PEDIATRIC DENTISTRY V 35 I NO 7 NOV Í DEC 13

Clinical Article CROSS-SECTIONAL

A National Survey of Pédiatrie Dentists on Antibiotic Use in ChildrenSujathaS, Sivaraman, BDS, DMD' • Mohamed Hassan, BDS, MS^ • Julie M. Pearson,

Abstract: Purpose: The purposes of this study were to: (1) examine the antibiotic prescribing practices of pédiatrie dentists and adherenee to pro-fessional guidelines; and (2) assess their knowledge of and attitudes toward antibiotie resistanee. Methods: A cross-sectional survey regardingantibiotic use, resistance, and knowledge of antibiotie stewardship programs was emailed to 4,636 members of the Ameriean Academy of Pédi-atrie Dentistry (AAPD). Results: 987 surveys (21 pereent) were completed: 984 were analyzed. Lack of adherence to AAPD antibiotic guidelineswas noted. There was a trend toward overuse of antibiotics for the following conditions: irreversible pulpitis with (32 percent) and withoutvital pulp (42 pereent): loeallzed dentoalveolar abseess with (68 pereent) and without draining fistula (39 percent): mitral valve relapse with régu-rgitation (43 percent); intrusion (15 percent); extrusion (13 percent); and rheumatoid arthritis (12 pereent). Determinants of antibiotie use were:faelal swelling (88 pereent): pain relief (15 pereent): unavailable appointment for several weeks (six pereent): and parental satisfaetion (fourpereent). Although 98 pereent of respondents believed that antibiotie resistanee is of growing eoneern, only 15 pereent were aware of antibioticstewardship programs. Conclusion: AAPD members overprescribe antibiotics. Educational programs to increase knowledge of antibiotic resist-ance and stewardship programs should be implemented to increase adherence to professional guidelines. (Pediatr Dent 2013:35:546-9) ReceivedJuly 13, 2012 i Last Revision September 11, 2012 I Aeeepted September 12,2012

KEYWORDS: ANTIBACTERIAL AGENTS, GUIDELINES AS TOPIC, INFECTION

In recognition of the growing problem of antibiotic resistance, pro-fessional organizations of health care practitioners have developedguidelines regarding the appropriate use of antibiotics. Althoughdental practitioners may not treat patients with antibiotics asfrequently as physicians, dentists prescribe between seven percentto 11 percent of all common antibiotics.' The American DentalAssociation (ADA) and the American Academy of PédiatrieDentistry (AAPD) have published guidelines for antibiotic use.-'The AAPD describes clinical situations in which antibiotic useis recommended, while the ADA recommends the overall con-servative use of antibiotics to minimize the risk of developingantibiotic resistance. These guidelines have been summarized inpreviously published articles and are presented in Table 1.'''

Previous studies have sought to investigate the degree towhich dentists' prescribing patterns adhere to published guidelines.Few studies, however, have investigated US dentists' practicesregarding antibiotic prescribing patterns.''" To the best of ourknowledge, only one study surveyed pédiatrie dentists in NorthCarolina. That study provided preliminary data on one state'sreported adherence to professional guidelines for prescribing anti-biotics and found that adherence was notably low, ranging from10 percent to 42 percent.'*

The purposes of this study were to: (1) conduct a nationalsurvey to assess the antibiotic prescribing practices of pédiatriedentists and compare these practices to American Academy ofPédiatrie Dentistry guidelines; and (2) assess their knowledgeof antibiotic resistance and antibiotic stewardship programs.

^Dr, Sivaraman is a pédiatrie dentist at Family Dental Center. Federally Qualified

Health Center. Columbia. Mo. 'Dr, Hassan is an assistant professor. Department of

Pédiatrie Dentistry. Tufts University. Boston. Mass,, and an associate director. Depart-

ment of Pédiatrie Dentistry. Holyoke Health Center. Holyoice, Mass,: and -'Ms, Pearson

is a clinical research manager. Department of Clinical Research. Lutheran Medical

Center. Brooklyn. N.T. USA,

Correspond with Dr, Sivaranmnat drsueii@gmoii.com.

