Original Research

Knowledge of Antibiotics among Dentists in Saudi Arabia

Noriya Mohammed Al Khuzaei, Mansour K Assery1, Tahani Al Rahbeni2, Mohammed Al Mansoori3
Departments of Pharmacy and 3Dental, Rumailah Hospital, Hamad Medical Corporation, Doha, Qatar, 1Dean for Post Graduates and Scientific Research,
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2
Vice Dean of Pharmacy, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia

Abstract
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Aims and Objectives: The aim of this study is to assess the pattern and knowledge of the use of antibiotics by dentists in Saudi
Arabia. Furthermore, over the last decades, antibiotic resistance has become a global problem which can affect morbidity and mortality.
Materials and Methods: A simple questionnaire was distributed to dental practitioners over Saudi Arabia between August and October
2015. It included questions about sociodemographic characteristics, professional profile, and antibiotic prescription in dental practice. A total
of 228 dentists responded to this questionnaire, and the responses (86%) showed medium level of knowledge. The data were analyzed using
Statistical Package for Social Science version 22. Results: The majority (92.5%) of respondents used penicillin as the first line in case of local
infection. About 65.4% believed that completion of the antibiotics course is necessary for its effectiveness in some cases only. In addition, for
patients allergic to penicillin, azithromycin was the most common antibiotic prescribed by respondents (63.2%); furthermore, the antibiotic
preferred for acute periapical infections; the results showed the high percentage choose amoxicillin (77.2%), and for acute ulcerative gingivitis,
the respondents prescribed metronidazole (44.7%). In addition, 44.7% of respondent’s chose amoxicillin as preferred therapy for cellulitis.
Furthermore, there was no statistically significant difference in the knowledge level by gender (P = 0.240). Furthermore, the level of knowledge
among dentists regarding the antibiotics and place of the study showed no statistically significant relationship between government and
private dental schools (P = 0.740). Furthermore, there was no statistically significant difference in the level of knowledge amid respondents
who had attending antibiotic courses undergraduate and postgraduate (P = 0.325). Conclusion: Based on our findings, it was concluded that
most dentists had medium knowledge in prescribing antibiotic therapy for dental infection. This study confirmed the need to further extend
education of dental doctors is an important part for patient and society awareness, which will lead to a reduction in antibiotic resistance, and
enhancement of the level of the dental care services by delivering high standard quality, effective and efficient health care.

Keywords: Antibiotics, dental practice, knowledge, penicillin

Introduction of their genes when they are exposed to an antimicrobial.

Antibiotic resistance is global problem which can affect
“Antibiotic” is a Greek word, anti (“against”) and bios
morbidity and mortality. Its consequence increases health
(“life”).[1]
cost and adverse effect.[3] In the United Kingdom, 9%–10%
Antibiotics are chemical structures that arise from special antibiotic prescriptions are in primary care.[4] In addition,
microorganisms which are formed using a fermentation empirical broad‑spectrum antibiotic therapy used by a
process.[2] In the 20th century, the standard of antibiotic action dentist can predispose to selection of resistance species,[5]
was discovered. In 1929, Alexander Fleming discovered and antibiotic resistance is rising more from odontogenic
penicillin, the first chemical compound with antibiotic infection.[6]
characteristics. On the other hand, Howard Florey (1898–1968)
The Food and Drug Administration (FDA) in America
and Ernst Chain (1906–1979) developed a form of penicillin
classifies medications into five different pregnancy
that could be used to fight bacterial infections in humans.[2]
All the antibiotics used in dental practice are listed in Table 1. Address for correspondence: Dr. Mansour K Assery,
Dean for Post Graduates and Scientific Research, Riyadh Colleges of
Some bacteria are naturally resistant to some antibiotics, Dentistry and Pharmacy, Riyadh, Saudi Arabia.
for example, penicillin not effective against Gram‑negative E‑mail: [email protected]
bacteria; others can acquire resistance by mutation in some
This is an open access article distributed under the terms of the Creative Commons
Access this article online Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak,
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DOI: How to cite this article: Al Khuzaei NM, Assery MK, Al Rahbeni T, Al
10.4103/0976-7428.203634 Mansoori M. Knowledge of antibiotics among dentists in Saudi Arabia.
J Int Oral Health 2017;9:71-80.

