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AN AUDIT OF ANTIBIOTIC PRESCRIBING PATTERNS IN GENERAL DENTAL PRACTICE

Leslie Campbell, Project Coordinator and General Dental Practitioner Elaine Wilson, Clinical Effectiveness Project Officer

With the assistance of Terry Simpson, Dental Audit Facilitator Primary Care Clinical Audit Team Clinical Governance Support Team Lothian Primary Care NHS Trust Stevenson House 555 Gorgie Road Edinburgh EH11 3LG

CONTENTS Introduction Aims Methodology Results: Background Information about dentists Antibiotic Prescribing Patterns
Amoxycillin Metronidazole Penicillin Erythromycin Clindamycin Cephalexin Doxycycline Oxytetracycline Tetracycline

2 3 3 4 6
8 10 12 14 16 17 18 19 20

Discussion Recommendations References Appendix 1: Antibiotic prescribing data collection form Appendix 2: Dentist questionnaire

21 23 24

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INTRODUCTION
Antibiotics are prescribed by general dental practitioners (GDPs) for both therapeutic and prophylactic reasons. How and what GDPs prescribe is limited by the dental practitioners formulary, but this publication does not provide definitive or standardised prescribing policies for oral or dental infections1 . Other studies have shown that GDPs prescribe a range of antibiotics with large variations in the dosage and frequency1,2,3. The increase in antibiotic resistance has heightened the importance of rational prescribing by GDPs. Inappropriate prescribing also has cost implications, in Lothian during April 1999 March 2000, 45,918 prescriptions were issued at a cost of 90,147.164. In accordance with recommendations from the Department of Health5, prescribing guidelines were drawn up locally and published as the Lothian Dental Formulary. The guidelines were distributed to all GDPs in the Lothian area to provide up-to-date information to help practitioners prescribe appropriately. Subsequent to the distribution of the Formulary, this audit was conducted on antibiotic prescribing amongst a group of volunteer dentists.

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AIMS
The main aims were to enable practitioners to examine their prescribing practice, establish if they were following best current advice in their prescribing of antibiotics and to raise their awareness of the need to conform to current recommendations. The audit also aimed to assess the implications of giving written guidance for increased or decreased costs.

METHODOLOGY
A letter was sent to all GDPs in Lothian inviting them to take part in the audit. One hundred and forty two returned the initial form expressing an interest. An audit pack containing the necessary information and data collection sheets was sent to all of these GDPs. GDPs were asked to record information on all antibiotics prescribed during a 4 week period between November 1999 and February 2000. This information included patient sex, age, name of antibiotic, dosage, frequency, duration of the prescription, condition and reason for which it was prescribed (Appendix 1). The total number of patients that were seen during the audit period was recorded to enable prescribing rates to be calculated. Each dentist was also asked to complete a questionnaire looking at general background information such as how long they had been qualified, whether they had attended any relevant courses and what source they would refer to when prescribing (Appendix 2). At the end of the period all forms were returned to the Primary Care Clinical Audit Team for collation and analysis using SPSS. The report has been written in a format where the current guidance for prescribing is stated, followed by the results obtained from the audit. The guidance was taken from the Lothian Dental Formulary, however, for antibiotics not contained within this document (i.e. cephalexin, doxycycline, oxytetracycline and tetracycline) the Dental Practitioners Formulary was used. The percentage of antibiotics prescribed in accordance with the guidance has been noted for each antibiotic with the exception of those not included in the Lothian Dental Formulary (see above) as the guidance in the Dental Practitioners Formulary is vague.

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RESULTS
One hundred and two GDPs returned completed data collection forms and questionnaires.

BACKGROUND INFORMATION ABOUT DENTISTS


Year of Qualification

The year of qualification ranged from 1961 to 1999 and the distribution can
25.0 %

20 .0 %

percentage

1 5.0 %

1 0 .0 %

5.0 %

0 .0 % 1 961 -1 965 1 966 -1 970 1 971 -1 975 1 976 -1 980 1 981 -1 985 1 986-1 990 1 991 -1 995 1 996-2 000 year of qualification

be seen in Chart 1.
Chart 1

Attendance at Postgraduate Courses When asked if they had attended within the last 2 years any postgraduate course, which covered the appropriate circumstances for antibiotic prescribing, only 24.3% reported that they had. Altered Antibiotic Prescribing Practices Since Qualified
yes 2 8. 2 %

not recorded 1 . 0% no 70. 9 %

Chart 2

When asked if they had fundamentally altered their prescribing practices since they first qualified, the majority 70.9% said that they had not (Chart 2). Of the 73 dentists who reported that they had not fundamentally altered their prescribing practice since they first qualified, 64.4% had qualified prior to and including 1990. 04/10/00 4

