a Department of Clinical Dental Sciences, University of Liverpool, Liverpool L69 3BX; b Infection Research Group, University of Glasgow, Glasgow G2 3JZ, UK
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Abstract |
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Introduction |
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Materials and methods |
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The questionnaire first sought information on the place and year of qualification, gender, age (banded in decades from 2161+ years) and whether any postgraduate courses had been attended on antibiotics in the previous 2 years.
The questionnaire investigated practitioners' knowledge of the indications for prescribing antibiotics for a number of clinical signs that may be associated with a dental infection. The clinical signs chosen were elevated temperature, evidence of systemic spread, localized fluctuant swelling, gross diffuse swelling, difficulty in swallowing and closure of the eye due to infection. GDPs were asked to indicate their chosen antibiotic regimen for an acute infection in a patient not allergic to penicillin and for patients allergic to penicillin.
GDPs were also asked whether a number of clinically presenting conditions required antibiotics and, if so, their choice of agent. The clinical conditions were acute pulpitis, acute periapical infection (before, with and after drainage), chronic apical infection, pericoronitis, cellulitis, periodontal abscess, acute ulcerative gingivitis, chronic marginal gingivitis, sinusitis, chronic periodontitis, dry socket, trismus and re-implantation of teeth. A number of non-clinical factors that can influence prescribing were investigated. The questionnaire asked whether patient expectation of a prescription, pressure of time or workload in the surgery, the patient's social history, uncertainty of diagnosis or where treatment had to be delayed might be a reason for prescribing antibiotics.
GDPs were asked if prophylactic antibiotics were required for dental treatment or oral surgery in non-medically compromised patients. They were asked specifically whether antibiotics were required for surgical extractions, apicectomies and before or after root-canal treatment. If antibiotics were indicated, practitioners were asked to state their choice of antibiotic.
The next part of the questionnaire sought knowledge on the medical conditions and dental procedures that may require prophylactic antibiotics. The dental procedures were scaling and polishing, subgingival restorations, root-canal therapy, extractions and impressions. The medical conditions included patients with cardiac and immunological problems, renal pathology and transplantation, prosthetic joints and radiotherapy-treated head and neck cancer together with diabetes, Hodgkin's disease and AIDS. A copy of the questionnaire can be obtained from the corresponding author.
Subjects and data handling
Ten Health Authorities in England and four Health Boards in Scotland were chosen for sampling. These were Liverpool, Wirral, Oxfordshire, Buckinghamshire, North Tyneside, Northumberland, Newcastle, Nottingham, North Nottinghamshire, Sheffield, Lothian, Argyle and Clyde, Grampian, and Dumfries and Galloway. All GDPs contracted to provide National Health Service (NHS) general dental services were included with the exception of specialist orthodontic practitioners. A total of 1544 questionnaires were sent in England and 672 in Scotland. The questionnaires contained a Health Authority/Health Board identifier, but no individual respondent could be identified. The responses were analysed using a Statistical Package for Social Science (SPSS) database.9 The total response rate and scores for each question were calculated, correct answers were given a score of 1, with a maximum correct score for the questionnaire of 84. The correct answers were based on a review of the clinical literature, expert opinion where there is a lack of good evidence and the recommendations of specialist societies, e.g. the British Society for Antimicrobial Chemotherapy. The knowledge of GDPs was equated to their total score for the questionnaire. Mean scores were compared using gender, age band, attendance at postgraduate courses, Health Authority/Board and University of qualification as grouping variables.
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Results |
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A t-test (t = 6.582; P < 0.01) showed that there was a significant difference in total scores between English Health Authorities (mean total score 57.28, s.d. 6.73) and Scottish Health Boards (mean total score 54.47, s.d. 7.56). When comparisons were made between individual Health Authorities/Boards of mean total scores (shown in Table III) using a one-way ANOVA, significant differences in scores were evident [F(13,1273) = 4.527; P < 0.01]. Table IV
shows small but non-significant differences between the mean total scores for the respondents' university of qualification.
