http://dx.doi.org/10.

17159/2519-0105/2022/v77no2a5
The SADJ is licensed under Creative Commons Licence CC-BY-NC-4.0. RESEARCH <
85

Oral antibiotic prescription patterns for dental

conditions at two public sector hospitals in
Pietermaritzburg, KwaZulu-Natal
SADJ March 2022, Vol. 77 No. 2 p85 - p91

P Ramnarain1, S Singh2

ABSTRACT for asthma treatment (pump) (n=3; 1%). The findings from
the focus-group discussions suggested that there is a need
Introduction to improve practitioner understanding of the indications for
Antibiotic resistance is a growing public health concern. Yet, antibiotic prescriptions for dental conditions.
there is a paucity of published data in KwaZulu-Natal on
antibiotic prescription trends and patterns related to dental Conclusion
use. This study showed some differences in antibiotic therapy
prescription patterns at the two public health institutions,
Study Objectives especially for dental conditions that did not require such
The objectives of this study were to identify the range of management. This suggests a need for consensus-
dental conditions for which oral antibiotics are prescribed building among health professionals and the provision of
at two public health settings (Institution A and B) in the more dedicated guidance for antibiotic prescription in the
Pietermaritzburg Complex, KwaZulu-Natal and to explore management of dental conditions.
practitioner understanding of the indications for antibiotic
prescription for dental conditions. INTRODUCTION
Antimicrobial resistance is a global threat, it is estimated
Methods that 700 000 people die annually as a result of antimicrobial
The study used a two-phased approach and collected a resistance.1 By 2050, this figure is set to escalate to 10
combination of qualitative and quantitative data. Phase 1 million.2 The reported indiscriminate or inappropriate
comprised a retrospective clinical chart review (n=720), use of antibiotics for dental conditions requires a review,
while phase 2 comprised a focus-group discussion with specifically in light of the proliferation of resistant bacterial
purposively selected health care practitioners at each strains that could lead to antibiotic resistance.3 There is an
institution. unclear picture of antimicrobial consumption rates as well
as discrepancies in antibiotic prescriptions across different
Results countries.4 Despite adequate knowledge of appropriate
The results of the retrospective clinical chart review indicated antibiotic use, health care practitioners in Australia still over-
that dental abscesses were the most common dental prescribe, while dentists in Switzerland are cautious and
infections requiring oral antibiotic therapy (n= 479; 66%), unsure about prescribing antibiotics.5
followed by acute alveolar osteitis (dry socket) (n=110; 15%),
dental impactions (n=78; 11%) and dental extractions (n=62; From a South African perspective, Mthethwa et al. reported
9%). At Institution A, antibiotic therapy was prescribed for that oral health care practitioners lack adequate knowledge
conditions such as trismus (n=13; 6%), soft palate swelling of the available treatment guidelines and best practices
of unspecified origin (n=9; 4%), fibrous epulis (n=6; 3%) and related to prescribing antibiotic prophylaxis.6 A more recent
acute herpes simplex (n=2; 1%). Interestingly, antibiotics were study reported that antibiotic prescribing patterns by
not prescribed at Institution B for the same dental conditions. dentists following tooth extraction did not appear to follow
Antibiotic therapy was also prescribed for eruption pain (n=4; a consistent or coherent set of guidelines for antibiotic use.3
1%) and for cases when patients did not bring their inhaler Despite the availability of several clinical practice guidelines
on the use of systemic antibiotics to treat pulpal and peri-
apical infections 7, there is very little published evidence on
Author affiliations:
1. P Ramnarain: BDT, BDS, M.Sc (Dental Therapy). Discipline of antibiotic- prescribing practices of dentists in South Africa.8
Dentistry, School of Health Sciences, University of KwaZulu-Natal,
Durban, South Africa. ORCID: 0000-0003-0428-201X The South African Antibiotic Stewardship Programme was
2. S Singh: B. Oral Health, PG Dip (Health Research Ethics), M.Sc
(Dentium), PhD. Discipline of Dentistry, School of Health Sciences,
developed in 2012 in response to the general identified
University of KwaZulu-Natal, Durban, South Africa.ORCID: 0000- gap in antibiotic prescription trends and patterns in health
0003-4842-602X care. Its purpose is to implement antibiotic stewardship
Corresponding author: Shenuka Singh:
programmes in hospitals and primary health care facilities.9
