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Antibiotic use for treating dentalinfections in childrenA survey of dentists' prescribing practices

William R. Cherry, DDS, MS; Jessica Y. Lee, DDS, MPH, PhD; Daniel A. Shugars, DDS, PhD;Raymond P. White Jr., DDS, PhD; William F. Vann Jr., DMD, PhD

Misuse of antibiotics hasgiven rise to the growingproblem of antibiotic resist-ance.'"'' Even when antibi-

otics are used correctly, there can beproblems because past antibiotic usecan be linked to a person's developingresistant microbes." Therefore, thedecision to prescribe an antibiotic isimportant, and the potential positiveresults must be weighed against thepotential negative consequences.'

Pallasch' reported that there aresix possible results of antibiotic use,and only one of them is a positiveoutcome for the patient. The positiveoutcome occurs when the antibiotichelps a host's immune system to gaincontrol and eliminate the infection.^The negative results include toxicityor allergy, superinfection withresistant bacteria, chromosomalmutations to resistance, genetransfer to vulnerable organisms andexpression of dormant resistantgenes.' Recent data revealed thatantibiotic resistance is present in the

Dr. Cherry is in private practice in Wilmington. N.C.Dr. Lee is an associate professor. Department of Pédi-atrie Dentistry, School of Dentistry. Brauer Hall 228, CB7450, University of North Carolina at Chapel Hill,Chapel HiU, N.C. 27599-7450, e-mail"jessicajee@dentistry.unc.edu". Address reprintrequests to Dr. Lee.Dr. Shugars is a research professor. Department ofOperative Dentistry, School of Dentistry, University ofNorth Carolina at Chapel Hill.Dr. White is a distinguished professor. Oral and Max-illofacial Surgery, School of Dentistry, University ofNorth Carolina at Chapel Hill,Dr. Vann is a research professor. Department of Pédi-atrie Dentistry, School of Dentistry. University of NorthCarolina at Chapel Hill.

Background. The authors conducted a studyto examine the antibiotic prescribing practices ofgeneral and pédiatrie dentists in the manage-ment of odontogenic infections in children.Methods. The authors relied on a cross-sectional 'study design to assess the antibiotic prescribing prac-tices of general and pédiatrie dentists in North Carolina. Thesurvey instrument consisted of five clinical case scenarios thatincluded antibiotic-prescribing decisions in a self-administeredquestionnaire format. The participants were volunteers attendingone of four continuing education courses. The authors invited allpédiatrie dentists in private practice to participate in the study, aswell as general practitioners who treated children in general prac-tice. The authors compared the practitioners' responses for eachclinical case scenario with the prescribing guidelines of theAmerican Academy of Pédiatrie Dentistry and the American DentalAssociation.Results. A total of 154 surveys were completed and returned (55percent response rate). The mean age of respondents was 47 years,and the mean number of years in practice was 19. Of the 154overall, 106 (69 percent) were general practitioners and 48 (31 per-cent) were pédiatrie dentists. Across the three in-offiee elinieal casescenarios, adherence to professional prescribing guidelines rangedfrom 10 to 42 percent. For the two weekend scenarios, overall ad-herence to the professional prescribing guidelines dropped to 14and 17 percent. Dentists who had completed postgraduate educa-tion (n = 73 [51 percent]) were more likely (P < .05) to have adheredto published guidelines in prescribing antibiotics.Conclusions. The results of this survey show that dentists'adherence to professional guidelines for prescribing antibiotics forodontogenic infections in children was low. There appears to be alack of concordance between recommended professional guidelinesand the antibiotic prescribing practices of dentists. Clearer, morespecific guidelines may lead to improved adherence among dentists.Key Words. Antibiotics; clinical protocols; infection; guidelines.JADA 2012;143(l):31-38.

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B O X 1

Professional guidelines forantibiotic use.