MethodsA cross-sectional survey was developed. A literature review wasconducted and setved as a guide in survey development. To assessthe use of the newly developed survey in the target populationof pédiatrie dentists, the survey was emailed to a small numberof pédiatrie dentists for review. This pilot test rectified remainingissues with the survey questions (eg, confusing wording, use ofjargon). Tlie survey was modified based on the recommendationsfrom the pilot test and finalized. The final survey was composedof 19 questions, including: demographic information; antibioticuse in various clinical situations; endocarditis prophylaxis; anti-biotic resistance; and knowledge of antibiotic stewardship pro-grams. Clinical situations were designed to reflect conditionsaddressed in the AAPD guidelines for antibiotic use (Table 1).

This study, including the final survey instrument, was ap-proved by the Institutional Review Board at Lutheran MedicalCenter in Brooklyn, N.Y. An electronic version of the surveywas constructed using Survey Monkey (Survey Monkey Inc,Palo Alto, Calif, USA) an internet online survey tool which wasemailed to current AAPD members. A reminder e-mail was sentone month after the initial e-mail. Postgraduate students, retiredpédiatrie dentists, and general dentists who are AAPD memberswere excluded, because we were only interested in practices amongcurrent pédiatrie dentists. Data were downloaded into an excelspreadsheet from Survey Monkey and descriptive statistics weretabulated using SPSS 19.0 (SPSS Inc, Chicago, 111., USA).

ResultsThe survey was emailed to 4,636 pédiatrie dentists; 987 surveyswere completed (response rate=21 percent). Three surveys wereremoved from analysis because respondents indicated that theywere retired. Of the 984 surveys included in the analysis, themajority were from respondents in private practice (N=822 , 84percent) who had been practicing pédiatrie dentistry for fewerthan 10 years (N=426, 43 percent). Demographic information isprovided in Table 2. The majority of respondents reported thatscientifically published literature was their primary source for

546 NATIONAL SURVEY ON ANTIBIOTIC USE

PEDIATRIC DENTISTRY V 35 I NO 7 NOV I DEC 13

OFESSIONAL GUIDELINES EOR ANTIBIOTIC USE EROM THE AMERICAN ACADEMY OE PEDIATRIC DENTISTRY*

Oral wound management: Antibiotic therapy should be considered with oral wounds that are at an increased risk of bacterial contamination.Examples are soft-tissue lacerations, complicated crown fractures, severe tooth displacement, extensive gingivectomy, and severe ulcérations.Pulpitis/atypical periodontitis/draining sinus tract/localized intraoral swelling: If a child has acute symptoms of pulpitis and the infection is con-tained within the pulpal tissue or the immediate surrounding tissue, treatment should be performed and an antibiotic should not be prescribed.Acute facial swelling of dental origin: Facial swelling secondary to a dental infection should receive immediate dental attention; depending onclinical fmdings, treatment may consist of treating or extracting the tooth or teeth in question with antibiotic coverage ot prescribing antibioticsfot several days to contain the spread of infection and then treating the involved tooth or teeth.

Dental trauma: Application of an antibiotic to the root surface of an avulsed tooth is recommended to ptevent résorption and increase rate ofpulpal revascularization; the need for systemic antibiotics with avulsed teeth is unclear.

Pédiatrie periodontal diseases: In pédiatrie periodontal diseases associated with systemic diseases such as neuttopenia, Papillon-LeFevre syndrome, andleukocyte adhesion deficiency, antibiotic therapy is indicated.

* Adapted from: Cherry WR, Lee JY, Silugars DA, White RP, Vann WF. Antibiotic use for treating dentai infecüons in children: A survey of dentists' prescribing practices.J Am Dcnr Assoc 2012;l43:.il-8.

updated information on antibiotic use (N=526, 54 petcent), fol-lowed by continuing education coutses (N=370, 38 petcent) andthe Intetnet (N=88, nine petcent).

When asked to indicate what othet sources of teliable infortn-ation on antibiotic use they tely on, 25 petcent of the 60 pediatticdentists who answeted the question tepotted that they consultguidelines of the AAPD ot othet ptofessional organizations.Othet sources frequently reported were residency training andother forms of education, the hospital formulary, and colleagues(including other pédiatrie dentists, pediatricians, oral surgeons,and pharmacists).