Discipline of Dentistry, School of Health Sciences, University of KwaZulu- The aim of this programme is to ‘strengthen the antimicrobial
Natal.Tel: 031-2068591, Fax: 031-2608069. E-mail:[email protected] surveillance, ensure uninterrupted access to quality essential
medicines, to enhance infection prevention and control and
Author contributions:
1. P Ramnarain: Study conceptualization, data collection and analysis, to stimulate further research innovations’.4 Antimicrobial
report writing prescribing practices in the public sector in South Africa
2. S Singh: Research supervision, study conceptualization, review of are also guided by the Standard Treatment Guidelines and
study results, manuscript review and revision.
Both authors approved the final submission. the Essential Medicines List 2020.10 These documents
are available electronically (http://www.kznhealth.gov.za/
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pharmacy/PHC-STG-2020.pdf) and is a valuable resource Phase 2 comprised FGDs with health care practitioners
to guide practitioners on antibiotic prescriptions.4,11,12 A (dental and medical practitioners) and pharmacists, involved
properly developed antibiotic surveillance programme in prescribing and dispensing antibiotics for dental purposes.
coupled with clearly defined protocols for the judicious Purposive sampling was used to set up the two FGDs
prescription of antibiotics can collectively contribute to comprising six volunteers per group at each research site. The
delays in the emergence of resistant bacteria.1 Adherence inclusion criteria entailed practitioner eligibility to prescribe or
to the Standard Treatment Guidelines and the South African dispense antibiotics for dental use; and registration with the
Antibiotic Stewardship Programme can also contribute to Health Professionals Council of South Africa or the Pharmacy
the reduction of inappropriate antibiotic prescribing that Council of South Africa (in the case of pharmacists). A semi-
could in turn result in improved prescribing practices in structured focus group schedule was used to collect data.
dentistry. Yet, it is unclear to what extent health practitioners
use these guidelines for the prescription of antibiotics for The focus group schedule comprised open-ended questions
dental clinical conditions. that explored participants’ perspectives on the National
Strategic Framework, Essential Medicines Lists, Standard
Given this unclear picture of oral antibiotic prescription Treatment Guidelines, The South African Antibiotic Stewardship
patterns for dental conditions, this study aimed to determine Programme, antibiotic prescription patterns for dental
antibiotic prescription trends and patterns for dental use in conditions, adverse events related to antibiotic prescription
the public health care sector in Pietermaritzburg, in order to and trends and perceptions of antibiotic prescription practices
have a better understanding of the current management of from a multi-disciplinary approach. Other questions included
dental conditions. perceived barriers, challenges and opportunities to access
oral health care, patient compliance, and the value of a multi-
METHODOLOGY disciplinary team approach in combating antibiotic resistance.
This was an exploratory study, using a combination of Written informed consent was obtained from all participants
qualitative and quantitative data. The research sites comprised and ethical considerations such as confidentiality and
two purposively selected hospitals (Institution A and Institution anonymity were upheld. All participants were informed that
B) in the Pietermaritzburg Complex, given that these two they had the right to withdraw from the study at any stage
institutions offer both basic oral health services such as without any negative consequences.
management of dental caries and periodontal disease as well
as more advanced services related to trauma and various The FGDs were audio recorded and the recordings were
types of pathology. Two phases were used in this study. The transcribed verbatim and then cleaned. The information was
first phase comprised a retrospective clinical chart review for transcribed onto a Microsoft Word document. A research
the period March 2012 to July 2018 (n=720). The second consultant assisted with the data analysis process. Data
phase comprised two focus-group discussions (FDGs) with coding was done independently by the researcher and the
purposively selected health practitioners (one FGD at each research consultant to identify significant features of the data
institution). The study selection criteria included all health care and to sort out the data, thereby allowing for the emergence of