© 2017 Journal of International Oral Health | Published by Wolters Kluwer - Medknow 71

 Al Khuzaei, et al.: Knowledge of antibiotics

risk categories [Table 2]. Drugs are set in different risk more protein bound (a drug are less likely to cross the
categories depend on available studies in humans and placenta).[7,8]
animals. There are four characteristics to evaluate in
Penicillins and cephalosporins are safe to use throughout
drug selection; these characteristics are based on the high
pregnancy; tetracyclines should not be used in pregnancy, which
molecular weight, unionized and highly lipophilic; the
will affect the bone and teeth in the fetus. The erythromycin ‑ not
known to be harmful and metronidazole ‑ manufacturer advises
avoidance of high‑dose regimens (Empirical Antimicrobial
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Table 1: Antibiotics useful in dental practice

Guidelines for Forth Valley Hospitals 2013–2015).[9] Penicillins
Antibiotic used Cidal/static Important characteristic
and cephalosporins are the drugs of choice in breastfeeding.
Amoxicillin Cidal Good oral tolerance
Less frequent dosing One study in exploring health professionals’ experiences of
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Still respond to a lot of odontogenic medication error in the Kingdom of Saudi Arabia found that
infection
68.6% of errors were related to medication error.[10]
Less toxicity
Amoxicillin + Cidal Like amoxicillin plus beta‑lactamase There are no specific dental guidelines for the treatment of
clavulanate resistance infections, and every association and ministry of health have
Cephalosporins Cidal Active against Gram‑positive their own guidelines and nothing is international standard.
cocci, Gram‑negative bacteria and
penicillinase producing staphylococci
Furthermore, there is no clear published guideline available
Beneficial in some case of penicillin in saudi arabia. So it is mandatory to publish one [Table 3].
allergy
A graduate dentist acquires solid foundation in the principle
Metronidazole Cidal More activity against negative
anaerobes and less activity against
therapeutic and up‑to‑date knowledge. Little information
Gram‑positive anaerobes and aerobic is available on knowledge and understanding of antibiotic
cocci prescribing patterns in dentists in Saudi Arabia; hence, the aim of
Useful in ANUG the study is to assess the knowledge of antibiotic among dentists.
Should be taken with other antibiotic
that cover Gram‑positive aerobic
Clindamycin Static Appropriate for penicillin‑allergic Materials and Methods
patients A cross‑sectional prospective survey in Saudi Arabia was
Great active against gram position
conducted among dentists in Riyadh College of Dentistry and
anaerobe
Tetracyclines Static It cover wide range spectrum
Pharmacy and members of Saudi Dental Society at Riyadh
High tissue penetration College of Dentistry and Pharmacy website from August to
Not recommended for children and October 2015 in the Kingdom of Saudi Arabia. The Ethics
pregnant Committee in Riyadh Colleges of Dentistry and Pharmacy
Macrolides Static More activity against Gram‑negative approved the protocol for this study of knowledge of antibiotics
Increase resistance with new drug among dentists on April 9, 2015; Registration Number:
better use other
FPGRP/43439003/109 on April 9, 2015.
ANUG: Acute necrotizing ulcerative gingivitis
The questionnaire required consent to participate in the
study. Confidentiality and anonymity were confirmed so that
Table 2: United States Food and Drug Administration responses cannot be linked to individual participants.
(pregnancy risk categories)
The questionnaire was developed after reviewing several
Category Definition of previous relevant literature[11‑14] using Google forms. The
A Controlled studies in women fail to demonstrate a risk to questionnaire included 25 questions and was divided into
the fetus in the first trimester, and the possibility of fetal
sections by demographic data which included, age, gender,
harm appears remote
B Either animal studies do not indicate a risk to the fetus
qualification, specialization, years of experience, place of
and there are no controlled studies in pregnant women, studying dentistry, university from which the dental degree
or animal studies have indicated fetal risk, but controlled was acquired, any antibiotic course attended, and current
studies in pregnant women failed to demonstrate a risk occupation. Another part is to measure the aim to identify the
C Either animal studies indicate a fetal risk and there are level of knowledge of dentists about antibiotics. It consists of
no controlled studies in women, or there are no available
studies in women or animals 17 questions; respondent takes one degree in the case of correct
D There is positive evidence of fetal risk, but there may answer and takes zero in the case of wrong answer [Table 4]
be certain situations where the benefit might outweigh represents the level of knowledge and degree.
the risk (life‑threatening or serious diseases where other
drugs are ineffective or carry a greater risk) It was posted online on August 30, 2015, through Riyadh
X There is definite fetal risk based on studies in animals College of Dentistry and Pharmacy website and was briefly
or humans or based on human experience, and the risk explained, and enquiry was answered. The invitation letter
clearly outweighs any benefit in pregnant women and questionnaire were provided in the English language to all