Amoxicillin was the most commonly prescribed antibiotic(N=764, 78 percent), followed by penicillin (N=201 , 20 percent).Less than one percent of the respondents indicated that clinda-mycin and augmentin wete the most commonly prescribed anti-biotics in their practice. Nearly all of the respondents reported thatthe most common toute of administration was oral (N=982, 100percent); the remaining reported using intravenous administration.When asked the average minimum number of days the pédiatriedentists prescribed antibiotics, the majority indicated seven days(N=659, 67 percent), while 30 petcent (N=292) reported a min-imum of 10 days. Most tespondents (N=861, 88 petcent) indicatedthat they follow-up with caregivers at the next clinical visit toensure that the full course of the antibiotic was administered. Fewprescribed for a shortet duration of two to three days (N=26) ora duration of more than 10 days (N=seven). The most commondeterminant fot prescribing antibiotics was facial swelling(N=853, 87 percent), followed by pain telief (N=142, 15 percent),unavailable appointment for several weeks (N=53, six percent), andparental satisfaction (N=34, fout percent).

The percentage of respondents that teported prescribing anti-biotics for various pulpal and periapical conditions is listed inTable 3. Two percent of respondents prescribed antibiotics forteversible pulpitis. For clinical conditions of irreversible pulpi-tis with and without vital pulp, 32 petcent and 42 percent pre-scribed antibiotics, respectively. Sixty-eight percent of respondentsptescribed antibiotics for local dentoalveolar abscess with gin-gival swelling, while 39 percent prescribed for teeth with localdento-alveolar abscess with dtaining fistula. In the clinicalscenario of facial cellulitis with lymphadenopathy, 99 percent ofrespondents prescribed antibiotics.

Respondents were also asked to indicate the conditions underwhich they would give infective endocarditis ptophylaxis. Themost commonly reported conditions included cardiac transplanta-tion after valvular damage (N=861 , 88 percent), unrepaired cyanoticheart disease (N=796 , 81 petcent), and ptevious infective endo-

Table 2i = RESPONDENTS' DEMOGRAPHIC INFORMATION AND

PRACTICE CHARACTERISTICS (N=984)

Variable

Gender

Male

Female

Years practicing pédiatrie dentistry<10

10-2526-40

Practice type

Private practiceAcademic institution

Hospital dentistry

Community health center

AAPD district

District 1 (CT, ME, MA, NH, NY, Rl, VT, NL, NS,PEI, NB, QC)

District 2 (DE, DC, MD, NJ, PA)

District 3 (AL, FL, GA, KY, MS, NC, SC, TN, VA,WV, PR)

District 4 (IL, IN, IA, ONT, OH, MI, MN, NE, ND,SD,WI)

District 5 (AR, CO, KS, LA, MO, NM, OK, TX, MX)

District 6 (AK, AZ, CA, HI, ID, MT, NV, OR, UT,WA, WY, SK, AB, BC, NT, NU, YT)

N (%)

535 (54)

449 (46)

426 (43)

307(31)251 (26)

822 (84)

65(7)

53(5)

44(5)

119(12)

92(9)

195(20)

174(18)

185(19)

219(22)

carditis (N=793, 81 percent). A smaller percentage of tespondentsalso indicated that they would ptescribe antibiotic prophylaxis forconditions that do not warrant antibiotics according to the guide-lines,'- including mitral valve ptolapse with régurgitation (N=426,43 percent) and rheumatoid arthritis (N=1 19, 12 percent).

Regatding dental trauma, 95 percent of the respondents(N=937) reported that they would prescribe antibiotics for reim-plantation cases after avulsion; this was followed by trauma withsoft tissue lacerations ( N = 3 6 9 , 38 percent), intrusion (N = 1 5 0 ,15 percent), exttusion (N=131, 13 petcent), lateral luxation (N=70,seven percent), and subluxation (N=33, three petcent). Less thanone percent of the tespondents indicated that they would pre-scribe antibiotics for noncontaminated dental injuries (N=seven).