AMERKAM ACADEMY OF PEDIATRK DEimSTRY*• Oral wound management: Antibiotic therapy should

be considered with oral wounds that are at anincreased risk of bacterial contamination; examplesare soft-tissue lacerations, complicated crown frac-tures, severe tooth displacement, extensive gingivec-tomy and severe ulcérations

• Pulpitis/apical periodontitis/draining sinus tract/local-ized intraoral swelling: If a child has acute symptomsof pulpitis and the infection is contained within thepulpal tissue or the immediate surrounding tissue,treatment should be performed and an antibioticshould not be prescribed

• Acute facial swelling of dental origin: Facial swellingsecondary to a dental infection should receive imme-diate dental attention; depending on clinical findings,treatment may consist of treating or extracting thetooth or teeth in question with antibiotic coverage orprescribing antibiotics for several days to contain thespread of infection and then treating the involvedtooth or teeth

• Dental trauma: Application of an antibiotic to theroot surface of an avulsed tooth is recommended toprevent résorption and increase rate of pulpal revas-cularization; the need for systemic antibiotics withavulsed teeth is unclear

• Pédiatrie periodontal diseases: In pédiatrie perio-dontal diseases associated with systemic diseases suchas neutropenia, Papillon-LeFevre syndrome andleukocyte adhesion deficiency, antibiotic therapy isindicated

AMERICAN DENTAL ASSOCIATION*• Make an accurate diagnosis• Use appropriate antibiotics and dosing schedules• Consider using narrow-spectrum antibacterial drugs in

simple infections to minimize disturbance of thenormal microf lora, and preserve the use of broad-spectrum drugs for more complex infections

• Avoid unnecessary use of antibacterial drugs intreating viral infections

• If treating empirically, revise treatment regimen basedon patient progress or test results

• I Obtain thorough knowledge of the side effects anddrug interactions of an antibacterial drug before pre-scribing it

• Educate the patient regarding proper use of the drugand stress the importance of completing the fullcourse of therapy (that is, taking all doses for the pre-scribed treatment time)

• I Diagnosis and antibiotic selection should be based onthorough medical and dental history

• Weigh the known risks against the potential benefitsof antibiotic use

• Use antibacterial drugs in a prudent and appropriatemanner

* Adapted with permission of the American Academy of Pédi-atrie Dentistry from the American Academy of Pédiatrie Den-tistry Council on Clinical Affairs."

t Source: American Dental Association Council on ScientificAffairs.'=

oral flora.* Gram-negative anaerohes haveappeared in most microbiological studiesreviewed in the literature. Most strains tested

showed penicillin resistance." In short, the poten-tial negative outcomes make the use and choiceof antibiotics crucial to their continued success intreating both dental and medical infections.

ANTIBIOTIC USEIn the United States, more antibiotics than over-the-counter drugs are sold.' Dentistry accountsfor roughly 200 to 300 million prescriptions annu-ally in the United States.'* Although dentists donot treat as many patients with antibiotics as dophysicians, antibiotic therapy is a valuable optionfor certain dental infections. Antibiotics and anal-gesics are the medications prescribed most com-monly by dentists,'" and researchers estimatethat 10 percent of antibiotic prescriptions in theUnited States are related to dental care.'"

There are several indications for the use ofantibiotics in dentistry, including treatment ofperiodontal disease and of severe soft-tissue lac-erations." Clinicians treat children with antibi-otics primarily to treat oral infections and to pre-vent bacteremia caused by dental treatment.'^The goal of antibiotic treatment is to use thesmallest amount of drug that is most effectiveagainst the organism that is causing the infec-tion.'^ Antibiotic therapy for orofacial infectionscan achieve excellent results in selected clinicalsituations,^ but it should not be the primarytreatment modality for orofacial infectionsunless spreading cellulitis is present.' To preventmisuse of antibiotics, dentists need to know theindications and contraindications to prescribingthem; the proper dosing schedule; and the risk ofallergic and toxic adverse reactions, superinfec-tions and development of antibiotic-resistantorganisms.^ A major distinction between medicaland dental conditions is that most dental infec-tions can be treated successfully by removal ofthe source of the infection.'^'^

