|Year : 2021 | Volume
| Issue : 4 | Page : 245-250
Antibiotic prescribing practices in various periodontal surgeries in vicinity of Nagpur City: A survey
Grishmi Niswade1, Deepti Gattani1, Suresh Ughade2
1 Department of Periodontology, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India
2 Professor and Faculty in Clinical Epidemiology Unit, Government Medical College, Nagpur, Maharashtra, India
|Date of Submission||21-Sep-2020|
|Date of Decision||22-Nov-2020|
|Date of Acceptance||29-Jan-2021|
|Date of Web Publication||08-Oct-2021|
Department of Periodontology, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Among the postoperative complications following periodontal surgery, the risk of infection stands out the most since infection of the surgical site can lead to poor surgical outcomes in terms of wound healing. Aim: This study aims to evaluate antibiotic-prescribing practices for various periodontal surgeries in vicinity of Nagpur city. Materials and Methods: An anonymous survey was distributed to periodontists through Google forms. The survey questioned prescribing practices for various periodontal surgeries, the demographic data and place of practice of the clinician, rationale for prescribing or not prescribing antibiotics, and acceptability of guidelines. The survey consisted of 12 questions, 7 of which were questioned to the practitioners “In an otherwise healthy patient, would you prescribe antibiotics for a X procedure” where X included various periodontal surgeries. Response choices were limited to “In most cases yes, in most cases no and I do not perform this procedure.” Results were analyzed using statistical software. Results: A total of 50 periodontists responded out of 98 who were contacted to participate in the survey with a response rate of 51%. Nearly 58% of practitioners had a predominant work setting of a dental college and 42% have a predominant work setting of private practice. Practitioners were significantly more likely to prescribe antibiotics all the periodontal surgical procedures. The most common rationale for prescribing antibiotics was to decrease the chances of developing an infection, whereas the most common rationale for not prescribing antibiotics was a healthy patient and based on current and previous literature. Nearly 66% of practitioners reported that they would follow the guidelines for antibiotic prescription if they were developed by American Academy of Periodontology (AAP). Bivariate analysis revealed that there is no significant role of other characteristics on the response of an individual. Even multivariate analysis does not reveal significance of baseline characteristics although it revealed that respondents working in a dental college are 2.15 times more likely to follow AAP guidelines as compared to private practitioners. Females are 1.64 times more likely to follow AAP guidelines as compared to males and respondents practicing inside Nagpur are 1.35 times more likely to follow AAP guidelines as compared to those practicing outside city. Conclusion: Practitioners are more likely to prescribe antibiotics in the majority of the periodontal surgical procedures despite the standard indications for prescription. This misuse can lead to numerous complications in treatment and development of antibiotic resistance. Based on these results, specific guidelines for the use of antibiotics suggesting a particular antibiotic to be used in a particular periodontal surgery and its duration is the need of the hour to prevent the overuse of antibiotics.
Keywords: Antibiotics, guidelines, infection, periodontal surgeries, questionnaire
|How to cite this article:|
Niswade G, Gattani D, Ughade S. Antibiotic prescribing practices in various periodontal surgeries in vicinity of Nagpur City: A survey. Indian J Dent Sci 2021;13:245-50
|How to cite this URL:|
Niswade G, Gattani D, Ughade S. Antibiotic prescribing practices in various periodontal surgeries in vicinity of Nagpur City: A survey. Indian J Dent Sci [serial online] 2021 [cited 2021 Oct 19];13:245-50. Available from: http://www.ijds.in/text.asp?2021/13/4/245/327809
| Introduction|| |
Stringent asepsis for every patient undergoing periodontal surgery is a challenging job for most of the clinicians to achieve. However, in spite of being aware about indiscriminate prescription of antibiotics, periodontists are prescribing it on a regular basis to the patients. This use of antibiotics can lead to gastrointestinal problems, compromised immune system, and increased susceptibility of developing a superinfection.