professionals who prescribed and dispensed antibiotics for sub-themes and themes from the participants’ responses, as
dental use. The study excluded dental and medical managers, part of the thematic analysis.14-16 The data was then compared
and practitioners not involved in the clinical management and in order to identify common themes. The qualitative data was
prescription of antibiotics for dental use. Ethical clearance was analyzed using Nvivo version.11 The credibility of the study was
obtained from the Biomedical Research Ethics Committee, achieved by establishing that the findings of the study were a
University of KwaZulu-Natal (Reference number. BE026/190) true reflection of the participant’s’ original view.17 Transferability
while permission to conduct the study was obtained from was achieved by comparing the study findings with previous
the KwaZulu-Natal Department of Health (Reference number. and current literature.18 Conformability was achieved through
NHRD Ref: KZ_201902_018). the use of quotations of actual dialogues expressed by study
participants.19
For the retrospective clinical record review, managers for
each admissions department in the respective research site The quantitative data was analyzed using IMB SPSS (version
selected and retrieved the clinical records based on the criteria 25R). Univariate descriptive statistics such as frequency and
set by the researcher. The rationale for this approach was to mean distribution were conducted for all variables. Bivariate
minimize potential researcher bias in the selection of clinical statistics was also used to assess the outcome and thereafter,
records for review. The inclusion criteria included patients aged the outcome was analyzed by the explanatory variable.20
6 to 80 years; evidence of documented antibiotic prescription
for dental conditions; antibiotic prophylaxis for systemic RESULTS
conditions such as infective endocarditis in a patient who
suffered from rheumatic heart fever; or oral antibiotic cover Phase 1
prior to dental surgery and/or after dental treatment. A data A total number of 220 clinical charts (30.6%) were reviewed
capturing sheet was used to document the patients’ age, at Institution A and 500 clinical charts (69.4%) at Institution B.
gender, dental history, main complaint, symptoms, differential The study sample across the two institutions comprised 490
diagnosis, laboratory reports, prescribed treatment, number females (65.3 %). Almost half of the study sample (n= 357;
of prescribed medications, drug dosage, frequency and route 49.7 %) were in the age group 40-60 years. Only 86 patients
of administration. An antibiotic therapy worksheet12,13 was (12%) recorded were in the 6-year-old age group.
used to gather information related to the appropriateness of
the antibiotic regimen, therapeutic duplication and adverse The most common dental infection requiring oral antibiotic
reactions, and comparisons were made with the Standard therapy at both institutions was dental abscesses (n= 479;
Treatment Guidelines and the Essential Medicines List (2020). 66%), followed by acute alveolar osteitis (dry socket) (n=110;
This worksheet has been validated in previous studies.12,13 15%); surgical removal of impacted third molars (n=78;
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Table 1: Oral antibiotic prescriptions for dental and health related conditions
Health conditions for which antibi- Institution B (n=500 files)
Institution A (n=220 files) Total (n=720 files)
otics are prescribed
1. Other dental conditions
Necrotizing gingivitis 8 (4%) 12 (2.4%) 20 (3%)
Facial Cellulitis 10 (5%) 21 (4%) 31(4%)
Pericoronitis 8 (4%) 5 (1%) 13 (2%)
Trismus 13 (6%) 13 (2%)
Fractured Maxilla/Mandible 6 (3%) 5 (1%) 11 (2%)
Soft palate swelling 9 (4%) 9 (1%)
Gingivitis 8 (4%) 1 (0.2%) 9 (1%)
Acute Herpes 2 (1%) 2 (0.3%)
Aphthous Ulcers 3 (1%) 4 (0.8%) 7 (1%)
Fibrous Epulis 6 (3%) 6 (1%)
2. Trauma
Motor vehicle accidents 2 (1%) 3 (1%) 5 (1%)
Facial trauma 4 (2%) 4(1%)
Assault 16 (7%) 9 (2%) 25 (3%)
Bony spicules 3 (1%) 3 (0.4%)
3. Systemic conditions that resulted in postponement of dental treatment
Uncontrolled Hypertension 19 (9%) 39 (8%) 48 (7%)
Uncontrolled Diabetes 3 (1%) 10 (2%) 13 (2%)
Infective endocarditis 5 (2%) 2 (0.4%) 7 (1%)
Valve replacements 1(0.4%) 1 (0.1%)
Uncontrolled Asthma 3 (1%) 3 (0.4%)
3. Miscellaneous
Fillings 3(1%) 5 (1%) 8 (1%)
Biopsy 1(0.4%) 2 (0.4%) 3 (0.4%)
Root canal therapy 7 (3%) 2 (0.4%) 9 (1%)
Eruption Pain 4 (1%) 4 (0.5%)
Referrals to regional and tertiary
5 (2%) 6 (1%) 11 (2%)
hospitals for further management
Patients undergoing dental treat-
13 (6%) 2 (0.4%) 15 (2%)
ment under General Anaesthesia
Patient request 2 (1%) 2 (0.2%)
Uncooperative Patients 20 (9%) 4 (1%) 24 (3%)
Treatment deferred 2 (1%) 16 (3%) 18 (3%)