Reported Sources of Reference When asked if they had seen the Lothian Dental Formulary 84.5% of practitioners reported that they had. When asked what source(s) they would refer to when prescribing 91.3% said the British National Formulary/Dental Practitioners Formulary, 46.6% said the Lothian Dental Formulary and 1.9% said an other source. The other sources were reference book and Mosbys Dental Drug Reference. Total Number of Patients Practitioners were asked to record the total number of patients seen over the audit period. The average for the Lothian audit was 374 (min 61, max 967). It should be noted that some dentists worked full time and others part time. Number of Antibiotics Prescribed The average number of antibiotics prescribed during the audit period was 12 (min 0, max 53). Rate of Prescribing Using both of the above figures the rate of antibiotics prescribed per patients seen was calculated for each practitioner. The average for the Lothian audit was 3.3 per 100 patients (min 0, max 10.7).

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ANTIBIOTIC PRESCRIBING PATTERNS


Between the 102 general dental practitioners a total of 1204 antibiotics were prescribed during the 4 week audit period. Age of Patients The mean age of patients was 39 years (min 3, max 86), the distribution can
5 0

4 0

3 0

20

frequency

10

0 3 8 13 18 23 28 3 3 3 8 4 3 4 8 5 3 5 8 6 3 6 8 7 3 7 8 85

A e in ye rs g a

be seen in Chart 3.
Chart 3

Sex of Patients 41.9% of the sample were male, 57.3% were female and in 0.8% the data was not recorded. Drugs Prescribed Chart 4 shows the range of drugs prescribed with amoxycillin, metronidazole and Penicillin V accounting for 91.5% of prescriptions. The figures for Lothian were provided by ISD4.

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100

10

20

30

40

50

60

70

80

90

%0

Chart 4
Amoxycillin 42.7 23.5 26.7 25.9 22.1 6.3 5.5 0.5 Clindamycin 1 Audit Sa ple m 0.7 Cephalexin 1 0.3 Doxycycline 0.7 0.3 Oxytetracycline 0.2 0.4 Tertracycline 0.2 41.5

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Metronidazole Penicillin V All Lothia GDPs n Erythromycin

Condition and Reason for Prescription The condition for which the antibiotic was prescribed and the dentists reason for prescribing can be seen in Tables 1 and 2. Condition Dental & perio. abscess/infection Periocoronitis Post extraction/surgical procedure Dry socket Pre-operative AUG Chronic periodontitis Pain of unknown aetiology Sinusitis Following RCT Trauma Scale & polish Other Trismus Not recorded
Table 1

no 786 111 65 58 55 42 20 18 16 14 7 6 6 3 5

% 65. 3 9.2 5.4 4.8 4.6 3.5 1.7 1.5 1.3 1.2 0.6 0.5 0.5 0.2 0.4

Reason Definite clinical indication Patient in pain Prophylaxis Hedging bets Unable to return for interval Other Shorten appointment Patient expectation Placebo Not recorded
Table 2

no 812 210 77 61 59 15 42 20 1 25

% 67. 4 17. 4 6.4 5.1 4.9 1.2 3.4 1.7 0.1 2.1

The Other conditions cited were for non-specific post-operative conditions such as tenderness and swelling and for infected ulcer. The Other reasons cited were where treatment goal was not achieved due to existing conditions e.g. infection, fractured roots or where the patient was not co-operative.

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AMOXYCILLIN
Guidelines
The indications for amoxycillin are:
The treatment of dento-alveolar infection, dento-facial abscess, acute sinusitis.