Professional organizations and guide-lines. Many medical and dental practitionersand professional associations have recognizedthe growing problem of antibiotic resistance.Two dental organizations have promulgatedguidelines (Box 1"" ) in an attempt to cope withthis growing problem. The American Academy ofPédiatrie Dentistry" (AAPD), Chicago, is con-cerned with the upward trend in antibioticresistance and has developed specific clinical

ABBREVIATION KEY. AAPD: American Academy ofPédiatrie Dentistry. ADA: American Dental Associa-tion. AEGD: Advanced education in general dentistry.ASA: American Society of Anesthesiologists. GPR:General practice residency. NS: Not significant.UNC-CH: University of North Carolina at ChapelHill.

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indications for antibi- BOX 2otic use. The AAPDguidelines rely onclinical presentationto underscore conser-vative antibiotic use.The American DentalAssociation (ADA)Council on ScientificAffairs,'" Chicago, hasacknowledged theantibiotic resistancephenomenon and itsrelevance to dentistryand has developedclinical guidelines forpractitioners.

Study aims.Investigators in pre-vious studies haveexamined physicians'antibiotic prescribingpractices but, to date,few have examinedU.S. dentists' prac-tices and no one, toour knowledge, hasexamined pédiatriedentists' practices.We conducted thisstudy to examine theantibiotic prescribingpractices among gen-eral and pédiatriedentists in North Carolina for children whohave odontogenic infections with various symp-toms and under varying circumstances. Specifi-cally, we examined dentists' adherence to avail-able professional guidelines.

METHOOSStudy design and sample. We relied on across-sectional survey (available as supple-mental data to the online version of this article[found at "http://jada.ada.org"]) approved by theinstitutional review board at the University ofNorth Carolina at Chapel Hill (UNC-CH) toassess the antibiotic prescribing practices of gen-eral and pédiatrie dentists in North Carolina.Two data collectors (W.R.C. and A. Diane Baker)identified a convenience sample of general andpédiatrie dentists during professional meetingsand continuing education courses across a six-month period. One of the two data eolleetors sur-veyed the dentists if they attended one of themeetings during whieh data were collected.

We excluded from the study full-time faculty

Clinical case scenarios for use of antibiotics.CASE1

A healthy (ASA I*) 9-year-old child, who is a patient of record, visits your office during regularbusiness hours with tooth pain in the lower right quadrant. On clinical examination, younotice a deep carious lesion on tooth T (mandibular right primary second molar). Would youprescribe antibiotics for the following: pain only? symptoms of pain and local swelling withno radiographie evidence of pathology? symptoms of pain and local swelling with radio-graphic evidence of pathology? symptoms of pain and facial swelling with radiographieevidence of pathology?

CASE 2A healthy (ASA I) 9-year-old child, who is a patient of record, visits your office during regularbusiness hours with tooth pain in the lower right quadrant and a fever of lOTF. On clinicalexamination, you notice a deep carious lesion on tooth T (mandibular right primary secondmolar). Would you prescribe antibiotics for the following: pain and fever? symptoms of painand local swelling with no radiographie evidence of pathology? symptoms of pain and localswelling with radiographie evidence of pathology? symptoms of pain and facial swelling withradiographie evidence of pathology?

CASE 3A healthy (ASA I) 9-year-old child, who is a patient of record, visits your office during regularbusiness hours with tooth pain in the lower right quadrant. The ehild has no fever. On eliniealexamination, you notiee a deep carious lesion on tooth T (mandibular right primary secondmolar) along with a draining fistula. Would you prescribe antibiotics for the following: painonly? symptoms of pain and local swelling with no radiographie evidence of pathology?symptoms of pain and local swelling with radiographie evidenee of pathology? symptoms ofpain and faeial swelling with radiographie evidence of pathology?

