Abstract

Aim: This study was designed to find out the awareness among the dental practitioners using American Heart Association (AHA) guidelines for dental implants and for prescribing the dosage of Antibiotic Prophylaxis (AP) as per the AHA guidelines. Methodology: A cross-sectional questionnaire projected across the Saudi Arabia among practicing dentists (general and specialists) and dental students (final year undergraduate and postgraduate). The questionnaire was distributed to 1000 dental practitioners, who willingly consented to participate in the study. The questionnaire consists of 11 (either multiple choice or dichotomous) questions regarding the awareness and practice of AHA guidelines for dental implants and prescribing AP pre- or post-dental implants. Statistical analysis was performed using SPSS version 21. A chi-square test was performed with both descriptive and inferential statistics. The level of significance was P ≤0.05. Results: Total responses from 893 (89.3%) participants were received and were considered for statistical analysis. Male and female participants were 485 (54.3%) and 408 (45.7%), respectively. The majority of the participants responded wrongly for prescribing AP for dental implants as a routine practice, immediate implant, and immediate implant with systemic disease. However, the majority of the practitioners responded correctly in prescribing amoxicillin as the first line of AP to be used during implants but with the wrong dosage of the drug. Moreover, more than half of the practitioners answered correctly for prescribing AP to post-operation. The primary factors in prescribing AP for dental implants were selected wrong by a significant number of practitioners. To increase the success of the dental implants, an overwhelming number of the practitioners answered correctly by opting for pre operation use of AP. Conclusion: The present study outlines and indicates the lack of awareness of AHA recommendations and guidelines among dental practitioners in KSA. Besides, it recorded a high number of AP prescriptions during dental implant placement as a routine practice without any supporting evidence.

1. Introduction

Tooth replacement and insertion of dental implants is a common practice in modern dentistry. An increase in awareness of oral health leads to a dramatic upsurge for dental implants in the past few decades ¹. Dental implants, though seem to be a minor procedure, as the patient-dentist contact period is of a few hours and the success rate is high with satisfaction to the majority of the patients. Yet, failures and complications in dental implants may occur. It causes tremendous pain to the patient and a damaging effect on the dentist-patient relationship ¹. Dental implants failures can be characterized into two types; early failures and late failures. Early failures are usually caused by implant contamination, trauma during surgery, or implant stability, while the late failures are usually caused by an overload of occlusal, peri-implantitis, or systemic disease. Infections are the primary reasons linked with both failures, either early or late ². There is a 10% to 15% chance of local infection in dental implants’ sites ³. Local infections are mostly caused by bacterial contamination in early dental implant failures, which is the primary focus of this study.

It is very difficult to remove or cure the site of the implant surface if it gets colonized by the bacteria. There is no dental practice or protocol available to date to disinfect the contaminated implant surface ⁴. To prevent contamination and accumulation of bacteria at the dental implant surface, the dentist uses prophylactic antibiotics. The dosage of prophylactic antibiotics prescribed by the dentist has no specific dosage or quantity guidelines in dental practice rather it is based on clinical decision. Bacterial endocarditis is prevented by using prophylaxis antibiotics before the start of surgery ⁵. AHA guidelines also recommend prophylaxis antibiotics to prevent bacterial infection when bleeding occurs around the site of dental implants. Likewise, the Canadian Dental Association also recommends the use of prophylaxis antibiotics to prevent contamination due to bleeding during or after dental surgical treatment. Amoxicillin is the first line of prophylaxis antibiotic recommended by the AHA. The alternative antibiotic for amoxicillin is clindamycin as it also helps to cure the allergy of penicillin. The protocol of using prophylactic antibiotics in dental surgeries can be categorized into five different categories. In the first category, 0.12% chlorhexidine rinse is recommended, pre and post-operation. The second category is when the moderate risk of infection can occur during extractions procedures which are traumatic or when socket preservation and immediate implant placements are required. Such cases required a pre-surgical antibiotic followed by a single dose of an antibiotic after surgery. Also, rinse of 0.12% chlorhexidine is advised daily twice a day till sutures are removed. The third category is when the risk of getting the infection is from moderate to high due to multiple implants placements or immediate implants placements along with bone grafting and membrane. Such cases required a pre-surgical antibiotic followed by a three-dose per day of the antibiotic after surgery to be taken for three days. Besides, rinse of 0.12% chlorhexidine is advised daily twice a day till sutures are removed. The fourth category is when the risk of getting an infection is high due to implants surgeries with sinus floor lifts, autogenous block bone grafts, and medically compromised patients in the same surgeries such as category 2 and 3. The regime of antibiotics is the same as category three but postoperative antibiotics are recommended for five days. The last and the fifth category is when the risk of getting the infection is high due to all sinus augmentation procedures are performed. The pre-surgical dose of antibiotics should be one day and also beta-lactamase antibiotics to be used for five days after the surgery. Also, rinse of 0.12% chlorhexidine is advised twice a day till sutures are removed.