The recommended dosage is


Adult: Child (up to 10 years): Short course: Prophylaxis: 250mg (doubled in severe infections) every 8 hours for 5 days 125mg (doubled in severe infections) every 8 hours for 5 days 3g repeated after 8 hours single 3g dose

Findings of Lothian Audit


For amoxycillin and the subsequent antibiotics, the shaded area in the table indicates where the antibiotic prescribed was in line with guidelines. Of the 514 prescriptions for amoxycillin, 9.1% were given to children aged up to an including 10 years old. CHILDREN (up to and including 10 years)
No of prescriptions 28 3 8 1 1 1 5 Total = 47
Table 3

Dose 125mg 125mg 125mg 125mg 250mg 250mg 250mg

Frequency (no of times a day) 3 3 4 4 3 4 4

Duration (in days) 5 7 5 7 3 5 5

59.6% of prescriptions were in accordance with the guidelines

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ADULTS
No of prescriptions 1 1 2 1 16 1 178 58 44 1 2 8 3 3 76 14 4 44 9 1 Total = 467
Table 4

Dose 125mg 125mg 200mg 200mg 250mg 250mg 250mg 250mg 250mg 250mg 250mg 500mg 500mg 500mg 500mg 500mg 500mg 3g 3g 3g

Frequency (no of times a day) 3 4 2 4 2 3 3 3 4 4 4 2 2 3 3 3 4 1 2 3

Duration (in days) 7 5 5 5 5 3 5 7 5 6 7 5 7 3 5 7 5 1 1 2

65.7% of prescriptions were in accordance with the guidelines


Condition Dental & perio. abscess Pre-operative Post extraction Periocoronitis Dry socket Pain of unknown aetiology Following RCT Trauma Scale & polish AUG Sinusitis Other Chronic periodontitis Not recorded
Table 5

no 36 7 37 28 24 10 10 9 6 6 5 5 4 2 4

% 71. 4 7.2 5.4 4.7 1.9 1.9 1.8 1.2 1.2 1.0 1.0 0.8 0.4 0.8

Reason Definite clinical indication Patient in pain Prophylaxis Hedging bets Unable to return for interval Shorten appointment Patient expectation Other Placebo Not recorded
Table 6

no 284 106 54 31 31 22 10 8 1 16

% 55.3 20.6 10.5 6.0 6.0 4.3 1.9 1.6 0.2 3.1

71.4% of prescriptions were issued for the appropriate condition, dental & perio abscess.

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METRONIDAZOLE
Guidelines
The indications for metronidazole are:
Acute necrotising ulcerative gingivitis (AUG) and periocoronitis.

The recommended dosage is:


Adult: AUG 200mg every 8 hours for 3 days Pericorinitis 200mg every 8 hours for 5 days Child: 1-3 years 3-6 years 7-10 years 1-3 years 3-6 years 7-10 years AUG 50mg every 8 hours for 3 days 100mg every 12 hours for 3 days 100mg every 8 hours for 3 days Pericorinitis 50mg every 8 hours for 5 days 100mg every 12 hours for 5 days 100mg every 8 hours for 5 days

Doubling the dose may be indicated in severe infection

Findings of Lothian Audit


There were 322 prescriptions for metronidazole. CHILDREN There were no prescriptions for children under 3. There was one prescription for a child aged 3-6:
No of prescriptions 1
Table 7

Dose 200mg

Frequency (no of times a day) 2

Duration (in days) 5

This prescription was in line with the guidelines There was one prescription for a child aged between 7-10
No of prescriptions 1
Table 8

Dose 100mg

Frequency (no of times a day) 2

Duration (in days) 5

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ADULTS
No of prescriptions 18 1 39 4 173 6 20 1 10 1 2 2 3 1 1 10 4 21 2 1 Total = 320
Table 9

Dose 200mg 200mg 200mg 200mg 200mg 200mg 200mg 200mg 200mg 200mg 250mg 250mg 250mg 250mg 400mg 400mg 400mg 400mg 400mg 400mg

Frequency (no of times a day) 2 3 3 3 3 3 3 3 4 4 3 3 3 3 2 2 3 3 3 6

Duration (in days) 5 2 3 4 5 6 7 10 5 7 4 5 7 14 4 5 3 5 7 5

74.1% of prescriptions were in accordance with the guidelines.


Condition Dental & perio. abscess Periocoronitis Post extraction AUG Dry socket Chronic periodontitis Pre-operative Other Trismus Pain of unknown aetiology Not recorded
Table 10

no 16 0 65 14 36 26 16 3 2 1 1 1

% 49. 7 20. 2 4.3 11. 2 8.1 5.0 0.9 0.6 0.3 0.3 0.3

Reason Definite clinical indication Patient in pain Unable to return for interval Shorten appointment Hedging bets Prophylaxis Patient expectation Other Not recorded
Table 11

no 25 1 53 11 10 8 7 4 2 4

% 78. 0 16. 5 3.4 3.1 2.5 2.2 1.2 0.6 1.2

31.4% of prescriptions were given for the appropriate condition.