11%); dental extractions (n=62; 9%), and surgical extractions Penicillin (n=5; 0.7%) while those in Institution B prescribed
(n=22; 3%) (Figure 1). Allergies were recorded and alternate Erythromycin (n=2; 0.3%). According to the Standard
antibiotics were prescribed in a small number of clinical Treatment Guidelines 2020 (STG), adult patients should
files (n=5; 3% in Institution A and n=7; 1% in Institution receive Amoxicillin, oral, 500 mg 8 hourly for 5 days and
B). Healthcare practitioners in Institution A prescribed Metronidazole, oral, 400 mg, 8 hourly for 5 days. In cases
both Clindamycin and Azithromycin for patients allergic to where patients have severe penicillin allergies, Azithromycin,
oral, 500 mg daily can be prescribed for 3 days. The doses
Figure 1: Common dental conditions requiring antibiotic therapy for the same antibiotics used in children presenting with
dental abscesses, differed according to the guideline. The
STG (2020) does not out outline antibiotic prescription for
dental caries and dental extractions.

At Institution A, antibiotic therapy was prescribed for

conditions such as trismus (n=13; 6%), soft palate swelling
(n=9; 4%), fibrous epulis (n=6; 3%), and acute herpes simplex
(n=2; 1%) (Table 1). With regards to herpes simplex lesions
(such as those on the lips), the STG (2020) indicates that an
antiviral agent such as Acyclovir, oral, 400 mg, 8 hourly, for
7 days should be prescribed for adult patients with extensive
oral herpes for 7 days. This again reflects that the STG
(2020) does not highlight the need for antibiotic prescription
for patients with acute herpes simplex lesions. Antibiotic
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Table 2: Recommendations for improved antibiotic prescriptions