Patients with a high risk of endocarditis or prosthetic joint infection in dentistry are cured by AP. The reason for using AP is to prevent or decrease transient bacteremia from the patients caused by the dental procedures manipulations. Though, long term usage of AP to counter bacteremia is still not guaranteed. Guidelines for prescribing antibiotics have changed in recent years, due to antimicrobial resistance globally ⁶. The USA and the UK follow their respective guidelines for using AP ^{5, 7}. Whereas, Australia, New Zealand and Europe (excluding the UK) have their own set of guidelines for using AP ^{5, 8, 9, 10}. Lack of evidence and the absence of coherent findings can be a reason for using different guidelines for AP by dentists across the globe. Although not every dental implant required a dosage of AP. However, AP is useful in preventing postoperative infections caused by dental implants.

To the best of our knowledge, no study or literature is available to provide the data of AP dosage and usage prescribed by the dentist in Saudi Arabia. Thus our study was designed to find out the awareness among the dentist practitioners using AHA guidelines for dental implants and for prescribing the dosage of AP as per the AHA guidelines.

2. Methodology

This study was designed on a cross-sectional questionnaire projected across Saudi Arabia among practicing dentists (general and specialists) and dental students (final year undergraduate and postgraduate). A self-assessed questionnaire was performed to assess the use of prophylactic antibiotics in implant dentistry practice and awareness of the practitioners’ knowledge about AHA standards in this regard. One-page computer survey questionnaires with 11 questions include multiple-choice and dichotomous questions were included. Initially, the questionnaire was tested on a small group of dentists (n=50) to identify the scope, reliability, and consistency of the questions. The majority of the dentist (56.3%) were not aware of AHA guidelines and does prescribe antibiotics randomly to the patient during dental implants. In the final phase, the survey was conducted across 1000 dentists. Not only the selection of questions for our questionnaire but also their answers were screened by two independent health care providers to ascertain that it is within the AHA guidelines. The Riyadh Elm University, Research center’s ethics committee approved the study with FGBRB/43731006/990 approval number.

The first question was related to the AHA standards’ recommendation on AP for dental implants. The second question was related to awareness towards AHA recommendations on AP for an immediate implant. The third question was related to prescribing antibiotics with different scenarios. The fourth question inquired about the first option of antibiotic given to patient during dental implant. From questions five to seven, dental practitioners’ opinion on the prescribed dosage of different antibiotics was inquired. The eighth question inquired about the possibility of AP in post-implant surgery. The ninth question was related to time AP prescribed before to implant surgery. The tenth question was the primary factor affecting the decision in prescribing AP for dental implants. The eleventh question was related to the option of increasing the chance of the implant’s success with antibiotics. Further details and clarification of the survey questions can be seen in Table 1.

Statistical analysis was performed using SPSS version 21 (SPSS Inc., Chicago, Ill, USA). A chi-square test was performed between the dependent variable versus independent factors with both descriptive and inferential statistics. The level of significance was set at P ≤0.05.

3. Results

Total responses from 893 (89.3%) participants were received and were considered for statistical analysis. Male and female participants were 485 (54.3%) and 408 (45.7%), respectively. Participants who fulfilled the complete questionnaire belonged to diverse groups, such as undergraduate students 244 (27.3%), post-graduate 247 (27.7%), general dentist 291 (32.6%), and specialist 111 (12.4%). Gender distribution for each category of the participant can be seen in Table 2.

When questioned about prescribing AP for dental implants as a routine practice and for an immediate implant, only 41.3% of the participants and 38.2% of the participants responded correctly, respectively, see Table 3. As AHA does not recommend prescribing AP for the dental implant as a routine practice and immediate implant. There was a significant difference (all P ≤ 0.05) recorded for the correct approach between males (33%) and females (51.2%) participants for prescribing AP for dental implants. There was no significant difference (all P > 0.05) recorded for the correct answer between males (33.2%) and females (44.1%) for prescribing AP for immediate implants.