CASE 4The parent of a healthy (ASA I) 9-year-old ehild, who is a patient of record, calls you on a Saturdayafternoon because the child has a chief complaint of tooth pain in the lower right quadrant.Would you prescribe antibiotics for the following: pain only? symptoms of pain and local swelling?symptoms of pain and facial swelling? Would you see the child before prescribing antibiotics?

CASE 5The parent of a healthy (ASA I) 9-year-old ehild, who is a patient of record, calls you on aSaturday afternoon and reports that the child has pain on the lower right quadrant withsome warmness of the skin and some swelling that she noticed that morning. Would youprescribe antibiotics for the following: pain only? symptoms of pain and warmness of theskin? symptoms of pain, warmness of the skin and localized swelling? symptoms of pain,warmness of the skin and facial swelling? Would you see the ehild before preseribingantibioties?

* Source: American Society of Anesthesiologists." ASA: American Society of Anesthesiologists.

members at UNC-CH, those not engaged in clin-ical practice and those who did not treat chil-dren 15 years or younger.

Survey development. Before data collec-tion, we completed the development andpretesting of a survey instrument in threephases; expert panel review, recording and tran-scription of struetured interviews and pilottesting. An expert panel eomposed of two pédi-atrie dentists (J.Y.L., W.F.V.), a general dentist(D.A.S.) and an oral surgeon (R.P.W.) developedthe open-ended interview questions. They basedthe content of the survey questionnaire on theobjectives of the overall study, on informationobtained from a review of the literature, on theAAPD and ADA guidelines and on structuredinterviews with practicing dentists.

One of us (W.R.C.) conducted a total of nineone-hour structured interviews with pédiatrie,general and public health dentists. We tapedand transcribed the interviews. The expertpanel members reviewed the AAPD and ADAcHnical guidelines (Box 1"'*) to determine the

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recommended professional practices for pre-scribing antibiotics. Because the ADA guidelinesdo not provide clinical information aboutpatients' signs and S3miptoms, the expert panelrelied on the AAPD guidelines for developmentof the case scenarios and, largely, determinationof adherence. They reviewed the data gatheredfrom the structured interviews and developedthe survey instrument. The survey instrumentconsisted of three main domains: dentist charac-teristics, practice characteristics and case sce-narios (Box 2") involving the decision-makingprocess for prescribing antibiotics duringselected clinical situations.

To assist with modifications for survey con-tent, clarity and length, we pilot tested thesurvey instrument with four general and sixpédiatrie dentists in private practice in the com-munity. The final survey instrument was athree-page, self-administered questionnaire. Itincluded demographic questions pertaining torespondents' personal characteristics, as well asto their practice characteristics. Box 2" presentsthe five clinical case scenarios. Each case variedwith regard to the clinical signs and symptoms.Clinical signs and symptoms included pain,fever, localized swelling, skin warmness andfacial swelling. We also incorporated practice-related factors (such as during regular officehours, after hours, patients of record) into thescenarios. The survey asked dentists whetherthey would prescribe an antibiotic on the basisof the case information provided.

Data collection and statistical analysis.The two data collectors distributed and collectedall of the surveys during professional meetingsand continuing education courses. At the courseregistration, they asked dentists whether theytreated children 15 years or younger in theirpractice and, if so, they asked them to partici-pate in the study.

The Data Capture Services Unit in theUNC-CH School of Dentistry produced the finalsurvey instrument by using TeleForm software.The scannable TeleForm format reduces errorsthat might have been introduced during dataentry. A data collector (W.R.C.) verified eachreturned survey for completeness before it wasscanned. Staff members in the BiostatisticalSupport Unit at the UNC-CH School of PublicHealth who work in the School of Dentistry'sData Capture Services Unit scanned the ques-tionnaires. They then analyzed the data byusing statistical software (SAS, Version 7.0,SAS Institute, Cary, N.C). The primary out-come measure was dentists' prescribing deci-sions for each of the five clinical case scenarios.