Recommendations Quotations
“Strategies are implemented to combat antimicrobial resistance.” (Institution A)
“The last line of antibiotics prescribed now requires authorization from the consultant.” (Institution B)
“Diagnostic tests are recommended before prescribing antibiotics for clients.” (Institution B)
Improvement of antibiotics prescrip-
“Start first line antibiotics based on differential diagnosis and prescribe the definitive treatment based on confirmed
tion
diagnosis test results.” (Dental practitioners from Institution A)
“Antibiotic prescription was changed according to weight as instructed by the Standard Treatment Guidelines as
opposed to assuming the dosage as per the age of the pediatric patient.” (Institution A)
2. Reduce the adverse effect from incorrect antibiotic prescription “Yes, there has been one incident of an
2. Reduce the adverse effect from
adverse effect from the incorrect antibiotic prescribed which was due to insufficient history taking and patient
incorrect antibiotic prescription
transparency.” (Dental Practitioner from Institution A)
“The pharmacists always check and approve the prescriptions recommended by medical and dental practi-
tioners” (Institution A).
3. Multi-disciplinary team approach “If there is an adverse effect related to antibiotic allergy, the medical practitioners always work together with the
dentists to stabilize the patient.” (Institution B).

prescription is also not mentioned for conditions such as However, there is no indication if antibiotics were prescribed
trismus and fibrous epulis in the STG (2020). because the treatment had to be postponed, in the case
of a patient who did not bring his/her asthma treatment
Antibiotics were prescribed for necrotizing gingivitis (n=20; (pump) to the dental clinic, or due to the dental condition.
3%). The STG (2020) indicates that chlorhexidine 0.2%, 15
mL as a mouthwash, should be prescribed twice daily for Phase 2
patients with uncomplicated gingivitis while Metronidazole, The following themes emerged from data analysis:
oral, 400 mg, 8 hourly, for 5 days should be prescribed for inconsistency in antibiotic use for dental treatment needs;
patients with necrotizing periodontitis for 5 days together adherence to the standard treatment guidelines, and strategies
with chlorhexidine 0.2%, 15 mL as a mouthwash. The STG to combat antibiotic resistance.
(2020) does not mention antibiotic prescriptions for dental
conditions such as gingivitis, facial cellulitis, aphthous Theme 1: Inconsistency in antibiotic cover for dental-
ulcers, and fibrous epulis. However, Cefalexin, oral 500mg related treatment
6 hourly for 5 days or Flucloxacillin, oral, 500mg 6 hourly for Study participants indicated that medical practitioners are
5 days are indicated in the case of adults presenting with not primarily involved in the prescription of antibiotics for
cellulitis. common dental conditions and instead refer patients to the
dental department.
Antibiotic therapy was prescribed for 16 patients treated
for assault (7%) at Institution A while only 9 such cases “Antibiotics were prescribed for dental abscesses, patients
were recorded at Institution B (2%). However, it is possible with multiple carious teeth presenting for general anesthesia,
that more patients requiring management for assault could prophylaxis for rheumatic heart fever [Prophylaxis for infective
have presented at Institution A, hence this can explain endocarditis in a patient who suffered from rheumatic heart
the skew in the prescription trends between the two fever] and cases of open wound fractures and trauma”
institutions. Moreover, there is no indication in the STG (Institution A). On the other hand, antibiotic coverage was
(2020) that antibiotics should be prescribed for patients prescribed for dental abscess, open wound fractures,
presenting with trauma. Antibiotics were prescribed for cellulitis, dry socket, pericoronitis, and periodontitis, and
patients for whom dental treatment was complicated due antibiotic prophylaxis after tooth extraction, necrotizing
to systemic conditions or the treatment was deferred ulcerative gingivitis, rheumatic heart fever and infective
(n=18; 3%). and/or when the patient was referred to other endocarditis at Institution B.
health facilities for further clinical management (n=11; 2%).
The systemic condition necessitated the postponement of Theme 2: Antibiotic prescription and the adherence to
dental treatment but antibiotics appeared to be prescribed the Standard Treatment Guidelines
because the patient needed dental extractions, in most All participants (medical and dental practitioners) confirmed
cases. Less than half of the cases with uncontrolled blood that antibiotics were prescribed according to the STG,
pressure (n=48; 7%) were prescribed antibiotic therapy as reflected in the following quotation. “Yes, the standard
across both institutions. Patients undergoing treatment treatment guidelines are followed when prescribing antibiotics.”
under general anaesthesia for dental extractions involving (Institution A) “The medical and dental practitioners seem to
multiple teeth, were prescribed antibiotics at both Institution be prescribing the correct regimen according to the Standard
A (n=13; 2%) and Institution B (n=2; 0. 4%). Institution A treatment guidelines.” (Pharmacists from Institution A).
was much more likely (n=20; 9%) than Institution B (n=4; However, this finding is not congruent with the results of the
1%) to prescribe antibiotics for un-cooperative patients. clinical record analysis reported earlier.

