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Clinical Article

CROSS-SECTIONAL

A National Survey of Pdiatrie Dentists on Antibiotic Use in Children

SujathaS, 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 pdiatrie dentists and adherenee to professional guidelines; and (2) assess their knowledge of and attitudes toward antibiotie resistanee. Methods: A cross-sectional survey regarding
antibiotic use, resistance, and knowledge of antibiotie stewardship programs was emailed to 4,636 members of the Ameriean Academy of Pdiatrie Dentistry (AAPD). Results: 987 surveys (21 pereent) were completed: 984 were analyzed. Lack of adherence to AAPD antibiotic guidelines
was noted. There was a trend toward overuse of antibiotics for the following conditions: irreversible pulpitis with (32 percent) and without
vital pulp (42 pereent): loeallzed dentoalveolar abseess with (68 pereent) and without draining fistula (39 percent): mitral valve relapse with rgurgitation (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 (four
pereent). Although 98 pereent of respondents believed that antibiotie resistanee is of growing eoneern, only 15 pereent were aware of antibiotic
stewardship programs. Conclusion: AAPD members overprescribe antibiotics. Educational programs to increase knowledge of antibiotic resistance and stewardship programs should be implemented to increase adherence to professional guidelines. (Pediatr Dent 2013:35:546-9) Received
July 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, professional organizations of health care practitioners have developed
guidelines regarding the appropriate use of antibiotics. Although
dental practitioners may not treat patients with antibiotics as
frequently as physicians, dentists prescribe between seven percent
to 11 percent of all common antibiotics.' The American Dental
Association (ADA) and the American Academy of Pdiatrie
Dentistry (AAPD) have published guidelines for antibiotic use.-'
The AAPD describes clinical situations in which antibiotic use
is recommended, while the ADA recommends the overall conservative use of antibiotics to minimize the risk of developing
antibiotic resistance. These guidelines have been summarized in
previously published articles and are presented in Table 1.'''
Previous studies have sought to investigate the degree to
which dentists' prescribing patterns adhere to published guidelines.
Few studies, however, have investigated US dentists' practices
regarding antibiotic prescribing patterns.''" To the best of our
knowledge, only one study surveyed pdiatrie dentists in North
Carolina. That study provided preliminary data on one state's
reported adherence to professional guidelines for prescribing antibiotics and found that adherence was notably low, ranging from
10 percent to 42 percent.'*
The purposes of this study were to: (1) conduct a national
survey to assess the antibiotic prescribing practices of pdiatrie
dentists and compare these practices to American Academy of
Pdiatrie Dentistry guidelines; and (2) assess their knowledge
of antibiotic resistance and antibiotic stewardship programs.

Methods
A cross-sectional survey was developed. A literature review was
conducted and setved as a guide in survey development. To assess
the use of the newly developed survey in the target population
of pdiatrie dentists, the survey was emailed to a small number
of pdiatrie dentists for review. This pilot test rectified remaining
issues with the survey questions (eg, confusing wording, use of
jargon). Tlie survey was modified based on the recommendations
from the pilot test and finalized. The final survey was composed
of 19 questions, including: demographic information; antibiotic
use in various clinical situations; endocarditis prophylaxis; antibiotic resistance; and knowledge of antibiotic stewardship programs. Clinical situations were designed to reflect conditions
addressed in the AAPD guidelines for antibiotic use (Table 1).
This study, including the final survey instrument, was approved by the Institutional Review Board at Lutheran Medical
Center in Brooklyn, N.Y. An electronic version of the survey
was constructed using Survey Monkey (Survey Monkey Inc,
Palo Alto, Calif, USA) an internet online survey tool which was
emailed to current AAPD members. A reminder e-mail was sent
one month after the initial e-mail. Postgraduate students, retired
pdiatrie dentists, and general dentists who are AAPD members
were excluded, because we were only interested in practices among
current pdiatrie dentists. Data were downloaded into an excel
spreadsheet from Survey Monkey and descriptive statistics were
tabulated using SPSS 19.0 (SPSS Inc, Chicago, 111., USA).