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Discussion |
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There was a significant difference in knowledge of the use of antibiotics amongst those who had attended postgraduate courses in the previous 2 years, although only 22% of all respondents had received education in this area. This may be because very few courses had been organized, or that the majority of practitioners felt that they were up to date with current opinion. Most practitioners scored well on the clinical signs indicating the need for prescribing antibiotics (spreading infection, patient malaise, temperature elevation, lymphadentitis),12 but about a third felt that there was a need for antibiotics where there was only localized swelling. Generally, practitioners scored well on the non-clinical factors that should not influence prescribing. A number did feel, however, that it was acceptable to prescribe when short of time, if a definitive diagnosis could not be made or if treatment had to be delayed.
As can be seen from Table II, there were low scores for the questions on the common clinical conditions presenting in everyday practice. This may be due to practitioners thinking that antibiotics are required for conditions that are easily dealt with by routine operative dental treatment. Low scores were also evident for questions on prophylactic prescribing for medical conditions. The total mean score of 56 out of a possible 84 indicates a poor understanding of the use of antibiotics in dental practice.
There was no significant difference in scores relating to age bands, with the recently qualified scoring little better than those who had been qualified for 30 years. This perhaps calls into question the efficacy of present undergraduate teaching and the retention of knowledge. Graduates of some dental schools scored more poorly than others, although this was not statistically significant. The Standing Medical Advisory Committee (SMAC) recommended that greater emphasis should be placed on education of clinical students and qualified clinicians about antimicrobial prescribing.
The SMAC also recommended that teaching about antimicrobials should be better integrated with teaching about the infections against which they are used.2 There is a clear need to re-evaluate the teaching of antibiotic usage to undergraduates to see if these recommendations have been put into practice. Practitioners working in some Health Authorities/Boards showed less knowledge than others, though this may be linked to the place of qualification. There is therefore a need to standardize the teaching of antibiotics to all undergraduates.
It would appear from this study that dental practitioners' knowledge about the use of antibiotics in general practice is far from ideal. This mirrors general medical practice, where studies have shown that decision making in antibiotic therapy requires improvement.13 Rational prescribing based on a thorough knowledge is an important objective. Effective communication between microbiologists and practitioners, and the publication of prescribing guidelines and protocols could help to achieve this.13
A study in medical practice has shown the effectiveness of educational intervention, using guidelines, in attaining the appropriate prescribing of antibiotics within a specific clinical situation.14 An audit of antibiotic prescribing in dental practice showed that there was a reduction in the number of prescriptions following the introduction of guidelines.15 The use of clinical audit as a tool to increase knowledge of antibiotic prescribing and improve patient care should not be underestimated. Computers as a tool for education and behaviour change, along with direct mail interventions have been shown to be effective in medical prescribing.16,17
This study supports the conclusion that there is a lack of knowledge of the use of antibiotics in practice and that GDPs need clear advice on when and what to prescribe, for how long and in what dosage. The Faculty of General Dental Practitioners of the Royal College of Surgeons of England has recently published recommended standards for antimicrobial prescribing for dental practitioners, which may improve knowledge.18 There is also a need to improve undergraduate education and to increase the provision of postgraduate courses and other educational initiatives on antibiotic prescribing.
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Acknowledgments |
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Notes |
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References |
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2 . Standing Medical Advisory Committee. (1998). The Path of Least Resistance. Department of Health. London.
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10 . Dental Practice Board. (1999). Manpower tables. Eastbourne, UK.
11 . Kaner, E. F., Haighton, C. A. & McAvoy, B. R. (1998).So much post, so busy with practiceso, no time!: a telephone survey of general practitioners' reasons for not participating in postal questionnaire surveys. British Journal of General Practice 48, 10679.[ISI][Medline]
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15 . Steed, M. & Gibson, J. (1997). An audit of antibiotic prescribing in general dental practice. Primary Dental Care 4, 6670.[Medline]
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17 . Sadowsky, D. & Kunzel, C. (1991). The use of direct mail to increase clinician knowledge: an intervention study. American Journal of Public Health 81, 9235.[Abstract]
18 . Faculty of General Dental Practitioners, Royal College of Surgeons, England. (2000). Antimicrobial Prescribing in Primary Dental Care for General Dental Practitioners.
Received 14 March 2000; returned 31 July 2000; revised 12 September 2000; accepted 13 October 2000