Although antibiotics were prescribed for mostly the same Theme 3: Strategies to combat antibiotic resistance
dental conditions at both institutions, certain prescriptions There was no consensus among research participants
made at Institution B did not appear to be prescribed at on the need for diagnostic laboratory testing to improve
Institution A. Antibiotic therapy was prescribed for eruption antibiotics prescription. However, all participants agreed
pain (n=4; 1%) and in cases where patients required a that there is a need to improve antibiotic prescription in their
dental extraction but did not have their inhaler for their respective hospitals despite the fact that the respondents
asthma treatment (pump) (n=3; 1%) at Institution B (Table 1). indicated earlier that the standard treatment guidelines are
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followed.“Prescribers use empirical treatment which may Antibiotics were prescribed for dental conditions such
result in antibiotic resistance.” (Institution B). pericoronitis (2%), trismus (2%), acute herpes simplex (0.3%);
aphthous ulcers (1%), fibrous epulis (1%), and eruption pain
Some recommendations to improve antibiotics prescription or for procedures such as (0.5%) restorations (fillings) (1%),
trends and reduce possible resistance are listed in Table 2. biopsy (0.4 %) when the STG (2020) has not indicated
antibiotics for these conditions and procedures. Antibiotics
DISCUSSION were also prescribed for uncooperative patients requiring
The need for systemic antibiotic use in dentistry is limited dental extractions especially in Institution A (9%), or because
given that most dental infections such as pulpitis and the patient requested so (0.2%). Although these percentages
periapical periodontitis, require only operative procedures are low, the implications are the wholly inappropriate use
such as extractions, restorations or root canal therapy and of antibiotics for dental clinical management, in respect of
that it is only by exception that antibiotics are required for certain dental conditions.
dental conditions.6 Yet, the results of this study indicate that
some inconsistencies in antibiotic prescriptions for dental The results of the qualitative data analysis further indicated
conditions did exist in the two identified sites. According to that medical practitioners were more likely to refer patients
our study, a dental abscess (66%) was the most common to the dental department for the prescription of antibiotics for
dental infection requiring antibiotic therapy. Long postulates common dental conditions. At the same time all participants
that dental abscesses larger than 5 cm, cellulitis or conditions suggested that the prescription of antibiotics for dental use
with mixed abscess-cellulitis require antibiotics coverage.21 was based on the STG, yet the results of the retrospective
Incision and drainage (especially when there is substantial clinical records review illustrate that antibiotics were prescribed
inflammation and pain) with or without adjunctive antibiotic for conditions that are not covered in the guideline. This
therapy are recommended for localized infections such as finding is thus not consistent with the results of the clinical
a periapical abscess, periodontal abscess and a localized record analysis thereby suggesting some inconsistencies in
dentoalveolar abscess. Likewise, sepsis can progress to the pattern and trends in antibiotic prescriptions for dental
cellulitis, and possibly to Ludwig’s angina which could be conditions at the two health institutions.
life-threatening. Therefore, the prescription of antibiotics is
justified in the management of dental abscesses.22-24 Antibiotics were prescribed for patients for whom treatment
was complicated due to underlying systemic conditions. It
The clinical records revealed that antibiotics were is noteworthy that antibiotics were not prescribed for the
prescribed for the treatment of alveolitis (dry socket) (15%), systemic condition, but rather, were given because either the
as it is done in England, Kuwait and Turkey where almost dental treatment could not be performed or it was deemed
half the dentists surveyed would prescribe antibiotics for that the patient is at risk of infection due to the systemic
a dry socket.23 However, a single dose of Metronidazole condition. This finding is consistent with previous reviews
was not found to be effective in preventing the onset of dry which concluded that patients with low immunity may
socket. Similarly, most dentoalveolar surgical procedures in be at higher risk of infection.26 In such cases prophylactic
healthy individuals did not require antibiotic prophylaxis.23 antibiotics could be beneficial to patients, where applicable.26