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PENICILLIN
Guidelines
The indications for Penicillin are:
The treatment of dento-alveolar infection, dento-facial abscess, acute sinusitis.

The recommended dosage is


Adult: Child: 1-5 years 6-12 years 250mg-500mg every 6 hours for 5 days 125mg every 6 hours for 5 days 250mg every 6 hours for 5 days

Findings of Lothian Audit


There were 266 prescriptions for penicillin. CHILD Seven prescriptions were issued for children aged 1-5 years:
No of prescriptions 1 4 2 Total = 7
Table 12

Dose 125mg 125mg 125mg

Frequency (no of times a day) 4 4 4

Duration (in days) 3 5 7

57.1% of prescriptions were in accordance with the guidelines. Thirty-two prescriptions were issued for children aged 6-12 years:
No of prescriptions 9 2 1 16 2 1 1 Total = 32
Table 13

Dose 125mg 125mg 250mg 250mg 250mg 250mg 250mg

Frequency (no of times a day) 4 4 3 4 4 4 Not recorded

Duration (in days) 5 7 5 5 7 10 5

50% of prescriptions were in accordance with the guidelines 04/10/00 13

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ADULTS
No of prescriptions 1 5 160 3 31 1 21 4 1 Total = 227
Table 14

Dose 250mg 250mg 250mg 250mg 250mg 500mg 500mg 500mg 750MG

Frequency (no of times a day) 3 4 4 4 4 3 4 4 4

Duration (in days) 5 3 5 6 7 7 5 7 5

79.7% of prescriptions were in accordance with the guidelines.


Condition Dental & perio abscess Periocoronitis Post extraction Dry socket Other Pain of unknown aetiology Following RCT Trismus Pre-operative AUG Chronic periodontitis Sinusitis
Table 15

no 19 7 21 18 17 10 5 3 2 2 1 1 1

% 74. 1 7.9 6.8 6.4 3.8 1.9 1.1 0.8 0.8 0.4 0.4 0.4

Reason Definite clinical indication Patient in pain Unable to return for interval Hedging bets Shorten appointment Other Prophylaxis Patient expectation Not recorded
Table 16

no 208 37 17 18 7 4 4 2 2

% 78.2 13.9 6.4 6.8 2.6 1.5 1.5 0.8 0.8

74.5% of prescriptions were given for the appropriate condition.

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ERYTHROMYCIN
Guidelines
The indications for erythromycin are:
The treatment of dento-alveolar infection, dento-facial abscess, acute sinusitis and an alternative for penicillin in allergic patients.

The recommended dosage is


Adult: infections) 250mg (dose may be doubled in severe every 6 hours for 5 days Child: Up to 2 years Over 2 years 125mg every 6 hours for 5 days 250mg every 6 hours for 5 days

Findings of Lothian Audit


There were 66 prescriptions for erythromycin. CHILD Only 1 child up to the age of 2 years was given a prescription:
No of prescriptions 1
Table 17

Dose 250mg

Frequency (no of times a day) 4

Duration (in days) 5

Five children aged over 2 years and up to 8 years were given prescriptions:
No of prescriptions 4 1 Total = 5
Table 18

Dose 125mg 250mg

Frequency (no of times a day) 4 4

Duration (in days) 5 5

20% of prescriptions were in accordance with the guidelines.

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ADULTS
No of prescriptions 1 1 41 3 9 1 1 2 1 Total = 60
Table 19

Dose 125mg 250mg 250mg 250mg 250mg 250mg 500mg 500mg 500mg

Frequency (no of times a day) 4 3 4 4 4 4 3 4 4

Duration (in days) 7 5 5 6 7 Not recorded 5 5 7

71.6% of prescriptions were in accordance with the guidelines. Condition Dental & perio abscess Dry socket Post extraction Other Pain of unknown aetiology Following RCT Periocoronitis Chronic periodontitis Pre-operative Trauma
Table 20

no 51 4 3 3 2 2 1 1 1 1

% 77. 3 6.1 4.5 4.5 3.0 3.0 1.5 1.5 1.5 1.5

Reason Definite clinical indication Patient in pain Hedging bets Patient expectation Not recorded Shorten appointment Prophylaxis
Table 21

no 50 11 3 2 2 1 1

% 75. 8 16. 7 4.5 3.0 3.0 1.5 1.5

77.3% of prescriptions were given for the appropriate condition.