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Tiblc 3, PERCENTAGE Of RESPONDENTS WHO REPORTED PRESCRIBING ANTIBIOTICS fOR PULPAL AND PERIRADICULAR CONDITIONS(N=984)

Pulpal and periiadicular condition N %

Reversihle pulpitis: Pain is poorly localized, of very short duration, and not tender to percussion and normal radiographie appearance.

Irreversible pulpitis: Spontaneous pain, long duration, tooth tender to percussion, vital pulp, widened periodontal ligament radiographsor fiarcation radiolucency

Irreversihle pulpitis: Spontaneous pain, long duration, tooth tender to percussion, nonvital pulp, widened periodontal ligament onradiographs or furcation radiolucency

Localized dentoalveolar ahscess: Affected tooth is associated with swollen gingiva, sensitive to percussion, mobile, persistent pain, noswelling of the mucosa or the fascial spaces

Localized dentoalveolar ahscess with draining fistula: Sensitive to percussion, mobile, no swelling of the mucosa or the fascial spaces

Facial cellulitis: Diffuse swelling, tenderness and erythema of the affected part of the face, lymphadenopathy, and affected tooth is tenderwith a local dental ahscess

23318

416

671

380

971

232

42

68

39

99

Ninety-eight percent (N=959) reported that they did not be-lieve in tbe routine use of antibiotics during dental rehabilitationto reduce the frequency of postoperative infections. Respondentswere also asked if they believed that antibiotic use prior to anextraction of an abscessed tooth with a draining fistula providedless discomfort to pédiatrie patients; 64 percent ( N = 6 3 1 ) didnot believe antibiotics would decrease discomfort.

Overall, evidence suggesting overprescribing (concerningAAPD guidelines) was found for the following conditions: irre-versible pulpitis witb (32 percent) and without vital pulp(42 percent); localized dentoalveolar abscess with (68 percent)and without draining fistula (39 percent); mitral valve prolapsewith régurgitation (43 percent); intrusion (15 percent); extrusion(13 percent); and rheumatoid arrhritis (12 percent). Although 98percent of the respondents believed that antibiotic resistance isof growing concern, only 15 percent were aware of antibioticstewardship initiatives.

DiscussionThe results of this national survey of pédiatrie dentists on theirprescribing practices suggest common inappropriate use of anti-biotics. Self-reported adherence to the AAPD guidelines for variousclinical situations was inconsistent. For example, self-reportedadherence to some of the AAPD guidelines was high, such as 95percent prescribing for cases of reimplantation after avulsion andfor facial cellulitis (99 percent), and not prescribing antibioticsto prevent postoperative infections (98 percent) and discomfortduring extraction (64 percent). A lower percentage of pédiatriedentists in our study, however, also reported that they would pre-scribe antibiotics in trauma situations for which they are notrecommended [eg, intrusion (15 percent), extrusion (13 percent),lateral luxation (seven percent), and subluxation (four percent)].

Reported use of antibiotics also suggests a tendency to over-prescribe in clinical conditions involving the pulp when anti-biotic use is not recommended by the guidelines. In comparisonto reported use of antibiotics for these conditions among endo-dontists," respondents in our study were more likely to prescribeantibiotics for conditions such as irreversible puplitis with vitalpulp (32 percent vs. 17 percent of endodontists) and irreversiblepulpitis with nonvital pulp (42 percent vs. 19 percent of endo-dontists). In addition, 68 percent of our respondents prescribedantibiotics for local dentoalveolar abscess with gingival swellingand 39 percent prescribed for teeth with localized dentoalveolarabscess with draining fistula. Only 12 percent of endodontistsreported that they prescribe antibiotics for abscess with drainingfistula."

The lower percentage of antibiotic use for these conditionsamong endodontists, compared to the pédiatrie dentists in ourstudy, is likely attributable to increased training in the nature ofpulpal and periapical diseases. For example, pédiatrie dentists maynot be aware that pulpal circulation is compromised in irreversiblepulpitis with draining tracts, and localized swelling" makes itunlikely to achieve therapeutic concentrations with systemicantibiotics. Educational interventions on the benefits of pulpaltherapy vs. antibiotic therapy for these clinical situations wouldlikely increase adherence.