The AHA also does not recommend the use of AP for immediate dental implant only, an implant with guided bone regeneration, delayed implant only, delayed dental implant with guided bone regeneration and patients with systemic disease. The majority of the participants responded incorrectly, see Table 3. A significant difference (all P ≤ 0.05) was recorded for immediate dental implant only, an implant with guided bone regeneration, delayed implant only, delayed dental implant with guided bone regeneration and patients with systemic disease, in between male and female participants. Whereas females responded more correctly in comparison to males. The AHA does not recommend to prescribing AP to a patient having systemic diseases such as having cancer, endocrine, diabetes mellitus, and osteoporosis. In contrast, 48.7% of the participants opted yes for cancer, 44.5% of the participants opted yes for endocrine, 40.2% of the participants opted yes for diabetes mellitus, and 39.3% of the participants opted yes for osteoporosis can be seen in Table 3, with no significant difference (all P > 0.05) between the two genders.

When inquired about AHA recommendation, the use of amoxicillin as the first line of AP to be used during implants. 58.7% of the participants responded correctly, however, 26.8%, 10.9% and 3.7% selected augmentin, azithromycin, and other antibiotics respectively. In addition, males (58.2%) responded correctly with a presence of significant difference (all P ≤ 0.05) in comparison to females (47.3%). According to AHA recommendations, a prescription for amoxicillin and azithromycin are 2 grams and 500 milligrams, respectively. A total of 11.6% and 35.8% responded correctly for prescribing the amoxicillin and azithromycin, respectively, which can be seen in Table 3. No significant difference (all P > 0.05) was recorded among male and female practitioners in prescribing the amoxicillin and azithromycin. 11.6% of male and 14.5% of female responded correctly for prescribing the dosage for amoxicillin, see Table 3. Also, 35.7% of male and 36% of female responded correctly for prescribing the dosage for azithromycin, see Table 3. The recommended prescription for augmentin by AHA is 1 gm and 2 gm. A total of 23.1% and 6.2% of participants responded correctly for prescribing augmentin, see Table 3. As seen in Table 3, female participants responded correctly by 28.2% for 1 gram of augmentin dosage while male participants responded correctly by 18.8%, no significant different (all P > 0.05) was present. For prescribing 2 grams’ dosage of augmentin, both males and females responded almost equally with no significant different (all P > 0.05) was present.

AP should be used 30 min to 1 hour prior to surgery as per the guidelines by the AHA. The majority of the participants answered correctly by opting no, while 39.5% opted for yes, see Table 3. As AHA recommends the use of AP 30 minutes to 1 hour before the operation, the percentage of participants selected the correct options was 46.2%, see Table 3. Male prescribing AP before the operation were 47.4% correctly, while female respondent was 44.9% correct for prescribing AP before the operation with no significant difference (P > 0.05) between males and females practitioners.

The options implant is a foreign body and patient age is not considered as primary factors to influence to prescribe AP for a dental implant according to AHA. However, 61.4% and 53.9%, respectively selected implant as a foreign body and patient age as the primary factor in deciding the AP for dental implants, see Table 3. Females were recorded lower in prescribing antibiotics than males considering implant as a foreign body and patient age 55.4% and 55.6 %, respectively. There was no significant difference (P > 0.05) recorded between male and female for prescribing AP as the primary factor. To increase the success of dental implant, AP is recommended before operation by AHA. Thus 58.7% of the participants answered correctly, see Table 3. A higher number of males (66.6%) were recorded for practicing AP before operation compared to 49.3% females, with a presence of no significant difference (P > 0.05) between the genders.

4. Discussion

The findings of the present survey-based study displayed that prescribing AP for the course of dental implants among dental practitioners in KSA is not in line with the guidelines of the AHA. The response rate recorded in the present survey-based study was 89.3% of total participants, 54.3% males, and 45.7% females. Earlier survey-based studies also received the same responses from the dental practitioners in KSA ^{11, 12, 13}. Prescribing AP as a routine during the course dental implants, many dental practitioners believed that it is recommended by the AHA guideline. Male (67%) and female (48.8%), prescribed AP for dental implants, which is a significantly high and wrong prescription as per the AHA guidelines. In addition, a presence of significant difference is present between male and female for prescribing AP for dental implants. The female dental practitioners tend to be more aware of the AHA guidelines for not prescribing AP for dental implants. Earlier studies conducted in medical institutes across KSA corroborates our findings ^{14, 15, 16}. Whereas in few studies wrong medications and antibiotics were prescribed by the dental practitioner during dental implants ¹⁷.