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CLINDAMYCIN
Guidelines
The indications for clindamycin are:
Prevention of endocarditis in susceptible patients where a penicillin is contra-indicated.

The recommended dosage is


Adult: Child: Under 5 years 5-10 years 600mg orally, one hour before procedure 150mg one hour before procedure 300mg one hour before procedure

Findings of Lothian Audit


There were 12 prescriptions for clindamycin.
No of prescriptions 1 11 Total = 12
Table 22

Dose 150mg 600mg

Frequency (no of times a day) 4 1

Duration (in days) 1 1

91.7% of prescriptions were in accordance with the guidelines.


Condition Pre-operative
Table 23

no 12

% 100

Reason Prophylaxis Definite clinical indication


Table 24

no 11 1

% 91.7 8.3

100% of prescriptions were given for the appropriate condition.

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CEPHALEXIN
Guidelines
Cephalexin is not included in the Lothian Dental Formulary, however, the Dental Practitioners Formulary states that the indications for Cephalexin are:
The treatment of dento-alveolar infection, dento-facial abscess, acute sinusitis.

The recommended dosage is


Adult: Child: 1-5 years 6-12 years 250mg every 6 hours 125mg every 8 hours 250mg every 8 hours

Findings of Lothian Audit


There were 12 prescriptions for cephalexin.
No of prescriptions 12 Total = 12
Table 25

Dose 250mg

Frequency (no of times a day) 4

Duration (in days) 5

Condition Dental & perio abscess Post extraction


Table 26

no 10 2

% 83. 3 16. 7

Reason Definite clinical indication Shorten appointment Patient expectation Not recorded
Table 27

no 9 2 2 1

% 75.0 16.7 16.7 8.3

83.3% of prescriptions were given for the appropriate condition.

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DOXYCYCLINE
Guidelines
Doxycycline is not included in the Lothian Dental Formulary, however, the Dental Practitioners Formulary states that the indications for doxycycline are:
Destructive forms of periodontal disease.

The recommended dosage is


Adult: 200mg on first day then 100mg daily

The tetracyclines .. should not be given to children under 12 years of age.

Findings of Lothian Audit


There were 8 prescriptions for doxycycline.
No of prescriptions 2 2 1 2 1 Total = 8
Table 28

Dose 100mg 100mg 100mg 100mg 200mg

Frequency (no of times a day) 1 1 2 2 5

Duration (in days) 5 7 5 7 6

Condition Sinusitis
Table 29

no 8

% 100

Reason Definite clinical indication Patient in pain Other


Table 30

no 7 2 1

% 87.5 25.0 12.5

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OXYTETRACYCLINE
Guidelines
Oxytetracycline is not included in the Lothian Dental Formulary, however, the Dental Practitioners Formulary states that the indications for oxytetracycline are:
Destructive forms of periodontal disease (in particular recurrent aphthous ulcers and oral herpes).

The recommended dosage is


Adult: 250mg-500mg every 6 hours

The tetracyclines .. should not be given to children under 12 years of age.

Findings of Lothian Audit There were two prescriptions for oxytetracycline.


No of prescriptions 2
Table 31

Dose 250mg

Frequency (no of times a day) 4

Duration (in days) 5

Condition Sinusitis
Table 32

no 2

% 10 0

Reason Hedging bets Patient in pain


Table 33

no 1 1

% 50.0 50.0

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TETRACYCLINE
Guidelines
Tetracycline is not included in the Lothian Dental Formulary, however, the Dental Practitioners Formulary states that the indications for Tetracycline are:
Destructive forms of periodontal disease(in particular recurrent aphthous ulcers and oral herpes).

The recommended dosage is


Adult: 250mg every 6 hours

The tetracyclines .. should not be given to children under 12 years of age.