Results
The survey was emailed to 4,636 pdiatrie dentists; 987 surveys
were completed (response rate=21 percent). Three surveys were
^Dr, Sivaraman is a pdiatrie dentist at Family Dental Center. Federally Qualified removed from analysis because respondents indicated that they
Health Center. Columbia. Mo. 'Dr, Hassan is an assistant professor. Department of were retired. Of the 984 surveys included in the analysis, the
Pdiatrie Dentistry. Tufts University. Boston. Mass,, and an associate director. Depart- majority were from respondents in private practice (N=822, 84
ment of Pdiatrie Dentistry. Holyoke Health Center. Holyoice, Mass,: and -'Ms, Pearsonpercent) who had been practicing pdiatrie dentistry for fewer
is a clinical research manager. Department of Clinical Research. Lutheran Medical than 10 years (N=426, 43 percent). Demographic information is
provided in Table 2. The majority of respondents reported that
Center. Brooklyn. N.T. USA,
scientifically published literature was their primary source for
Correspond with Dr, Sivaranmnat drsueii@gmoii.com.

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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 ulcrations.
Pulpitis/atypical periodontitis/draining sinus tract/localized intraoral swelling: If a child has acute symptoms of pulpitis and the infection is contained 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 on
clinical fmdings, treatment may consist of treating or extracting the tooth or teeth in question with antibiotic coverage ot prescribing antibiotics
fot 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 rsorption and increase rate of
pulpal revascularization; the need for systemic antibiotics with avulsed teeth is unclear.
Pdiatrie periodontal diseases: In pdiatrie periodontal diseases associated with systemic diseases such as neuttopenia, Papillon-LeFevre syndrome, and
leukocyte adhesion deficiency, antibiotic therapy is indicated.
* Adapted from: Cherry WR, Lee JY, Silugars DA, White RP, Vann WF. Antibiotic use for treating dentai infecons 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), followed by continuing education coutses (N=370, 38 petcent) and
the Intetnet (N=88, nine petcent).
When asked to indicate what othet sources of teliable infortnation on antibiotic use they tely on, 25 petcent of the 60 pediattic
dentists who answeted the question tepotted that they consult
guidelines of the AAPD ot othet ptofessional organizations.
Othet sources frequently reported were residency training and
other forms of education, the hospital formulary, and colleagues
(including other pdiatrie dentists, pediatricians, oral surgeons,
and pharmacists).
Amoxicillin was the most commonly prescribed antibiotic
(N=764, 78 percent), followed by penicillin ( N = 2 0 1 , 20 percent).

Less than one percent of the respondents indicated that clindamycin and augmentin wete the most commonly prescribed antibiotics in their practice. Nearly all of the respondents reported that
the most common toute of administration was oral (N=982, 100
percent); the remaining reported using intravenous administration.
When asked the average minimum number of days the pdiatrie
dentists 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) indicated

that they follow-up with caregivers at the next clinical visit to
ensure that the full course of the antibiotic was administered. Few
prescribed for a shortet duration of two to three days (N=26) or
a duration of more than 10 days (N=seven). The most common
determinant 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), and
parental satisfaction (N=34, fout percent).
The percentage of respondents that teported prescribing antibiotics for various pulpal and periapical conditions is listed in
Table 3. Two percent of respondents prescribed antibiotics for
teversible pulpitis. For clinical conditions of irreversible pulpitis with and without vital pulp, 32 petcent and 42 percent prescribed antibiotics, respectively. Sixty-eight percent of respondents
ptescribed antibiotics for local dentoalveolar abscess with gingival swelling, while 39 percent prescribed for teeth with local
dento-alveolar abscess with dtaining fistula. In the clinical
scenario of facial cellulitis with lymphadenopathy, 99 percent of
respondents prescribed antibiotics.
Respondents were also asked to indicate the conditions under
which they would give infective endocarditis ptophylaxis. The
most commonly reported conditions included cardiac transplantation after valvular damage (N=861 , 88 percent), unrepaired cyanotic
heart disease (N=796, 81 petcent), and ptevious infective endo-