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 Al Khuzaei, et al.: Knowledge of antibiotics

Table 3: Different dental guidelines

Diseases Treatment References
Dental infections First line, amoxicillin Cambridgeshire and Peterborough Clinical
Mild empirical (streptococci, anaerobic streps, In penicillin allergy: Clarithromycin Commissioning Group Antimicrobial
Bacteroides spp (but rarely penicillin resistant) Second line, metronidazole Treatment Guidelines Primary Care June
Moderate/severe/recurrent (organisms as above but 2015
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note possibility of penicillin‑resistance)

If severe/spreading (e.g. lymph node involvement or
systemic symptoms) Consider adding metronidazole
Mild infection Amoxicillin‑clavulanate 875 mg orally every Complications, diagnosis, and treatment of
without comorbidities or signs of sepsis, with 12 hours odontogenic infections (UpToDate) 2015
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normal renal function In penicillin allergy:

Clindamycin
If local measures such as drainage have proved Frist line, amoxicillin or Drug Prescribing For Dentistry Dental
ineffective, spreading infection or systemic Phenoxymethylpenicillin Clinical Guidance August 2014
involvement In penicillin allergy:
Metronidazole or erythromycin
Second line, clindamycin,
amoxicillin‑clavulanate, clarithromycin
Acute necrotising ulcerative gingivitis A‑First choice, metronidazole alternative Drug Prescribing For Dentistry Dental
amoxicillin Clinical Guidance August 2014
B‑ Metronidazole or amoxicillin‑clavulanate or Complications, diagnosis, and treatment of
ampicillin‑ sulbactam or clindamycin odontogenic infections (UpToDate) 2015
C‑First choice, metronidazole alternative British National Formulary 2014
amoxicillin
Acute periapical Amoxicillin British National Formulary 2014
Alternative metronidazole
Cellulitis A‑Amoxicillin‑clavulanate Cambridgeshire and Peterborough Clinical
In penicillin allergy: Clarithromycin Commissioning Group Antimicrobial
B‑ First line, amoxicillin or Treatment Guidelines Primary Care June
phenoxymethylpenicillin 2015
In penicillin allergy Drug Prescribing For Dentistry Dental
Clinical Guidance August 2014
Metronidazole or erythromycin
Second line, amoxicillin‑clavulanate,
clindamycin, clarithromycin

statistical models and analyses were used based on the type of

Table 4: Levels of knowledge
data from question. Descriptive analysis was used to present
Knowledge level Degree an overview of findings from this population, and Chi‑square
Low 1‑6 test was used to test difference between groups. The level of
Medium 6‑12 significance was set at P ≤ 0.05.
Excellent 12‑17

Results
dental practitioners and dentists at Riyadh College of Dentistry
This study sought to identify the knowledge of antibiotics
and Pharmacy [Appendix 1]. On the 5th week, a final reminder
among dentists in Saudi Arabia. A total 228 dental practitioners
was sent to participants and the participants were thanked for
responded to this survey.
their assistance.
Table 5 shows the distribution of the study sample according to
Inclusion criteria
age; the results reflect that the highest proportion of the study
• Dentists in their internship year
sample was at the age range of 21–30 (36.4%) years, compared
• Postgraduate dentists
to 29.8% of the study sample aged between 31 and 35 years,
• Practicing dentists.
and the study sample individuals who were between the ages
Exclusion criteria of 36 and 40 years accounted for a percentage of 18.0%, while
• Any person outside the dental practice a proportion (14.9%) were aged above 45 years.
• Dental students.
Furthermore, the results showed that most of the study samples
Data analysis were males at a rate of 67.5%, while female rate was 31.6%.
The data were analyzed using Statistical Package for Social In addition, the results showed that most of the dentists
Science (IBM SPSS version 22, USA). The appropriate were government dental school graduates at a rate of 66.2%,