Mechanical debridement or scaling and root planing lacks to remove periodontal pathogens residing in the subepithelial gingival tissue, epithelial cells of crevicular epithelium, collagenous substrata, altered cementum and dentinal tubuli, subgingival hard deposits, furcations, and other anatomic features complicating periodontal instrumentation on the tooth surfaces. Periodontal pathogens may also be located in nonperiodontal sites such as oral mucosa, dorsum of tongue, and tonsils. Therefore, antibiotics are used in periodontal therapy to overcome these difficulties along with the evidence of bacterial specificity of periodontal diseases. The route of administration and duration of antibiotic prescription are chosen by practitioners more often on the basis of their clinical skills and training, rather than data from the literature. This preferably should be based on microbiological analysis and antibiotic susceptibility testing.,
The procedure of antibiotic selection in a patient suffering from periodontitis is not yet supported by guidelines or by an organization/association like AAP considering the fact that periodontitis has a complex microbial etiology such as yeasts and viruses in addition to bacteria. The American Heart Association has given guidelines for the use of prophylactic antibiotics before dental procedures to prevent the development of infective endocarditis, resulting from transient bacteremia that occurs as a result of dental treatment. The rate of postoperative infection after periodontal surgeries as reported by the literature is however, relatively low, if strict aseptic protocol is followed and anti-infective measures such as proper sterilization, disinfection, and barrier techniques are undertaken. Antibiotics are usually recommended in regenerative periodontal surgeries and placement of implants. However, evidence suggests that the use of antibiotics for the sole purpose of preventing postsurgical infections is of limited use. They should, however, be prescribed in a case if the patient is medically compromised or the site of surgical procedure is already infected. Development of multidrug-resistant periodontal pathogens is a serious concern to which all periodontists should pay attention to, while prescribing antibiotics as it can eventually lead to treatment failure and development of deadly strains of microbes.
Therefore, specific guidelines for the use of antibiotics suggesting the use of specific antibiotic in a particular periodontal surgery and its duration is the ongoing need to prevent the indiscriminate and overuse of these lifesaving drugs. This study aims to evaluate antibiotic prescribing practices for various periodontal surgeries as well as acceptability of evidence-based guidelines in and around Nagpur city.
| Materials and Methods|| |
A cross-sectional questionnaire-based study was undertaken in the form of a survey with the help of a designed pro forma. The survey was conducted through Google Forms and circulated among the periodontists in and around Nagpur city in Maharashtra. The study protocol was approved by the ethical committee. The responses were anonymous and not linked to the e-mail address or any other identifying information of the respondent. The survey consisted of 12 questions, seven of which were questioned to the practitioners “In an otherwise healthy patient, would you prescribe antibiotics for a X procedure” where X included acute periodontal abscess, conventional periodontal flap surgery, guided tissue regeneration, guided bone regeneration, socket preservation, sinus augmentation, implant placement, and mucoginigval surgical procedures. Response choices were limited to “In most cases yes, in most cases no and I do not perform this procedure.” Two questions were asked regarding the rationale of prescribing or not prescribing antibiotics in periodontal surgery through multiple responses. The remaining questions were about the demographic information, use of guidelines, place of practice, and years of practice information. Statistical software was used for all analysis of the data. Tests performed were bivariate analysis using t-test and Chi-square test and multivariate analysis.
Data were coded and analyzed in a statistical software STATA, version 10.1 (2011, Stata Corp., Texas, USA) designed by Stata Corp., Texas (USA). Descriptive analysis included summary measures such as mean and standard deviation for quantitative variables or frequency and percentages for categorical variables. Bivariate analyses for testing associations with quantitative outcomes by Student's t-test for two-independent samples with equal variances and categorical outcomes with Pearson's Chi-square test were performed. Binary multiple logistic regression analysis was also performed to adjust observed association between outcome and response for respondent's characteristics and other variables.
| Results|| |
A total of fifty periodontists responded out of 98 who were contacted to participate in the survey with a response rate of 51%. Among the fifty responses received, maximum number of respondents ranged from a age group of 25–30 years of age [Table 1] and [Figure 1] and 36% were from females and 66% from males [Table 2] and [Figure 2]. Nearly 58% practitioners had a predominant work setting of a dental college and 42% have a predominant work setting of private practice [Figure 3]. Nearly 36.7% of clinicians were from outside Nagpur and 63.3% from Nagpur itself. Nearly 60.4% of clinicians reported a practice duration of 0–5 years, whereas 22.9% reported the duration of 6–10 years [Figure 4]. Nearly 16.3% of practitioners reported the inflow of medically compromised patients in their outpatient department [Figure 5].