This study further indicated that antibiotic prophylaxis The results of this study showed that antibiotics were
was prescribed for impacted third molar surgery (11%). prescribed for the prevention of infective endocarditis in
Prophylactic antibiotic therapy in third molar surgery in a patient who suffered from rheumatic heart fever (1%).
healthy patients is highly controversial.25 There is no This observation is consistent with the findings reported
clear evidence that pre-operative antibiotic prophylaxis by Mthethwa et al., in that 2.2% of antibiotic prescriptions
for routine third molar surgery is necessary for patients were given for this purpose. Bacterial endocarditis remains
with no underlying medical complications.23 A Cochrane a risk following dental treatment.27 This is supported by
review indicated that prophylactic antibiotics reduces the British Society for Antimicrobial Chemotherapy and the
the risk of infection, dry socket and pain following third American Heart Association which recommend that only
molar extraction.6 Yet, at the same time, the STG (2020) high-risk patients require such cover.28, 29 Although antibiotic
has limited information on the management of dental prophylaxis to prevent infective endocarditis in patients who
conditions, with no mention of antibiotic prophylaxis to suffer from rheumatic heart fever, is widely accepted by
be given prior to the surgical removal of impacted third the dental profession,6 the effectiveness of such antibiotic
molars. prophylaxis in humans, however, remains unproven.30, 31 The
question however, remains as to whether antibiotics were
Likewise, the STG (2020) does not provide guidance for all prescribed judiciously in this study. Future research in this
dental conditions that are managed within clinical settings area is needed to further explore these identified issues.
in South Africa. The implications are that this guideline
does not provide adequate guidance for dental clinical Overall, the results of the study suggest that some over-
management. This inadvertently creates loopholes for prescription of antibiotics does exist. This needs to be
health and dental practitioners to use their own discretion reviewed because an increase in bacterial resistance to
in deciding when to prescribe antibiotics. This finding antibiotics and the associated costs will have an impact on
is consistent with Lalloo et al. who also observed that care care delivery as well as resource allocations.3 Dental
practitioners might be using subjective measures or even practitioners have a responsibility to reduce and improve the
personal preferences when deciding whether to prescribe way they prescribe antibiotics and should prescribe with the
antibiotics or not.3 This highlights the need for an urgent correct indications. Practitioners should not be swayed or
review of the STG (2020) so that this document is able to influenced by the patient's demands for antibiotics cover.32
provide more comprehensive guidance to practitioners in Dental practitioners also have a responsibility to educate
the country. patients on the spread and consequences of antimicrobial
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resistance.32 There should be greater community awareness 4. Schellack, N., Benjamin, D., Brink, A., Duse, A., Faure,
on the appropriate use of antibiotics.32 and the injudicious K., Goff, D., Mendelson, M., Meyer, J., Miot, J., Perovic,
prescription of antibiotics for the treatment of ‘toothache’ O. and Pople, T. (2017). A situational analysis of current
should be avoided.33 Clinicians thus need to be aware of the antimicrobial governance, regulation, and utilization in
ongoing evidence base for antibiotic prescription practices.3 South Africa. International journal of infectious diseases,
More research is required for the appropriate antibiotic 64, pp.100-106.
prescription in the field of clinical dentistry.34 Some participants 5. Mainjot, A., D’hoore, W., Vanheusden, A. and Van
in the FGDs also indicated that pharmacists played an important Nieuwenhuysen, J.P.(2009). Antibiotic prescribing in
in the oversight and approval of antibiotic prescriptions dental practice in Belgium. International endodontic