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 Al Khuzaei, et al.: Knowledge of antibiotics

compared to 32.9% of the study sample was private dental

Table 5: Demographic profile of the sample popoulation
school graduates. According to Table 5, the Kingdom of Saudi
Arabia has the highest rate in locations where the dental degree Demographic characteristics Frequency (%)
was obtained at a rate of 77.2%, while Arab country graduates Gender
at rate of 14.5%, compared to Europe at a rate of 3.1%, Female 72 (31.6)
followed by North America graduates at a rate of 2.6%, and Male 154 (67.5)
the least percentage (1.8%) for the Indian subcontinent. Table 5 Age
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also shows the distribution of the study sample according 21‑30 83 (36.4)
to years of experience. The results reflected that the highest 31‑35 68 (29.8)
36‑40 41 (18)
percentage of the study sample for the years of experience
>45 34 (14.9)
was <10 years at a rate of 62.7%, followed by experience of
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Location of acquiring dental degree

10–20 years at a rate of 17.5%, and the least percentage for
Government dental school 151 (66.2)
the years of experience was 20–30 years at a rate of 7.9%.
Private dental school 75 (32.9)
The results also showed that the highest percentage of dentists International location of acquiring dental degree
who acquired their drug knowledge was for both “before Arab country 33 (14.5)
and after graduation courses” at a rate of 43.9% and 43%, Europe 7 (3.1)
respectively, and the least percentage was for after graduated at KSA 176 (77.2)
a rate of 9.2%. The majority of the participants were graduate North America 6 (2.6)
dentists at a rate of 96%, followed by interns at a 0.9%. The Indian subcontinent 4 (1.8)
Years since graduation
Table 6 shows the distribution of the study sample according to <10 143 (62.7)
the specialization. It was evident from the results that the highest 10‑20 40 (17.5)
percentage of the study sample was prosthodontics at a rate of 20‑30 18 (7.9)
27.2%, followed by endodontics and conservative dentistry at Pharmacology courses taken
a rate of 25.4%, as a percentage of periodontics (12.7%) with After graduated 21 (9.2)
equal percentage for pediatric dentistry, orthodontics and During under graduation 98 (43.0)
dentofacial orthopedics, and oral and maxillofacial surgery Both 100 (43.9)
reached 8.3%, and the least percentage was for dental public Current degree
health at a rate of 3.9%. Graduate 219 (96.1)
Intern 2 (3.1)
Table 7 demonstrates what type of drug dentist prefer to n=Total number of sample: 228
prescribe in localized infection or to those patients who are non
allergic to penicillin, penicillin in 92.5 % while 2.2% chose
metronidazole. Azithromycin and cephalexin were the drugs Table 6: The distribution of the study sample according
of choice for 1.3% of sample. to area of specialization
Area of specialization Frequency (%)
Table 8 shows that with the case of localized infection and
Dental public health 9 (3.9)
patient is allergic to penicillin, the majority of study sample
Endodontics and conservative dentistry 58 (25.4)
chose doxycycline at a dose 100 mg every 12 h (80.7%),
Oral and maxillofacial surgery 19 (8.3)
followed by amoxicillin/clavulanate 875 mg every 12 h at rate
Oral and maxillofacial radiology 1 (0.4)
of 7.9% and amoxicillin 875 mg every 12 h (7%).
Orthodontics and dentofacial orthopedics 19 (8.3)
Table 9 shows that the highest percentage of the doctors Pediatric dentistry 19 (8.3)
considered that amoxicillin/clavulanate 875 mg every 12 h at a Periodontics 29 (12.7)
rate of 77.6% is the drug of choice in the treatment of spreading Prosthodontics 62 (27.2)
infection in a nonallergic patient, while amoxicillin 875 mg No answer 12 (5.3)
every 12 h has a rate of 14.5%, and the least percentage for Total 228 (100.0)
doxycycline 100 mg every 12 h at a rate of 4.8%.
1 tablet every day for 3 days, and the least percentage estimate
Figure 1 shows that most dentists in case of penicillin allergy
that 1 tablet every day for 7 days at a rate of 17.5%.
of the study sample considered that azithromycin is most
suitable in case of spreading infection by rate of 63.2%, while Table 11 shows that the majority percentage of the doctors chose
25.4% consider that doxycycline is most suitable, and the least clindamycin at a rate of76.3%, followed by metronidazole at
percentage is for amoxicillin/clavulanate at a rate of 8.3%. a rate of 14.9%, while the least percentage for amoxicillin/
clavulanate at a rate of 5.3% in the case of a patient with
Table 10 shows that the highest percentage of the study sample
spreading oral infection and cannot tolerate penicillin.
reported that the requirement for azithromycin 250 mg to improve
the patient compliance is 2 tablets for the 1st day and then once Figure 2 shows that the distribution of the study sample
daily for 5 days at a rate of 46.5%, while 32.5% consider that according to the source of information during prescription.