Table 2i = RESPONDENTS' DEMOGRAPHIC INFORMATION AND

PRACTICE CHARACTERISTICS (N=984)
Variable

N (%)

Gender
Male
Female

535 (54)
449 (46)

Years practicing pdiatrie dentistry

<10
10-25
26-40

426 (43)
307(31)
251 (26)

Practice type
Private practice
Academic institution
Hospital dentistry
Community health center

822 (84)
65(7)
53(5)
44(5)

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)

119(12)

92(9)
195(20)
174(18)
185(19)
219(22)

carditis (N=793, 81 percent). A smaller percentage of tespondents

also indicated that they would ptescribe antibiotic prophylaxis for
conditions that do not warrant antibiotics according to the guidelines,'- including mitral valve ptolapse with rgurgitation (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 reimplantation cases after avulsion; this was followed by trauma with
soft tissue lacerations (N=369, 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 than
one percent of the tespondents indicated that they would prescribe 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)
N

23
318

2
32

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

416

42

Localized dentoalveolar ahscess: Affected tooth is associated with swollen gingiva, sensitive to percussion, mobile, persistent pain, no
swelling of the mucosa or the fascial spaces

671

68

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

380

39

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

971

99

Pulpal and periiadicular condition

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 radiographs
orfiarcationradiolucency

Ninety-eight percent (N=959) reported that they did not believe in tbe routine use of antibiotics during dental rehabilitation
to reduce the frequency of postoperative infections. Respondents
were also asked if they believed that antibiotic use prior to an
extraction of an abscessed tooth with a draining fistula provided
less discomfort to pdiatrie patients; 64 percent ( N = 6 3 1 ) did
not believe antibiotics would decrease discomfort.
Overall, evidence suggesting overprescribing (concerning
AAPD guidelines) was found for the following conditions: irreversible pulpitis witb (32 percent) and without vital pulp
(42 percent); localized dentoalveolar abscess with (68 percent)
and without draining fistula (39 percent); mitral valve prolapse
with rgurgitation (43 percent); intrusion (15 percent); extrusion
(13 percent); and rheumatoid arrhritis (12 percent). Although 98
percent of the respondents believed that antibiotic resistance is
of growing concern, only 15 percent were aware of antibiotic
stewardship initiatives.

Discussion
The results of this national survey of pdiatrie dentists on their
prescribing practices suggest common inappropriate use of antibiotics. Self-reported adherence to the AAPD guidelines for various
clinical situations was inconsistent. For example, self-reported
adherence to some of the AAPD guidelines was high, such as 95
percent prescribing for cases of reimplantation after avulsion and
for facial cellulitis (99 percent), and not prescribing antibiotics
to prevent postoperative infections (98 percent) and discomfort
during extraction (64 percent). A lower percentage of pdiatrie
dentists in our study, however, also reported that they would prescribe antibiotics in trauma situations for which they are not
recommended [eg, intrusion (15 percent), extrusion (13 percent),
lateral luxation (seven percent), and subluxation (four percent)].
Reported use of antibiotics also suggests a tendency to overprescribe in clinical conditions involving the pulp when antibiotic use is not recommended by the guidelines. In comparison
to reported use of antibiotics for these conditions among endodontists," respondents in our study were more likely to prescribe
antibiotics for conditions such as irreversible puplitis with vital
pulp (32 percent vs. 17 percent of endodontists) and irreversible
pulpitis with nonvital pulp (42 percent vs. 19 percent of endodontists). In addition, 68 percent of our respondents prescribed
antibiotics for local dentoalveolar abscess with gingival swelling
and 39 percent prescribed for teeth with localized dentoalveolar
abscess with draining fistula. Only 12 percent of endodontists
reported that they prescribe antibiotics for abscess with draining
fistula."