Findings of Lothian Audit


There were two prescriptions for tetracycline.
No of prescriptions 1 1 Total = 2
Table 34

Dose 250mg 250mg

Frequency (no of times a day) 4 4

Duration (in days) 5 7

Condition Dental & perio abscess Dry socket


Table 35

no 1 1

% 50. 0 50. 0

Reason Definite clinical indication


Table 36

no 2

% 100

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DISCUSSION
Antibiotics must be prescribed only on the basis of a well-defined clinical need. Before any prescription is issued the principals of surgical debridement and/or drainage must be considered6. A prescribing rationale must include a thorough clinical examination to establish if there is fever, spreading cellulitis or trismus. A medical history must also be recorded to identify systemic medical conditions that may place the patient at increased risk from infection. As with other recent studies2,7,8,9 the results of this audit highlight a wide range of treatment regimes, with dosage, frequency and duration all varying. This variation occurred although almost 84.5% of participants stated that they had seen the Lothian Dental Formulary and that 91.3% of participants said that they referred to the Dental Practitioners Formulary for prescribing information. Of the audit participants, 70.9% said that they had not fundamentally altered their prescribing practices since qualifying, with 64.4 % of these having qualified prior to 1990. In addition, only 24.3% had attended a postgraduate course on antibiotic prescribing within the last 2 years. These figures suggest that there may be a need for improved education and wider publicity for current advice. Patient expectation was infrequently cited as the reason for issuing a prescription, only 1.7% of instances. Prior to undertaking the audit, it was thought that there may be considerable pressure on a practitioner in this respect, however, the results of this audit suggest that this is not a significant factor in their decision making process. In 4.9% of cases, participants prescribed antibiotics for patients who were unable to return for an interval. Some doubt may exist in the minds of dentists as to whether or not they should be issuing prescriptions in these circumstances, particularly where the patient is due to go abroad and may be doubtful on the availability and quality of local dental services. To what extent this proportion may be affected by the fact that the audit period was between November and February, which includes the Christmas holidays, is unclear. Amoxycillin, Metronidazole and Penicillin V were the 3 main antibiotics of choice, accounting for 91.5% of prescriptions. Since Penicillin and Amoxycillin are pharmacologically very similar it may well be worth pointing out again to GDPs the advantages that Amoxycillin has over Penicillin. Firstly, it only has to be given three times per day instead of four to ensure sufficient blood saturation levels. This enables greater patient compliance. Amoxycillin can also be given as a powder, which can be mixed in water and taken orally. Since this course only lasts one day compliance is better but the cost of the drug given in this manner is substantially higher (15 x 250mg capsules = 1.20, 2 x 3g sachet = 4.484). However, the Dental Practitioners Formulary would appear to contradict this advice and suggest that penicillin V is still the drug of choice. The recommended dosage in severe infections is higher in the Dental Practitioners Formulary than the Lothian Dental Formulary (750mg as against 500mg). 04/10/00 23

The recently published Faculty of General Dental Practitioners prescribing guidelines10 recommend that any patient for whom antimicrobials are prescribed should be reviewed after 2-3 days of therapy. If at this review the patients temperature is normal and swelling is resolving the antimicrobials should be discontinued. The design of the data collection form did not allow for recording such cessation of therapy. The practice of prescribing prolonged courses of antibiotics (as followed by some of the GDPs in the audit for a period of up to 10 days) could lead to resistant bacteria and is not recommended. There is no evidence that antibiotics are effective in the management of pulpitis and a previous study3 has highlighted that a substantial minority of patients are given antibiotics for this condition within the general practice setting. This audit did not specifically verify or refute this finding but it is possible that this is a factor especially where time is of the essence or the dentist is unsure of the diagnosis (i.e. approximately 5% admitted to hedging their bets when giving antibiotic therapy. In 4.8% of cases, participants prescribed antibiotics for dry socket and the value of this has been called into question3. Some issues surround some of the less commonly use antimicobials. Tetracycline, Oxytetracycline, Doxycycline are all are available to GDPs but the Lothian Dental Formulary does not mention them. The Dental Practitioners Formulary indicates there may still be a role for these but it is limited to systemic, destructive forms of periodontal disease. More specificity would be helpful in this area so that GDPs can be absolutely clear exactly when, if ever, there is a clear advantage in prescribing any of these. The cephalasporins, although appearing in the Dental Practitioners Formulary (but not Lothian Dental Formulary ) seem to have no indication to recommend their use and have more contra-indications than the penicillins. A very high percentage of antibiotics prescribed for prophylactic reasons were for regimes that conformed to current guidelines. The Faculty of General Dental Practitioners publication has an excellent section on the use of prophylactic antimicrobials describing which medically comprised patients require prophylaxis, and for which dental procedures. There is a problem with certain drugs not being mentioned in local guidelines and the Dental Practitioners Formulary not giving sufficient guidance, therefore the Faculty of General Dental Practice publication seeks to redress this and may help to eliminate some confusion that may be present for some GDPs.