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 Al Khuzaei, et al.: Knowledge of antibiotics

The results reflect that the highest percentage of the dentists Figure 3 shows that the majority of the respondents chose
go for textbooks and guidelines for information at a rate of amoxicillin at a rate of 77.2%, while penicillin V at a rate of
50.9%, while relay on their background knowledge from 12.7%, and the least percentage for tetracycline at a rate of
pharmacology course at a rate of 42.5%, and the least 5.7% to treat acute periodical.
percentage go for colleague for information at a rate of Table 13 shows that the highest percentage of the respondents
3.1%. chose metronidazole at a rate of 44.7%, while tetracycline at
a rate of 35.1%, and the least percentage for amoxicillin at
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Table 12 shows that most of the dentists decided that no

prophylactic therapy is needed in case of stable angina at a a rate of 15.8% for the management of ulcerative gingivitis.
rate of 78.5%, followed by congenital heart disease at a rate Figure 4 shows the distribution of the dentists according to
of 11.4%, prosthetic cardiac valve at the rate of 4.8%, and the which antibiotics preferred for cellulites. The results reflect
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least percentage for cardiac transplant at a rate of 1.3%. that most of the dentists chose amoxicillin at a rate of 44.7%,
followed by penicillin V at a rate of 32.5%, and the least
percentage for penicillin at a rate of 19.3%.
Table 7: In case of localized infection and penicillin
nonallergic patient, what antibiotic will be the first line to Table 14 shows that the percentage of the dental practitioners
begin asking the patient about allergic or any disease history before
prescription at a rate of 95.2%, while not asking the patient
Antibiotic Frequency (%)
about having allergy or any related disease before prescription
Penicillin 211 (92.5)
came back at a rate of 1.3%.
Metronidazole 5 (2.2)
Azithromycin 3 (1.3) Figure 5 shows that the highest percentage of the dentist
Cephalexin 3 (1.3) did not prescribe antibiotics before considering surgical
No answer 6 (2.6)
Total 228 (100.0)

Table 8: The first‑line antibiotic selection for localized

infection in penicillin‑allergic patients
In case of localized infection (e.g., progressive Frequency (%)
dental caries and periodontal disease)
Doxycycline 100 mg bid 184 (80.7)
Amoxicillin/clavulanate 875 mg bid 18 (7.9)
Amoxicillin 875 mg bid 16 (7.0)
No answer 10 (4.4)
Total 228 (100.0) Figure 1: Antibiotic selection in case of spreading infection in
penicillin‑allergic patients

Table 9: The first line antibiotic selection for spreading

infection in penicillin nonallergic patient
In case of spreading infection Frequency (%)
Amoxicillin/clavulanate 875 mg bid 33 (77.6)
Amoxicillin 875 mg bid 177 (14.5)
Doxycycline 100 mg bid 11 (4.8)
No answer 7 (3.1)
Total 228 (100.0)
Figure 2: The distribution of the doctors according to their source of
information during prescription
Table 10: Dosing for azithromycin to improve the patient
compliance
Dosage requirement Frequency (%)
Two tablets (250 mg) for the 1st day then 106 (46.5)
once daily for 5 days
One tablet (250 mg) every day for 7 days 40 (17.5)
One tablet (250 mg) every day for 3 days 74 (32.5)
No answer 8 (3.5)
Total 228 (100.0) Figure 3: Responses to acute periapical infection

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 Al Khuzaei, et al.: Knowledge of antibiotics
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Figure 4: Antibiotic of choice for treating cellulitis Figure 5: Prescription of preoperative prophylactic antibiotic