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The lower percentage of antibiotic use for these conditions

among endodontists, compared to the pdiatrie dentists in our
study, is likely attributable to increased training in the nature of
pulpal and periapical diseases. For example, pdiatrie dentists may
not be aware that pulpal circulation is compromised in irreversible
pulpitis with draining tracts, and localized swelling" makes it
unlikely to achieve therapeutic concentrations with systemic
antibiotics. Educational interventions on the benefits of pulpal
therapy vs. antibiotic therapy for these clinical situations would
likely increase adherence.
Consistent with otir findings regarding determinants of antibiotic use, four percent of endodontists prescribed antibiotics if a
weekend or holiday were approaching," compared to six percent
of the respondents in our study who indicated that they would
prescribe antibiotics when appointments were unavailable for
weeks. A smaller study of pdiatrie dentists in North Carolina
found that overall adherence to professional guidelines regarding
prescribing practices decreased when the patient called on a weekend with a dental emergency."^ Interestingly, four percent of the
pdiatrie dentists in our study reported parental demand as one
of the most common reasons to prescribe antibiotics. Preparing
pdiatrie dentists on how to educate parents on the risks and
benefits of antibiotic use will aid in the reduction of antibiotic
use solely for parental satisfaction." Although antibiotics are not
recommended for use as pain relief medication for inflammation," 15 percent of the respondents in our study reported that
they use antibiotics for this purpose.
The main limitation of our study and survey research in general that may influence our findings was that we did not monitor
actual prescribing patterns; thus, we cannot confirm that the
responses we received were accurate. Given that we found that
adherence was low, however, it is unlikely that the respondents
misreported their prescribing practices. We believe our study
population is representative of tbe national pdiatrie dentist
population, despite our relatively low response rate (21 percent),
because of our large sample size and similar geographic distribution to total AAPD membership. An e-mailed survey is the
most cost-effective and efficient way of surveying large numbers
of people who are geographically distant.
Despite these limitations, the lack of adherence to the antibiotic prescribing guidelines among pdiatrie dentists was
apparent and underscores the need for increased promotion of
antibiotic stewardship programs in this population. Although most
survey respondents indicated that they rely on scientific published
literature 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 resistance was of growing concern, but few had heard of antibiotic
stewardship. Various hospitals have adopted antibiotic stewardship
programs promoting adherence to published guidelines as well
as continuing education programs and antimicrobial order forms
to increase adherence.'^
Knowledge of the professional guidelines and awareness of
antibiotic stewardship programs could be a requirement for new
licensure and renewal to ensure widespread adoption. Antibiotic
stewardship programs that focus on collaborative care between
physicians and dentists, who may have different prescribing patterns,"" may also be beneficial to improve antibiotic prescribing
practices in dentistry. Increased awareness and knowledge of professional guidelines regarding antibiotic stewardship are needed to
promote the appropriate use of antibiotics in this population.

Conclusions
Based on this study's results, the following conclusions can be
made:
1. Pdiatrie dentists reported a low adherence to antibiotic
prescribing guidelines. The tendency is toward overtreatment.
2. Adherence to antibiotic prescribing guidelines among
pdiatrie dentists is adequate for conditions that warrant
antibiotic treatment, such as facial cellulitis, avulsion,
and infective endocarditis.
3. Pdiatrie dentists reported that their prescribing patterns
are influenced by parental request, pain, and unavailable
appointments.
4. Although most pdiatrie dentists believed that antibiotic
resistance is a growing problem, few were aware of antibiotic stewardship programs.

Acknowiedgments
The authors wish to thank Drs. Sarat Thikkurissy, DDS, MS,
director, residency program. Division of Pdiatrie Dentistry and
Orthodontics, Gincinnati Children's Hospital, Ohio, and Kavitha
Viswanathan, BDS, PhD, assistant professor. Department of
Pdiatrie Dentistry, Baylor College of Dentistry, The Texas A&M
University, Dallas, Texas, who served as content experts in the
field and helped guide the research process, and Dr. Silvia Perez,
who passed away on November, 13, 2011. She was the program
director of Pdiatrie Dental Medicine at Lutheran Medical Center,
in Brooklyn, N.Y., from 1990-2011, who served as the inspiration
to examine antibiotic stewardship in pdiatrie dentistry and whose
mentoring and guidance was appreciated.

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