|Figure 5: The most common category of patients observed in the practice of respondents|
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Results of the survey study depicted that practitioners were significantly more likely to prescribe antibiotics for acute periodontal abscess, for periodontal flap surgery, socket preservation, guided tissue regeneration, guided bone regeneration, surgeries with bone grafting, sinus augmentation, implant placement, and mucogingival surgical procedures [Figure 6] and [Figure 7]. The most common rationale for prescribing antibiotics was to decrease the chance of developing an infection, whereas the most common rationale for not prescribing antibiotics was a healthy patient and based on available literature [Figure 8] and [Figure 9]. Nearly 66% of practitioners reported they would follow the guidelines for antibiotic prescription if they were given by the AAP [Figure 10].
|Figure 6: Percentage of respondents prescribing antibiotics for acute periodontal abscess in an otherwise healthy patient|
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|Figure 7: Percentage of respondents prescribing antibiotics for periodontal flap surgery in an otherwise healthy patient|
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Bivariate analysis revealed that there is no significant role of other characteristics such as age, gender, predominant work setting, and years of practice on the response of an individual [Table 3]. Even multivariate analysis does not reveal significance of baseline characteristics although it revealed that respondents working in a dental college are 2.15 times more likely to follow AAP guidelines than private practitioners [Table 4]. Females are 1.64 times more likely to follow AAP guidelines as compared to males [Table 4] and [Table 5] and respondents practicing inside Nagpur are 1.35 times more likely to follow AAP as compared to those practicing outside city [Table 4].
|Table 3: Bivariate analysis showing association of acceptance of American academy of Periodontology guidelines with other variables|
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|Table 4: Association of acceptance of American academy of Periodontology guidelines with gender|
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|Table 5: Multivariate analysis with logistic regression of acceptance of American academy of Periodontology guidelines, age, gender, and questions 3, 4, and 5|
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| Discussion|| |
This survey depicts that, in most of the periodontal surgeries, clinicians prescribe antibiotics after periodontal surgery in a maximum number of patients. Although it appears from the current literature that antibiotics are mostly prescribed in regenerative and implant surgical procedures., This is in agreement with the study by Demolon et al., 1993, and Loos et al., 2002, who have concluded that antibiotics in regenerative periodontal surgeries may help to control initial inflammation but have no effect on bone regeneration or soft tissue attachment at 12 months.
The most common rationale for prescribing antibiotics according to the present study was to decrease the chance of developing an infection. This is in agreement with studies conducted by Demolon et al., 1993, and Loos et al., 2002. Oswal et al., 2014, conducted a trial to evaluate the need of antibiotics in periodontal surgeries in reducing postoperative infection. The author concluded that the prevalence of postoperative infections following periodontal surgery is <1% and this low risk does not justify the routine use of systemic antimicrobial therapy to prevent infections following periodontal surgeries. Infection remains the prime concern to the clinician for postsurgical healing and literature suggests it being the most common reason for antibiotic prescription. However, infection rates following periodontal surgeries have ranged from 1% to 4.4% for traditional periodontal surgery and 4.5% for implant surgery.,
Nearly 66% of practitioners reported in the survey they would follow the guidelines for antibiotic prescription if they were given by the AAP. Similar findings were reported by Hai et al., 2019, who evaluated the practices in prescribing antibiotics for periodontal surgeries with and without bone grafting and acceptability of guidelines. The survey suggested that practitioners were more likely to prescribe antibiotics with more complex bone grafting such as guided bone regeneration and sinus augmentation compared with socket preservation. The most common rationale for prescribing antibiotics was to decrease the chances of developing an infection. Around 75% of practitioners reported acceptability of guidelines if formed by the AAP.