recommended by medical and dental practitioners. This journal, 42(12), pp.1112-1117.
reiterates the value of a multidisciplinary team approach for 6. Mthethwa, S.R. and Matjila, S.A. (2018). Antibiotic
antibiotic stewardship so as to ensure that there is oversight prescribing practices of dentists at Medunsa Oral Health
and accountability for antibiotic prescriptions. Centre. South African Dental Journal, 73(8), pp.520-
526.
Study strengths and Limitations 7. Matthews, D.C., Sutherland, S. and Basrani, B. (2003).
This study provided much needed data on antibiotic Emergency management of acute apical abscesses
prescription patterns for dental conditions in the public in the permanent dentition: a systematic review of the
health sector in Pietermaritzburg. While the value of such literature. Journal of the Canadian Dental Association,
timely data cannot be overstated, several limitations were 69(10), pp.660. In Database of Abstracts of Reviews
noted. The study findings are limited to the two participating of Effects (DARE): Quality-assessed Reviews [Internet].
health institutions and the reporting period (March 2012- July Centre for Reviews and Dissemination (UK).
2018). Poor record keeping and insufficient diagnostic data 8. Lalloo, R., Solanki, G., Ramphoma, K. and Myburgh,
could have skewed the study findings. From a data analytical N.G. (2016). Antibiotic‐prescribing patterns of South
process, inferential statistics were a challenge given the nature African dental practitioners following tooth extractions.
of the data collected in the retrospective clinical chart review. A Journal of Investigative and Clinical Dentistry, 8(4),
further research question could focus on practitioners’ source p.e12247
of knowledge for antibiotic prescriptions (e.g. is it university 9. National Department of Health of South Africa (2017).
education, continuing professional development, national Guidelines on the Implementation of the Antimicrobial
guidelines, etc.). This could perhaps identify the gaps that Strategy in South Africa: One Health Approach and
seem to contribute to practitioners’ decision-making. Despite Governance. Ministerial Advisory Committee on
these limitations, a clear picture has emerged on antibiotic Antimicrobial Resistance, National Department of Health
prescription patterns at the identified health institutions. Affordable Medicines Directorate, Department of health,
RSA, June 2017.
CONCLUSION 10. Standard Treatment Guidelines and the Essential
This study showed that there were some differences in Medicines List (2020). Available at: http://www.
antibiotic prescription trends for dental conditions at the kznhealth.gov.za/pharmacy/PHC-STG-2020.pdf
two public health institutions. There is a need for consensus 11. Perumal-Pillay, V.A. and Suleman, F. (2017). Selection of
building among health professionals and for better guidance in essential medicines for South Africa-an analysis of in-
respect of antibiotic prescription in the management of dental depth interviews with national essential medicines list
conditions. committee members. BMC health services research,
17(1), p.17.
Acknowledgements 12. Huang, W.H. and Owen, C.P. (2012). Antibiotic
All study participants for their active participation in the study. prophylaxis for dental procedures: is it necessary?
The administrative departments at the two research sites for Clinical review. South African Dental Journal, 67(7),
their support. pp.413-419.
13. Ntšekhe, M., Hoohlo-Khotle, N., Tlali, M. and Tjipura, D.
Conflict of interest (2011). Antibiotic prescribing patterns at six hospitals in
None Lesotho. Submitted to the US Agency for International
Development by the Strengthening Pharmaceutical
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Surgery and Anesthesia, and the Quality of Care and

CPD questionnaire on page 109

The Continuous Professional Development (CPD) section provides for twenty general questions and
five ethics questions. The section provides members with a valuable source of CPD points whilst

also achieving the objective of CPD, to assure continuing education. The importance of continuing
professional development should not be underestimated, it is a career-long obligation for
practicing professionals.