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RECOMMENDATIONS
Circulation of the results of this audit to all participants should raise awareness of the existence of current standards and guidelines. It is hoped that as a consequence GDPs will review and rationalise their prescribing practices, and that the result will be an improved service to patients. In order to determine whether the audit achieved its aim it would be appropriate to repeat the audit after a suitable period. It is clear that there is a need for improved education, whether this is undergraduate and/or postgraduate. The Dental Practitioners Formulary is vague and the Lothian Dental Formulary does not include all the available drugs. Therefore, the Lothian Dental Formulary needs to be reviewed to provide more definitive advice. While the Faculty of General Dental Practitioners guidelines are promising, they are not widely distributed to all GDPs and have a cost implication. Local research projects in this topic should also be encouraged.

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REFERENCES
1. An Investigation of Antibiotic Prescribing by General Dental Practitioners: A Pilot Study. Palmer and Martin. Primary Dental Care 1998:5(1) : 11-14. Antibiotic Prescribing by General Dental Practitioners in the Greater Glasgow Health Board, Scotland. Roy and Bagg. BDJ 2000 188(12) 674-676. Antibiotic Prescribing for Acute Dental conditions in the Primary Care Setting, Thoms, Satterwaite, Absi, Lewis, Shepherd. BDJ 1996 181(11/12) 401-404 Dental Prescribing in Lothian 1999/2000, Information & Statistics Division, Common Services Agency for the National Health Service in Scotland The Path of Least Resistance: Department of Health Standing Medical Advisory Committee Subgroup on Antimicrobial Resistance. Sep 98. Acute Dentoalveolar Infections: An Investigation of The Duration Of Antibiotic Therapy Martin, Longman, Hill and Hardy BDJ 1997; Vol.18 No. 4:135-137 A Study of Therapeutic Antibiotic Prescribing in NHS General Dental Practice in England. Palmer, Pealing, Ireland and Martin. BDJ 2000 (188) 554-558. An Audit of Antibiotic Prescribing in General Dental Practice. Steed and Gibson. Primary Dental Care 1997; 4(2): 66-70 An Audit of Antibiotic Prescribing by General Practitioners in the Initial Management of Acute Dental Infection. Muthukrishnan, Walters and Douglas. Dental Update Oct 1996. 316-318. Adult Antimicrobial Prescribing in Primary Dental Care for General Dental Practitioners. Faculty of GDPs (UK) Royal College of Surgeons of England 2000

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5. 6.

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8. 9.

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Appendix 1
Reason

ANTIBIOTIC PRESCRIBING DATA COLLECTION FORM


Age Sex Name of Antibiotic Loading dose Dosage Frequenc y Duration (days) Condition

32

Pen V

250mg

4x

Condition for which given: 1 AUG 2 dental & perio abscess 3 dry socket 4 periocoronitis 5 chronic periodontitis 6 pain of unknown aetiology 7 post extraction 8 pre-operative 9 trauma If not listed above please write condition in table

Reason a b c d e

for prescription: definite clinical indication hedging bets prophylaxis, rheumatic fever, SBE, implant, other patient expectation patient unable to return for interval (eg Fri. pm with no surgery until Mon.) f shorten appointment (eg insufficient time to open and dress) g patient in pain h placebo If not listed above please write reason in table

Appendix 2 Audit of Antibiotic Prescribing Patterns

DENTIST QUESTIONNAIRE
Please complete the following questions and return this form with your data collection sheets at the end of the audit period.

YEAR

OF QUALIFICATION

Have you attended within the last 2 years any postgraduate course which covered the

Yes

No

Have you fundamentally altered your antibiotic prescribing practices since you first Have you seen the Lothian Dental Formulary (please tick)

Yes

No

Yes

No

What source would you refer to when prescribing (please tick): British National Formulary/ Dental Practitioners Formulary Lothian Dental Formulary Other ________________________ None

TOTAL

NUMBER OF PATIENTS SEEN OVER THE AUDIT

(use daily record sheet) PERIOD

HOW

MANY DAYS A WEEK DO YOU WORK?