Consistent with otir findings regarding determinants of anti-biotic use, four percent of endodontists prescribed antibiotics if aweekend or holiday were approaching," compared to six percentof the respondents in our study who indicated that they wouldprescribe antibiotics when appointments were unavailable forweeks. A smaller study of pédiatrie dentists in North Carolinafound that overall adherence to professional guidelines regardingprescribing practices decreased when the patient called on a week-end with a dental emergency."^ Interestingly, four percent of thepédiatrie dentists in our study reported parental demand as oneof the most common reasons to prescribe antibiotics. Preparingpédiatrie dentists on how to educate parents on the risks andbenefits of antibiotic use will aid in the reduction of antibioticuse solely for parental satisfaction." Although antibiotics are notrecommended for use as pain relief medication for inflamma-tion," 15 percent of the respondents in our study reported thatthey use antibiotics for this purpose.

The main limitation of our study and survey research in gen-eral that may influence our findings was that we did not monitoractual prescribing patterns; thus, we cannot confirm that theresponses we received were accurate. Given that we found thatadherence was low, however, it is unlikely that the respondentsmisreported their prescribing practices. We believe our studypopulation is representative of tbe national pédiatrie dentistpopulation, despite our relatively low response rate (21 percent),because of our large sample size and similar geographic distri-bution to total AAPD membership. An e-mailed survey is themost cost-effective and efficient way of surveying large numbersof people who are geographically distant.

Despite these limitations, the lack of adherence to the anti-biotic prescribing guidelines among pédiatrie dentists wasapparent and underscores the need for increased promotion ofantibiotic stewardship programs in this population. Although mostsurvey respondents indicated that they rely on scientific publishedliterature and continuing education as an information source,self-reported adherence to published guidelines was inadequate.

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Furthermore, most respondents reported that antibiotic resist-ance was of growing concern, but few had heard of antibioticstewardship. Various hospitals have adopted antibiotic stewardshipprograms promoting adherence to published guidelines as wellas continuing education programs and antimicrobial order formsto increase adherence.'^

Knowledge of the professional guidelines and awareness ofantibiotic stewardship programs could be a requirement for newlicensure and renewal to ensure widespread adoption. Antibioticstewardship programs that focus on collaborative care betweenphysicians and dentists, who may have different prescribing pat-terns,"" may also be beneficial to improve antibiotic prescribingpractices in dentistry. Increased awareness and knowledge of pro-fessional guidelines regarding antibiotic stewardship are needed topromote the appropriate use of antibiotics in this population.

ConclusionsBased on this study's results, the following conclusions can bemade:

1. Pédiatrie dentists reported a low adherence to antibioticprescribing guidelines. The tendency is toward over-treatment.

2. Adherence to antibiotic prescribing guidelines amongpédiatrie dentists is adequate for conditions that warrantantibiotic treatment, such as facial cellulitis, avulsion,and infective endocarditis.

3. Pédiatrie dentists reported that their prescribing patternsare influenced by parental request, pain, and unavailableappointments.

4. Although most pédiatrie dentists believed that antibioticresistance is a growing problem, few were aware of anti-biotic stewardship programs.

AcknowiedgmentsThe authors wish to thank Drs. Sarat Thikkurissy, DDS, MS,director, residency program. Division of Pédiatrie Dentistry andOrthodontics, Gincinnati Children's Hospital, Ohio, and KavithaViswanathan, BDS, PhD, assistant professor. Department ofPédiatrie Dentistry, Baylor College of Dentistry, The Texas A&MUniversity, Dallas, Texas, who served as content experts in thefield and helped guide the research process, and Dr. Silvia Perez,who passed away on November, 13, 2011. She was the programdirector of Pédiatrie Dental Medicine at Lutheran Medical Center,in Brooklyn, N.Y., from 1990-2011, who served as the inspirationto examine antibiotic stewardship in pédiatrie dentistry and whosementoring and guidance was appreciated.

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