TABLE 1

Demographics and practicecharacteristics of study sample(N = 154).VARIABLE

Sex

Male

Female

Dental School Attended

University of North Carolina at Chapel Hill

Other

Postgraduate Residency

AEGD*/GPR*Pediatrics

Other (public health)

None

After-Hours Telephone Calls

Solo

Share with others

No calls

Other

Practice Type

GroupSoloPublic healthMilitary

Other

Practice Location

Urban

RuralSuburban

NUMBER (%)OF

* Not all numbers total 154 because of missing data.t AEGD: Advanced Education in General Dentistry.t GPR: General Practice Residency.

DENTISTS*

101 (66)53 (34)

102 (68)

47 (32)

23 (16)

48 (34)

2 (1)69 (49)

79 (51)

58 (38)

10 (6)7 (5)

53 (34)83 (54)

11 (7)

1 (1)6 (4)

55 (36)35 (23)

61 (40)

RESULTS

A total of 280 dentists attended one or more ofthe four meetings at which we collected the data.Dentists who attended more than one meetingcompleted only one survey. The final sampleincluded the 154 dentists who treated childrenin their practices and agreed to participate.

Table 1 presents dentists' demographic andpractice characteristics. The mean age of respond-ents was 47 years, with a range of 27 through 68years. The mean number of years in practicewas 19, with a range of one through 43 years.Nearly 30 percent of respondents were pédiatriedentists and 70 percent were general dentists.Most respondents were male and alumni of theUNC-CH School of Dentistry. Among the 94 gen-eral dentists who answered the question, 23 (24percent) completed a general practice residency(GPR) or advanced education in general den-tistry (AEGD) postgraduate education program.

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TABLE 1 (COiUTliUUED)

VARIABLE

Type of Antibiotic PrescribedPenicillinAmoxicillinClindamycinCephalexin

How Many Cblldren Do You Threatper Montb?<15

> 15

How Many Hours per Week Do YouProvide Patient Care?10-2021-30>30

How Often Do You Write Prescriptionsfor Antibiotics for Dentai Infections?DailyWeeklyMonthlyHardly ever

How Often Oo You Write AntibioticPrescriptions for Subacute BacterialEndocarditits?DailyWeeklyMonthlyHardly ever

iUUiMBER (%)OF DEiUTiSTS*

47 (31)103 (67)

2 (1)2 (1)

36 (26)104 (74)

5 (3)15(10)

134(87)

11 (7)41 (27)51 (33)50 (33)

4 (3)17(11)40 (26)92 (60)

The majority of dentists worked in a solo privatepractice setting.

Table 2 presents dentists' responses to theclinical case scenarios. We deemed dentists to bein adherence with the professional guidelines ifthey reported that they would prescribe antibi-otics for the appropriate collective signs andsymptoms. Scenarios 1, 2 and 3 were in-officecases and scenarios 4 and 5 were weekend cases.For the weekend cases, we deemed dentists to bein adherence with the clinical guidelines if theysaw the child before prescribing antibiotics and ifthey prescribed antibiotics for the appropriatecollective signs and symptoms.

Overall, adherence rates were low, rangingfrom 10 to 42 percent. Although not significant,there was a trend toward pédiatrie dentists'having higher levels of adherence to professionalguidelines than did general dentists. Accordingto the AAPD professional guidelines, dentistsshould consider prescribing antibiotics when apatient has facial swelling with or without pain,radiographie evidence of pathology or a combina-

tion of the preceding. Case 1 represents the col-lective symptoms of facial swelling, pain andradiographie evidence of pathology. Overall, 26percent of the dentists in the study were inadherence with the professional guidelines.Among the pédiatrie dentists, 31 percent were inadherence with the professional guidelines andamong the general dentists, 24 percent were inadherence. When we added fever to the list ofeoUeetive signs and symptoms (ease 2), theoverall adherenee level dropped to 12 pereent.When we added loeal swelling and removedfever from the list of eoUeetive signs and symp-toms (ease 3), the overall adherenee levelincreased to 32 percent of respondents.