Implant with immediate prophylaxis does not require AP according to AHA guidelines. In contrast, our findings displayed that male and female practitioners are prescribing AP, 66.8% and 55.9% respectively, which is not correct as per the guidelines of the AHA. This is a significantly high number of male and female practitioners in practicing the wrong practice for an immediate implant in KSA. Moreover, no significant difference was found between the two genders. Similar results were recorded in an earlier study for prescribing antibiotics ¹⁸. Another wrong practice observed from this study was prescribing AP to patients with systemic diseases, which is again a wrong practice according to the guidelines. The selection of dosage for antibiotics such as Amoxicillin, Augmentin, and Azithromycin was also wrong according to the guidelines of the AHA. The highest amoxicillin dosage prescribed by the doctor was 500mg (44.7%), which is wrong, whereas only 11.6% was prescribing the correct dose of 2 gm. In case of azithromycin antibiotic, only 35.8% prescribed the correct dose. Our results are in line with an earlier study where 31% wrong dose prescription and 44% wrong antibiotic prescription were given to patients ¹⁹. A study earlier conducted in KSA found various reasons for the increase in the prescriptions by the doctors to use antibiotics. The authors’ findings stated that 41% to 92% Saudi population is getting overdosage of antibiotics, especially among children ²⁰. Lack of awareness among physicians can be the reason for prescribing antibiotics. Thus physicians require more education, practicing and training regarding antimicrobial prescriptions ²¹. Another study conducted in Jeddah, KSA, where 447 physicians from different medical fields where enquired about their knowledge, attitude, and practice in antimicrobial resistance. The findings displayed that those physicians have a deficiency in their awareness and educational references ²². Our findings showed that dentists in KSA preferred Amoxicillin (58.7%) over other antibiotics. There was no significant difference recorded between male and female dental practitioners. However, the wrong dosage is being practiced by dental practitioners in KSA. Thus proving that dentists have low awareness and knowledge of AHA guidelines.

Our findings recorded that only 6.9% dentists prescribed antibiotics preoperatively, whereas 40.5% tend to give them especially during the postoperative period and 38.1% preferred to prescribe antibiotics both pre- and post-operatively. Hence it shows the absence of guidelines among dental practitioners in antibiotic prescribing through dental implant placement ²³. The majority of the pharmacies in Riyadh, KSA sell antibiotics without a medical prescription. The most commonly bought antibiotic was amoxicillin/clavulanate. Lack of ethics and professionalism, breaking the law and financial benefits among pharmacist’s community can be the reason for the high consumption of antibiotics in Riyadh ²⁴. In the USA 142,505 patients visit per year to emergency departments in the hospital due to adverse events of antibiotics consumed ²⁵. Allergic reactions due to antibiotics can also be associated with an adverse effect on health ²⁶.

Globally, the misuse and abuse of antibiotics have become a serious and problematic health issue which can lead to the occurrence of multiple organism resistance ²⁷. Unfortunately, in KSA and the world studies on the prescription and overdosage of antibiotics are still not enough to establish a guideline in prescribing an antimicrobial medication. Drug adverse effects are caused due to ignoring guidelines for prescribing antibiotics that can lead to an increase in antimicrobials resistance ²⁸. Randomly prescribing antibiotics raises antimicrobial resistance which prevents the treatment of the infection efficiently. In KSA, resistance to penicillin has risen among all strains of streptococcus pneumonia due to the random consumption of antibiotics ²⁹. In 2018, the Saudi Ministry of Health (MOH) chartered that all pharmacies in KSA should not sell any antibiotics without a medical prescription. The aim was to minimize the misuse of antibiotics and thus decrease the bacteria resistance. These laws are meant to spread awareness among health care employees, patients, and the general public to minimize the use and misuse of antibiotics. The Infectious Diseases Society of America (IDSA) made strategies to avoid infection and achieve a high clinical treatment by improving the selection, dosage of administration and duration of antimicrobial therapy ²⁷. Its primary aim is to develop an ideal clinical cure and reduce the number of undesirable complications caused by antimicrobial use like the occurrence of resistance and toxicities due to drugs ³⁰.

The present study outlines and indicates the lack of awareness of AHA recommendations and guidelines among dental practitioners in KSA. In addition, it recorded a high number of AP prescriptions during dental implant placement as a routine practice without any supporting evidence. However, female tends to be significantly more aware of the AHA guidelines and more conscious of their prescription for AP. Therefore, continuing awareness and education in this topic is mandatory especially for dental practitioners to avoid antibiotic misuse and be updated with AHA guidelines.

References