Table 11: The alternative antibiotics prescribed by dentist Discussion

in case the patient with spreading oral infection who Prescribing medicine is a challenging skill that requires a
cannot tolerate penicillin‑related to the side effects physician to understand the principle of clinical pharmacology
In case the patient with spreading oral infection Frequency (%) to make the clinical decision to prescribe drug safely and
Clindamycin 174 (76.3)
effectively.[15,16] Antibiotics are common drugs used by the
Metronidazole 34 (14.9) dental practitioners to treat infections that affect orofacial
Amoxicillin/clavulanate 12 (5.3) region. Nevertheless, there is an increased evidence in the
No answer 8 (3.5) dental literature regarding their inappropriate or sometimes
Total 228 (100.0) unnecessary use of these medications that may lead to
antibiotic resistance, adverse body reactions, and an increase
in health‑care cost.[14,17]
Table 12: Dentists response to in which cardiac case, the
The objective of this study was to investigate the knowledge of
patient will not need prophylaxis with antibiotics
antibiotics among dentists in the Kingdom of Saudi Arabia. In
In which cardiac case, the patient will Frequency (%) this study, the majority (92.5%) of respondents used penicillin
not need prophylaxis with antibiotics as the first line in case of local infection. Although penicillins
Stable angina 179 (78.5) have a narrow antibiotic spectrum, it covers most bacteria
Congenital heart disease 26 (11.4) involved in oral infections.[18] For patients allergic to penicillin,
Prosthetic cardiac valve 11 (4.8) azithromycin was the most common (63.2%) antibiotic
Cardiac transplant 3 (1.3) prescribed by respondents, followed by doxycycline (25.4%)
No answer 9 (3.9) and amoxicillin/clavulanate potassium (8.3%). This finding
Total 228 (100.0)
is consistent with the earlier findings of Abdulkader et al.[13]
and Vessal et al.,[12] who found that erythromycin was the
most common antibiotic prescribed by 21.2% and 70% of the
Table 13: Antibiotic preferred by dentists for acute
practitioners in Malaysia and Iran, respectively. On the other
ulcerative gingivitis
hand, Mainjot et al.[19] found that macrolides were the most
Which antibiotic preferred for Frequency (%) commonly (57.1%) prescribed antibiotics in Belgium, followed
acute ulcerative gingivitis by clindamycin (16.3%). Erythromycin is a bacteriostatic
Metronidazole 102 (44.7) antibiotic that is weakly active for most infection and
Tetracycline 80 (35.1) resistance may occur during the courses.[20] Furthermore, it
Amoxicillin 36 (15.8) has an increased resistance with new macrolides.[21] Therefore,
No answer 10 (4.4) in penicillin‑allergic patients, it is recommended to use
Total 228 (100.0)
clindamycin which is highly effective against Gram‑positive,
anaerobic, and some Gram‑negative bacteria.[22] Erythromycin
procedure at a rate of 55.3%, while 40.8% from the study and tetracycline are not recommended due to the increasing
sample prescribe antibiotics before considering surgical resistance developed by some strains of streptococci and their
procedure. deficiency of optimal anaerobic coverage.[23,24]
Table 15 shows the relationship between the level of knowledge Antibiotics should continue until the local inflammation is
for dentists about antibiotics and place acquiring their dental cured completely which typically occurs after 7–14 days
degree; there is no statistically significant association between depending on the severity of infection. Noncompliance with
the level of knowledge and location of acquiring the dental antibiotics treatment would lead to treatment failure, and
degree (P ≤ 0.05). the prolongation of treatment will cause adverse effects or

76 Journal of International Oral Health ¦ Volume 9 ¦ Issue 2 ¦ March‑April 2017

 Al Khuzaei, et al.: Knowledge of antibiotics

In this study, the vast majority (86%) of the self‑administered

Table 14: The dentist ask the patient about any allergic
questionnaire by dentists had a medium level of knowledge
or any disease history before prescription
in prescribing antibiotics. Al‑Huwayrini et al.[32] showed by
Do you usually ask the patient about having Frequency (%) self‑survey that 70% of dentists working in private clinics in
allergy or any related disease before prescription Riyadh area had a good information level about prescribing
Yes 217 (95.2) antibiotics, while Baadani et al. [33] concluded that by
No answer 8 (3.5) self‑administered questionnaire, both the dentists in public
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No 3 (1.3) and private practices in western region of Saudi Arabia had