Dentists' adherence to the professional guide-lines decreased for the weekend cases. The ADAguidelines state that to prescribe antibacterialdrugs, the dentist must "make an aeeurate diag-nosis." ** In other words, he or she should see thepatient before preseribing antibioties. Fewer thanone-fourth of the dentists reported that theywould preseribe antibioties only after seeing thepatient.

Table 3 (page 37) presents the results of thebivariate analyses in whieh we examined factorsassociated with dentists' preseribing praetiees.For eases 1 and 3, dentists who reported pre-seribing antibiotics more frequently (weekly ormore often) and those who praetieed in ruralareas were less likely to have adhered to profes-sional guidehnes (P < .05). In addition, for ease3, dentists who had eompleted some type ofpostgraduate edueation (pédiatrie dentistry,GPR or AEGD programs) were more likely tohave preseribed antibiotics in aeeordanee withthe professional guidelines (P < .05). For theweekend ease 5, treating more than 15 ehildrenper month and writing prescriptions for antibi-oties more frequently were assoeiated with laekof adherenee to the professional guidelines. Inall five cases, provider type (pédiatrie dentistsversus general dentists) and age were not asso-eiated with adherenee to the guidelines.

DISCUSSIONThis is the first study, to our knowledge, toinvestigate the use of antibiotics to treat dentalinfections in ehildren. Overall, adherenee to theAAPD and ADA clinieal guidelines was low withrespeet to preseribing antibioties for odontogenicinfections in children. Our findings show a laekof eonsisteney between the way in which den-tists in North Carolina treat dental infeetions inehildren and the reeommended praetiees setforth in the professional guidelines. Speeifieally,our results indieate a potential problem in how

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TABLE 2

Responses to clinical scenarios: adherence to professional guidelines(N = 154).CUMICAL SCENARIOS AMDRESPOMSESt

Case 1Prescribe Antibiotics Only forPain, Faciai Sweiiing andRadiograpiiic Evidence ofPathoiogy

Case 2Prescribe Antibiotics Oniy forPain, Faciai Sweiiing andRadiograpiiic Evidence ofPatboiogy

Case 3Prescribe Antibiotics Oniy forPain, Faciai Sweiiing andRadiographic Evidence ofPathoiogy

Case 4Wouid See Patient BeforePrescribing Antibiotics andPrescribe Antibiotics Oniy forPain and Faciai Sweiiing

Case SWouid See Patient BeforePrescribing Antibiotics andPrescribe Antibiotics Oniy forPain, Warmness of Sicin andFaciai Sweiiing

OVERALL ADHEREiyCETO CUiDELilHES,

i«O. (%) OF OEiVTiSTS(iU = 154)

40 (26)

18(12)

49 (32)

22 (14)

26 (17)

iW. (%) OF CENERALDEiUTiSTS ADHERiiVC TO

CUiDELiMES(n = 1O6)

25 (24)

11 (10)

29 (27)

16(15)

17(16)

¡HO. (%) OF PEDiATRICOEiHTISTS AOHERiiHC TO

CUiDELiiHES(n = 48)

15(31)

7(15)

20 (42)

6(13)

9(19)

* Sources: American Academy of Pédiatrie Dentistry Council on Clinical Affairs," American Dental Association Council on Scientific Affairs."t The guidelines-recommended response is below the case numher.

clinicians are using antibiotics to treat dentalinfections in children.

