Adolesc Health. 2014;55:467-
16. Baig QA, Muzaffar D, Afaq A, Bilal S, Iqbal N. Prevalence
of self medication among dental patients. Pak Oral & Dent J. 2012;
17. Zafar SN, Syed R, Waqar S, Irani FA, Saleem S. Prescription of
medicines by medical students of Karachi, Pakistan: A cross-sectional
study. BMC Public Health. 2008;8:162-68.
18. Abahussain E, Matowe LK, Nicholls P. Self-reported medication
use among adolescents in Kuwait. Medi Principles Practi. 2005;14:161-
19. Rawlani SM, Rawlani S, Bhowte R, Degwekar S, Rawlani S,
Chand0k R. Prevalence of self-medication among dental patients in
rural area of Maharashtra, India: A cross-sectional study. Indi J of Oral
Sci. 2015;6:51-4.
20. Sarahroodi S, Arzi A. Self medication with antibiotics, is it a
problem among Iranian college students in Tehran. J Biol Sci.
21. Awad A, Eltayeb I, Matowe L, Thalib L. Self-medication with
antibiotics and antimalarials in the community of Khartoum State,
Sudan. J Pharm Pharmaceut Sci. 2005;8:326-31.
22. Zoorob R, Grigoryan L, Nash S, Trautner BW. Nonprescription
Antimicrobial Use in a Primary Care Population in the United States.
Antimicrob Agents Chemotherap. 2016;60:5527-532.
23. André M, Vernby Å, Berg J, Lundborg CS. A survey of public
knowledge and awareness related to antibiotic use and resistance in
Sweden. J Antimicrob Chemotherap. 2010;65:1292-296.
24. Cals JW, Boumans D, Lardinois RJ, Gonzales R, Hopstaken RM,
Butler CC, et al. Public beliefs on antibiotics and respiratory tract
infections: an internet-based questionnaire study. Br J Gen Pract.
25. Wutzke SE, Artist MA, Kehoe LA, Fletcher M, Mackson JM,
Weekes LM. Evaluation of a national programme to reduce inappropriate
use of antibiotics for upper respiratory tract infections: effects on
consumer awareness, beliefs, attitudes and behaviour in Australia.
Health Promotion Int. 2006;22:53-64.
26. Curry M, Sung L, Arroll B, et al. Public views and use of antibiotics
for the common cold before and after an education campaign New
Zealand, N Z Med J , 2006;119:1957

27. McNulty CA, Boyle P, Nichols T, Clappison P, Davey P. Don’t
wear me out-the public’s knowledge of and attitudes to antibiotic use.
J Antimicrob Chemotherap. 2007;59:727-38.
28. Belongia EA, Naimi TS, Gale CM, Besser RE. Antibiotic use and
upper respiratory infections: a survey of knowledge, attitudes, and
experience in Wisconsin and Minnesota. Prevent Medi. 2002;34:346-
29. Shehadeh M, Suaifan G, Darwish RM, Wazaify M, Zaru L, Alja’fari
S. Knowledge, attitudes and behavior regarding antibiotics use and
misuse among adults in the community of Jordan. A pilot study. Saudi
Pharmaceut J. 2012;20:125-33.
30. Gualano MR, Gili R, Scaioli G, Bert F, Siliquini R. General
population’s knowledge and attitudes about antibiotics: a systematic
review and meta-analysis. Pharmacoepidemiol Drug Safety. 2015;24:2-
31. Oh AL, Hassali MA, Al-Haddad MS, Sulaiman SAS, Shafie AA,
Awaisu A. Public knowledge and attitudes towards antibiotic usage:
a cross-sectional study among the general public in the state of Penang,
Malaysia. J Infect Develop Countri. 2011;5:338-47.
32. Grigoryan L, Burgerhof JG, Degener JE, Deschepper R, Lundborg
CS, Monnet DL, et al. Attitudes, beliefs and knowledge concerning
antibiotic use and self-medication: a comparative European study.
Pharmacoepidemiol Drug Safety. 2007;16:1234-243.
33. Pan H, Cui B, Zhang D, Farrar J, Law F, Ba-Thein W. Prior
knowledge, older age, and higher allowance are risk factors for selfmedication with antibiotics among university students in southern
China. PloS one. 2012;7:e41314.
34. Chate R, White S, Hale L, Howat A, Bottomley J, Barnet-Lamb
J, et al. The impact of clinical audit on antibiotic prescribing in general
dental practice. Briti Dent J. 2006;201:635.
35. Palmer N, Dailey Y, Martin M. Pharmacology: Can audit improve
antibiotic prescribing in general dental practice? Briti Dent J.
36. Seager J, Howell-Jones R, Dunstan F, Lewis M, Richmond S,
Thomas D. A randomised controlled trial of clinical outreach education
to rationalise antibiotic prescribing for acute dental pain in the primary
care setting. Briti Dent J. 2006;201:217.

  1. Demonstrator, Department of Prosthodontics, Institute of Dentistry, CMH Lahore Medical College.
  2. General Dentist, Institute of Dentistry, CMH Lahore Medical College.
  3. Oral Surgeon, , Institute of Dentistry, CMH Lahore Medical College.
    Corresponding author: “Dr. Azka Yaseen” < >