Periodontal surgery is measured as the pillar of periodontal therapy since it allows access to the tooth surfaces for debridement and treatment of bony defects through resective/regenerative procedures. However, with any surgical procedure, comes the risk of complications and failures. The complications of periodontal surgical therapy can be bleeding, swelling, postoperative pain, root hypersensitivity, increased tooth mobility, delayed wound healing, and trismus. Antibiotics are an adjunct that are generally given to the patients to prevent these complications. These are prescribed for prevention of bacterial endocarditis, medically compromised patients with advanced periodontitis, aggressive periodontitis, patients showing progressive periodontal breakdown even after conventional mechanical therapy, patients not responding to periodontal therapy, and in patients with recurrent disease.,
However, nowadays, overuse and misuse of antibiotics are of concern in periodontal therapy as it can lead to the development of antibiotic-resistant microbes, which is a growing problem and one of the world's most pressing public health concerns according to the Centers for Disease Control and Prevention. The consequences of antibiotic resistance include development of more serious illnesses, longer recovery, and more expensive treatments. There could be several possible reasons for the misuse such as the complex and broad etiology of periodontal infections, patients demanding a prescription from the clinician, self-medication by some patients after surgery, prescribing antibiotics to compromise inadequate asepsis, and sterilization or traumatic surgical technique by the clinician and lack of knowledge of the clinician regarding the use of antibiotics.
The literature reports many studies stating the use of antibiotics for reduced pain and postoperative discomfort, swelling, to improve wound healing, and treatment outcomes. Antibiotic prophylaxis does not offer any benefits in preventing the postoperative infections or affecting the treatment outcome in gingivectomy, osseous resective, mucogingival, osseous graft, or implant procedures.
Antibiotics should be used in patients with refractory and aggressive periodontitis, in medically compromised patients with reduced host response, for treatment of postsurgical infections, performing surgery in an already infected site, duration of surgery exceeding 2 h and when large foreign materials are implanted. Therefore, it is the responsibility of the dentist not to overprescribe antibiotics just to prevent infection and keep them in reserve for the above clinical situations. Similarly, Patil et al. 2013 suggested that the indications of systemic antimicrobial therapy as an adjunct to mechanical debridement should be in patients with aggressive periodontitis, refractory periodontitis, acute and severe periodontal infections, and systemically compromised patients. Prabhu et al., 2014, suggested that systemic antibiotics when properly used are beneficial for the treatment of periodontal disease, but the dentists should be aware that, with indiscriminate use, the problems of adverse effects and bacterial resistance may be increased. Garg et al., 2014, conducted a questionnaire-based survey to determine the pattern of antibiotic prescription in Indian oral health-care workers. They found that 92.4% oral health-care providers among 552 overprescribed antibiotics in their daily practice. Kapoor et al., 2012, suggested that the use of antibiotics should be justified on the basis of clearly established need and should not be substituted for adequate local treatment.
Many studies in the periodontal literature suggesting the effectiveness of antibiotics in periodontal therapy are difficult to interpret because of small sample size, smaller duration of study, bias of patient associated risk factors, varying patient groups, and unknown periodontal microbiota. Limitations of the present study include smaller sample size, methodology of conducting the survey in a questionnaire form where respondents may not be 100% truthful with their answers, and differences in understanding and interpretation of questions. Larger sample sized randomized clinical trials are required to evaluate the outcome of antibiotic use in periodontal therapy.
| Conclusion|| |
Antibiotics are an important medication with many benefits in treating bacterial infections, preventing the spread of disease and decreasing the complications of disease. Practicing good oral hygiene should be promoted so as to prevent periodontal infections and further requirement of periodontal surgery. The low rate of postoperative infection following periodontal surgery eliminates the need of adjunctive antibiotics in every periodontal surgery. However, proper guidelines for the use of antibiotics in periodontal surgery as to which antibiotic to be used, dose, duration, and time to begin its administration are warranted, as that would ensure a predictable outcome of periodontal treatment without the overuse of antibiotics. Large-scale controlled clinical trials should be conducted to evaluate the role of antibiotics in various periodontal surgeries for the guidelines to be developed.
The study was approved by the Institutional Ethical committee. Also, the study protocol followed the Ethical Guidelines of the 2013 Declaration of Helsinki.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]