3. Discussions
Since their discovery, antibiotics have permitted to treat a wide variety of infections, even deadly ones. However, their correct and responsible use is essential in order to prevent the manifestation of drug-related adverse reactions and to reduce the risk of developing bacterial resistance to the currently available antibiotics. The aim of this study was to investigate Italian dentists’ knowledge and practices of antibiotic use in pediatric patients using a specific questionnaire. In this article, the authors discuss the findings relating to the use of antibiotics for the complementary treatment of dental or oral cavity infections in pediatric dentistry.
In the total sample of 242 Italian dentists, a mean good preparation emerged regarding the clinical situations in which the prescription of antibiotics is indicated or not, as they answered correctly for more than 80% of the questions. According to the current pediatric dentistry available Guidelines of the AAPD [
14] and EAPD [
15], there are not many oral clinical conditions in which the prescription of antibiotics is really indicated in pediatric dentistry. They can be cited: acute infection, with modest swelling, rapid progression, diffuse cellulitis with moderate-to-severe pain, or with fever (in addition to the treatment of the offending tooth); infection progressed to extraoral fascial spaces; trauma, with significant soft-tissue or dentoalveolar injuries that appear contaminated by debris, extrinsic bacteria or foreign bodies; replantation of avulsed permanent tooth; osteomyelitis; and acute salivary gland swelling of bacterial nature.
It should be noted that to the question relating to “Well-localized vestibular abscess, with little or no facial swelling”, only approximately 50% of dentists answered correctly, and the majority were specialists in pediatric dentistry. According to the mentioned above Guidelines, antibiotic prescription is not indicated in this clinical situation. In fact, endodontic therapy or, if necessary, the extraction of the element responsible for the abscess is often sufficient to resolve the condition in healthy pediatric patients without the need for a complementary antibiotic treatment. However, the prescription of the antibiotic would be indicated (always in addition to dental therapy) if the infection of dental origin shows a tendency toward rapid progression, the manifestation of systemic signs (such as fever), and diffuse cellulitis and/or progression to the extraoral fascial spaces.
In the case of permanent tooth avulsion and subsequent replantation, too, the question in which specialists in pediatric dentistry and dentists who mainly treat children/teenagers in their clinical practice showed a statistically significant greater preparation, the prescription of antibiotic therapy appears indicated. Following a trauma, the periodontal ligament of the avulsed tooth can be contaminated by bacteria present in the oral cavity, in the conservation medium or in the environment in which the avulsion occurred. Therefore, in order to prevent any reactions related to infection and to reduce the risk of inflammatory root resorption, the AAPD and EAPD Guidelines and the Guidelines for the management of dental trauma of the International Association of Dental Traumatology (IADT) [
16] recommend the prescription of antibiotic to the patient following reimplantation of the avulsed element, although the role of systemic administration still remains questionable.
According to the Guidelines, in the presence of a pulpal or periapical tissue infection, without clinical signs of systemic infection, in a non-medically compromised patient, the prescription of antibiotics is not indicated. In fact, in case of infection involving the pulpal tissue of the tooth or the tissue immediately surrounding it (i.e., the periapical tissue), systemic antibiotic therapy would not be effective in the resolution of the infection. The indicated treatment is endodontic therapy or the extraction of the involved tooth; a complementary antibiotic therapy would be indicated in the presence of concomitant systemic signs of infection or in immunocompromised patients. For the question relating to this clinical situation, dentists who practice the profession only in the private sector showed a statistically significant higher rate of correctness of the response compared with other sectors of dental profession practice.
As regards to the choice of the most indicated type antibiotic and its relative posology for the complementary pharmacological therapy in pediatric patients suffering from dental or oral cavity infection, the authors of the present study considered a reference the AWaRe Antibiotics Manual [
3] (i.e., the Italian translation of the English version of the WHO AWaRe Antibiotic Book of the World Health Organization) published by AIFA, the national authority competent for the regulatory activity of medicines in Italy. According to the Manual, the antibiotic of first choice for the patient with no allergy to penicillin is Amoxicillin, to be assumed orally with a maximum pediatric daily dose of 80–90 mg/kg (to be divided into two equal daily doses, one every 12 h). The Manual indicated the Phenoxymethylpenicillin (or PcV), too; it must be assumed orally with a maximum dosage of 10–15 mg/kg/dose (one every 6–8 h). However, this drug is less used in dentistry in comparison to Amoxicillin. The duration of the antibiotic therapy should be 3 or 5 days, depending on whether the source of the infection has been respectively controlled or not; the patient must be re-evaluated by the dentist before deciding to end the therapy.
Almost all the dentist’s participants of this study correctly indicated Amoxicillin as the first-choice antibiotic in case of dental or oral cavity infection. Nevertheless, most of the total sample would prescribe it with a maximum daily dosage lower than that indicated by AIFA and for an average duration of 6 days. This duration of therapy could be explained by the common and well-known practice among doctors and dentists of prescribing the patient the antibiotic until the end of its packaging (in the case of a tablet formulation); since the package generally contains 12 tablets and the dosage is two tablets per day (one every 12 h), the result is a treatment of 6 days’ duration. The general dentist appeared to be the one who would mostly prescribe antibiotic therapy for less than 6 days compared with the specialist, even though more than 80% of the sample divided based on an academic level, which indicated treatment of 6 days.