We hypothesized that there would be a differ-ence in antibiotic prescribing practices betweengeneral dentists and pédiatrie dentists becausethe latter treat children more often and usuallyhave more years of education through their resi-dency programs. In addition, the AAPD guide-lines" offer more specific guidance than do theADA guidelines "'(Box 1). In four of the five clin-ical case scenarios, pédiatrie dentists' reportedpreseribing praetices were more closely alignedwith the recommended professional guidelinescompared with the preseribing praetiees of gen-eral dentists; however, the results were onlymodestly better for pédiatrie dentists and noneof the differenees were statistieally significant(P > .05). However, we did find significant differ-ences (P < .05) in adherence to the clinical guide-lines according to location of the dental practice.Dentists who reported practicing in rural areaswere less likely to prescribe antibiotics in aeeor-dance with the elinieal guidelines than werethose praetieing in urban or suburban areas.Although the exaet reasons for this finding are

beyond the seope of this investigation, we theo-rize that patients in rural areas may experieneemore diffieulty aeeessing dental eare and mayhave mueh higher dental eare needs thanpatients in urban or suburban areas; therefore,dentists may be treating these patients' dentalinfeetions more aggressively with antibioties.

The survey findings revealed a low pereentageof adherenee, ranging from 10 to 42 percent. Theresults of previous investigations of dentists'adherence to professional guidelines also showlow adherence. Nelson and Van Blaricum'**reported that dentists and physicians had lowadherence (32.9 percent) when prescribingantibiotics for subacute bacterial endocarditiscoverage. Although one might conclude that theparticipants were unaware of, or unwilling toadhere to, professional guidelines, there may beanother explanation for our findings. The profes-sional guidelines may lack clear direction for cer-tain clinical situations. The ADA guidelines'*^(Box 1) do not include clinical scenarios to illus-trate prescribing practices. Although most clin-ical situations are specific to the patient, theguidelines might be more helpful if they con-

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tained representative clinical TABLE 3cases to illustrate recommendedprescribing patterns. The AAPDguidelines appear to be more spe-cific than the ADA guidelines, butthese too could be expanded orexplained further. Moreover, giventhe significance of this issue, bothorganizations could undertakemore active roles in educatingtheir members.

With regard to dentistry, localdrainage often may be sufficient totreat orofacial infections. This mayinvolve removal of the infectedtooth to achieve drainage throughthe socket or drainage through anincision in the area. Cliniciansshould consider antibiotics as anadjunct to treatment when thereare signs of systemic involvementsuch as diffuse swelling. Althoughno clear evidence exists regardingthe optimum duration of antibiotictherapy, the AAPD Council onClinical Affairs" recommends thattreatment be continued for a min-imum of five days past improve-ment or resolution of the patient's S3miptoms.However, evidence from the medical literature ischallenging the longer duration of antibiotictherapy. Singh and colleagues ** examinedpatients in an intensive care unit and found thatthose who received a shorter (three-day) course ofantibiotic therapy experienced fewer instances ofantimicrobial resistance, superinfections or bothcompared with patients who received the longerstandard antibiotic therapy (15 versus 35 percent,respectively).

Antibiotic resistance. Antibiotic resistanceoccurs when bacteria modify themselves viamutations or by exchanging resistance determi-nants so they can survive even in the presenceof antibiotics.'^"^' Some researchers argue thatreduction in antibiotic resistance can occur onlyafter a substantial reduction in antibiotic usehas taken place.^°^' Widespread use of antibi-otics by health care professionals and people inthe livestock industry has resulted in analarming increase in the prevalence of drug-resistant bacterial infections; moreover, theincrease in antibiotic resistance has contributedsubstantially to the morbidity and mortalityassociated with infectious diseases.^^

Investigators in several studies found thatchildren treated with an antibiotic were morelikely to be colonized soon thereafter with bac-

Bivariate analyses.VARIABLE

Postgraduate ResidencyAEGDt/GPRtPediatricsOther (pubiic heaitii)None

Location of PracticeUrbanRuraiSuburban

Number of Children Treatedper Month<15>15

How Often Dentist WritesPrescriptions for Antibioticsfor Dentai InfectionsDailyWeekiyMonthiyHardly ever