Total 228 (100.0) good antimicrobial prescribing knowledge. However, it was
emphasized that the dentists needed to have an effective wide
understanding of the worldwide effect of unrequired antibiotic
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Table 15: The relationship between the level of knowledge prescription and adverse effects.[20,33]
for dentists about antibiotics and place acquiring their
dental degree Statistical analysis in the current study showed that the level
of knowledge among dentists regarding the antibiotics was
Where did you study Knowledge Total
dentistry not affected by the participants’ gender, type of the dental
Low Medium Excellent school (public or private), and timing of attending the sessions
Government dental school on the prescription of antibiotics. These findings were in line
Frequency (%) 11 (4.9) 131 (58.0) 9 (4.0) 151 (66.8) with the previous findings of two studies that evaluated the
Private dental school effect of gender[12] and timing of study[12,34] on the level of
Frequency (%) 4 (1.8) 65 (28.8) 6 (2.7) 75 (33.2) antibiotics prescription knowledge.
Total
Frequency (%) 15 (6.6) 196 (86.7) 15 (6.6) 226 (100.0) Study limitation
χ2=0.602, Significant=0.740 • Cross‑sectional study design occurring only in Riyadh
region
resistance.[25,26] The majority of respondents in this study • The sample size of the study only 228 although larger
believed that completion of the antibiotics course is necessary sample size would add further data results
to maximize its therapeutic effect only in some case (65.4%), • Lack of the previous studies utilizing resembling
while 23.7% responded that completion of the antibiotics is questionnaire makes comparison of all features of result
essential in its effectiveness. Interestingly, it was found that formidable.
8.3% of dentists believed that completion of the course is not
Implications
essential for its effectiveness.
• Revise the educational content of the undergraduate and
When an acute periapical infection is present in severe postgraduate courses to meet the appropriate therapeutic
cases the use of antibiotics is recommended; amoxicillin is guidelines, for example, Drug Prescribing for Dentistry
the drug of choice and it is preferred over penicillin V. In Dental Clinical Guidance
this study, the antibiotics preferred by the respondents for • Monitor and audit the antibiotic use in dental clinical
treating acute periapical infection were amoxicillin (77.2%), practice and make the necessary improvements where
penicillin V (12.7%), and tetracycline (5.7%). This finding needed
was similar to the findings of Vessal et al.,[12] who reported that • Focus on patient education which has valuable role in
amoxicillin was preferred over penicillin V (70.6% and 18.1%, lowering inappropriate use of antibiotic and at the same
respectively) to treat acute periapical infections. time restrain the antibiotic resistance
• Further studies are needed to reassess the compliance of
In acute ulcerative gingivitis, a number of antibiotics
the current cohort of practitioners with the established
have been suggested to treat this condition including
guidelines, for example, Drug Prescribing for Dentistry
metronidazole, amoxicillin‑clavulanate, or ampicillin‑
Dental Clinical Guidance. In addition, more studies
sulbactam or clindamycin.[25,27,28] In this study, 44.7% preferred
involving other areas of Saudi Arabia are needed to
metronidazole, 35.1% preferred tetracycline, while only15.8%
allow a more comprehensive evaluation of the antibiotics
of the respondents preferred amoxicillin. This result was in
prescription skills while treating dental infections.
agreement with the study of Jaunay et al.,[20] who found that
metronidazole was the drug of choice among South Australian Conclusion
practitioners to treat acute ulcerative gingivitis.
Most of the surveyed dentists had medium knowledge by
In the current survey, 44.7% used amoxicillin to treat cellulitis. the self‑administered questionnaire in prescribing antibiotic
Other surveys reported different antibiotic regimens to treat this therapy for clinical dental infections. The dentists used different
condition including amoxicillin,[12] combination of amoxicillin antibiotics and combination of antibiotics to treat the different
and clavulanate acid,[29] combination of amoxicillin and dental infections. The level of knowledge among dentists
metronidazole,[14,30,31] or penicillin.[13] regarding the antibiotics was not affected by the participants’