True allergy to penicillin, i.e., the immune-mediated allergic reaction (manifested, for example, with anaphylactic shock), is really rare and often self-reported by the patient but not supported by specific diagnostic confirmation tests. According to AIFA’s Manual, in case of true allergy to aminopenicillins (like Amoxicillin or Ampicillin), there is a risk of cross-reaction toward other beta-lactam antibiotics with closely related chemical structures, such as aminocephalosporins (for example, Cephalexin), even if the percentage of allergic patients who can develop allergic reactions if exposed to different beta-lactams is <2% with cephalosporins, <1% with carbapenems and 0% for monobactams. However, in case of severe real allergy to penicillin, an alternative pharmacological option is Macrolides, such as Claritromicin. This antibiotic can be assumed orally, with maximum pediatric daily dosage of 15 mg/kg and a therapy’s duration equal to that of Amoxicillin.
In the present study, most of the total sample indicated Macrolide as the antibiotic of first choice in pediatric patients with an allergy to penicillin suffering from dental or oral cavity infection, while 21% would prescribe Clindamycin. Most of the total sample would prescribe the antibiotic therapy with the incorrect dosage (lower or higher) for 6 days. It must be mentioned that according to the most recent Guidelines of AAPD and AHA [
4,
5,
7,
17], Clindamycin has been associated with significant and frequent adverse reactions related to community-acquired Clostridium difficile infections, with possible and even serious complications, including sepsis and death. For this reason, the use of this antibiotic is no longer recommended. In this study, despite the higher general preference for Macrolide, dentists who practice the profession only in the public sector or both in the public and private sector showed a statistically significant greater tendency to choose Clindamycin for allergic patients in comparison with those who practice exclusively in the private sector.
In the literature, similar studies [
2,
8,
18] in pediatric population have been conducted in different countries around the world by different researchers who used specific questionnaires. Levels of adherence to the Guidelines by dentists dealing with pediatric dentistry have been reported variable from 10 to 56%, with rates on average lower among generic dentists if compared to specialists in pediatric dentistry. In general, the reported trend is that of an inappropriate, unjustified, and excessive prescription of antibiotics. In Italy, no other study like this appears to have been conducted in pediatric dentistry. However, similar studies [
7,
9,
10,
11,
19,
20,
21,
22] have been conducted in the adult population; their results revealed a tendency for excessive and improper use of systemic antibiotics among the interviewed Italian dentists. In fact, it has been reported that many dentists prescribed systemic antibiotics, both for prophylactic and therapeutic purposes, even in clinical situations not recommended by the Guidelines, resulting in over-prescribing. Thus, for both pediatric and adult patients, greater knowledge of the most up-to-date Guidelines between dentists appears necessary.
In the present study, an average good preparation of the total sample emerged in relation to the indications for antibiotic prescription in the pediatric population in case of dental or oral cavity infection, although the authors expected higher levels of preparation, in particular among dentists who are specialists in pediatric dentistry and who mainly treat children/adolescents in their professional activity, given the availability of Guidelines and manuals on this topic. Therefore, a greater knowledge of the Guidelines appears necessary, especially regarding the choice of the type of antibiotic and its posology. This is important for preventing the excessive or inappropriate use of antibiotics and, on a larger scale, to reduce the risk of developing drug-related adverse reactions and bacterial resistance to available antibiotics. Furthermore, more information is needed regarding the adverse effects of Clindamycin, due to which it is no longer recommended by the most recent Guidelines, as a considerable number of Italian dentists would still prescribe this type of antibiotic in pediatric patients with true allergy to penicillin.
The hope of the authors is to have contributed, thanks to the informative material provided to the participants at the end of the compilation of the questionnaire, to diffuse basic knowledge on the correct prescription of antibiotics in pediatric dentistry and to provide the sources through which the dentists will be able to independently inform and stay updated themselves in the future, so that the use of these drugs can become more aware and correct, and unnecessary prescriptions can be drastically reduced.
It should be specified that the sample of specialists in Pediatric Dentistry who participated in the study was limited: only approximately 10% of the total. This limited number can be considered indicative of specialists in this branch currently present in Italy, as the activation of the schools of specialization in pediatric dentistry in Italy is recent and available in fewer than 20 Italian universities. The expectation is that, in Italian specialization schools, importance will be given to the antibiotic therapy in pediatric dentistry by adequately training the residents on the correct prescription of antibiotics. Possible limitations of this study can be represented by the choice to use a convenience sample, the lack of an initial sample size calculation, and the limited number of specialists in pediatric dentistry in the sample.
In addition, a further possible limitation of the study could be the fact that the questionnaire submitted may have appeared excessively long and/or complex, discouraging some participants from continuing until completion and, consequently, the generation of dropouts. This could have negatively influenced the response rate obtained (i.e., 34,6%), which, for the authors, appeared lower than expected: given the response rates reported in similar studies conducted in Italy available in the literature [
7,
9,
10], the expectation was to reach around 50% of responses. However, on the contrary, some participants may have been encouraged to complete the questionnaire with the promise of receiving the final informative material.
It has to be clarified that in the questions where the indication of a duration of prescription of antibiotic therapy was requested, the answer “<6” was considered right; since this value includes all those between 5 and 1, this could appear misleading in the interpretation of data. Although the authors believe that this can have a limited impact on the statistical results of the survey, they consider it correct and transparent to report this clarification as a possible limitation of the present study.
Since the design of this questionnaire-based study could be considered a pre-test one, given the consequent lack of data resulting from a post-test repeated after providing the participants the informative material on antibiotic therapy in pediatric dentistry, the starting point for a future continuation of the study could be represented by the resubmission of the same questionnaire as a post-test to the same cohort of participants, to verify the effectiveness of the informative material provided in terms of professional updating and the propensity for learning of dentists.
Other possible ideas for future research are represented by the repetition of the study when the cohort of specialists in pediatric dentistry will be increased in Italy and by the diffusion of the questionnaire on a larger scale, for example through multicentric studies, conducted in collaboration between various Italian universities.