CLiiUICAL CASE SCEIUARIO

1

NS*

P<.OS

NS

P<.05

2

NS

NS

NS

NS

3

P<.05

P< .05

NS

P<.05

4

NS

NS

NS

NS

5

NS

NS

P<.05

P< .05

* NS: Not significant.t AEGD: Advanced Education in General Dentistry.t GPR: General Practice Residency.

teria resistant to the same antibiotic. "-^^ Moreimportantly, it appears that some type of resist-ance has been developed for all currently avail-able antibiotics.^" Dentists and their medical col-leagues can help address this growing andpotentially devastating problem by prescribingantibiotics only when appropriate and necessaryto resolve an infection. '*

The demographic data gathered were notinconsistent with expectations for a survey ofNorth Carolina dentists.^" Most respondentsattended UNC-CH for dental school, their meanage was 47 years and they had been in practicefor a mean of 19 years.™ Almost the entiresample reported taking some type of solo tele-phone calls or sharing calls with others for after-hours emergency cases. In addition, most of thedentists worked in solo or group practices. Mostdentists identified their practice as being in asuburban or urban location within the state.Amoxicillin was the drug of choice for treatingdental infections. Almost 90 percent of thesample reported that they practiced more than30 hours per week. We should point out thatmost respondents reported that they did notwrite prescriptions often for dental infections.

Study limitations. We need to consider theseresults in light of some study limitations. Thecross-sectional design limited our ability to draw

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eausal inferenees. Because the survey was self-administered and based on clinical case scenarios,responses may have been susceptible to responsebias. The dentists, who were participating in con-tinuing education courses where the surveys weredistributed, may not have been a representativesample of dentists in North Carolina. They mayhave been more informed and more motivated toleam about new ideas in dentistry. In addition,dentists who completed this survey may havebeen more comfortable with the topic. In theaggregate, these limitations suggest that dentists'adherence to the guidelines for antibiotic use maybe worse than the findings reported here indicate.The power of the study is another limitation.Although a few trends were evident, the samplesize was small and, thus, inferences were difficult.

Despite these limitations, this study has sev-eral strengths, including being the first, to ourknowledge, to report on this topic of importanceand clinical relevance. Little is known aboutantibiotic preseribing practices of dentists in theUnited States, and almost nothing is knownabout prescribing practices in treating children.The study results provide preliminary data forone state regarding the extent to which dentalprofessionals are adhering to professional guide-lines for prescribing antibiotics for children withdental infections. The data also indieate faetors(sueh as géographie loeation) assoeiated with pre-scribing practices. Understanding these factorswill help shape educational strategies and thedevelopment of future professional guidelines.

This study sets the stage for future research.We obtained self-reported data from dentists inNorth Carolina, which is a first step to under-standing their antibiotic prescribing practices.Future research should include a more random-ized approach with more participants to increasestatistical power. In addition, investigatorsshould examine antibiotic prescribing practicesof dentists in an adult population. Practice-based networks would be an excellent researchenvironment for further study of this topic.

CONCLUSIONThe results of this study show a low adherenceamong general and pédiatrie dentists to profes-sional guidelines for preseribing antibioties forodontogenie infections in children. Thereappears to be a lack of concordance between rec-ommended professional guidelines and theantibiotic prescribing practices of dentists.Clearer and more specific professional guide-lines may lead to improved adherenee. •

Disclosure. None of the authors reported any disclosures.

38 JADA 143(1) http://jada.ada.org January 2012

The authors thank the following people for their help with thisstudy: A. Diane Baker, MBA, for her help with data collection; ShadiCinpinski, Sue Felton and Lindsay McCollum for their assistance inthe recruitment of dentists; and Ceib Phillips and Debbie Price forassisting with data management and analysis.

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