Journal of International Oral Health ¦ Volume 9 ¦ Issue 2 ¦ March‑April 2017 77

 Al Khuzaei, et al.: Knowledge of antibiotics

gender, type of the dental school (public or private), and timing region. Malaysia Dent Assoc 2010;31:35.
of attending the sessions on the prescription of antibiotics. 14. Palmer NA, Pealing R, Robert I, Martin MV. Therapeutics: A study of
therapeutic antibiotic prescribing in National Health Service general
This study supported the need for continuous education to dental practice in England. Br Dent J 2000;8:554‑8.
15. Likic R, Maxwell SR. Prevention of medication errors: Teaching and
contribute to wise use of antibiotics such as establishing training. Br J Clin Pharmacol 2009;67:656‑61.
standard guidelines for antibiotics used in clinical dental 16. Heaton A, Webb DJ, Maxwell SR. Undergraduate preparation for
practice. prescribing: The views of 2413 UK medical students and recent
graduates. Br J Clin Pharmacol 2008;66:128‑34.
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Financial support and sponsorship 17. Ramasamy A. A review of use of antibiotics in dentistry and
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Conflicts of interest 18. Flynn TR. What are the antibiotics of choice for odontogenic infections,
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and how long should the treatment course last? Oral Maxillofac Surg
There are no conflicts of interest. Clin North Am 2011;23:519‑36, v‑vi.
19. Mainjot A, D’Hoore W, Vanheusden A, Van Nieuwenhuysen JP.
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 Al Khuzaei, et al.: Knowledge of antibiotics

Appendix
Appendix 1: Study questionnaire Do you think that combining of antibiotics course is important
in its effectiveness
Knowledge of Antibiotic among Dentists in Saudi Arabia
Yes
Age
No
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21–30 In some cases

31–35
In case of localized infection in allergic to penicillin patient,
36–40
the first line is
More than 45
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Doxycycline 100 mg bid

Gender
Augmentin 875 mg bid
Female Amoxicillin 875 mg bid
Male
If the patient is nonallergic to penicillin, the drug of choice
Where did you study dentistry?
Amoxicillin 875 mg bid ×3 days
Private dental school Metronidazole 500 mg bid ×3 days
Government dental school Doxycycline 100 mg bid ×5 days
Which area in the globe did you acquire your dental degree? In case of spreading infection ‑ nonallergic patient, the first
drug of choice is
KSA
Arab country Augmentin 875 mg bid
For East Doxycycline 100 mg bid
The Indian Subcontinent Amoxicillin 875 mg bid
Europe
In case of spreading infection‑ allergic patient, the first line is
North America
Doxycycline
Area of specialization
Azithromycin
Prosthodontics Augmentin
Periodontics
What dose requires for azithromycin to improve the patient
Oral and Maxillofacial Surgery
compliance?
Endodontics and Conservative Dentistry
Orthodontics and Dentofacial Orthopedics 2 tablets the 1st day the once daily for 5 days
Dental Public Health 1 tablet every day for 7 days
Oral and Maxillofacial Radiology 1 tablet every day for 3 days
Pediatric Dentistry
In case the patient is not allergic to penicillin but has history
Years of experience of diarrhea problem to antibiotics, what will be the first line?
Clarithromycin
Augmentin
Did you have or attend any courses in using and prescribing
Metronidazole
antibiotics in daily dental practice
In case the patient with spreading oral infection who cannot
During undergraduate
tolerate penicillin, what is the alternative antibiotics?
After graduated
Both Metronidazole
Augmentin
Currently, you are a
Clindamycin
Intern
What is your source of information during prescription?
Graduate
Textbook and guideline
In case of localized infection, nonallergic patient; what
Classmate
antibiotic will be the first line to begin
Your background knowledge from pharmacology course
Penicillin
In which cardiac case, the patient will not need prophylaxis
Cephalexin
with antibiotics
Metronidazole
Azithromycin Prosthetic cardiac valve

Journal of International Oral Health ¦ Volume 9 ¦ Issue 2 ¦ March‑April 2017 79

 Al Khuzaei, et al.: Knowledge of antibiotics

Congenital heart disease Penicillin v

Cardiac transplant
Do you usually ask the patient about having allergy or any
Stable angina
related disease before prescription?
Which antibiotics preferred for acute periapical infection?
Yes
Amoxicillin No
Penicillin V
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Tetracycline Do you prescribe antibiotics before considering surgical

procedure?
Which antibiotic preferred for acute ulcerative gingivitis?
Yes
Amoxicillin
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Metronidazole No
Tetracycline Do you prescribe the same antibiotics to the patient suffering
Which antibiotics preferred for cellulitis? recurrent oral infection?
Amoxicillin Yes
Penicillin No

80 Journal of International Oral Health ¦ Volume 9 ¦ Issue 2 ¦ March‑April 2017